Criteria For Literature Review

The search databases included Medline, psych Abstracts, and ERIC. Key words were crossed, including community, health promotion, school and health education, and adolescents. Additional sets of key words were crossed to yield information about specific sub areas of prevention. For example, since most prevention programs evaluated have been in the areas of smoking, alcohol, and drug abuse prevention, these were included as key terms. Other key terms included student assistance programs (SAPs), school health centers, and school clinics. With some exceptions, the initial criteria for selection were publication in a nationally disseminated peer-reviewed professional journal, studies or reviews since 1990, U.S. populations, a primary focus on late childhood or adolescence, and report of behavioral outcomes. The exceptions included papers representing models of health education rather than studies (see below), non-peer reviews where peer-reviewed publications were relatively lacking, and a few studies published before 1990 if they were particularly illustrative of a type of program or approach or other studies were lacking. The initial search resulted in 73 community health education citations, plus 37 keyed specifically for drug abuse prevention; 55 keyed for SAPs, school clinics, and health centers; and 15 non-peer review technical reports or monographs on studies from ERIC. The ERIC reports were eliminated. Elimination of redundant studies and studies in which behavioral outcomes were not clear resulted in 16 papers discussing models of health education programs that involved both schools and communities (school and community programs), 22 papers and reviews of school prevention studies, 5 of community prevention, and 25 of school and community prevention studies. The resulting review is intended to provide a selective but representative sample of studies and models, since an in-depth review of separate aspects of health education by health area (e.g., sex education) or type of service (e.g., SAPs) would be beyond the scope of this paper.

Models Of Integrated School And Community Health Education

Numerous models of comprehensive school health education have been proposed, most since 1990, and many of them have been published in one or more special issues of the Journal of School Health. As part of the literature review for this paper (see criteria below), 16 models with varying degrees of specificity were identified (1, 7, 8, 12–24). Two of the models were general (12, 13). One conceptualizes comprehensive school health education as an educational package within larger population-based health promotion efforts that include community education, worksite wellness programs, and legislative efforts (12). The other conceptualizes health education as part of a "Healthy Children Ready to Learn" initiative that is targeted to the family, rather than the school, and integrates health education with referrals to social services (13). All of the models directly include or assume the following criteria for achievement of comprehensive school health education:

• interaction of personal (educational skills), social or situational (provision of support services, communication, referral), and environmental levels (changing or monitoring school environment, surrounding physical environment) of health promotional activity (see 17, 24);
• integration of school and community efforts;
• extensive, regular school health education programs from kindergarten through grade 12; and
• coordination of school and other health efforts through a coordinating council or team.

However, the models differ on or do not specify several points:

• What constitutes "community efforts" is not well defined, with various models interpreting community as the presence of coalitions or local and state partnerships (e.g., 8), clusters of partnerships such as agencies and universities (e.g., 20, 21), community health councils involving the school and/or teams directly developed within or through the school (e.g., 23), and/or extra-school educational programming (e.g., 24).
• Assumption of the need for integrated school and community efforts is based on practical considerations rather than on theory or empirical evidence.
• With one exception (23), no models articulated specific mechanisms or functions that community efforts could provide in comprehensive health education; none related mechanisms to theoretical principles of health behavior change.
• Although most of the models directly addressed or alluded to school health services as part of comprehensive school health education (e.g., in the form of school health clinics or student assistance programs), none attempted to represent the continuum of school services from primary prevention through early intervention.
• What constitutes community programs is not well defined. Some models assume that community programming is restricted to community health education in the form of courses or materials, whereas others include mass media, parental involvement, community organization, or policy efforts. In addition, some models address the need for health education that is culturally sensitive and that integrates school and community efforts through systems intervention, but neither of these concepts is well defined (e.g., 15).

The remainder of this paper focuses on the first four points. It attempts to differentiate practical from theoretical arguments for integrated school and community programming and articulate specific mechanisms for behavior change according to theory; to delineate several levels of prevention activity in schools and use of mechanisms by each level; and to provide a selective overview of studies that represent school, school and community, or community interventions for health behavior.

Rationale For Integrating School And Community Efforts

Theoretical Considerations

One of the models reviewed proposes that schools and communities can integrate their health education efforts as a series of one-way, two-way, and multiple exchanges (23). For example, voluntary community health agencies can distribute health information materials that complement the messages delivered in school (a one-way exchange). Several potential avenues or functions in which school/community exchanges can occur are elaborated, including sharing and extending information, health services, training, and advocacy or policy change. Although both the functions and the exchanges are feasible given that they currently exist and are funded with varying degrees of integration, none of these is related to theories of health behavior change. Consideration of theory is necessary if one intends to design an integrated school/community program that has treatment construct validity and thus is likely to be testable for efficacy and replicable in multiple communities.

Several theories figure prominently in school and school/community programs that have shown significant effects on youth health behavior. These include, but are not limited to, the following. Social learning theory explains how models, practice opportunities, and reinforcement affect behavior; this theory translates to the development and testing of school educational programs that focus on teaching skills and the use of community leaders as models for behavior (34). Reasoned action and expectancy value theories explain how actual and perceived social norms affect behavior; these theories translate to promoting mass media coverage of health behavior and advocacy and formal policy change initiatives for health behavior (35). Social support theories explain the types of support that a community can provide a school and supportive health communications that parents and other adults can provide to youth; these theories translate to parent skills and communications programs; interactive parent/child homework activities; and community coalition, council, or partnership action planning (36). Peer cluster theory explains how and why youth will gravitate toward certain peer groups that represent specific norms for health and serve as models for behavior; this theory translates to group settings for health education (37). Diffusion of innovation theories (and, to a lesser extent, persuasion theories such as spiral-of-silence theory) explain how a small critical mass of community leaders or innovators may influence youth and adults to adopt health programs; these theories translate to lobbying for education referenda and local policy change, as well as the use of mass media to complement school health education programs (38, 39).

Potential mechanisms for integrating community efforts with school health education, according to theory, are summarized in Table A-1. Potentially, each could be evaluated for its contribution to school health education, based on its relevant theoretical principle for behavior change. All of the school + community studies reviewed included distribution of materials to schools and complementary community education or activities; studies varied on the use of other mechanisms. With the exception of parent trainers or participants and mass media coverage, none of the other mechanisms was evaluated for its independent effects.

TABLE A-1

Potential Mechanisms for Interfacing Community Efforts with School Health Education, According to Theory.

The Concept Of Strategic Prevention

Comprehensive school health education can be conceptualized in terms of level of prevention services provided to youth. Four levels are shown in Table A-2. Ideally, these levels of services are reciprocal and synergistic in terms of their effectiveness; thus, inclusion of all four levels in a comprehensive school health education plan would be considered a strategic use of prevention services (40). Level 1 is primary prevention or universal health education involving whole populations of youth in school settings. Because schools are the single most available normative setting for youth, primary prevention programs would be expected to be a major focus of school health education. Some qualitative results of process evaluations suggest that primary prevention programs promote increases in student requests or self-referrals for other levels of programming (40). Level 2 consists of special topic activities and prevention and group counseling programs oriented toward high-risk youth (e.g., children of alcoholics) and underserved youth. These programs are typically voluntary, are scheduled to complement primary prevention programs, and can provide a forum for more detailed discussion and assistance with such health problems as drug abuse (41). Level 3 involves student assistance programs or related core team efforts in schools. This level is aimed at youth who are already experiencing academic difficulties and who probably are experiencing difficulties in health behavior, particularly drug abuse and mental distress. Health problems identified in SAPs may lead to referral to school clinics or health centers for screening or early intervention (42, 43). Level 4 represents the prevention/treatment linkage within school services (from education to school clinic or health center) as well as outside the school (from education or school clinic to community health clinics, agencies, and hospitals). Innovative use of existing school counselors, nurses, and other personnel in school clinics in Level 4 can link back to services at other levels of prevention (44). Routine referring and mainstreaming of youth across different levels of prevention where appropriate should result in more comprehensive school education service delivery than is available through single-level service (45). Table A-2 illustrates the studies and reviews of studies that focused on each level of prevention, the primary mechanisms for interfacing school and community efforts that were employed, and the primary areas of health addressed by each level. The majority of studies and reviews of studies have been concentrated at Level 1. Mechanisms for school/community interface at this level—when they are used at all—typically include the use of school, community, or peer leader trainers for education and the distribution of materials. The fewest published studies were in Level 3, or SAPs, which used complementary community education or activities to interface with the community. Smoking and drug abuse prevention predominated as the major health areas addressed at all four levels.

TABLE A-2

Levels of Strategic Prevention.

The Argument For School + Community Programs

The major question under consideration in this paper is whether school + community programming is more efficacious than school programming alone. Addressing this question requires comparison of school, community, and school + community prevention studies. The working definition of ''community" was any health promotion or disease prevention intervention conducted outside of the school and representing potentially significant channels of influence and programming for youth. The community channels included parent programs; mass media programming, campaigns, and materials; community organization and training, including the use of councils, coalitions, and partnerships or the use of extra-school settings for education, such as Boys and Girls Clubs or health agencies; and policy change initiatives, including school and community (46–49). Two types of behavioral outcomes were considered: those representing participation or implementation in prevention and those representing change in health behaviors, such as smoking or nutrition. Several factors were examined, based on assumptions made in the general model and discussion papers described earlier, including evidence of collaboration or integration across community program components, levels of prevention involved, and mechanisms employed for achieving health-behavior outcomes and, where relevant, school/community interface. Results are summarized in Table A-3.

TABLE A-3

Effectiveness of School, Community, and School + Community Programs.

School Programs

Twenty-eight literature studies and reviews, representing more than 246 separate studies, are summarized. A standard for comparison might be the School Health Education Evaluation (SHEE) studies, which showed a 1.5 percent difference in student self-reported health practices after 40 to 50 hours of teacher-taught school health education in the 1980s (50). The majority of the studies shown in Table A-3 focused on smoking and drug abuse prevention at Level 1 and used teachers or peer leader trainers as mechanisms for achieving health behavior change. Although some individual studies included participation variables as behavioral outcomes, fewer than 10 percent of studies in review articles did so. Overall, the pattern of school-based studies suggests strong short-term effects on experimental use rates of smoking, drug use, and sexual risk behaviors; few effects on regular use rates; and no effects at five-year follow-up, with one exception, which required 30 sessions of instruction (62). Effects on nutrition and exercise appeared to be smaller overall than effects on smoking or drug use. The magnitude of effects overall appears to be larger than those achieved from the SHEE studies averaging 7 percent (122), perhaps attributable to the shift from didactic to interactive education (e.g., 52). None of the studies reviewed emphasized mechanisms to link or interface with the community (78). None reported using a systems or restructuring intervention as suggested in some comprehensive school health education models and none reported placing a special emphasis on cultural sensitivity (15, 79).

School + Community Programs

State-of-the-art school health education should include one or more of the mechanisms shown in Table A-1 to promote cross-referrals, cross-communication, and resource sharing with community agencies for general health, as well as specific prevention services (compare 88). The mechanisms should also include community leaders and parents as participant or discussants in the health education process, particularly for such sensitive health areas as AIDS education (89). Using these mechanisms to integrate school programs with parents, mass media, community organizations, and health policy change efforts may be increasingly necessary to offset the new ''social morbidity" posed by youth, families, and schools that are failing in health achievement (90).

A total of 25 studies, including two reviews, was found, representing more than 30 studies. Based on youth-related experiences of the heart health trials, multicomponent community-based programs should include substantial school programming to initiate behavior change, in conjunction with a community organization structure and process that promotes mass media programming and coverage, parent and adult education, and informal or formal policy change (91). A standard for comparison might be the 3 percent decrease in adult smoking found in the COMMIT trial and the 2–15 percent short-term decreases found in school-based studies of smoking.

Overall, school programs that included one or more community program components showed short-term effects on monthly smoking and drug use similar to comprehensive school programs that included a large number of sessions and boosters; however, school + community programs appeared to have a greater range of effects and larger long-term effects on heavier use rates, averaging 8 percent net reductions (122). School + community programs were the only programs to show any effects on parent participation and parent health behavior or any effects on program or materials dissemination and health service delivery in the community. Effects of school + community programs on nutrition and exercise appear to be somewhat larger than effects of school programs; differential effects on sexual risk behaviors are not clear.

Prevention levels varied among the studies, but emphasized Level 1. Most studies used a variety of mechanisms to link the community with the school. The most common were the inclusion of parents, peers, and community leaders in a community task force or council and, to a lesser extent, as leaders or participants in education. About half of the studies reported information on participation or dissemination rates as well as health behavior outcomes.

Twelve studies included parent involvement or programming with a school program. Eight of these suggested that parent involvement increased effects on youth health behavior; two studies suggested that parent involvement increased effects on parent health behavior; all but one study showed increased parent participation in school or other program activities as a result of a parent involvement component.

Twelve studies included a mass media component. Because most of these included mass media as part of additional program components, the independent effects of media are not altogether clear. However, three studies suggest that media involvement increased parent participation and changed parent health behavior.

Nineteen of the studies included the integrating of some type of community organization or education with a school program. Since most integrated community organization with other components, the independent effects of community are not clear. Across studies, however, those with community organization appeared to have greater dissemination and parent and community participation rates, more referrals for health services, and possibly greater rates of implementation of other components.

Only seven studies included some informal or formal policy change component. Policy change mostly involved reducing youth access to substances and controlling product availability. The independent effects of this component are not clear.

Only six studies (two of them reviews) directly compared a school program component with other community program components. Three studies and a review of four other studies compared the effectiveness of school programming with parent and/or mass media involvement versus school programming alone for changing tobacco use. Overall, these studies showed greater effects on youth smoking when school programs included parent and/or mass media programs and showed small effects on parent smoking with inclusion of a parent program. Two studies showed no effects and attributed the findings to poor implementation and/or a resistant cultural norm for tobacco use. Two other studies, one on physical fitness and one a review of reproductive health, compared school programs or activities with programs or activities in alternative community settings (99, 100); the physical fitness study reported no differences among settings, whereas the other study showed variability in condom use among settings.

Remaining questions

What is the community? Most of the studies reviewed here involved efforts by small- to moderate-size communities to integrate efforts with school programs. Involvement of large cities showed a greater range of health services and resources, but also more competition. Communities that consisted of large, sparsely populated rural areas relied on the local school as a community for program dissemination and training. Thus, meaning of and affiliation with community may vary at least by size.

Should the school reach out to the community or should the community "reach in" to the school? Results of studies suggest that school outreach may be both a more feasible and a more acceptable strategy for linking the community with the school for health education. Several studies suggested that attempts by a community organization to reach in to the school to provide training failed.

Can the effects of community be disentangled from those of the school? Because the largest community effects appear with a synergistic relationship to the school, the question should be reconceptualized as, Is school + community better than school or community alone? The present review suggests that, overall, the answer is yes.

Are school + community programs replicable, and can technology be transferred from schools across communities? Given the consistency of positive findings of school + community programs on participation, dissemination, and youth and parent health behavior variables, the general answer would appear to be yes. However, communities show great variability in the structure and action plans of the coalition, council, core team, or task force component used to integrate health education with the school. This type of component may not be replicable in a standardized fashion, and communities report the need for flexibility to develop such a component to reflect their own individual needs.

Is school + community research feasible? Several methodological papers have addressed this question indirectly (e.g., 118-121). The demographics and past health behavior involvement of communities is difficult to match, suggesting that a large number of communities would be necessary for randomizing to experimental conditions, with the community as unit. Such a study would be expensive. Most of the studies reviewed school plus multiple community components versus a control or delayed intervention group. The ability to evaluate the effects of separate components in a school + community intervention would require the use of a factorial design, in which the effect size associated with each component intervention or sets of components compared to each single-component intervention would be assumed to be significantly different. Only a few studies have included enough schools to be able to detect differences between interventions or components of interventions (e.g., 93, 94).

Are school + community programs cost-effective? A recent analysis of prototype integrated school health education programs included projected costs and reported outcomes from seven comprehensive school-based programs and two school + community-based programs (122). Results indicated that annual costs per student for program delivery ranged from $10 to $35, depending on whether the primary focus of the program was on sexual behavior, substance use, or smoking. Effects, measured as percentage net reduction between program and control groups, ranged from 6 to 9 percent. The benefit-to-cost ratio ranged from 5 for sexual behavior to 19 for smoking, for an average of 14. Sensitivity analyses suggested that benefit–cost ratios for comprehensive school health education programs were lower for smoking, higher for drug abuse, and higher for sexual behavior. This suggests that, compared to single health focus, overall a comprehensive multicomponent, multihealth focus school health education program is apt to be more beneficial. A recent analysis of a school + community program for drug abuse prevention supports this finding (123).

Who would coordinate integrated school and community health education programs, and who would fund these programs? To address the first part of the question: the programs examined in the studies and reviews varied in terms of who was responsible for coordinating programming; those responsible needed research staff, health educators, school personnel, and paid and volunteer community leaders. However, none of the studies systematically compared the effectiveness of types of coordinators. In an integrated program, it is more likely that coordination will be the task of a group rather than an individual. A major question, then, is whether school health advisory councils that draw from community leaders but are organized by the school or school district generate more credibility and cooperation than do coalitions that draw from community leaders and are organized by the community (see 18). The studies show that school + community programs are effective, but the studies made no comparisons with community-only programs. The second part of the question is related to the first. If coalitions are used to coordinate school health education, then community agencies and federal and state funds that are allocated to community agencies for health services might be used to augment existing school health education budgets. However, if school-based health advisory councils are used, then accessing community health care funds may be difficult and resented. A long-term alternative would be qualifying school health clinics as managed health care service delivery organizations, which would be reimbursable by insurance and federal funds. In this case, managed care funds could be combined with existing school health education funds to create a unified funding package for school health education. As long as health care reimbursements were forthcoming, this alternative should be more stable than relying on the graces of volunteered community agency funds.

Can integrated school + community programs affect educational outcomes as well as health outcomes? Comprehensive school programs that included more than seven sessions, booster sessions, standardized training, and monitoring of implementation had substantial effects on knowledge change, as did school + community programs. To the extent that knowledge is measured as an educational outcome in health education classes, comprehensive school programs and integrated school + community programs could be considered effective in improving educational achievement. However, no studies reported significant effects of a health program on grade point average, absenteeism, or drop out rates, which are considered overarching indices of educational achievement.

Conclusions And Future Directions

Review of multiple studies suggests that in a school + community interface, "community" can include the use of mass media, parent programs, community education and organization, and local policy change. Results suggest that community + school health education may yield higher participation, implementation, and dissemination rates of health education; greater effects on the more serious levels of health risk (e.g., on daily smoking compared to monthly smoking), greater effects on parents as well as youth, and perhaps longer effects than are currently obtainable from most school programs alone. Overall, the magnitude of effects on such health behaviors as smoking, substance use, and sexual behavior appears slightly greater for school + community versus school programs alone (6 versus 8 percent net reductions). Benefit-to-cost ratios appear overall higher for comprehensive school health education programs than for single-component (e.g., smoking) programs.

Several caveats apply to these summary conclusions. First, the school + community studies reviewed here were based on a model of intensive community involvement that probably exceeds the realistic capacity, resources, and time of most schools and school systems. The integrated school + community health education program mentioned in general models at the beginning of this paper (e.g., 18) represents much less intensive community involvement than the studies reviewed here, for example, following the Child and Adolescent Trial for Cardiovascular Health (CATCH) model of fliers to parents, invitational health nights held at school, and changes in cafeteria menu choices versus the organized community council activities of the Minnesota Heart Health Project (cf. 70 vs. 102). Less intensive community involvement could also take the form of simple community leader advisement on health education materials or protocols to adopt in schools, facilitation of health service referrals from school to community, and/or assistance in administering or managing health care funds in school health clinics. However, none of these lesser involvement roles has been adequately evaluated in research. Third, for simplicity's sake, studies were not separated for their effects by level of prevention. For example, school health education programs at Level 1 were not separated from school health services at Level 3 or 4. Because of the use of different research designs and outcomes, stratification and comparisons on these levels are not yet feasible.

The review of studies points to several gaps in the literature that should serve as directions for future research. These include:

• more systematic evaluation of cost-benefit and cost-effectiveness of school and school + community programs that rely on true costs;
• evaluation of the efficacy of extensive school programming alone (e.g., 30 sessions or more with boosters delivered over several years) versus the same school programming with additional community components, with school district or community as the unit of assignment and analysis if possible; and
• comparison of school + community programs that vary in intensity or type of community involvement.

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