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University Microfilms International 300 N. Zeeb Road Ann Arbor, Ml 48106 8400566 H ansen, Stella Ann THE CURRENT STATUS OF COMPREHENSIVE SCHOOL HEALTH EDUCATION AND PROGRAM CRITERIA IN MICHIGAN PUBLIC SCHOOLS, 1981-83 Ph.D. M ichigan State University University Microfilms International 300 N. Zeeb Road, Ann Arbor, Ml 48106 Copyright 1983 by Hansen, Stella Ann All Rights Reserved 1983 PLEASE NOTE: In all cases this material has been filmed in the best possible way from the available copy. Problems encountered with this document have been identified here with a check mark V 1. Glossy photographs or pages______ 2. Colored illustrations, paper or print______ 3. Photographs with dark background______ 4. Illustrations are poor copy______ 5. Pages with black marks, not original copy______ 6. Print shows through as there is text on both sides of page______ 7. Indistinct, broken or small print on several pages 8. Print exceeds margin requirements_____ 9. 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Other____________________________________________________________________ __ University Microfilms International THE CURRENT STATUS OF COMPREHENSIVE SCHOOL HEALTH EDUCATION AND PROGRAM CRITERIA IN MICHIGAN PUBLIC SCHOOLS, 1981-83 By Stella Ann Hansen A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Administration and Curriculum 1983 ABSTRACT THE CURRENT STATUS OF COMPREHENSIVE SCHOOL HEALTH EDUCATION AND PROGRAM CRITERIA IN MICHIGAN PUBLIC SCHOOLS, 1981-83 By Stella Ann Hansen This dissertation uses both a survey research method, and a participant observation research method to assess the 1981-83 status of comprehensive school health education in Michigan public schools. The survey consists of a statewide assessment, of all public school principals on various health education program criteria. The participant observation study includes observation of health education programs in three different size school districts in Michigan. Results of the survey indicated that Michigan public schools lack a sound organizational structure necessary to implement and maintain a health education program. The or­ ganizational structure surrounding a comprehensive school health education program is quite complex, and should include a health education program coordinator, advisory board, com­ munity participation and sponsorship, parent and student par­ ticipation, integration with community professionals and a mechanism for continuous evaluation. Instructors of health have not received adequate college preparation in general health education, nor do they receive health education on a yearly schedule. The content of most health education courses is fragmented and inconsistent with different curricula being used by teachers within same grade levels in same districts. The results of the participant observation indicated that for health education to be effective, it should be pre­ sented in terms of students* personal responsibility and de­ cision-making, as well as be relevant to the students' own experience. Hands-on educational experiences and positive student-teacher relationships were observed to be important components for effective health instruction. The major barriers to implementation were observed to be time constraints, incomplete teacher compliance, and lack of a health content. The major innovations observed were parent involvement, participation by community professionals, and the use of a closed circuit television for broadcasting health instruction and health education inservice. DEDICATION To my loving husband Peter, and to our beautiful daughter Adrienne ii ACKNOWLEDGMENTS Many people deserve special recognition for their help in making this dissertation possible. I would like to especially thank my thesis director, Professor Frederick Erickson, for his encouragement and insight in qualitative research as well as in health education. I would also like to thank my committee members, Professors Keith Anderson, Max Raines, and Vandel Johnson, for their support and assistance throughout my graduate school years. My appreciation also goes to Dr. Wanda Jubb and Maria Valone for their efforts to review and critique the thesis, and to my friend and editor, Dorothy Deehr. Although their names have necessarily been kept anonymous, my sincere appreciation and admiration goes to the administrators, teachers, and students who shared their time, experiences and perspectives for the i m­ provement of the health education learning process. I would like to express my sincere appreciation to Jean Dolansky for her patience and persistence in helping to edit and in typing the thesis. I would also like to thank the members of my family, who gave me a lifetime of support and encouragement. Most of all, I would like to thank my husband Peter, whose strength and encouragement has helped to make this dissertation possible. iii TABLE OF CONTENTS Page LIST OF T A B L E S ........................................... ix LIST OF F I G U R E S ......................................... x CHAPTER I. THE P R O B L E M .................................... 1 ............. 1 PURPOSE OF THE S T U D Y ........................ 10 PROCEDURES USED IN THE S T U D Y ................ 11 LIMITATIONS OF THE S T U D Y .................... 13 DESCRIPTION OF THE CONTENTS OF THE D I S S E R T A T I O N ....................... 15 STATEMENT OF THE PROBLEM . . II. REVIEW OF THE L I T E R A T U R E ....................... 16 DEFINING THE REALMS OF COMPREHENSIVE SCHOOL HEALTH EDUCATION: LAWS AND POLICIES P E R ­ TAINING TO COMPREHENSIVE SCHOOL HEALTH E D U C A T I O N ................................. 16 PREVIOUS STUDIES OF COMPREHENSIVE SCHOOL HEALTH EDUCATION ........................... 28 NEED FOR CURRENT R E S E A R C H .................. 33 PROGRAM PLANNING IN HEALTH EDUCATION . . . . 35 SELECTED HEALTH EDUCATION ISSUES ........... 37 ORGANIZATIONAL COMPONENTS OF A COMPREHENSIVE SCHOOL HEALTH EDUCATION PROGRAM ......... 42 HEALTH EDUCATION AS A MEANS OF EDUCATIONAL C H A N G E ...................................... 47 iv CHAPTER III. Page METHODS USED IN THE D I S S E R T A T I O N .......... 53 INTRODUCTION TO THE RESEARCHER ............. 53 CONDUCTING A REVIEW OF THE LITERATURE ... 56 .................... 58 HEALTH EDUCATION SURVEY Health Education Grant Proposal Why Public School Principals ......... 58 ............. 58 Instrumentation or Survey Construction . . 60 Data C o l l e c t i o n ........................ 64. Data A n a l y s i s .......................... 68 SELECTION OF A THESIS T O P I C ............. 71 NEGOTIATION OF ENTRY INTO THE FIELD . . . . IV. 75 U r b a n d a l e .............................. 76 H o b a r t ................................... 76 Botham C i t y ............................ 79 METHODS OF COLLECTING DATA AND RANGE OF DATA C O L L E C T E D ...................... 80 DATA A N A L Y S I S ............................ 84. RESULTS OF THE HEALTH EDUCATION SURVEY . . . . 87 ORGANIZATIONAL STRUCTURE .................... 89 CONTENT OF HEALTH INSTRUCTION 93 ............. PROFESSIONAL PREPARATION OF INSTRUCTORS METHODS OF INSTRUCTION . . ...................... 99 101 PRINCIPAL OPINIONS REGARDING PROGRAM I M P R O V E M E N T ..............................101 SUMMARY OF THE FINDINGS OF THE NON-RESPONDENT PHONE SURVEY ............. C O N C L U S I O N .................................. 105 v 104- CHAPTER ETHNOGRAPHIES OF THE THREE HEALTH PROGRAMS . . 108 MAIN ISSUES IN THE THREE S I T E S ......... 108 GENERAL OVERVIEW OF THE THREE SITES . . . . ANALYSIS AND NARRATIVE VIGNETTES OF HOBART HEALTH PROGRAM .................... 117 123 Description of the Setting . 1 ....... 124. The 3rd Grade C l a s s r o o m .............126 The 6th Grade C l a s s r o o m .............126 General Research Questions for Hobart Health Program ........................... 128 Questions, 3rd and 4-th Grade Foods for Health U n i t .................. 128 Questions, 6th Grade Growing Up Unit Why These Questions Were Chosen . . 128 . . . . 129 An Afternoon at the Advisory Board . . . . 139 A Day in the Life of a 3rd 14-6 Grader . . . . A Day at the K i t c h e n ................. . V. Page 151 Nutrition and You - C h o i c e ............163 The Human B o d y ......................... 167 A Day in the Life of a 6th Grader . . . . 173 A Human Being is B o r n ............... 178 Girl to W o m a n ........................ 188 Human Growth I I I ....................... 199 ADDITIONAL ANALYSIS OF THE HOBART HEALTH P R O G R A M ................................ 206 Organizational Structure .................. 206 Methods of Instruction .................... 207 vi CHAPTER V. (Cont'd.) - Page Behavioral Choice and Decision-Making . . 208 I s s u e s .........................................210 Paths Not T a k e n ............................. 215 SUMMARY .................... INTRODUCTION TO URBANDALE Urbandale School District 216 .................. 218 ................ 219 Dissemination of the Health Curriculum . . 220 Home Visitation by Student Nurses 222 . . . . Inservice Health Education ................ 223 Urbandale Research Questions 224. Description of the S e t t i n g ..................226 ............. A Day in the Life of a Kindergarten S t u d e n t .................................... 229 Learning How to Go to S c h o o l ................ 233 The Weekly R e a d e r ........................... 236 Raymond in the Health L e s s o n ................ 24.0 The Health L e s s o n ........................... 24-4. Inservice Education: Integration of School Health Services ............. Another Day in the 253 Health L e s s o n ...........258 Conclusion of Urbandale Findings ......... 262 INTRODUCTION TO BOTHAM C I T Y .................. 264 Description of the S e t t i n g .................. 265 Research Questions: Organizational Structure, Methods, Content ........... 268 Health Class in the Yellow Pod, An Open Classroom of K - 1 2 .........................270 CHAPTER Page V. (Cont *d .) Name the N u t r i e n t ............................ 279 Dental Health in Special Education, Grades 4 - 6 .................................. 288 Concluding Discussion on Botham City . . . VI. A COMPARISON OF PROGRAMS IN THE THREE SITES. . ORGANIZATIONAL STRUCTURE .................... 296 298 298 METHODS USED IN THE HEALTH P R O G R A M ........... 309 Methods of Instruction .................... 309 Methods Used for Inservice Education . . . 310 Additional Health Program Activities . . . 311 CONTENT OF HEALTH INSTRUCTION . . . . . . . 312 MAJOR BARRIERS TO IMPLEMENTATION AND MAJOR INNVOATIONS IN THE THREE HEALTH PROGRAMS . 314 Barriers .................................. 314 Innovations ......................... 316 ADDITIONAL FACTORS INFLUENCING HEALTH E D U C A T I O N .................................... 317 S U M M A R Y ........................................ 320 VII. CONCLUSIONS AND RECOMMENDATIONS ............. 322 ORGANIZATIONAL STRUCTURE .................... 322 HEALTH PROGRAM CONTENT ...................... 325 METHODS OF INSTRUCTION ...................... 327 PROFESSIONAL PREPARATION OF INSTRUCTORS 330 . . SELECTED HEALTH EDUCATION ISSUES.. .......... 330 RESEARCH METHODS FOR HEALTH EDUCATION 332 . . . S U M M A R Y ........................................ 336 A P P E N D I X ....................................................338 BIBLIOGRAPHY ............................................ viii 344 LIST OF TABLES Table 1. Page 4-th, 7th, and 10th Grade Health Education (MEAP) Test R e s u l t s ......................... 27 2. Part I of Survey Questions by Category . . . . 62 3. Schedule of Survey Procedures 67 4. Sources of Data C o l l e c t e d .................... 83 5. Survey Respondents . ............... 87 6. Organizational Structure Survey Results ... 90 7. Frequency Distribution of Health Education Content Areas ............................... 95 8. Content Responses of Health Education Survey . 97 9. Percent of Elementary Teachers with at Least Four Semester Hours of General Health E d u c a t i o n ............................. 99 10. ............... . . . . . Professional Preparation of Elementary Teachers ........................... . . . . . 100 Improvements Suggested by All Public School Principals . . . . . ......................... 103 Areas of Desired Assistance from Michigan Department of Education .................... 104 13. Non-Respondent Phone Survey 107 14* Comparison of Size for the Three Sites . . . . 118 15. Main Issues Investigated in Each Site . . . . 120 16. Components of Hobart's Health Education Organizational Structure .................... 136 11. 12. ................. 17. Botham City Health Topic Recommendations by Grade L e v e l ..................................284 18. Comparison of Organizational Structure for the Three Health Programs .................. ix 302 LIST OF FIGURES Figure Page 1. Nests of the Five Health Education Factors 2. Hobart 3rd and 6th grade c l a s s r o o m s ............ 127 3. Drawing of an E p i s i o t o m y ..........................182 A. Diagram of Urbandale Kindergarten Health Project ............................... 225 Urbandale Kindergarten Classroom .............. 227 .................. 267 5. 6 . Robin Hood School Structure 7. . . Ill Typical "Pod" at Robin Hood S c h o o l ...............267 8 . Organizational Charts of the Three Health Programs .................. x . . . . . 301 CHAPTER I THE PROBLEM STATEMENT OF THE PROBLEM Health education in Michigan public schools has been an overlooked and under-supported aspect of general edu­ cation throughout Michigan educational history. jority of public schools, In the ma­ comprehensive school health education is virtually non-existent, or totally inadequate to meet the rapidly expanding complex needs of today's children and youth. (Sliepcevich, 1965). One of the more important problems in health edu­ cation has been to reach a concensus on terminology. In 1972, the Journal of School Health published a report on Health Education Terminology. The following terms are defined in this dissertation using the Journal of School Health*s terminology. Health education. "A process with intellectual, psychological, and social dimensions relating to activities that increase the abilities of people to make informed de­ cisions affecting their personal family, and community well­ being. This process facilitates learning and behavioral change in both health personnel, and consumers, including children and youth."'*' ^■"Report of the 1972 Joint Committee on Health E d u ­ cation Terminology", Journal of School Hea lt h. (January 1974)» Comprehensive school health education program. "All the health opportunities affecting learning and behavior of children and youth in the total school health curriculum. The health content for comprehensive school health education includes such concepts as: quality of life, the human or­ ganism (growth and development), nutrition, safety, disease control; including venereal disease, drug use and abuse; including alcohol and tobacco, family health or family life education (human sexuality), mental health, consumer health, personal health practices, health careers, and community health including environmental health factors and ecology." 2 The Michigan Board of Education has also been in­ volved in the clarification of terminology. In 1980, the Board published a position paper on comprehensive school health education which defined a school health program as: School health prog ra m. "The composite of learning activities and experiences within the school setting that are directed toward developing an environment that promotes and protects the health of the students and the school 3 personnel." Health education is often regarded by the public school curriculum committees as a fringe subject on a similar 2 "Report of the 1972 Joint Committee on Health Edu ­ cation Terminology", Journal of School Health, (Januarv 1974.). 33-37. 3 Michigan State Board of Education. "Position Paper on Michigan Comprehensive School Health Education", (Lansing, Mi: Michigan Department of Education, 1980) 5. status as music or art, and does not consider health an im ­ portant priority. The Michigan Department of Education has tried to improve this lack of emphasis on health education by making health education one of the Michigan Essential Skills for grades K-9» and in the Life Role Competencies for grades 10-12 (MDE, 1980). Despite this emphasis, health education continues to be fragmented and inconsistent. There are several important issues in health edu­ cation involving content, methods of instruction, quali­ fications of instructors, appropriate age of students re ­ ceiving certain information, budget cutbacks, limited en­ rollments, etc., which this thesis will address. The following is a summary of some of the more important issues. 1. Health is defined by the World Health Organization as ,Ta state of physical, psychological and social well-being."^ However, the concept of health also needs to be understood in terms of behavioral choices that an individual makes which affect her/his health condition. The health oriented (positive) behaviors and the anti-health (negative) behaviors must be examined in view of their physical, emotional and social results. 2. The teaching of health education may or may not influence or affect the decision-making and ultimate behavior choice of the students. The presentation of health education information to students does not guarantee that the students will choose health-oriented or positive health behaviors. ^"World Health Organization, 1967, Geneva, Switzerland. 4 3. Health education tends to teach information about anti-health options; ie., smoking and drug abuse, and perhaps may be addressing only the symptoms and not the causes of the problems. The motivation for engaging in anti-health behaviors may be based more on an in­ dividual’s social role models, need for attention, peer pressure, etc. Young women especially, get messages from childhood through adulthood that they need to a p p e a r . and/or behave in certain ways if they are to be considered attractive and accepted. 4. (Daly, 1978). The content of most K -6 health education pro­ grams contains typical health issues such as nutrition, safety, etc. However, the non-typical social issues which affect students' lives also need to be included. Some of these issues are: o o o o o o o o 5. moving and mobility--pulling up roots drugs, crime, and violence loss and grief--death, disappointment contradictory health messages in the media, stores, etc. teaching of respect for others who are different, handicapped, etc. new brothers and sisters, new roles, competition, etc. parents' unemployment domestic assault, child abuse Health education is being taught mostly by instructors who do not have any professional preparation in health education. (Sophiea, 1981). In grades K-6 , four semester hours of health education are recommended by the Michigan Department of education before instructors are qualified to teach health. Although the Michigan 5 Department of Education has made this recommendation, most of the Michigan colleges and universities do not require health education as a prerequisite for teacher certifi­ cation. As a result, very few instructors have met this professional standard. Parallel to this issue is the additional dilemma of providing financial assistance to the public schools. The Michigan Department of Education sets the standards for comprehensive school health education, but has not provided any financial support to the local schools for its implementation or training. If these curricular changes are to be implemented statewide, there needs to be some sort of financial assistance available to the local schools to meet the costs of health education materials, teacher training, and program implementation and maintenance. Without some sort of financial com­ pensation, local school districts are unlikely to invest the time, money, and effort for development and maintenance of acomprehensive school health 6. education program. Health .education has a different type of con­ tent from that of other public school subjects, in that community professionals, agencies, and organizations are involved in health promotion. Health education instruction needs to have community integration with outside resources such as nurses, physicians, public health personnel, plus health agencies such as March of Dimes, etc. 7. The diagnostic tests used for identifying 6 students with developmental lags or in need of special attention may actually be an unreliable and invalid in­ strument, that is culturally biased. The labelling of these students as slow, or remedial, often affects their self-esteem and self-concepts in negative ways. These students begin to learn that they will receive more at­ tention if they are not achieving the same level as their classmates. Health education needs to be more sensitive to these cultural misinterpretations. 8. The Michigan Department of Education uses test items based upon the objectives found in the Essential Performance Objectives for Health Education in Michigan to determine whether the students in 4-th, 7th, and 10th grades are receiving and. learning health education concepts. These objectives may or may not be accurately reflecting what is being learned by the students in their health education classes. Alternative ways of describing the content being taught in health education courses is necessary. Perhaps a more descriptive narrative of the actual content of the classes could help to neutralize some of the fears and inappropriate accusations which are directed at certain content areas of health education (such as sex education). 9. Teaching of reproductive health education is felt by some individuals to be immoral and to be an appropriate content for public school education. in­ Others argue however, that not teaching reproductive health encourages ignorance and experimentation, and also increases the likelihood of unwanted pregnancy. The omission of re­ productive health education in the health education curri­ culum is one example of a general educational phenomenon that occurs in several academic subjects where fundamental value-laden topics are omitted from the curriculum. The omission of controversial issues may serve to protect the schools from political conflict, but it comes at the cost of student awareness and ability to comprehend critical issues affecting their lives. 10. Program criteria for comprehensive school health education have not been approved by the Michigan Department of Education. The Department is now in the process of developing these criteria. Research is needed to contribute to the development of these program criteria so that the criteria are defined in ways that can be applied to actual school settings. 11. The methods in which health education is taught can be as important as the content itself. A description of the different methods used to teach health education can contribute to the literature and development of comprehensive school health education programs. Resolution of these important issues will be possible only if there is valid information and descriptions provided on the practice of comprehensive school health education in Michigan public schools. This information needs to go beyond the simple survey of health education program criteria, especially when the results are being used to evaluate educational policies. A more detailed analysis of the implementation of this criteria is needed to give a realistic understanding of the actual status of comprehensive school health education. Accordingly, this dissertation uses two different methods to provide understanding about health education. One method includes a statewide health education survey of all public school principals in Michigan. The results of this survey give a broad overview of health education ongoing in Michigan. The second method involves par­ ticipant observation of three health education programs that have implemented the health education program criteria in varying degrees. These three participant observation studies serve the purpose of illustrating how three different programs have implemented the health education program criteria. The broad overview provided by the statewide health education survey, and the more focused analysis provided by the participant observation of the three health programs serve to complement each other and provide a more thorough examination of comprehensive school health education in Michigan public schools. In view of the severe budget cutbacks and decreasing enrollments now faced by public schools in Michigan, des­ criptive research that sheds light on the current status of comprehensive school health education is essential for development and allocation of public resources. Changes within educational priorities are rapidly taking place. These changes must be identified and documented so that the needs of the students, the school personnel, and the community at large can be addressed. In May, 1981, Ms. Muriel VanPatten, Acting Director of School Program Services, Mighigan Department of Education, addressed the Michigan School Health Association at their annual meeting in Southfield, Michigan. In her speech she said: I believe the State Board of Education should take on the responsibility of defining statewide program standards. We can influence quality of programs across the state by: 1. Establishing the program standards. 2. Providing a needs assessment mechanism. 3. Preparing educators and seeing to it that trained people are available to assist the local school staff. The standards should be based both on research and good judgment and experienced (professional) wisdom. The standards must be reasonable and reachable, they must provide a level of quality possible for all schools to achieve, and a level that Michigan citizens and educators believe should be a c h i e v e d . 5 The program criteria for comprehensive school health education are necessary to provide a level of quality and a standard by which comprehensive school health education programs can be measured. A standard document developed and now used by the Michigan Department of Education tests student performance in health education based on Essential Performance Objectives for Health Education in Michigan. This document was made available to local school districts ^Michigan State Board of Education, 1980. 10 by the Michigan Department of Education in 1974. (it was then termed Minimal Performance Objectives). In 1979» a statewide sample of 4-th, 7th, and 10th grade students were tested on their achievement of the Essential Performance Objectives. It was found that the overall attainment for 4-th grade students was the highest of all three grade levels with a 70$ achievement. The average attainment for 7th graders was 4-7$, and a further decline was achieved by the 10th graders, who achieved only U5% on the Essential Performance Objectives. These Essential Objectives are used by the Michigan Department of Education and various other organizations involved in school health as a standard for comprehensive school health education. However, these objectives may or may not reflect what the students are actually learning in their health education courses. The reliability and validity of the objective testing of the Essential Objectives is beyond the scope of this study. However, one aspect of this dissertation will be to investigate the major reasons for such poor achievement of these objectives, and whether the health education being provided in the schools reflects the Essential Objectives for Health Education in Michigan. PURPOSE OF THE STUDY The purpose of this study is to provide valid in­ formation regarding the current status of health education 11 being taught in Michigan public schools and to investigate the program criteria on which identified comprehensive school health education programs are based. These program criteria will focus on the K -6 aspects of the comprehensive school health education programs. PROCEDURES USED IN THE STUDY Two main procedures were used to describe the current status of comprehensive school health education in Michigan and to investigate the program criteria on which identified school health education is based. The first procedure was a statewide survey that was sent out to all public school principals in Michigan (ap­ proximately 3,766). The findings of this survey provide a global understanding of what the current status of compre­ hensive school health education is in Michigan public schools. Also derived from the survey was a list of high quality health education programs, three of which were selected for an indepth study using participant observation of the health program criteria. The second procedure was a participant observation study of three target schools (identified by the statewide survey) that assessed the program criteria being used in the actual teaching of the comprehensive school health education program. These three health education programs were then compared to each other on a number of criteria that comprised their health education programs. 12 These procedures were chosen to answer a number of problems that are characteristic of single method studies of educational programs. The health education survey allows a quantitative analysis of identified health education program criteria that are reported to be provided by the public school principals. This information allows a statewide frequency count on several health education program criteria. In addition, the survey also asks the principals to answer what they believe are the major improvements needed for their health education program. Although the survey is effective in providing an overview of the Michigan health education program status, it does not allow an indepth or qualitative analysis of what is actually happening within a comprehensive health education program. A qualitative par­ ticipant observation investigation of three different health programs was conducted to give perspective on the inside functions of a health program. This qualitative research method gives insight into the roles and obligations of the various "actors” who pro­ vide and contribute to the health education program, as well as describing the program components that they must administer. An indepth qualitative study often has the limi­ tations of not being characteristic of a typical health education program. By selecting three different health education programs each with a different program emphasis, I have tried to include some of the possible variations that occur within comprehensive school health education programs. By conducting both a quantitative health education survey and a qualitative indepth participant observation study of three different health programs, I have tried to overcome several of the limitations experienced by the use of only one method. LIMITATIONS OF THE STUDY One limitation of this study is the impossibility of verifying the health education survey results. Surveys tend to inflate the frequency of desired responses (Hays 1973 Borg and Gall, 1963), as the principals at schools that did not have a health education program tend either not to res­ pond, or to give inaccurate responses on the survey. A phone survey of non-respondents was conducted to estimate the validity of the respondent population. However, these measures do not correct inaccurate survey responses. A second limitation in the participant observations of health education classrooms involves the nature of the volunteer teacher who has been willing to allow observation in the classroom. The teacher who volunteers to participate in collaborative research such as participant observation may not be representative of the general health education teacher population. The observed health education programs were selected because of their unusually high quality based on the survey results. Perhaps the teachers who volunteered to allow observations in their classrooms are also of an unusually high quality. This factor could not be assessed in the present study. A third limitation is the ability of this study to provide the total picture of comprehensive school health education ongoing in Michigan. Participant observation study of three K-6 health education programs and a statewide survey of school principals can provide only a limited perspective of the total picture of comprehensive school health education in Michigan. The total picture of com­ prehensive school health education in Michigan is beyond the scope of this study. However, this study does provide valuable information and a framework on which future research in health education can be based. 15 DESCRIPTION OF THE CONTENTS OF THE DISSERTATION The dissertation that follows consists of six chapters. There is a chapter on the review of the current literature, followed by a chapter on the methods used to conduct the research. The findings of the dissertation are divided into three chapters. One chapter gives the results of the Statewide Health Education Survey. A second findings chapter contains the ethnographies and commentaries of each of the three sites studied using the participant observation method. The third findings chapter gives a comparison of these three sites based on a number of health education program criteria as well as an assessment of the major strengths and barriers found in each program. The final chapter provides the reader with the con­ clusions and recommendations for continued research and program development in comprehensive school health education. CHAPTER II REVIEW OF THE LITERATURE DEFINING THE REALMS OF COMPREHENSIVE SCHOOL HEALTH EDUCATION: LAWS AND POLICIES PERTAINING TO COMPREHENSIVE SCHOOL HEALTH EDUCATION Comprehensive school health education has been in the process of becoming an institutionalized goal of Michigan general education for several years. Michigan Comprehensive Health Education had its first formal definition in 1969 with the passage of Public Act 226. This Act gave the Michigan Department of Education (hereafter referred to as MDE) the authority to promote, support, and conduct critical health problems and educational programs. The Act states that such programs "shall include, but not be limited to, the following topics as the basis for comprehensive health education in Michigan public schools: drugs, narcotics, alcohol, tobacco, mental health, dental health, vision care, nutrition, disease prevention and control, accident prevention and related safety topics".^ Additional laws that have affected Comprehensive School Health Education is the School Code of 1976 of Michigan Compiled Laws (MCL). This law has several sections that affect Comprehensive School Health Education. Section 1169 (MCL 380.1169) mandates that the principal modes by ■^Public Act 226 of the Public Acts of 1969, Michigan Compiled L a w s . Lansing, Mi. 16 17 which dangerous communicable diseases are spread and best methods for the restriction and prevention of these diseases 2 shall be taught in every public school in this state. Communicable diseases include syphilis, gonorrhea, and 3 chancroid. Section 1170, (MCL 380.1170) mandates instruction be given in physiology and hygiene with special reference to substance abuse, including the abusive use of tobacco, a l ­ cohol, and drugs, and their effect on the human system.^To date, this section is the only mandate of a specific con­ tent area in health education. Section 1170 mandates that Comprehensive School Health Education programs shall be d e ­ veloped as prescribed in Public Acts 226. An important clause of Section 1170 mandates that a child, upon the written statement of parent or guardian, shall be excused from attending classes where instruction is being given that is in conflict with her or his sincerely held religious beliefs. This clause allows for students to be excused from any health education class (among other subjects) if the parents feel that it conflicts with their religious beliefs. The definition of sex education is also defined in Section 1501 of the School Code of 1976. It defines sex 2Section 1169 of the School Code of 19 76 , (MCL 380.1169)» Lansing, Mi. 3 Section 151 of the "Venereal Diseases Act", (MCL 329.151), Lansing, Mi. ^Section 1170 of the School Code of 19 7 6 , (MCL 380.1170), Lansing, Mi. 18 education as "the preparation for personal relationships between the sexes by providing appropriate educational opportunities designed to help a person develop understanding, acceptance, respect, and trust for herself/himself, or others. Sex education includes the knowledge of physical, emotional, and social growth and maturation and understanding of the individual needs. It involves an examination of m e n s ’ and womens' roles in society, how they relate and react to supplement each other, the responsibilities of each toward the other throughout life, and the development of responsible use of human sexuality as a positive and creative force. This definition of sex education is extremely broad. It includes the topics of sex roles, family relationships, emotional and mental health, growth and development, and human sexuality. Under this definition of sex education, it is quite probable that sex education is taught in a variety of educational subjects, and is not limited to health education. Other aspects of the School Health Code of 1976 pertaining to Comprehensive Health are: Section 1502 states that health education and physical education shall be established and provided in all £ Michigan public schools. ^Secti.on 1501 of the School Code of 1976 (MCL 380.1501), Lansing, Mi. ^Section 1502 of the School Code of 1976 (MCL 380.1502), Lansing, Mi. 19 Section 1502 mandates that school districts offering a course in health education or physical education shall 7 engage qualified instructors for that instruction. Section 1506 specifies that a program of instruction in reproductive health shall be supervised by a registered physician, nurse, or other person certified by the State Board as qualified. Section 1506 also states that upon the written request of a pupil or the pupil's parent or guardian, a pupil shall be excused without penalty or loss of academic credit, from attending classes in which the subject of g reproductive health is under discussion. Section 1507 states that a board of a school dis­ trict may engage qualified instructors and provide facilities and equipment for instruction in sex education, including family planning, human sexuality, and the emotional, physical, psychological, hygienic, aspects of family life. economic, and social Instruction may also include the subjects of reproductive health and the recognition, prevention, and treatment of venereal disease. There are six main stipulations on Section 1507. 1. The class shall be elective and not required for graduation. 2. The pupil shall not be enrolled in a class in ^Section 1503 of the School Code of 1976 (MCL 380.1503), Lansing, Mi. ^Section 1506 of the School Code of 1976 (MCL 380.1506), Lansing, Mi. 20 which the subjects of family planning or reproductive health are discussed unless the pupil's parent or guardian is n o ­ tified in advance of the course content and is given prior opportunity to review the materials to be used in the course, and is notified in advance of her/his right to have the pupil excused from the class. The State Board shall determine the form and content of the notice required. 3. Upon the written request of a pupil or pupil's parent or guardian, a pupil shall be excused without academic penalty. 4. A school district that provides a class thus described shall offer the instruction by teachers qualified to teach health education. A school district shall not offer this instruction unless an advisory board is established by the district board to periodically review the materials and methods of instruction used, and to make recommendations to the district regarding changes in the materials or methods. The advisory board shall consist of parents having children attending the district's schools, pupils in the district's schools, educators, local clergy, and community health professionals. 5. As used in 1507 and 1508, "Family Planning" means the use of a range of methods of fertility regulation to help individuals or couples avoid unwanted pregnancies, bring about wanted births, regulate the intervals between preg­ nancies, and to plan the time at which births occur in relation to the age of the parents. It may include a study 21 of fetology, and marital and genetic information. Clinical abortion shall not be taught as a method of family planning, nor shall abortion be taught as a method of reproductive health. 6. A person shall not dispense or otherwise distri9 bute in a public school a family planning drug or device. Section 1508 of the School Code of 1976 states that the State Board shall: 1. Aid in the establishment of educational programs designed to provide pupils in elementary and secondary schools, institutions of higher education, and adult education programs, with wholesome and comprehensive education and instruction in sex education. 2. Establish a library of motion pictures, tapes, literature, and other educational materials concerning sex education, available to school districts authorized to receive the materials under rules of the State Board. 3. Aid in the establishment of educational programs within colleges and universities of the state, and inservice programs for instruction of teachers and related personnel to enable them to conduct effective classes in sex education. 4. Recommend and provide leadership for sex education instruction established by school districts, guidelines for family planning information. q Section 1507 of School Code of 1976 (MCL 380.1507), Lansing, Mi. including 22 5. Establish guidelines and may review and r e­ commend materials to be used in teaching family planning, reproductive health, and the recognition, prevention, and treatment of venereal disease. The guidelines shall be formulated in cooperation with the Departments of Public Health, Mental Health, and State Department of Social Services. A school district that provides instruction as permitted in Section 1507 may adopt the guidelines estab­ lished by the State Board, or shall establish its own guidelines in cooperation with its Intermediate School District, and its County or District Department of Public Health.10 Section 1531 of the School Code of 1976 states that the State Board shall determine the requirements for and issue all licenses and certificates for teachers, and the requirements for and endorsement of teachers as qualified counselors in the public schools of the state.11 The State Board shall certify as qualified the supervisors required in Section 1506. The State Board shall certify the teachers as qualified to teach the class described in Section 1507, based on the recommendations of a teacher's educational qualifications and experience, and upon any additional requirements the State Board considers necessary. 10Section 1508 of School Code of 1976 (MCL 380.1508), Lansing, Mi. 11Section 1531 of School Health Code of 1976 (MCL 380.1531), Lansing, Mi. 23 The laws that have been enacted by the Michigan Legislature have encouraged the development of materials and policies that further define Comprehensive School Health Education. The most important document was the adoption, in 197.4, by the State Board of Education, of the Minimal Performance Objectives for Health Education in M ichigan. This document was a part of an accountability model that developed performance objectives for eight basic educational disciplines. The objectives address ten different topical areas in health that include the topical areas listed in Public Acts 226 of 1969. These ten topic areas are listed below with a descriptive summary of the possible contents m curriculum. 12 12 Taken in part from the Health Education Curricular Progression Chart prepared for the Primary School Health Curriculum Project, the School Health Curriculum Project, the Minimal Performance Objectives for Health Education in Michigan, and the Recommendations for Comprehensive School Health Education. 24 Topical Area Summary Disease Prevention and Control Study of factors contributing to the development of chronic, degenerative and communicable diseases and dis­ orders, methods for the detection, prevention, and/or control of cardio­ vascular disease, digestive and res­ piratory disorders, sexually trans­ mitted diseases, cancer, and other health problems. Personal Health Practices Development of positive health care habits, including grooming, physical fitness and other personal health habits that maintain the body and promote overall wellness. Nutrition Sources of the principal nutrients, function of food in meeting body needs, essential components of a balanced diet, significance of eating a wide range of foods, potential in­ fluence of food fads and fallacies on nutrition. Growth and Development Structure and function of the systems of the body, their interdependence and contribution to the health func­ tioning of the body as a whole, re ­ ciprocal relationships between growth and development. Family Health Exploration of the roles and inter­ a c ti on of individuals within the family life cycle, responsibility and pri­ vileges experienced by each family member, physical, mental and social changes anticipated for each person from birth to death, the family's responsibility for the health maturation and socialization of children. Emotional and Mental Health Ability to handle stress appropriately, to apply problem solving skills to the resolution of individual and family concerns, achievement of a positive self-concept that respects the rights of others to be different, and a c ­ ceptance of responsibility for her/his own health as well as for that of others. 25 Topical Area Summary Substance Use and Abuse Knowledge of the effects which drugs and other substances have on the body, the ability to distinguish between substance use facts and fallacies, knowledge of possible contributing causes to drug dependency, drug pre­ vention strategies, such as decision­ making and coping with peer pressure. Consumer Health Study of forces influencing indi­ viduals in the selection of health information, products, and services, evaluation of commercial appeals m o ­ tivating the sale and purchase of health related products and services. Safety Methods of the identification and elimination of hazardous conditions or situations, rules for safe living in home, school, and community, pat­ terns of behavior promoting accident prevention, techniques for first aid and emergency care. Community Health Study of ways the individual can effectively contribute to the solution of community-wide health problems, functions of voluntary, official, professional and other health organizations. These Minimal Performance Objectives (now referred to as Essential Objectives) are currently being used as one of the content standards for Comprehensive School Health Education throughout Michigan. Other documents developed and/or adopted by the State Board of Education consist of the Guidelines for a Compre­ hensive School Health Education Program, Essential Skills, (1979); Michigan Program Criteria for Essential Skills Education, Role Competencies, (1979); Michigan (still in draft); Michigan Life (1980); State Board of Education Position 26 Statement Regarding Comprehensive School Health Program, (1980); Support Materials for Health Education, (1980). All of these documents support and/or apply the definitions of comprehensive school health education contained in the Essential Performance Objectives for Health Education in Michigan. Other organizations in Michigan have also developed policies and/or programs that define comprehensive school health education. The main organization addressing Compre­ hensive School Health in Michigan is the Michigan School Health Association (MSHA). In 1981, the MSHA adopted re­ cognition standards for the identification of Comprehensive School Health Education models. These standards require that (l) the Comprehensive School Health Education model meets the established Minimal Performance Objectives for Health Education in Michigan (Essential Objectives), (2) and/ or be based on the Health Related Michigan Life Role Com­ petencies, (3) have potential to become part of a Compre­ hensive School Health Education program, (/.) follow the state guidelines for Comprehensive School Health Education. The recognition standards address the goals and objectives of the models, methods/material resources, evaluation, content and management. The Michigan School Health Association has also pub­ lished a document entitled 1979-80 Michigan Educational Assessment Program Health Education Interpretive R e p o r t . This publication analyzes the results of a statewide testing 27 of Health Education Objectives under the Michigan Education Assessment Program (MEAP). The results of this assessment showed that 4-th, 7th, and 10th graders in Michigan public schools have poor attainment of the health education ob­ jectives tested. The following table indicates the pe r ­ centage of 4-th, 7th, and 10th grade objective attainment for the ten topic areas of health education. Table 1. 4-th, 7th, and 10th Grade Health Education (MEAP) Test Results 4th 7th 10th Disease Prevention and Control 69.8# 56.2# 52 .3# Personal Health Practices 62.0 52.6 56 .1 Nutrition 54.0 24.0 21 .5 Growth and Development 66.0 35.6 33 .7 Family Health 77.3 64.6 53 .6 Emotional and Mental Health 81.2 64.2 49 .1 Substance Use and Abuse 74.5 63.1 36 .5 Consumer Health 75.7 49.7 48 .4 Safety 77.1 40.1 57 .5 Community Health 65.6 24.3 37 .1 One of the most interesting findings that can be seen in the table is that as the grade level increases, the attainment of objectives in the same topic area generally decreases. 28 There are many, reasons why the results of the Michigan Educational Assessment Program tests for Health Education have been so poor. One reason may be that the students simply are not learning comprehensive health edu­ cation in Michigan public schools. Another reason may be that the Michigan Educational Assessment Program Health Education tests being given to the students are not measuring what the students are learning. The students may be learning health education concepts, but are not able to apply these concepts to the health education objective tests used in the Michigan Educational Assessment Program (MEAP). One of the purposes of this research is to investi­ gate why these test results may be so poor, and to answer the question "What are the students actually learning in their health education classes?" Other organizations that have addressed Comprehensive School Health Education are the Statewide Health Coordinating Council with staff assistance from the Office of Health and Medical Affairs, which have combined efforts to prepare the State Health Plan. 1980-81. The State Health Plan addresses various health topics, such as heart disease, cancer, health promotion, and the identification of a specific role for school health education. PREVIOUS STUDIES OF COMPREHENSIVE SCHOOL HEALTH EDUCATION_________ Perhaps the most significant national study conducted to document the status of comprehensive school health 29 education was the School Health Education Study (SHES). This study was first supported by the Samuel Bronfman Foun­ dation of New York, and then later supported by the Minnesota Mining and Manufacturing Company (known as 3M Company). The School Health Education Study achieved two main objectives. First, the Study described the status of school health instruction in the United States public schools. Second, the Study described the health knowledge, health attitudes, and health practices of a wide sample of ele­ mentary and secondary students. sulted from this study. Several publications re­ Some of these publications are: Synthesis of Research in Selected Areas of Health Instruction, School Health Education Study: A Summary Report , and School Health Education: A Call to A c t i o n . The study consisted of a survey of 135 school dis­ tricts across the United States selected by the use of a multistage, stratified cluster sampling procedure. A total of 1,101 elementary schools containing 529>656 students from 38 states were represented in the study. had a return rate of the surveys. Elementary schools The findings of this study showed that most health instruction in elementary schools is integrated into the curriculums of other subjects. There were eight health education topics that were neglected or not emphasized by the elementary schools. were: These topics consumer education, boy-girl relationships, health careers, international health activities, non-communicable 30 diseases, sex education, venereal diseases, and foot care. The only health education topics that were emphasized by the schools were accident prevention, nutrition, and exercise. cleanliness, dental health, (Sliepcevich, 1964.) . The School Health Education Study Director, Elena M. Sliepcevich, stated that in a majority of public schools, health instruction is either virtually non-existent or totally inadequate to serve the needs of a rapidly expanding, increasingly complex society. 13 Some of the recommendations from the School Health Education Study are that local school systems or states should do an evaluation study of their school health edu­ cation programs that includes a critical appraisal of pro­ fessional preparation of instructors, teaching effectiveness, inservice allotment, omission of content areas, policies regarding controversial health topics, instructional methods and teaching approaches, grade level appropriateness, com­ munity organization, and parent education. Other recommendations suggest that communities pa r­ ticipate in the health education program. The health program should be linked with school health services and a building health coordinator should be appointed. Graduate schools need to address health education preparation of instructors. Another national study on Comprehensive School Health Education was conducted in 1981 by the Education Commission 13 Elena M. Sliepcevich, Study Director: School Health Education Study: A Call to Actio n. (New York: Samuel Bronfman Foundation, 19o5) p"I 8"! 31 of the States. The purpose of this study was to document the state level support for activities in school health. This study found that thirty-seven states' and District of Columbia Boards of Education have addressed school health education in a variety of ways including policy or position statements, resolutions, guidelines, a d ­ ministrative regulations or bylaws. Twenty-four states r e ­ quire a definite amount of health instruction to graduate, and forty-one states offer health certification for health teachers at secondary level. Forty-seven states have a health education coordinator, and thirty-four states and the District of Columbia have published health education curri­ culum and planning guides. (Education Commission of the States, 1982). There have been several studies related to Compre­ hensive School Health Education in Michigan. A study by Frank H. Myers, in 1969, (Myers, 1969) assessed the features and patterns of school health edu­ cation in Michigan junior and senior high schools. One of the recommendations Myers made was that a health education study on the current status of health education should be conducted at the K-6 level of education in Michigan. Myers also recommended that schools should appraise and evaluate their own health education programs in light of current goals and objectives of health education. An unpublished dissertation conducted by John A. Romas in 1976 (Romas, 1976) surveyed all the public school 32 superintendents in Michigan school districts. Romas found that Comprehensive School Health Education continues to be fragmented and inconsistent, offering little or few learning experiences for children and youth to examine crucial health issues affecting their lives. Romas found that health edu­ cation topics are usually integrated with other subjects and that there are no curriculum guidelines regulating what, when, or how health education should be taught. In most cases, when a separate health education course is offered, it is taught by an individual who lacks professional preparation in health education. This finding was later confirmed in a more recent study, conducted in 1981 by Kathleen Sophiea (Sophiea, 1981). Sophiea surveyed all teacher preparation institutions in Michigan with regard to their health education requirements for teacher certification. Sophiea found that 11% of the colleges required zero hours of professional preparation in health education for graduation, 8% required three hours or less, and U% required four to six hours. It may be noted that the Michigan Department of Education recommends that all elementary health instructors have at least four semester hours of professional preparation in general health education, Michigan Department of Education Teacher Competency Guidelines (draft document). These studies all point to the conclusion that com- ■ prehensive health education lacks competent instructors, and a sense of educational priority in Michigan public schools. 33 These studies also have several limitations. The most important limitation in both the School Health Education Study and the Romas Study is that they were completed in 1969 and 197U respectively--more than fifteen and nine years ago. Educational programs and values can change dramatically in a short time, and a more recent assessment of the current status of Comprehensive School Health Education is needed. Also, with the recent decline in economic prosperity in the State of Michigan and the resultant budget cutbacks, educational programs have had to curtail their expenditures. Health education, along with other curriculum subjects, has been affected by these economic factors. Although the Romas Study had a high return rate, a survey of the superintendents may not reveal as specific health program information as is possible from a school principal or a health education instructor. NEED FOR CURRENT RESEARCH A need for a study that describes the current status of Comprehensive School Health Education has been called for by a number of agencies and organizations concerned with school health. The Michigan School Health Association, Michigan Department of Public Health, Michigan Health Council, and the Michigan Department of Education have all worked together to propose the statewide health education survey that was conducted as a part of this dissertation. This statewide health education survey uses the public school 34principal as the key respondent. It was felt that the public school principals would be sufficiently close to the health education to give specifics about the health education program content. The health education survey also offers the prin­ cipals an opportunity to voice their concerns and opinions regarding the improvement of Comprehensive School Health Education in their district. The Health Education Survey does have several limi­ tations. Some of these limitations are inherent in the pr o­ cesses of survey research. Problems such as second-guessing the researcher, and the distortion of reality by subjects are often unintended consequences of survey research (Argy ri s, n.d.). A quantitative study such as the health education survey provides a reliable method of data collection. How­ ever, the health education survey cannot give any reliable information on the roles of individuals within a health education program. Quantitative research continues to pay insufficient attention to individuals who comprise social settings, and instead, puts undue emphasis on the effects of the system and its capacity to shape behavior. It is abundantly clear that the acts of individuals have a great role in shaping the system (Swartz and Jacobs, 1979). To understand the processes that comprise a health education program, the researcher must get close to the people whom (s)he studies, and (s)he can best understand 35 their actions when observed from within the natural ongoing environment (Schatzman and Strauss, 1973). In the school health education literature, there is a shortage of detailed research about the processes and relationships that allow a health education program to function. To answer this void in qualitative health edu­ cation research, this study has combined the methods of quantitative survey research with qualitative participant observation research. The purpose of these combined methods is to maximize discovery of the structure and functions of a health education program. PROGRAM PLANNING IN HEALTH EDUCATION One of the most significant frameworks for health education program planning is the PRECEDE"^ framework sug­ gested by Green, Kreuter, Deeds, and Partridge in their book Health Education Planning: A Diagnostic Approach. The authors describe a process by which to conduct five diag­ nostic assessments: life concerns, etiologies, (1) a social diagnosis or assessment of (2) an epidemiological diagnosis to assess (3) a behavioral diagnosis to assess relevant health behaviors, (l) an educational diagnosis to assess the causes of health behaviors, and (5) an administrative diagnosis that assesses organizational capacities. Each of these factors are assessed as to their importance and ^ P R E C E D E is an acronym for predisposing, reinforcing and enabling causes in educational diagnosis and evaluation. 36 changeability, followed by a selection of targets that can most readily be changed. The PRECEDE framework has been applied to anticipate the outcomes of school health education programs in order to plan program activities more effectively. (Green, Kreuter, Deeds, and Partridge, 1980). Program planning in health education is a very com­ plex process. Depending on the goals and directions of the local school district, health education programs may vary considerably in their overall organizational structure. One of the first steps in establishing a health education pro­ gram is to have the school board develop an overall policy of school health (Anderson and Creswell, 1976). Other steps that need to be taken are to organize a health education steering committee and/or advisory board to assess the local status of the school district's comprehensive school health education, to generate program objectives and ideas, and to implement the program and evaluate program progress and outcomes (National Parent Teacher Association, (NPTA) n.d.). In Michigan, there is no reason to "reinvent the wheel" or to recreate a new health education curriculum. Model health education programs that have been validated by the Michigan Department of Education and recognized as being comprehensive by the Michigan School Health Association are available for any school district to adopt or adapt for their own school health program. Information regarding these model health programs may be obtained through contacting the 37 Michigan Department of Education. In a school district that has a high quality compre­ hensive school health program, it is often one individual, perhaps a teacher, or administrator who has played a key role in development and maintenance of the health education program (Bensley, 1970). The process of establishing and maintaining a comprehensive school health program is often beset with problems and barriers. In most school districts, an influential administrator needs to be an advocate of Comprehensive School Health Education, if a program is to survive. An administrator who wants to improve school health in his district needs to orientate himself, the faculty, and school employees in the descriptions of what a Comprehensive School Health Education program is, and why such a program is warranted. The administrator should have a "master plan" on how to implement school health, and should not permit ob­ jecting minority groups to distort and impede program progress (Byrd, 1964.). This is not always an easy task. There are many issues and concepts taught as a part of Comprehensive School Health Education that certain groups find objectionable. SELECTED HEALTH EDUCATION ISSUES There is probably no other factor in the school's curriculum that influences a pupil's identity, values, attitudes, or habits as directly as health education (Kolacki, 1981). Some groups and/or parents find this influence quite threatening to their personal and/or pro­ fessional status. In an experimental study on child initiated care that teaches children health education con­ cepts, decision-making, and self-care, the parents became very concerned and threatened if their children became "un-child" like and began to look after themselves. When students became active participants in their own health and well-being, many adults became extremely discomforted (Lewis and Lewis, 1982). Perhaps this is because the parental role is usurped when the children begin to take responsibility for their own health care. Another reason is that much of the health education concepts taught to the students may contradict the behaviors, attitudes, habits, and values that are practiced in the home setting. For example, if a student learns that cigarette smoking can lead to lung cancer, and that the children of parents who smoke have an increased level of respiratory ailments, and (s)he has parents or adults in the house who smoke, the student is faced with a value discrepancy that may cause him to be at odds with the smoker, particularly if that student confronts the smoker and urges her/him to quit. Although this is a minor example, it points out how discomforting health education can be. However, this struggle may be necessary for social change to take place. Another point expressed by Lewis and Lewis is that children have very little power in the adult world. They are passive participants in activities for which they will be expected to assume responsibility without formal 39 training at some magical age. Children are undervalued by- adults and are perceived to be far less competent than they truly are (Lewis and Lewis, 1982). This issue of children’s competence is at the root of another vital and difficult issue facing comprehensive school health education. This is the issue of teaching re­ productive health education. certain religious groups) Some individuals, (particularly feel that teaching reproductive health is immoral and inappropriate for public school education. One perspective on reproductive health education suggests that if students learn reproductive health education, they will try sexual experimentation. This experimentation is suggested to increase unwanted pregnancies and venereal diseases. This sentiment is echoed by James Pawsey, who states "Despite the growing emphasis on the teaching of sex (reproductive health), the rate of abortions continues to increase, and small wonder, for if we teach our children German, can we be surprised when they practice it?" 15 An article by Donald Reid, Assistant Director of the Health Education Council in London, reviews the literature on reproductive health education and the causes of teenage pregnancies. Reid cites several authors who have studied the effects of reproductive health education on students. 15 Wo rk in g. Pawsey, James M. P. The Sex Education That I s n ’t (London Daily Mail, Au gu s t , 1980). 4-0 Reid classifies these effects into three categories: Effects on knowledge, effects on attitudes, and effects on behavior. The effects of reproductive health on knowledge show that there are short term knowledge gains (Rogers, 1974), et al, 1980), (Kapp, (Hoch, 1971); however, long term gains are minimal (McGuffin, 1980), (Zelnik and Kanter, 1977). The effects of reproductive health education on attitudes is reported to have a general liberalizing effect on attitudes to sexuality, but without any accompanying effect on personal behavior (Scales, 1978; Kirby, 1980). Reproductive health serves to reduce embarrassment (Watson and Rogers, 1980), and does not influence students' personal permissiveness toward sexual activity (Hoch, 1971; Parcel and Luttman, 1981). The student's peers, family., and the media seem to dilute any attitudinal effect (Reid, 1982). The effects of behavior are more difficult to assess. Kirby conducted a study on college age students that showed reproductive health education showed no evidence of behavior change. "If college classes which are more explicit do not increase sexual behavior, then high school classes which are 16 more limited probably do not affect behavior either." One question regarding the teaching of reproductive health education and its consequences is, "Who is it that gets pregnant, and why didn't they use contraception?" 16 Kirby, D. The Effects of School Sex Education Programs: A R e v i e w , (Journal of School Health, December 1980), 559-563. 41 Answers to this question come from the female teenagers who have become pregnant. Apparently these teenage women have an increase in sexual activity and also have lingering puritanical values. It seems that teenagers are sufficiently liberated from these attitudes to give in to their emotions, but too guilty to admit this even to themselves (Reid, 1982). A study by the Francomes points out that couples with high ’’moral" principles may be at particular risk--they are especially unlikely to take precautions for sexual activity (Francomes, 1979). This is confirmed by (Kanter and Zelnik, 1973), who found that white United States church attenders were less likely to use contraception when sexually active, while black church attenders were more likely to use contraception (Kanter and Zelnik, 1973). Another study by Kanter and Zelnik in 1979 points out that teenage sexual activity often begins with a risky phase of episodic and unanticipated activity. It is es­ timated that 20$ of United States teenage pregnancies occur in the first month of sexual activity (JBF Associates, 1980). Reid concludes his article that there is no evidence to support the view that school sex (reproductive health) education encourages experimentation. Reid suggests that to encourage younger teenagers to defer sexual activity to an age of greater maturity and deeper, more loving relation­ ships, parents must have greater involvement, and reproduc­ tive health must teach specific techniques to resist social pressures (Reid, 1982). kz Warren McNab reiterates Reid's conclusion that parents and the school need to work in a collective effort to emphasize the positive and rewarding aspects of sexuality. McNab recognizes that the question is not whether children will get reproductive health education, but how and what kind they will receive. "Parents are the main sex educators, whether they do it well or badly. Silence and evasiveness are just as powerful teachers." 17 Continuous parent involvement and community pa r­ ticipation in development, implementation, and evaluation of comprehensive school health education can serve to pre­ vent many of the objections frequently experienced toward reproductive health education. ORGANIZATIONAL COMPONENTS OF A COMPREHENSIVE SCHOOL HEALTH EDUCATION PROGRAM____________ A comprehensive school health education program can prevent many problems from occurring, and can overcome many of the problems that do arise by having a very strong or­ ganizational structure. There are several components of a strong organizational structure. One important component is a school health education advisory board made up of parents, students, health professionals, teachers, adminis­ trators, clergy, and community business representatives. The advisory board can serve as a liaison between the com­ munity and the district school board, review curriculum 17 McNab, Warren. "Advocating Elementary Sex Education", Health Educati on, September-October, 1981, p.22. A3 materials, and make recommendations to the school board r e ­ garding program improvements. The importance of community participation through a health education advisory board is strongly recommended by Zimmerli in his article on "Organizational School Health Education Programs at the Local Level". Zimmerli identifies community control of a Comprehensive School Health Education Program a key feature in program survival. Communities need to accept ownership of health education curriculum, develop­ ment implementation, and evaluation if they are to success­ fully fight opposition to the program (Zimmerli, 1981). Another important organizational component is the integration of school health services into the overall health education program. Health personnel (ie., school nurses) already present in the school district may greatly contribute to the improvement of a comprehensive school health education program (Sliepcevich, 1965; Newman, 1982). In a Florida Department of Education model for managing Comprehensive School Health Education, the collabo­ ration of community resources is also seen as a high priority in the overall model. The Florida Department of Education recommends that a Comprehensive School Health Education that provides community coordination will have a cost-effective, reasonable, and rewarding investment. "Because so many people and organizations are concerned about school health education, there is a constant, almost overwhelming flow of new programs, instructional materials, teaching techniques u and research.... There must be a system for becoming aware of these resources, reviewing their appropriateness and 18 effectiveness, and distributing them to the classroom.” The local Comprehensive School Health Education Advisory Board can serve such a role. However, this Board also needs another very important organizational structural component: the Health Education Coordinator. A strong health education coordinator, who is res­ ponsible for the implementation, coordination, and main­ tenance of the program is seen as the most important factor in the survival of the program. Several'studies have in­ dicated that a strong local leader and administrative support are the most vital elements in successfully es­ tablishing an educational program. (Emrick et al., 1977; Carlson, 1964.; Pincus, 1974-* Berman and McLaughlin, 1975). The Education Commission of the States identified that the most important factor at the state level for supporting school health education is the professional preparation, leadership, and commitment of the education specialists. Thus, a Health Education Coordinator must have adequate professional preparation, be a strong leader, and be willing to endure considerable opposition and conflicts that arise. Perhaps one of the most important reinforcements for health education coordinators is to have an adequate 18 Tremor, M. A Model for Managing Comprehensive Health'Education Programs in Schools (draft) . (Tallahassee , Florida: Florida Department of Education, 1979). U5 peer support system. The opportunity to share experiences and concerns with other health education coordinators can be an excellent source of new ideas and strategies for health education program improvement. Establishing oneself within the professional, network of health educators can help to strengthen health education statewide as well as in the local school district. The Health Education Coordinator has a multitude of responsibilities. One of the most important functions of the health education coordinator is to provide health education inservice to the teachers responsible for health instruction. For teachers who have not had any professional preparation in health instruction, inservice education may be the only way for them to gain adequate preparation. In- service education can be provided using a number of different teaching methods. A study by Elaine Anderson used a pretest/ post-test design on 192 school teachers learning reproductive and environmental health. Anderson recommended the use of a criterion-referenced test procedure for inservice health instruction. Another inservice study by Eugene Kolacki recommended that when planning a health education inservice program, it is important to identify specific learning objectives for the teachers. Examples of objectives for health education in- service are increased knowledge, increased skills, increased understanding, and the stress and problems elementary students face. (Kolacki, 1981). 46 Another method of teaching health education inservice is the use of a team teaching approach, where a team of teachers take a leadership role and teach the health instruction to other teachers. This method, advocated by Alyson Taub and Vivian Clark, generated several inservice recommendations. The first recommendation is that more team training of elementary personnel is needed. Second, a follow-up of health education inservice is necessary to avoid diminished effectiveness. Third, intensive, long inservice sessions are seen as more effective than numerous short courses. The fourth recommendation is that there needs to be a system of con­ tinuous feedback by the participants during the training period. This provides insights for trainers about program effectiveness, and facilitates evaluation of the inservice program. Fifth, the authors also felt that a requirement of a financial investment from the participants served to assure commitment from the participants as well as help to fund the inservice program. Requiring a financial invest­ ment also served as a means for screening out participants who were not genuinely interested in learning. Finally, Taub and Clark recommended that it is im­ portant to communicate regularly with the school adminis­ trators about the health education inservice program. This communication serves to ensure continued support for the training efforts. (Taub and Clark, 1977). K1 HEALTH EDUCATION AS A MEANS OF EDUCATIONAL CHANGE___________ Introducing a comprehensive health education program in a school district that has not been previously provided, may be met with considerable opposition. Because of severe budget cutbacks and limited hours in the teaching day, many teachers are opposed to trying to fit health education into their overcrowded curriculums. hensive health education, The introduction of compre­ or any educational change, is a delicate process. The literature on social and educational change offers many suggestions that can apply toward health edu­ cation. When introducing an educational change, it is better to persuade and motivate teachers rather than to give them orders. Educational innovations are more successful when teachers want to implement the educational change. To do this, teachers need to be allowed and encouraged to pa r ­ ticipate in the discussion and decision-making process of the educational innovation. (Argyle, 1967). Sharing decision-making authority is more likely to reduce many of the problems that accompany an educational change. The teachers are the ones who ultimately must im ­ plement the changes, and without their input, or enthusiasm, the educational innovation may not have the desired conse­ quences. A study by Lewis and Lewis regarding implementation of a new health education program showed that only teachers who were enthusiastic in their implementation of the 4.8 educational innovation had a significant impact on their students. Teachers who were opposed to the educational change, or neutral, did not induce a significant impact on their students. (Lewis and Lewis, 1982). There are many barriers to educational change that may affect the implementation and stability of a compre­ hensive health education program. Some of these barriers are: overload of tasks expected from the teachers, failure to provide adequate assistance or materials, weak support from administration, school board, or community, conflicts and misunderstandings between central administration and health education program director, absence of monitoring or feedback, and absence of leadership. (Gross, 1979). There are several steps that can be taken to overcome or prevent these problems from occurring. Perhaps the most important prevention strategy is to conduct a detailed needs assessment of the present status of health eudcation being taught in the school district. (Herriott and Gross, 1979). This needs assessment should include specific in­ formation on the health problems and concerns of the local community, as well as a list of persons who are supportive of the proposed health education program. (Havelock, 1974-) . Other suggestions to overcome some of the barriers to educational innovation include: continuous evaluation and critique of program by program participants, sharing of power and decision-making between administration and faculty, working from within the existing mechanisms for educational change if at all possible, building a permanent mechanism for obtaining resource information from both the inside and outside of the school district, and maintaining a realistic future orientation. (Argyle, 1967; Herriott and Gross, 1979 Leavitt, 1965; Havelock, 1970). Even if the health education program has a sound organizational structure, and the teachers have had adequate health education professional preparation, and the content of the health education program is comprehensive, the stu­ dents still may not beable to apply health cepts to their personal lives. behaviors are very complex. The education con­ sources of health The mere teaching of health concepts does not constitute an effective health education program. The curriculum must also influence normative beliefs about matters other than long or short term physiological effects. This influence (McAlister, 1981). on normative beliefs has frequently been challenged by opponents of health education. The argument against health education is summarized in the Surgeon General's Report on Health Promotion and Disease Prevention: "One of the fears associated with health education is that it interferes with individual lifestyles. Actually, the goal of health education is just the opposite--to guarantee the individual’s freedom of choice regarding his own health by giving him the reliable information he needs to make decisions about how he wants to l i v e . " ^ To make these kinds of life decisions, the individual must he responsible for her/his own life choices. This element of personal responsibility for one's own decisions and behaviors is seen as an essential characteristic of comprehensive health education. (Sliepcevich, 1965). Health education must allow for complete autonomy of the individual to choose her/his own behavior. Assumption of responsibility for health behaviors, and increased awareness of disease prevention and control has changed the overall complexion of the health care industry. A knowledgeable public can participate more effectively in decisions that tend to be made by lawyers, physicians, and politicians concerning the health care system, and environmental factors that influence health. (Green, 1974-) • A more active role by the public in health-related matters has caused considerable disarray in the power struc­ ture of medical and health care industries. The public has become more concerned with its own health and wellbeing, as is evidenced by the unprecedented rise in self-health care initiatives. (The Boston W o m a n ’s Health Collective, 1976). The wisdom and knowledge which was previously held only by health and medical professionals now has to be 19 U. S. Department of Health, Education, and Welfare, Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention (background papers), Washington, D"I C. USGPO, 4-36, 1979. 51 shared more freely. (Ehrenreich and English, 1978). Some of this knowledge dissemination has resulted through the efforts of general health education. This struggle over health and medical knowledge has been ongoing for several hundred years. The advent of the consumer movement has made considerable progress in achieving a more active role by the public toward health-related concerns. However, this progress has only just begun to address itself to the multitude of health and medical problems facing today's society. One of the purposes of this dissertation is to describe how the elements of personal choice and res ­ ponsibility for personal and social health are being used as a primary focus for an effective comprehensive school health education program. This discussion of the current literature suggests that comprehensive school health education is fragmented and inconsistent, or non-existent in Michigan public schools. When health education is taught, it is taught by instructors who lack adequate professional preparation in health edu­ cation. School health education programs often lack a sound organizational structure for program implementation and operation. Several components for this organizational structure have been suggested such as a competent health education coordinator, a community advisory board, parent involvement, inservice education for health instructors, integration of school health services, continuous program evaluation, school board endorsement, and a health education 52 content that emphasizes decision-making and personal responsibility. This review of the literature also suggests that there is a need for an updated study of the current status of comprehensive school health education in Michigan public schools. This study needs to include both quantitative and qualitative research methods in order to give both a broad overview of comprehensive school health education being provided throughout Michigan, as well as a more focused analysis of the processes and functions of a health education program. CHAPTER III METHODS USED IN THE DISSERTATION The methods used to conduct this dissertation com­ bine a participant observation of three health education programs with a statewide health education survey. The statewide survey gives a general overview of the status of comprehensive school health education ongoing in Michigan public schools. The survey results give a statewide frequency count of several health education program components. The survey results were also used to identify three health education programs that were used as sites for a participant observation study. The participant observation portion focuses in on three health education programs identified by the survey. Each site contains a description of the organizational structure, program content, methods of instruction, and how various health education issues are incorporated into the health education program. INTRODUCTION TO THE RESEARCHER To help the reader better understand the methods that were used to conduct this research, I have included a brief description of myself, my goals, and some of my personal philosophies. 53 5U My relationship to health education and the field of medicine has been developing since my birth. Since my father is a physician, and my mother a nurse, the practices of medicine and the emphasis toward health has been a continuous focus during my life. I have learned through my own experience that my health and lifestyle were greatly determined by the b e ­ havioral and psychological choices I made on a daily basis. I further believe that o n e ’s ability to lead a meaningful life is in part, determined by being able to assume full ownership and responsibility for one's behavioral and psychological choices, and to be able to use whatever adversity and misfortune that happens as a means for growth and improved understanding. Coupled with the process of learning individual res ­ ponsibility is also the process of learning global re s­ ponsibility. The term "global responsibility" refers to the responsibility all persons have toward maintaining and im­ proving the quality of all forms of life on our planet. Our recognition of our inter-connectedness with all other forms of life and matter carries with it our need to be responsible for life's past, present, and future existence. Individual and global responsibility cannot be separated. All individuals are a part of the whole, and any individual's action or choice necessarily affects the actions and choices of others. Thus, the health a n d .lifestyle of any one individual affects the health and lifestyle of others. 55 The process of assuming both an individual and global responsibility for one's life choices presents a paradox. The choices I make to give purpose and meaning to my life may not always be beneficial to the global totality. Similarly, choices made by others for their personal life's course may be detrimental to the opportunities and needs of the global society. In addition, what may be meaningful for me in my life may not necessarily be meaningful to others. I cannot help anyone else find meaning or purpose in their life, nor can anyone make my life meaningful to me. This is something all persons must find for themselves. One question at this point may be, "If I cannot help another person to find meaning in his life, what then is the purpose of education?" To me, education, in particular health education, is a process that provides the student with infor­ mation, ideas, and directions that help the student to under­ stand his body, his changes, and the effects they have on others and on the environment. Health education can serve as an impetus for personal, social, and global change. However, it is up to each individual student to learn and apply this education toward his own life choices. The student must be ready to receive and make these changes; no instruction or teacher can do this for the student. There are many factors that affect the educational process, ie., social, cultural, physical, etc. environmental, There are also certain educational conditions that may facilitate this process. One of the 56 purposes of this dissertation is to articulate some of the ways in which health education can be, and have been, optimally enhanced. CONDUCTING A REVIEW OF THE LITERATURE My review of the literature has been an ongoing process since I began my dissertation research in 1980. I conducted preliminary searches in order to prepare my dissertation proposal, and to prepare my report on the Statewide Health Education Survey for the Michigan School Health Association. There are three main health education journals that I have used extensively: The Journal of School H ea l t h , Health Education, and the Health Education Quarterly. I also conducted both a manual and a computerized ERIC Search. For the ERIC Search, I matched the descriptor Health Education with the following five categories of descriptors: 1. Educational planning, school administration, educational policy, administration program development, program implementation, compre­ hensive programs, educational administration. 2. Decision-making skills, decision-making, con­ flict resolution, student responsibility, educational responsibility. 3. School-community relationship, school-community coordination, educational sociology, cooperative programs, school involvement. U. Educational methods, educational strategies, methods, educational technology, classroom techniques, psycho-educational methods, educational practices. 57 5. Sex education, family health, sex, contra­ ception, ethical instruction, venereal disease. Out of these five categories, I got forty-eight printed abstracts of the articles or documents. Out of these forty- eight documents, eighteen were found to be the most useful for the review of the literature chapter. Additional sources for the review of the literature chapter were found through the personal file of the Health Education Specialist at the Michigan Department of Education, The Social Science Citations Index, Dissertation Abstracts, Rea de r’s Guide to Periodicals, and my previous review of the literature conducted in preparation for my Comprehensive Examinations. HEALTH EDUCATION SURVEY HEALTH EDUCATION GRANT PROPOSAL In response to the lack of current information regarding the status of health education in Michigan public schools, the Michigan School Health Association and the Michigan Health Council combined their expertise in grant writing and school health education and submitted a grant to the W. K. Kellogg Foundation. Among other components in the grant, it was proposed that the Michigan School Health Association and Michigan Health Council would together con­ duct a statewide survey of comprehensive school health education. The W. K. Kellogg Foundation awarded a grant to the Michigan Health Council and Michigan School Health Association. The grant project was entitled the School Health Education Resources Coordination Program, or "SHERC". Mrs. Mardi DuShaw was named Project Director, and I was hired as Research Consultant. WHY PUBLIC SCHOOL PRINCIPALS? An obvious question at this point is why were public school principals selected as the individuals from whom school health education information could be gained? A past survey in 1976 conducted by John A. Romas surveyed all public school superintendents. for this study was quite high, 58 Although the return rate (90$), it was felt that the 59 superintendents w e r e n ’t close enough to the actual teaching of health education to know the specifics of program instruction. Health education instructors were also considered as candidates for the survey respondents, however, it was noted that health education instruction w a s n ’t always existent. The problem of who would fill out the survey, if there w e r e n ’t any health education instructors still remained. It was decided that the public school principals were the most likely candidates to be both existent and close enough to health education instruction to be knowledgeable of the specifics of the program. It was also felt that even i f ‘the principals were not knowledgeable about health edu­ cation instruction, the survey could serve as an impetus for further learning and investigation. This proved to be the case for several principals, who responded that they d i d n ’t know about the Minimal Performance Objectives for Health Education (now termed "Essential Performance Objectives"), and desired a copy. After the principals were selected to be the target respondents, the question still remained--how many prin­ cipals, if it should be a random sample, or simply survey all public school principals in the state. It was decided that the findings would be more reliable and valid if the entire public school principal population were surveyed. In order to better understand the results of the 60 survey, let's now take an indepth view of the survey as an instrument to obtain information on the status of Comprehensive School Health Education. INSTRUMENTATION OR SURVEY CONSTRUCTION The school health education survey originally con­ sisted of only one major part (referred to as Part I). Part I contains twenty-five YES/NO/NA questions, two questions asking for a percentage, one question asking the principals to fill in the number of minutes per week, and weeks per year of health instruction taught in grades 1-9* and one question asking for a checklist of health education content. Part I of the survey was constructed prior to my involvement in the SHERC project. When I was hired by the SHERC project, I was invited to respond to the survey, and make suggestions for its im­ provement. I recommended to the SHERC project that surveys tend to make subjects feel depersonalized, dependent upon the researcher,. (Argyris, submissive and nd.)f and sug­ gested giving the principals an opportunity to voice their opinions through some open-ended questions. I developed Part II, containing three open-ended questions in consul­ tation with a Michigan State University learning and evaluation professor, Dr. Walker Hill, and the health education specialist for the Michigan Department of Education, Dr. Wanda Jubb. .61 ' Part I of the survey assessed several different components of health instruction. The largest category of questions concerns the organizational structure of the health instruction. Questions such as: Is there a school health advisory board, is health education integrated into other subjects, have curriculum guides for grades K-9, that in­ clude the Minimal Performance Objectives (Essential O b ­ jectives), been developed by the teachers? Are school health services integrated into the total comprehensive health program? All attempt to assess how extensively the compre­ hensive health education program has been structured into the schools. A second category of questions inquired about the content of health instruction being taught. Questions such as: Do all teachers within a grade level follow the same curriculum? Does your school district have a plan/policy for first aid, and a specific checklist of the ten topic areas for Comprehensive School Health Education for each grade level. All request information about the content of health instruction being provided in the schools. Professional preparation of instructors and the building health coordinator make up another category of questions on Part I of the survey. Questions regarding health education inservice, and whether health instructors have had four semester hours of professional preparation in health education assess whether the health instructors have had adequate health education preparation. 62 Other categories of questions in Part I of the survey include questions on health instruction methodology, time allotment of health education, and a self-assessment of personal leadership in health program development. For a breakdown of Part I survey questions by category, see Table 2. Part I of Survey Questions by Category Table 2. Category of Questions Survey Questions (Part I) Organizational Structure 1, 2, 7 , 9, 13, 14, 15, 18, 19, 22, 23, 25, 26, 28, 29 Content 17, 20, 21, 24, 27, 28, 29 Professional Preparation 3, 4, 5 , 6, 8, 12 Methods 11 Time Allotment 16 Leadership 10 Part II of the health education survey attempts to give the principals an opportunity to give their opinions on certain aspects of health education in their school district. Question One asks whether they consider the Minimal Performance Objectives for Health Education applicable to their school district. If not, why not? This question is to assess whether the principals are aware of the Minimal Performance Objectives, and if they are, whether they can apply them to their school district. Question Two asks the principals what improvements 63 they felt could be made within their school district to enhance the development of a comprehensive health education program. Instead of just leaving the question wide open, we suggested five possible areas: needs assessment, inservice training, curriculum development, integration with community professionals, and a healthful school environment. These options were suggested in order to help the principals identify what a particular stage of development their school district’s health education program may be in. If they did not have any idea of their health education program status, a needs assessment would be a likely choice. If their pro­ gram was more developed, integration with community pro­ fessionals may be more appropriate. As we had hoped, prin­ cipals also stated their own improvements, independent of the suggested areas provided in the question. Question Three asks the principals whether they believed their school district would like assistance from the Michigan Department of Education on developing or ex­ panding a comprehensive health education program. in what areas? If so, The purpose of this question is to provide a basis for identifying schools that desire assistance to im­ prove or develop their health education programs, and allowed a follow-up effort to be structured for this attention. In addition, all principals were offered a copy of the Final Survey Report by checking a box on the survey. 64 DATA COLLECTION On March 10, 1981, the first draft of the questionnaire was completed and sent out to six school principals. These six principals were selected by the Michigan Department of Education Health Education Specialist because of their known commitment toward improving compre­ hensive school health education. Enclosed with the survey was a cover letter asking the principals to evaluate the questionnaire and make suggestions for improvements. These suggestions were then incorporated into a revised final version of the questionnaire. The SHERC project director and the Michigan Depart­ ment of Education Health Education Specialist both decided that the superintendents of all school districts should be contacted prior to the principals, to inform them about the purpose of the survey, and ask for their cooperation. On March 27, 1981, approximately 780 letters were sent to 100# of the public school superintendents throughout Michigan. See Appendix for a copy of the superintendents' letter. On April 2, 1981, health education surveys totaling 3,766 were sent out to 100# of all public school principals in Michigan. Accompanying the survey was a cover letter that explained the purpose of the survey and a request that they complete the questionnaire and return it to the Michigan School Health Association by April 24th. The cover letter also assured principals that with the exception of principals who indicate they would like assistance from the Michigan 65 Department of Education, all answers to the survey will be held in strictest confidence by the Michigan School Health Association. The principals were informed that statewide statistics resulting from the survey would be shared with the Michigan Department of Education, Michigan Department of Public Health, and any other interested school health groups. The letter also indicated that they could receive a copy of the final report by checking the box in page four of the survey. By the April 24th deadline, 790, or 20.8# of the surveys had been returned. To improve the return rate, follow-up letters with a duplicate copy of the survey were sent out to all non-respondent principals. The cover letters indicated that we had not received their survey, and to have accurate and meaningful statewide results, their survey r es­ ponse is needed. May 27, 1981. The final cut-off date was established as Although some surveys did continue to straggle in throughout the summer and fall, this deadline was needed in order to meet the July 1st deadline for the completion of a Final Report. By the May 27th final deadline, a total of 1,536, or 40.7# of the total public school principal population had returned the health education surveys. All mailings of the superintendent letters and the two sets of principal letters and surveys were conducted by myself. I also drafted the cover letters that were later approved by the SHERC Project Director. All address labels 66 of the superintendents and principals were obtained through the Michigan Department of Education. During the weeks of June 1--June 12, a phone survey was conducted to non-respondent principals to determine their answers to six survey questions identified as being the most important and informative questions on the survey. This non-respondent phone survey was conducted to improve the external validity of the survey results, by comparing the answers of the non-respondent principals to the respon­ dent principals on the six questions.. There were approxi­ mately 100 non-respondent school principals randomly selected to participate in the phone survey. Because the timing of the non-respondent phone survey was so close to the end of the school year, time allowed for only fifty schools to be contacted, and thirty-one principals agreed to participate in the survey. A minimal sample size of thirty is needed to approximate a normal distribution (Hays, 1973). Not all questions received thirty responses, however, questions that did not have thirty responses are indicated. A table describing the questionnaire activity and date conducted follows. 67 Table 3. Schedule of Survey Procedures Activity Date Health Education Survey Development Prior to March 10 "Pilot" survey sent to six principals March 10, 1981 Final draft of questionnaire completed March 25, 1981 780 letters sent to all Michigan public school superintendents March 27, 1981 3,766 letters and surveys sent to all Michigan public school principals April 2, 1981 First cut-off date for survey return April 24-, 1981 Follow-up letters with duplicate survey sent to non-respondent principals April 30, 1981 Final cut-off date for survey return May 27, 1981 Non-respondent phone survey June 1--June 12, 1981 Final report completed July 1, 1981 68 DATA ANALYSIS The data from Part I of the survey was analyzed by computer. The statistical package for the Social Sciences (SPSS) was used as the computer program for questions 1-29 (Part I). Each of the three possible answers to each question (YES, NO, N/A) was cross tabulated with the grade levels contained in that particular principal’s school. The grade levels' categories were as follows: K-6 or K-5 Elementary 6-8 or 7-9 Junior high/middle school 9-12 or 10-12 High school 7-12 7-12 K-12 K-12 Other* The "other" category comprised schools that did not contain the standard grade levels. The "other" category contained special education schools, and schools with odd grade levels such as 1-3, 3-5, 5-7. So for any one question, there was a cross-tabulation of grade level by the answer to each question. In addition, there were eight different questions that had special statistical manipulation. Four of these questions were to correct for principal errors in their res­ ponses. Both questions number four and number six are to be answered only if the preceding question’s answer was no. However, many principals answered questions four and six regardless of their previous question's response. To 69 correct for this error, a cross-tabulation was done that showed the answers for questions four and six only if answers to questions three and five were no. Another cross-tabulation was done to match the pro­ fessional preparation of instructors with whether or not they received health education inservice on a yearly schedule. This statistic enabled me to assess the numbers and percent of principals who responded that the teachers in their school building did or did not have health education inservice training, and whether or not the teachers had p r o ­ fessional preparation in health education. This cross­ tabulation was done for both elementary and junior high school principals. A cross-tabulation was also conducted to combine the question of "Is health education integrated into other subjects" and the question whether health education is taught as an identified separate subject. This statistic allowed me to assess how many principals answered yes or no or n/a (not available) to both questions. The open-ended questions in Part II of the health education survey were entirely analyzed by hand. I tabulated the number and percent of each question, as well as accounted for any comments that were stated, and how often they occurred. There was no analysis by grade level for Part II of the survey. The non-respondent phone survey was also tabulated by hand. The different responses were analyzed as to the 70 actual number and percent of each question's possible responses. The time frame in which the data analysis of the health education survey was ongoing as soon as surveys began to be returned. Key-punching of Part I of the survey responses was begun immediately, but did not have a computer analysis until after the final deadline of May 27. Part II tabulation of data was ongoing throughout the months of May and June. All data analysis on the health education survey was completed by July 10, 1981. 71 SELECTION OF A THESIS TOPIC Because of my personal interest in health education, I was able to obtain several jobs that involved working in a health education context. Some of these jobs included Michigan State University Research Assistantships in the Departments of Surgery, College of Human Medicine; University Center for International Rehabilitation; and the Non-formal Education Information Center in the Institute for Inter­ national Studies. In addition, I worked as a health edu­ cation research consultant for the Michigan Health Council, (MHC), and the Michigan School Health Association (MSHA). During the academic year 1980-81, I participated in the ethnographic research methods course sequence offered at Michigan State University by Profs. Buschman, Florio, and Erickson. During the fall term, Prof. Erickson asked for three students to volunteer to be on a research team to in­ vestigate a health education program at Urbandale Public Schools. The research would involve using participant ob­ servation as a means to investigate the health program. I volunteered to serve on this team with Victor Cole and Marilyn Parkhurst. Prof. Erickson supervised our research, and each one of us focused on a different aspect of the health program. I studied the kindergarten health program, Victor looked at upper elementary, and.Marilyn investigated the high school component. 72 My participation in the research team on the health project, and my nine-month affiliation with the qualitative research methods class encouraged me to begin looking at educational research and health education with a totally different perspective. My previous research experience had been predominantly of a quantitative nature. I had taken numerous statistics and program evaluation courses, almost all of which emphasized quantitative methods for educational research. Almost all of the research in the health edu­ cation field was quantitative, comparing treatment groups to control groups on several numerical manipulations. Even the health program at Urbandale which we were investigating had been evaluated (somewhat unjustly) using means and deviations on educational objectives that had nothing to do with health education. I began to desire to investigate health education using more than a quantitative method. I also wanted to look qualitatively at other health education programs, and compare their differences and similarities and discover what makes a health program succeed or fail. In the spring of 1981, I was hired by the Michigan School Health Association (MSHA) to conduct a statewide health education survey of all public school principals in Michigan. My involvement in the research of the Urbandale Health Education Program and the opportunity to conduct the survey led me to the decision to focus on health education as my dissertation topic. I decided to use the survey 73 results to identify two additional health education programs that met a high standard of program criteria. These two programs would be used for possible sites to conduct two other participant observation investigations. The criteria set for selection of a health education program to be used in a participant observation study were that the principal of the school must have answered "yes" to the following survey questions: 1. Is health education taught as an identified separate subject? 2. Is health education integrated into other subj ects? 3. In grades 1-6, do the teachers have at least four semester hours of professional preparation in general health education, ie., personal health/community health, and school health problems? (This question is only for K- 6 ) . U- In grades 7-9» are the health education teachers certified teachers holding majors or minors in health education? (This question is only for 7-9 schools, and was later deleted as only K - 6 . schools were us ed ). 5. Has a person been appointed as the building health coordinator to help develop, coordinate, implement and evaluate the comprehensive school health education program? 6 . Do teachers receive health education inservice training on a yearly schedule? Additional criteria were that the school personnel were willing to participate in the study, that the three schools needed to differ in size, geographic location, and ethnic composition of the students, and finally, that the schools were accessible to the researcher without excessive mileage. My dissertation proposal to investigate health education using the statewide survey and participant observation of three health education programs was a p ­ proved by my doctoral committee in June, 1981. I also contacted the University Committee for Research on Human Subjects and gained their approval for my proposed research. I then began the long process of negotiation for entry into the two additional health education programs. NEGOTIATION OF ENTRY INTO THE FIELD The three sites selected for the participant ob­ servation portion of this study were Hobart, Urbandale, and Botham City. Hobart is a small rural town with approxi­ mately 7,000 residents, and is located on one of the Great Lakes of Michigan. The Hobart School District has approxi­ mately 902 elementary students and three elementary schools involved in the health education program. The Urbandale School District is located in a larger city with approximately 131,4-00 residents. The Urbandale School District has three different health edu­ cation program components for the kindergarten, and high school grade levels. elementary, My observations of the Urbandale health program focused on the kindergarten health education component. In the Urbandale school district, there were approximately 330 kindergarten students and six elementary schools (eleven classes) involved in the health program. The Botham City School District is located in a large urban area with approximately 197,650 residents. The Botham City School District has 13,974- elementary students and 4-5 elementary schools. A more detailed description of these three sites is provided in Chapter V on page 117. 75 URBANDALE Negotiation of entry into the Urbandale Health program was the easiest of all three sites. Because I was participating on a research team that had been invited to conduct research by the health program coordinator, the entry process went through without any major difficulties. I had approximately seven entry meetings with different combinations of the health program staff, the evaluation staff, and the research team to discuss our proposed re ­ search. The Urbandale School District requires a research study request form be approved by the Office of Evaluation Services before any educational research can be conducted in the Urbandale School District. I submitted this form on December 29, 1980, and received approval to conduct my research on January 16, 1981. HOBART The negotiation of entry to the Hobart School District was the most difficult and lengthy entry of any of the three sites. I first contacted the Director of the Hobart Health Program in April, 1981. At that time, I des­ cribed my research to her and asked for her recommendations on how best to proceed in the entry process. The Director said I would need to put my request in writing and contact both her and the superintendent of the Hobart School District. At that time, I was still unsure of my final site selection, so I told her as soon as I knew for sure, 77 I would make formal contact. During July, 1981, I met with the Hobart Health Program Director to discuss my proposed research, and to reaffirm my research plans. I provided a copy of my dissertation proposal and discussed what I would need to include in my formal written request for entry into the Hobart School District. In August, 1981, I submitted a formal request to both the health program director and the school superinten­ dent to conduct a participant observation investigation of the K -6 Hobart Health Education Program. On August 31st, I received a letter from the super­ intendent of Hobart Public Schools to inform me that he was "inclined to permit..." me to conduct research in the elementary schools, however, before a final decision was made, I was asked to meet with the elementary principals to explain in detail my research procedures. The letter stated that they were concerned that my research might interfere with student learning and/or teacher instruction. I had approximately fourteen different meetings to negotiate entry into the Hobart Public Schools. At first, I was informed that I could probably begin observations in early October, but that was retracted at a later date. I felt a pressing need to gain entry into the Hobart schools as soon as possible, because I was six months pregnant in October, and needed at least six weeks of ob­ servations to conduct my research. I wanted to complete my 78 observations of Hobart before the birth of my first child, due in January. By early November, I still had not been permitted to observe in any of the health education classes. to get quite impatient and discouraged. I began I had grossly underestimated the amount of time it would take to gain entry into the Hobart Schools. After I received official permission to conduct my research from the superintendent, the entry process and es­ tablishing rapport in the field still demanded considerable time and effort. Ultimately, I feel it was outside influence from health education professionals that eventually helped me gain rapport from the health education program director. Once I was able to gain the trust and approval of the pr o­ gram director, the process of gaining rapport from the teachers proceeded smoothly. Teachers from the 3rd, 6th, 2nd, and 1st grades volunteered to allow me to observe their health education classes. Because I had to synchronize my observations with the teaching of a particular health unit, my observations were ongoing into the spring of 1 9 8 2 . On November 17, I began observation of the 3rd grade Growing Up unit, and completed my observations of the Hobart health program on March 29, 1982. 79 BOTHAM CITY I began my entry into the Botham City School District with a letter to the Botham City school superintendent on March 9» 1982, to request permission to conduct participant observation of the health education program being taught at Schultz Elementary School. On March 11, a letter from the Health Education Specialist for the Michigan Department of Education was also sent to the school superintendent on my behalf, asking for his cooperation and support of my research. On March 30, I met with the principal of Schultz School to discuss my research. By this time, the Botham City school superintendent had already contacted the principal with regard to my research. The principal was very open and interested in facilitating my research study. The principal offered to contact the teachers on my behalf, and obtain a list of volunteers who would allow me to observe in their classrooms. Upon my second meeting with the principal on April 15, a schedule of observations for different health education classes was already established. I conducted my research observations with these volunteers between April 16 and May 2, 1982. 80 METHODS OF COLLECTING DATA AND RANGE OF DATA COLLECTED The predominant form of data collected in the par­ ticipant observations of the three health education programs was the use of a field note technique recommended by Anselm Strauss and Leonard Schatzman in their text, Field Research Strategies for a Natural Sociology. All observations were first recorded on paper and then recopied and expanded within a short period of time (usually within 24- hours). The expanded version of field notes included articulation of Observational Notes, Notes Theoretical Notes, and Methodological (Schatzman and Strauss, 1973). The observational notes are statements regarding events experienced through actual watching and listening to the setting. Observational notes are not interpretive, but instead try to describe the event as objectively as possible. Whenever possible verbatim accounts of the participants using either tape recordings or actual quotations, as well as description of behaviors and activities were used for evidence to enhance the internal reliability of the study. Theoretical notes describe my attempt to make sense of the observed activity. The theoretical notes were used as a means to hypothesize relationships, and to infer categories and classes from the data within the theoretical notes. I also used the "disciplined subjectivity" technique for monitoring my own tension and/or personal biases 81 regarding the observations. If a particular scene brought forth a particular emotion or response from me, I noted it as such, and used it to signal my own objectivity. The methodological notes were instructions within the context of my observations that directed me to seek additional tactical maneuvers to gain more observational and theoretical evidence. Methodological notes identified gaps in my data collection, as well as providing follow-up leads for further investigation. This transcription and expansion of the field notes was a very time consuming process. For one hour of class­ room observation, the transcription process required between three and four hours to type and analyze the observations. The tape recorder to record classroom observations and activities was only used in the observations at Urbandale. The difficult and tentative entry at Hobart made me decide not to further antagonize my informant re ­ lationships by asking to tape record their classroom a c ­ tivities. Instead, I used several methods for insuring internal reliability. Some of these methods included using verbatim accounts, interview data, using multiple field informants, and asking for participant reaction and partici­ pation in the observation and analysis of findings (LeCompte, 1982). I also developed my own methodology for obtaining participant reaction and participation in the research 82 process. In several key observations, I asked the teacher of the classroom to read over my expanded transcription of the field notes. I asked the teacher to "relive" the happenings of the situation with me as we together read the field notes, line by line. I asked the teacher to stop anywhere along the line and add what (s)he was thinking and/or feeling at the time, or to add any reaction (s)he had to my observations. This methodology of using partici­ pant reaction provided a rich source of analysis and pers­ pective that had not previously been obtained. For example, as Mr. O'Brian read over a section describing a student's question about how food gets down to the stomach, he stopped and said, "my example of using the long, skinny balloon (see page 1 6 8 ) just came to 'me....t h a t 's how this health education gets transmitted....no one told me to use that example, nobody could.... t h a t 's where the quality of the teacher really makes the difference in a health education course...." This method of using participant reaction was adapted from my previous work with Dr. Norm Kagan, using the Interpersonal Process Recall (IPR) technique for counselor training. (Kagan, 1975). Another type of data collected was that of several documents obtained from the various health programs I ob­ served. I also kept an introspective journal of my personal reactions and feelings during the research process. One source of data used to "piece together" the various health education programs was supplied through my 83 informal connections to the health education professional network. Several individuals outside of the observation sites helped me to better understand the processes involved in developing and maintaining a comprehensive health edu­ cation program. These individuals are professionals in the health education field and are very knowledgeable about various health education programs ongoing in Michigan. This form of peer review and examination also helped to improve the internal validity of the findings (LeCompte, 1982). For a summary of the sources and amounts of data collected for each of the three sites, see Table A . Table k * Sources of Data Collected Source of Data Collection Observations Urbandale Hobart 17 17 6 5 7 9 1 1 Interviews Letters Dairy Council Information 1 — All texts, K -6 Textbooks Health Project Documents Botham City 7 3 5 Bulletin Boards -- 3 2 Staff Meetings 11 2 Luncheon Discussion 1 Specific Entry Meetings 7 Curricular Notebooks 1 U 3 -- 84 DATA ANALYSIS The analysis of the data began while I was still in the field. In the beginning of ray research at the Urbandale health program, I met with the other members of the research team, and with the class members to discuss perceptions, and develop working hypotheses. Through the formulation of research questions, and subsequent alterations during the field research process, the analysis of the data became more focused. The Hobart health program was studied in greatest depth of any of the three sites. Early in the research process, I developed five main categories of data within my observations. These five categories were: organizational structure, program content, methods of instruction, behavioral choice and decision-making, and health education issues. The establishment of these categories and classes of data was reflected in the research questions and in the overall analysis of data. The Botham City health program was studied in the least depth of the three sites. I used three of the same categories I used for the Hobart data analysis for the analysis of the Botham City health program. These categories were: organizational structure, methods of instruction, and program content. Immediately following my observations of each site, 85 I wrote out a chronology of all meetings, observations, interviews and activities that took place during my ob­ servations. From this compilation and in the transcribed field notes, I color-coded the different categories of data and wrote up separate analysis for each category. This process illuminated how interdependent the five classes were in each of the three health education programs. It became apparent that the establishment of one category permitted the presence of other categories, and that some categories were dysfunctional without the other categories. For example, the overall organizational structure of the health program allowed for the categories of program content, instructional methods, and behavioral choice and decision­ making to exist. The methods of instruction were dependent upon the content of the health education. Some methods of instruction were more appropriate for teaching a certain health education content than others. Health education issues seemed to be found in all of the other categories. After mapping out the interdependency of the data categories, I was able to make sense of the whole picture by using a theme of a nesting effect of the five major categories. By nesting effect, I mean that some categories of the data were nested in other categories, and all were interdependent and interrelated with each other. The data analysis seemed to take on the shape of a spiral, with a more focused and specific constructs at the center, and a more broad and global constructs on the 86 fringes. The spiral nesting effect of the five categories allowed me to articulate a conceptual scale of health education program quality. The more a health education program reflected each of the five categories, the better the program quality seemed to be. Between the observations of all three health pro­ grams, I was able to theoretically combine parts of each program to propose an optimal health education program that contained components of each. Thus, the observations of the three health programs enabled me to create a synthesis of their program strengths, and to suggest recommendations for health education program improvement. CHAPTER IV RESULTS OF THE HEALTH EDUCATION SURVEY The statewide health education survey was sent out to all public school principals (approximately 3 »7 6 6 ) in iMichigan. After the final deadline date, 1,536, or 4-0.7# of the surveys, had been returned. The reader is reminded that 40.7# is a moderate return rate, and the interpretation of the results must be held in perspective of this moderate res­ pondent population. The following table gives a description of the respondent population who returned the survey. Table 5. Survey Respondents Grade Level K - 6 7 - 9 or 6 - 8 9 - 12 or 10 - 12 7-12 K - 12 Other % of Respondents Number of Principals % of total Population 760 53.3 33.7 an1 0 20.1 52.6 285 20.0 61.1 51 3.6 32.4 8 .6 33.3 30 2 .? 1,421 99.9 0 As can be seen from the table, 760 or 53.3# of the respondents were elementary principals, which was 3 3 .7% of the total elementary principal population. 87 Two hundred 88 eighty-seven or 2 0 .1 $ of the respondents were middle school or junior high principals, which was 5 2 .6$ of the total middle school/junior high principal population. Two hundred eighty-five or 20$ of the respondents were high school prin­ cipals, which was 6 1 .1$ of the total high school population. Fifty-one, or 3.6$ were 7-12 principals, which was 32.4.$ of the total 7-12 principal population. Eight, or .6$ of the respondents were K-12 principals, which was 33.3$ of the total K-12 principal population. fied as other principals. Thirty, or 2.1$ were classi­ The other category comprised schools that did not contain the standard grade levels, such as 1-3 , 3-5, 5-7, or special education schools.'*' Even though this effort was made, some high school principals did not respond to those specific questions. This made the high school principals' responses a smaller sample size, which may result in a higher discrepancy between the high school respondent answers and the high school non­ respondent answers. Most of the results of the survey have been reported by the total respondent population. Individual grade categories are reported only when a significant finding is shown. ■^Possible error in the survey findings might be due to the fact that certain questions asked the principals from K-9 to respond, and did not apply specifically to high schools. In an attempt to make the survey more applicable to high schools, all high school principals received an insert in their questionnaire which read as follows: "Your school building has been identified as containing grades 9-12. Please answer questions 5, 16, 27, 28, and 29 of Part I, and question 1 of Part II as they apply to your school building. Thank you." 89 The description of the results of the survey have been separated into five main categories: organizational structure, program content, professional preparation, methods of instruction, and principal opinions regarding program improvement. The following section discusses the survey results of these five categories. ORGANIZATIONAL STRUCTURE Perhaps the most important results of the health education survey indicate that Michigan Public Schools lack a developed organizational structure to implement a compre­ hensive school health education program. from the survey point to this conclusion. Several questions The following table summarizes the main organizational structure survey responses. Table 6. Organizational Structure Survey Results Total Principal Response Question Yes No N/A (Not available) Is health education taught as an identified (separate) subject? 54.2 45.5 .3 Has a person been appointed as the building health co­ ordinator to help develop, coordinate, implement, and evaluate the comprehensive school health education program? 31.0 66.3 2.6 Have curriculum guides for grades K-9 that include the ten areas, as defined by the Minimal Performance Ob­ jectives for Health Education in Michigan, been developed by the teachers? 32.1 57.4 10.5 Does your school district have a health curriculum planning committee to provide leadership in the de­ velopment and implementation of the comprehensive health education program? U.2 52.1 3.6 Has the local school board approved curriculum guides and policies for implementing a comprehensive health education program? 47.5 47.2 5.3 Table 6. (continued) Total Principal Response Question Yes No N/A (Not available) Has the school board appointed a school health advisory board made up of parents having children attending the district's schools, educators, (eg., administrators, teachers, professional staff), local clergy, community health professionals, and other interested citizens? 31.2 62.7 6.1 Is school health services component integrated into the total comprehensive health program? 49.8 35.1 15.1 First, 54.2$ of the total principal population, and A 3 . 3 % of the elementary principal population indicated that health education is taught as an identified (separate) subj e c t . Second, 6 6 . 3 % of the total principal population, and 70.2$ of the elementary principal population answered that their school did not have a building health coordinator ap­ pointed to help develop, coordinate, implement, and evaluate the program. The percentages of "yes" answers were the highest for the high school principals (3 6 .3 $), followed by the junior high principals (3 3 .0$), and lastly, the elementary principals with 27.3$ "yes". Third, 57.A% of the responses from principals in all grade levels, and 6 2 .6$ of the elementary principals in­ dicated that curriculum guides for grades K-9 that include the Minimal Performance Objectives have not been developed by the teachers. Fourth, 52.1$ of the principals from all grade level responded that their school district did not have a health curriculum planning committee to provide leadership in the development and implementation of a comprehensive health education program. Fifth, A 7 . 5 % of all principals from all grade levels except the 7-12 grade level, indicated that the local school board had approved curriculum guides and policies for im­ plementing a comprehensive health education program. four percent of the 7-12 principals Thirty (which comprised 3.6$ of 93 the total population), indicated that their local school board had approved curriculum guides and policies. Sixth, the majority of school principals {62.1%) in all grade levels answered that the school board had not appointed a school health advisory board, made up of parents having children attending the district's schools, educators, local clergy, community health professionals, and other interested citizens. There is a trend, however, that shows that as the grade level increases, the likelihood that the school board has appointed a school health advisory board also increases. Finally, when asked if the school health services component is integrated into the total comprehensive health program, 4.9 -8$ of all principals answered ''yes” , 3 5 . 1 % answered "no", and 15.1$ answered "N/A" (not available). CONTENT OF HEALTH INSTRUCTION The second category of questions pertains to the content of the health education program. The most informative question regarding program con­ tent asks the principals to check the appropriate boxes on a grid showing the ten topical areas contained in the Essential Objectives, and grade levels 1-9. There were a number of principals who did not respond to this question at all. The elementary principal responses ranged from an average of 568 or 39.4-$» to 169 or 11.7$ of the total responses received. The junior high principal responses 94 ranged from an average of 256 or 17.8$, to 179 or 1 2 .4 $ of the total responses received. The high school principal responses ranged from an average of 80 or 5 .5$> to 63 or 4 .4 $ of the total responses received. A distribution of the most frequently checked topic areas for grades 1 -6 , 7-9, and 1 0 -1 2 , to the least checked topic area is provided in Table 7. As shown in Table 7, the three different grade levels vary considerably as to what content areas are most frequently taught at each grade level. Certain topics such as Safety and Personal Health which are of particular im­ portance to the lower grade level students, are taught more frequently at elementary level than junior high and high school levels. The reverse is also true for areas such as Emotional and Mental Health, and Disease Prevention and Control; such topics seem to be more relevant to the older student and are more frequently taught at the high school level. The elementary principals' responses for grades 1-6 reveal certain trends. One trend shows that for grade levels 1-4 the order of health education topical areas checked was the same for all grade levels for the first four areas. Safety was the most frequently checked area, fol­ lowed by Personal Health, Nutrition, and Disease Prevention and Control. A second trend showed that Substance Use and Abuse was taught more frequently in the 4th, 5th, and 6th grade levels. Other trends showed Growth and Development Table 7. Frequency Distribution of Health Education Content Areas Grade Levels Most Frequently Checked Least Frequently Checked 1 - 6 7 - 9 1 Safety 1 Personal Health 2 Personal Health 2 Nutrition 3 Nutrition 3 Substance Use and Abuse 4 Disease Prevention and Control 4 Safety 10-12 1 Disease Prevention and Control 2 Emotional and Mental Health 3 Substance Use and Abuse 4 Nutrition 5 Growth and Development 5 Growth and Development 5 Personal Health 6 Substance Use and Abuse 6 Disease Prevention and Control 6 Growth and Development 7 Family Health 7 Emotional and Mental Health 7 Family Health 8 Emotional and Mental Health 8 Family Health 8 Consumer Health Community Health 9 Consumer Health 9 Safety 9 10 Consumer Health 10 Community Health 10 Community Health 96 was taught more in 5th and 6th grades. Community Health and Family Health were taught less frequently in the 4-th, 5th, and 6th grades than in 1st, 2nd, and 3rd grades. Disease Prevention and Control was taught less frequently in the 5th and 6th grades than in the earlier grades. For the junior high principal responses, Personal Health was the most frequently taught subject for 7th and 9th grades, and second for the 8th grade. Substance Use and Abuse was taught more frequently in the 9th grade than in 7th or 8th grades. Disease Prevention and Control was more often taught in the 9th grade level than in 7th and 8th grades. The last four topic areas that are the least fre­ quently taught for grades 7th, 8th, and 9th were (in des­ cending order): Emotional and Mental Health, Family Health, Consumer Health, and Community Health. For the high school level, Disease Prevention and Control, and Emotional and Mental Health seemed to be the most frequently taught subjects. The 10th grade level had equal numbers of the first four areas checked. were: Personal Health, Nutrition, and Disease Prevention and Control. These areas Substance Use and Abuse, In all three grade levels of high school, Community Health was the least taught subject area. Throughout all grade levels, there did not seem to be any one topic area that was taught most frequently. There was, however, a trend that showed Community Health and Consumer Health to be the least taught subject areas in all 97 grade levels. There was a small number of responses to this question from the high school grade levels, which makes it difficult to make any assumptions about what topic areas are most and least frequently taught in the high school population at large. There is also no way to guard against possible error in which principals marked topic areas being taught in grade levels other than those contained in their school building. There are enough responses, however, to indicate the general frequency of health education topic areas being taught in grades 1-9. For grades 1-9, the two most frequently checked topic areas were Personal Health and Nutrition. Additional survey questions that pertain to the con­ tent of the health education program are summarized in Table 8. Table 8. Content Responses of Health Education Survey No N/A 6 4 .4 27.7 7.4 Are the health education knowledge tests suited to the grade level where they are administered? 49.5 5.1 •45.4 Are current health education period­ icals and health reference materials available for classroom use? 76.7 21.1 2.3 Does the Minimal Performance O b ­ jectives for Health Education in Michigan serve as a guide for your school district's health curriculum? 58.5 31.3 10.3 Question Yes Do all teachers within a grade level follow the same curriculum? 98 As can be seen from the table, 64-.4-$ of all prin­ cipals in all grade levels responded that all teachers within a grade level followed the same curriculum. 2 1 . 1 % the principals responded no and 1 . 9 % answered N/A. of A closer look at the different grade levels shows that only 59*4-$ of the elementary principals answered yes, as compared to 74-.9$ and 1 1 . 2 % of the junior high and high school principals, respectively. This statistic indicates that elementary teachers are more likely to teach different health education curriculums within the same grade level. When asked whether health education knowledge tests were suited to the grade level where they are administered, 4-9.5$ of all principals answered yes, 5.1$ answered no, and a sizeable percentage, 4-5.4-$, answered N/A. A high majority of principals from all grade levels (76.7$) responded yes, that current health education periodicals and health reference materials are available for classroom use. The last content question refers to whether the Minimal Performance Objectives for Health Education in Michigan serve as a guide for the school district's health curriculum. A majority (58.5$) of principals from all grade levels re s­ ponded yes, 31.3$ responded no, and 10.3$ responded N/A. The questions regarding content of health instruction indicate that health curriculums being taught in the same grade level are not consistent and often do not provide a comprehensive health curriculum. 99 PROFESSIONAL PREPARATION OF INSTRUCTORS There were three main questions in the survey that inquired about the professional preparation of instructors. When the elementary principals were asked if the teachers have at least four semester hours of professional preparation in general health education (preservice education), only 19.5# answered yes, 59.2# answered no, and 21.3# answered N/A. Those who answered no were asked what percent of the teachers did have at least four semester hours of professional pre­ paration in general health education. Controlling for in ­ appropriate responses from junior high and high school prin­ cipals, the following table indicates the various percentages. Table 9. Percent of Elementary Teachers with at Least Four Semester Hours of General Health Education 0# 1-10# Percent of Principal Responses 10.6 37.0 11-24-# 25-4-9# 50-74-# 10.2 18.5 20.8 75+# 3.0 Perhaps the most important question regarding pro­ fessional preparation of instructors asks whether teachers receive health education inservice training on a yearly schedule. A high majority (81.1#) of principals in all grade levels answered that health education inservice is not being received by the teachers on a yearly schedule. just the elementary principals, Examining 12.2# responded yes, 84-.8# responded no, and 3.0# responded N/A. 100 The following table summarizes the elementary prin­ cipal responses to the survey questions regarding professional preparation. Table 10. Professional Preparation of Elementary Teachers Question Yes No N/A In grades 1-6, do the teachers have at least four semester hours of professional preparation in general health education, ie., personal health/community health, and school health problems? 19.5$ 4.1.6$ 21.3$ Do teachers receive health edu­ cation inservice training on a yearly schedule? 12.2$ 84.8$ 8.0$ Statistics regarding professional preparation of the teachers show that very few principals responded that their teachers had preservice education (college training) or inservice education in health education. A cross-tabulation of the question regarding pre­ service education, and the question on inservice education was made. This statistic showed that the largest percentage of elementary principals, 52.2$, indicated that the teachers did not have four semester hours of general health education, nor did they receive health education inservice on a yearly basis. The second largest category showed 16.1$ of the elementary principals answered that the teachers did not have at least four semester hours of professional pre­ paration, and responded N/A with regard to whether the teachers had health education inservice training on a yearly schedule. 101 The statistics regarding professional preparation of the instructors indicates that very few instructors in Michigan public schools receive inservice or preservice health education. METHODS OF INSTRUCTION Only one question on the health education survey referred to the Methods of Instruction. if the teachers offer study options, choice for students in projects. This question asked extra credit, and/or Of the elementary prin­ cipals, 55.1# answered yes, 32.3$ answered no, and 12.6$ answered N/A. PRINCIPAL OPINIONS REGARDING PROGRAM IMPROVEMENT Part II' of the questionnaire consists of three openended questions asking principals1 opinions on development of a comprehensive school health education program. There was no analysis by grade level for any of the three questions in Part II. Question #1 asks if they consider the Minimal Performance Objectives for Health Education in Michigan (MPO’s) applicable to their school district, and if not, why not? There was a total of 1,524 principal responses to this question. Out of these, 859 or 56.3# answered yes, 116 or 7.6$ answered no, 494 or 32.4# answered N/A, and 56 or 3.6$ answered that they did not know about the Minimal Performance Objectives. 102 There were ten principals who requested a copy of the Minimal Performance Objectives. These were sent to them soon after the requests were received. Out of the r e s ­ ponses that said no, the Minimal Performance Objectives were not applicable, the following reasons were given: "lack of funding or priorities" "we set our own objectives" "not used at present time" "we should develop our own" "not required" "not enough time"* "Berkley model is used"* "have never seen them" "lack of materials to teach from" "we d o n ’t have staff training district-wide, money to train them" or *This reason was cited by several principals. The second question in Part II asks the principals what they believe are the major improvements which could be made within their school district to enhance the development of a comprehensive health education program. There was a total of 1,524- responses to this question. Most of the principals answered that there was more than one area that could be improved in their school district. responses. The following table describes the principals' 103 Table 11. Improvements Suggested by'all Public School Principals # of Total Survey Responses* No answer 36.1 Inservice 27.4 Curriculum Development 20.3 Needs Assessment 9.3 Integration with Community Professionals 8.7 More money 6.8 All of the above 4.7 No improvements needed 3.4 Health Educator 3.0 Healthful environment 2.4 ^Percentages are based on number of principals responding, not on the total number of categories checked. Most respondents checked more than one category. Question ff3 of Part II asks if the principals believed that their school district would like assistance from the State of Michigan Department of Education in expanding or developing a comprehensive school health education program. If so, in what areas? There was a total of 1,483 responses to this question. Of these, 294 or 19.3# answered yes, 484 or 3 1 . 8 % answered no, 600 or 39.4# did not answer the question or answered N/A, and 105 or 6.9# answered that they didn't know. With regard to the areas of assistance in which the principals 104 who answered yes, the following table summarizes their responses. Table 12. Areas of Desired Assistance from Michigan Department of Education % of Total Survey Responses* Areas Inservice 25.0 Curriculum Development 22.2 All areas 16.0 Needs Assessment 10.0 More money 8.0 Materials 3.8 Integration with Community Professionals 3.5 Substance Abuse 4.8 ^Percentages are based on the number of principals re s­ ponding, not on the total number of categories checked. Most respondents checked more than one category. The survey questions of Part II indicate that the majority of principals feel that their school districts could use some improvement in expanding and developing a comprehensive health education program. Inservice Education and Curriculum Development were the two most frequently cited areas that needed improvement and assistance. SUMMARY OF THE FINDINGS OF THE NON-RESPONDENT PHONE SURVEY The non-respondent phone survey consisted of six questions (four of which are relevant to the K-6 principal population). The following table indicates the respondent 105 and non-respondent answers to these questions. The findings of the non-respondent phone survey in­ dicate that percentages for yes responses are generally higher on most questions for the respondent population than the percentages for the non-respondent population on all questions asked. These statistics suggest that the prin ­ cipals who did not return the survey have a less-developed comprehensive health education program than the principals who returned the surveys. CONCLUSION The results of the School Health Education Resources Coordination Project survey have suggested several impli­ cations that warrant particular attention. professional preparation, .The areas of inservice training, and application and utilization of the Minimal Performance Objectives for Health Education in Mich ig an, the content of health education, and the lack of a well-developed organizational structure for health education have been articulated as deficit areas in the current status of comprehensive school health education. Focused attention and enrichment of these deficit areas will be necessary for a continued improvement of comprehensive school health education in Michigan public schools. A statewide survey of public school principals on health education can provide only a small part of the total picture of comprehensive school health education ongoing in 106 Michigan. The total picture of comprehensive school health education in Michigan is beyond the scope of this study. However, this study does provide valuable information and a framework on which future research in health education can be based. Table 13. Non-respondent Phone Survey Survey Non-Respondent Question Is health taught as an identified (separate) subject? Is health integrated into other subj ects? Do teachers receive health education inservice training on a yearly schedule? % N % YES NO N/A 9 20 2 29.0 64.5 6.4 780 655 4 54.2 45.2 .3 YES NO N/A 25 2 2 86.2 6.8 6.8 1,291 124 15 90.2 8.7 1.0 YES NO N/A 9 18 31.0 62.0 6,8 446 953 38 31.6 YES NO N/A 3 25 10.0 83.3 6.6 222 1,162 15.5 81.1 3.4 2 2 *Indicates that the non-respondent population is less than 30. 49 66.3 2.6 107 Has a person been appointed as the building health coordinator to help develop, coordinate, implement and evaluate the comprehensive school health program?* N Survey Respondent CHAPTER V ETHNOGRAPHIES OF THE THREE HEALTH PROGRAMS MAIN ISSUES IN THE THREE SITES The analysis of the observations of the three health education programs identified five main factors necessary for a high quality health education program. These five factors are: 1. Organizational structure. 2. Content of health instruction. 3. Methods of health instruction. 4-. Presence of certain health education issues. 5. Health education in terms of the student’s behavioral choice and decision-making. Each of these five factors is described below. The organizational structure of the health program includes all aspects of the health education program that administer, plan, and provide health education to students, parents, instructors, and the community. Examples of or­ ganizational structure components include a health education advisory board, inservice education to teachers, of the health education program, health services evaluation integration of school (ie., school nurses) into the overall health education program. The content of the health education program refers to the substance of the curriculum being provided to the 108 109 students. Components of a health education content include nutrition education, family health, health. safety, and community A comprehensive health education content is defined by the Michigan Department of Education as meeting the Essential Objectives for Health Education in Michigan. These objectives represent the ten topic areas of health education: nutrition, safety, personal health, family health, consumer health, community health, disease prevention and control, substance use and abuse, emotional and mental health, and growth and development. The methods of instruction refer to the instructional technology being used to teach the health education. Some of these methods include hands-on experience, audiovisuals, textbooks, discussion* etc. The issues of health education refer to relevant issues that concern individual and social health. Examples of health education issues are conserving food, respecting the rights and privileges of others, being responsible for the health and well-being of others. The key factor of behavioral choice and decision­ making refers to the content of health education being pre­ sented in terms of the student's personal behavioral choices and decision-making. This framework enables the student to be aware that (s)he is responsible for her/his own health as well as affecting the health and well-being of others.... It was also evident in the observations of the three health education programs that there is a "nesting" 110 effect within these five main factors. The term "nesting" means that some of these factors are interdependent and enable other factors to be present. For a high quality health education program certain factors are necessary, but not sufficient. For example, an adequate organizational structure is necessary for a comprehensive health education program, but it is not enough; other factors such as a health education content, methods, and the content being presented in terms of behavioral choices and decision-making must be present. Figure 1 illustrates this nesting of the main factors found in the observations. Ill CHoice « DtOSioV ■ vM c th o o s or xnsticucHoM CoJiten r o liQ A N IZ A T i o M A i s tru c tu re •SfudtMV Home £rw it is time for the Health lesson. Today's lesson is on prenatal development in the Growing Up unit. There is a filmstrip that discusses the different gestation periods of different animals. "What is it called when the baby is born too early?" asks Mrs. North. "Test tube baby," answers a student. "No, not a test tube baby. What is it called, Jerry "Premature." "Right, is there anyone here who was a premature baby?" Two girls raise their hands. "What is a test tube baby?" The Health lesson lasts until 11:45, when all 6th grade students break for lunch. Lunch is over at 12:35. outside. leave. The students enter from Some take their seats, and others grab books and The students rotate to another classroom. The stu­ dents who leave are going to another teacher to learn mathe­ matics and science. teacher's homeroom, The students who stay are from the math and they will stay to learn English and Health with Mrs. North. Between 1:45 and 2:05 is afternoon rec es s. At 2:25, the students from Mrs. North's homeroom return and begin a handwriting exercise. At 2:40, the day is almost over, and Mrs. North reads some poetry until the final bell rings at 2 :5 0 . 176 Typical schedule for 6th graders: 9:06 10:00 10:3410:4-5 11:05 11:45 (12:35 ( Classes ( rotate ( ( 1:15 ( 1:45 ( 2:05 2:25 2:35 2:50 Day begins with Reading English Social Studies Recess Health Lunch Class rotates to another teacher for Math and Science while other class comes in for English and Health Health, other class Recess Health resumes Handwriting exercise Open time Day is over As can be seen from the vignette, a definite subject schedule they follow. the students have All students speak only when they have raised their hands and are recognized. The class is divided up into teams and each team competes for points awarded for correct responses. teaching health also use team competition. The methods for Another aspect of the organizational structure is represented by the pro­ vision of the fluoride rinse program entitled SWISH. All students who have returned permission slips may participate in a fluoride rinse program that is conducted once a week throughout the school year. The health program coordinates parent volunteers and obtains and delivers fluoride to every student participating in three elementary schools. The next vignette, several key factors. "A Human Being is Born" contains First, the content of the filmstrip and discussion contains aspects of the Essential Objectives for Health Education in family health. Second, the methods used to teach the health content using a filmstrip with a discussion provides the students with an opportunity to demonstrate their own knowledge of reproductive health. Third, the content represented several issues where the students could recognize that their behavioral choices and decisions make an impact on their health as well as the health of others. 178 A HUMAN BEING IS BORN Does anyone know what it's called when a baby doesn't come out with its head first?" asked Mrs. North. The class of twenty-four students is silent; no one knows the answer. "Breech was the answer I wanted. Today we will watch a filmstrip called A Human Being is Born." A woman who is nine months pregnant is featured in the filmstrip. She has her bags packed and is ready to go to the hospital. The baby is fully mature. The baby has grown to full size in the mother's uterus or womb, the film­ strip says. or a boy. The mother wonders if her baby will be a girl "Males and females are differe.nt--they have dif­ ferent sex organs at birth," the film strip says. "The dif­ ferences are that females have eggs, Fallopian tubes, uterus, and vagina. Born healthy, The males have testicles, scrotum, and a penis. this baby will have all the right part." The filmstrip ends with a picture of an artist's drawing of how a baby descends down the birth canal to be born. Mrs. North goes to the front of the room and writes: A new life in the mother is called a f--------- e-- c . "What is the answer?" All students are very disciplined; when their hand is raised. speaking only No one guesses the correct ending. Mrs. North writes in: fertilized egg cell. I have been observing the class for several days and the teachers and students have often included me in their 179 discussion. (I am 8-1/2 months pregnant at the time of this discussion.) Mrs. H a n s e n ’s baby is to be born, how does she kno w? ” Mrs. North asks the class. "Contractions," a student replies. "Of what?" "The uterus." "Yes, the uterus is a muscle and it contracts, forcing the baby to be born. W h a t ’s the next step?" "Call the doctor." "That’s right. I had a job once at a medical clinic taking telephone calls, and I remember if I ever got one from a mother in labor, I was supposed to give the call a red flag insignia and contact someone immediately." "Okay, what's next?" "Pack your bag," says a student. "I d o n ’t know about that; Mrs. Hansen, is your bag already packed?" "Yes, it has been packed for two weeks now." "Yes, I don't think it's wise to leave packing for the last minute. What should be in the bag?" asks Mrs. North. The students answer: brush", "book", "rattle", "clothes", "housecoat", "nightgown", "tooth­ "baby book". "Okay, anything else?" "Birth announcements," I add to the pool of answers. "Okay, now what?" asks Mrs. North. "-Leave for the hospital." 180 "That's right, and when you get there, doctors and nurses will assist you. the baby born, The doctors and nurses don't make the mother and baby do. The mother and baby do the work; the doctors and nurses assist," Mrs. North explains. Mrs. North asks, "Now what happens at the hospital?" A student answers, "The muscles of the uterus have to use more strength." "What has to happen before the baby can be born?" Silence. "What has to break?" "The uterus has to break." "No, not the uterus, what has to break?" "The egg has to break." (A couple people in the class laugh.) "No, the egg is what the baby is now." "The sac with water." "Right! What's it called?" No answer. Mrs. Hansen, help us out, what are the two things that have to break?" I explain to the class that the amniotic membrane is also called the bag of waters, and before the baby is born, the sac "Yes, be born and I is usually broken or ruptured. I remember when I was waiting for my baby to was home when the bag of waters broke and water came out, and I knew that so o n ." I was going to have the baby 181 "Okay, then the baby comes out, usually head first, and the head is very soft, so that the compression of birth often leaves the baby's head somewhat pointed. It doesn't hurt the baby, and soon it goes back to its normal shape." One student offers a story: "My Mom had a friend who spent fifty-two hours in labor." "Is that a long time?" Mrs. North asks the class. No answer. "Yes, that is long," she replies. "Sometimes when a baby doesn't come out as it is supposed to, or when it is a difficult birth, they can use forceps; Mrs. Hansen, will you explain what forceps are and how they work?" "Forceps are an instrument that is like large spoons that are inserted up the birth canal to grab the baby's head and pull it out. They are used when the baby must be taken out of the mother soon," I say. "I was delivered with forceps," a student says. "Both me and my brother were born Caesarian." "What's that?" asks Mrs. North. "It's when they take the baby out (?)" a student answers with a question (unsure). "Yes, a Caesarian is when they make a surgical cut on the mother's tummy." "Where's the cut, Mrs. Hansen?" "It's in one of two ways, either horizontal or vertical across the belly, but usually horizontal." 182 "Is there anything any of you want to share?" asks Mrs. North. "I heard about a baby that they didn't get out in time and they think it might be retarded," a student says. "Another trouble is when the cord is sometimes pinched in the baby, and that cuts off the baby's air. Things do happen and brain damage can result. it doesn't happen very often. Fortunately, Birth is a hard trauma; the cord can wrap around the neck or the baby may have trouble," Mrs. North explains. "Sometimes they need to get the baby out fast and they can make a cut, does anyone know what it is called?" No answer. "An episiotomy," Mrs. North answers her own question. "Mrs. Hansen, would you explain how they do an episiotomy?" I go to the chalkboard in the front of the room and make two drawings: *:....epi3»OTomY' fltjure e 3. I explain: "There are two ways of making a cut, one is di ­ rectly down from the vagina--almost to the rectum. Another way is to cut on an angle off to one side of the vagina and down toward the rectum. The reason they do this is to p re­ vent tearing of the peritoneum, vagina. the tissue surrounding the There is not always a need for doing this, because 183 the peritoneum doesn't always tear, but it is done routinely any way ." "If the mother is dead, can the baby still live?" a student asks. "les, if the baby gets air to breathe in time before it suffocates. The mother's oxygen is what supplies the baby with air. If the baby is born soon, and can use his own lungs, then he can live." "There's a problem oftentimes when the baby doesn't develop right--a defect, mutation, it is sometimes caused by a or an error in the chromosomes." I add to the conversation: "There are lots of mu ­ tations, but we don't see them, the bad ones are usually miscarriages (or when a baby is conceived but dies and is bled away). There are lots of good mutations. It's what gives us variation and change in our generations, but most of them go unnoticed." Mrs. North refers back to the episiotomy explanation: "When the doctors make an episiotomy, they use a drug similar to the novocaine that dentists use when filling teeth. This numbs the tissue so they can sew up the episiotomy after the baby is born." Mrs. North senses that the class has been somewhat reluctant to ask questions and to feel at ease about reproductive health. "There are very natural words that we should not be embarrassed to say: ovaries, Fallopian tubes, uterus, vagina, 184. penis; can we say these out loud?" The class does not respond--it is time for recess; the health class is over. The content of the filmstrip and the discussion fol­ lowing it illustrates three main themes that recur throughout the teaching of the 6th grade Growing Up unit. The first main theme is responsibility for behavioral decision-making. In this vignette, responsibility is implicit in the atypical issue of who makes the baby born. "That's right, and when you get there (the hospital) doctors and nurses will assist you. The doctors and nurses don't make the baby born, the mother and baby do. The mother and baby do the work, doctors and nurses assist." the Mrs. North is emphasizing that the mother is responsible for birthing her baby, and the doctors and nurses are there to help. This perspective is contrary to previous medical associations where the mother was not considered to be responsible for the birth of her child; instead, the doctor was perceived as being the one in charge who is responsible for childbirth. In today's medical practice, unless it is a Caesarian birth, the mother is given the main focus and responsibility for the birth of her child. A second main theme in the vignette is that the con­ tent of the filmstrip and discussion following presents the students with straightforward factual information regarding the male and female reproductive system. From the content of the students' questions and answers, it was apparent that this information provided the students with an improved 185 understanding of human reproduction. Mrs. North asked: be born?" For example, when ’’What has to happen before the baby can The students did not reply. asked Mrs. North. "What has to break?" "The uterus has to break." uterus, what has to break?" "No, not the "The egg has to break." "No, the egg is what the baby is now, what has to break?" The level of understanding evidenced by these stu­ dent responses indicates that these students lack a clear understanding of reproductive health. The content of the information being taught to the students not only provides them with needed factual information, it also meets the Essential Objectives for Health Education in Michigan. The presence of myself as an outside resource also contributed to the content of the class. Because I was 8-1/2 months pregnant during the observation of the Growing Up unit, I was often asked by the students and teacher to share my knowledge and experience about pregnancy and childbirth. "Mrs. H a n s e n ’s baby is to be born, how does she know?" "Mrs. Hansen, help us out, what are the two things that have to break before a baby can be born?" Mrs. North also used students’ questions as a basis for further discussion. as: Comments from the students, "I was delivered with forceps", were born Caesarian", "Both me and my brother "I heard of a baby that they d i d n ’t get out in time and they think it might be retarded", the mother is dead, such "If can the baby still live"? often prompted detailed discussion about the process and problems of childbirth. 186 A third theme present in the observations of the Growing Up unit was the students’ reluctance to ask questions and discuss reproductive health concepts and issues. reason may be due to the level of friendship, between the students. One or familiarity The students are relatively new to each other, as the restructuring of the school districts brought most of these students together for the first time. Another reason for the students' reluctance to discuss re­ productive health may be due to a historical precedent, where reproductive health was considered a very private and "non­ discussed" topic. Breaking new ground in the teaching of reproductive health may make it difficult for some students to discuss reproductive health in an open, factual manner. The health instructor discussed this problem in an interview. She said: "The hardest part about teaching reproductive health to these students was that the students did not know each other. This year they are coming together for the first time from all over town. Perhaps nudity in the films was difficult for them, but they still need to have this infor­ mation, even if they are uncomfortable at first." The next vignette, "From Girl to Woman" contains several key factors and main issues. First, the method of teaching this lesson is to separate the genders. complementary film entitled From Boy to M a n . Boys see a After the film, the girls and the boys have a discussion in their separate gender classes. Second, the content of the film and the discussion meets the Essential Objectives for Health Education for family health, and it is particularly ap­ plicable to the 6th grade girls' personal experience. Third, the content of the film and discussion is presented in terms of their own behavioral choice and decision-making. In this case, the content refers to the girls' lack of choice re ­ garding how and why they are not permitted to stay out as late as their brothers, and what choices they make to express their emotional changes. 188 GIRL TO WOMAN (GIRLS ONLY) "I've noticed that this class seems to be reluctant to speak out about issues and topics we are discussing in class. I was proud of Susie and Rosey and April, who asked some really good questions yesterday," said Mrs. North. "Maybe it's because you don't know each other very well, as you are all coming from five different schools. I want you to feel at ease to ask questions and make comments. I want everyone to think of one question, even review-type questions that you may know the answer to, that can help the class. I'll give you a plus on the health booklets for good participation. Today we are going to see a film entitled From Girl to Woman ." The film has several different adolescents being interviewed. A short summary of the main points of the film follows: • A girl can't go out and stay out as late as her brother. • One girl talks about going steady with a boy who dropped her and went back to his previous girl friend. She felt depressed and cried a lot. • We (adolescents) aren't mature enough to have relationships of big seriousness. • One girl says she is glad she is flat-chested because the guys won't be after her for her breast size. • Adolescence is a time when feelings unfold and many changes take place. • It's a time for growth spurts; boys mature slower than girls and may seem shorter, then suddenly they catch up. 189 • If you are uncomfortable with your differences from your peers, take heart, you are normal even if you have a different shape and size. • New glands are functioning, and sweat and pim­ ples will emerge. Take lots of baths and scrub face and change clothes regularly. • The physiology of a pimple is discussed. • Eat right, get lots of exercise, and get enough rest to be healthy. • The pituitary gland is the growth clock of your body; it is located at the base of the brain. It sends out hormones for sexual development. When this happens, breasts develop, body hair grows, hips get wider, and the ovaries begin to produce and emit eggs. • Anatomical description of the labia, hymen, clitoris, urethra, vagina, uterus, ovaries, Fallopian tubes. All these parts are ready for a mature egg. • Finally the egg is released from the ovary, and it travels down the Fallopian tubes to the lining of the uterus. If it does not get fer­ tilized, menstruation begins. • Menstruation cycles are usually every four weeks, often three to five weeks, and irregular at first. • Good health can help prevent cramps. • Sometimes the egg encounters sperm from the male, and fertilization occurs. • The path is traced that the sperm follows. Millions of sperm develop in the testicle, mix with fluids from m e n s 1 glands, and then are released through the penis during an erection. • An erection of the penis is caused by a muscular contraction of the penis as it engorges with blood. • During intercourse, the sperm is released in the woman's vagina. • A microscopic enlargement of sperm swimming toward an egg is shown. 190 • A fertilized egg implants itself in the uterus lining. Embryo grows and will mature into a baby. • Many changes must occur in your body, one’s feelings. especially • These changes take time. • Your feelings about boys will change; there is uncertainty, there is joy. Film ends. (About ten minutes.) "Okay," Mrs. North says as the front of the room, she moves her stool to "If I talk, I'lltake your questions a w a y ." No response--pause. "Health credits?" No response--pause. "How about the girls who were talking about their boy friend who was going with one girl, and dropped her and went back to a previous girl friend. How did she feel?" asks Mrs. North. "Depressed," answers one student. "What does depressed mean?" asks Mrs. North. "What do you do when y o u ’re depressed?" "Unhappy." "Cry." "Lock myself in the bathroom." "Okay, those are all things we can do. you feel if that happened to you, handle it?" No response. How would or if it has, how did you 191 "How many have had boyfriends already, or do have them now?" Three students raise their hands. "You may not think we know what's going on, but your teachers know who likes whom, and who your boyfriends are, we se e " "Do you think it's unusual for a 6th grader to have a boyfriend, and end up marrying him? Would you like that if you had a boyfriend now and were going to make plans to marry him?" asked Mrs. North. The majority of the class all say "no". "Why?" asks Mrs. North. "If you get married, you would get sick of each other soon and end up in divorce," says a student. Several of the students say how long their parents have been married, including one student who volunteers that her parents are divorced. Mrs. North says she would prefer not to have just one boyfriend, and end up marrying him. It was better for her to have relationships with more than one boy, could know what other boys are like. so she "How do you know what it's like out there if you only have one boyfriend?" she asks. "My Mom and Dad have been going together since 9th grade," a student says. I join in the conversation and add: "Marriage isn't always a good indication of how happy people are together. Lots of time people stay married to each other, even though 192 they aren't happy." "Yes, not everyone who is married is happy; what is the divorce rate now, one out of two, isn't it, Mrs. Hansen?" "Religion also has a lot to do with divorce; some religions are against divorce and people stay together regardless. Sometimes there is just too much fighting and they get divorced," Mrs. North describes. "Another part of the film showed the girl having to be in earlier than her brother; is that true for you? Can your brothers stay out later than you?" asks Mrs. North. "My sister had to come in a lot earlier than I do when she was my age," a student replied. "Why? Why does the girl have to be in earlier, or why can boys at sixteen drive to Florida for spring vacation, whereas girls are not permitted to do so?" "My Mom doesn't like the idea of me staying out too late." "Why?" No one replies. "Boys can take care of themselves," answers Mrs. North. "Let's say a girl in 11th grade has intercourse, and gets pregnant. She has some options as to whether or not to keep the baby, but the boy doesn't have to take the r e s ­ ponsibility. Although there are some who will, mandatory for the boy to be responsible, it is not but it is for a g i r l ." "How many girls have guys who are good friends?" 193 One student raises her hand. "What do you talk about with girls that you would only talk about with your girl friends? Not the content, but what topics do you only talk about with girls?" "Boys," says one girl. "Yes, boys, and perhaps how you're feeling about yourself, what's happening in the home, perhaps how you feel about your own developing, whether it's early orlate..." No response from students. "How many have a body part they don't like, that it's either too big or too small?" of you feel your butts are Six students raise "How many of you are size? Would you rather have Pause--no answer. "How many too big?" their hands. comfortable with your breast them small, or large like Dolly Parton?" "Small," the majority of the girls all respond. "How many of you think you will probably bepretty good looking by the time you're sixteen?" One student raises her hand. "Why do you think that?" "Well, my Mom is too skinny, and my sister is big, too soI will probably be somewhere in between." "You may be disappointed," Mrs. North says, "no matter how good we look, we are generally not satisfied." I add, "The media is of this insecurity, responsible for giving us a lot that we are not good enough as we are, 19 U in order to sell us their products." "Yes, we hear how much better we appear with that cigarette in our mouth, and it's just a gimmick," Mrs. North says. "How many of you would date and/or marry a boy shorter than you?" Five hands go up. "How many want a guy much taller than you?" "I married a man about the same height as I, and it doesn't bother us at all. If I wear high heels, he still doesn't mind even if I appear taller, he can handle that. I'm not sorry I married someone my height." "Another thing mentioned in the film was sweat and skin problems; how many of you notice extra oil on your skin?" Almost everyone in class raises their hands. "What did the movie say about why we sweat more?" "Nervous," answers one student. "Yes, and tense and afraid the film said." "How many use deodorant?" Six students raise their hands. "Well, get in the habit," says Mrs. North. "And how many wash your hair more often than you used to?" least The whole class says yes. "What did the film say to do? two times a day, and it's really oily, go see a Class is over. Wash your face at use soap and warm water, and if doctor for some special soap." 195 There were several main themes illustrated in this vignette. The most important main theme discussed was in relation to the girls' behavioral choice and decision-making. Some of the behavioral decisions discussed included: the decision of how they choose to cope with rejection and de­ pression; the decision of whether or not to wear deodorant, and to take care of their personal hygiene. Mrs. North also asked the girls why they are not given certain behavioral choices. Mrs. North asked the girls: "Why does the girl have to be in (home) earlier than the boys?" "Why does the girl have to come in earlier, or why can boys at sixteen drive to Florida for spring vacation, whereas girls are not permitted to do so?" asked Mrs. North. One student replies, "My Mom doesn't like the idea of me staying out too late." "Why?" asked the teacher again. No one replies. Mrs. North then explains that the boys can take care of themselves, but girls could get pregnant, and then the baby is their responsibility and not necessarily the boy's. The message behind this question is that the choice, to be able to stay out late and possibly engage in sexual relations, is not given to girls as easily as to boys. Girls are not being allowed the opportunity to decide for them­ selves; they must be "in" at a certain time, "safe". so they can be Perhaps what is even more implicit in this situation is that girls must learn that as they grow older, they will 196 have Increased sexual desires, and boys and men will also look to them to be a possible partner for sexual relations. Thus, they must learn to be responsible for their own sexual experiences. One question is, "what does this rule do to the girl's sense of self-responsibility?" Does the rule imply that she cannot be responsible enough to refuse sexual relations, therefore, she must be at home early, so she won't have to decide? To complicate the "message" even further, the rule to be in early may be for her own protection, because she could be forced to have sexual relations, (ie., rape). This point is emphasized because the decisions of maturity and responsibility revolve around an individual's ability to control her/his own sexual desires. The appetite for sexual experiences and relationships is very strong in the young adolescent. Our Western culture exaggerates this sexuality focus in the media, in the double standards for boys and girls, and in the advertising market to sell pro­ ducts. Everywhere a person turns, there are sexual messages that imply "if you choose a certain product, you will be sexually attractive". Mrs. North exemplifies this by her efforts to detoxify sexuality in advertising: "Yes, we hear how much better we appear with that cigarette in our mouth, and it's just a gimmick." Perhaps what the students need to believe (especially females) is that they are okay if they are without girl 197 friends or boy friends, and that they can have friends of the other sex and not be involved sexually. In the film, From Girl to Woman, it shows girls at the same age, but at different stages of physical maturity (also in From Boy to Man film). The message is: "If you are uncomfortable with your differences from your friends, take heart, you are normal even if you have a different shape." This message is trying to ease the students1 sense of self-consciousness about their differences. Learning how to filter out the messages of: "you're not good enough unless ..... " is what will make the adolescent choose a healthy, responsible life style. Also, if they have not learned this sense of self-security, their lives inevitably will be spent in search of social approval. Whether or not health education can influence the student's sense of selfaffirmation is debatable. What it can do however, is em­ phasize that the decisions the students will make will necessarily affect their health and the health of others. A second main theme illustrated in the vignette "From Girl to Woman" was the relevance of the content. Both the film and the discussion included some of the Essential Objectives for Health Education in Michigan, as well as being relevant to the student's own personal experiences. For example, when the instructor asked the girls how many felt their butts were too big, six students raised their hands. Other students volunteered how they coped with rejection and depression, and the whole class of girls agreed that they 198 had washed their hair more often. The film also included physiological changes associated with puberty, and encouraged the girls to "take heart" if they felt uncomfortable about their differences, as everyone matures at different rates, and differences are normal. A third main theme worth noting in the vignette was the various methods used for instruction. separated for the viewing of the film. The genders were The boys saw a com­ plementary film entitled From Boy to M a n . This separation of the genders allowed the girls and the boys to discuss concepts and issues they might not feel comfortable discussing in front of the other sex. Even with the gender separation, the girls were still reluctant to discuss reproductive health concepts and issues. Mrs. North was able to get the students to participate by offering them extra credit in their health notebooks, girls' and by making the discussion relevant to the own experience. The next vignette, "A Human Being is Born" contains two major themes or key factors. First, the methods used both in the film and the subsequent discussion allow the students to ask questions by recalling questions that were prompted by the film. Second, the content reflects infor­ mation that meets the Essential Objectives for Health Education in family health, and is presented in terms of be ­ havioral choices and decision-making. vious films, Unlike any other pr e ­ this film includes a very brief clipping showing an actual childbirth. 199 HUMAN GROWTH III Today's health lesson will feature a film entitled Human Growth I I I . It is the same film that was reviewed at an advisory board meeting. The film begins by showing lots of different stu­ dents running and exercising. What makes these kids grow? Glands produce hormones that affect their growth. Several boys are shown who are different sizes, but all six years old. When boys grow, they get broader shoulders and bigger muscles; girls' hips get rounder and they get taller. "What's so hard about growing up?" the film asks, and then interviews several kids who answer; "Learning right from wrong." "Problems with myself." "Problems with the opposite sex." "Don't know about the future, and I'm uptight about how hard it is out there." "Trying to understand myself." The film talks about how some religions and cultures have a special ceremony to demarcate the onset of adulthood, and then interviews some students as to whether they think it is a good thing to do. Some of the students' responses are: "No, the body and mind are not grown at the same time." "In my religion, boys have a ceremony for adulthood, but just because they are thirteen years old doesn't mean they are grown. There is a drawing of the penis and it is diagrammed 200 how sperm cells travel through the urethra and ejaculation occurs through masturbation, sleep, or sexual intercourse. Sexual intercourse is when the sperm travels from the penis through the vagina and meets with an egg cell. There is a drawing of an embryo and says it will develop into a baby. The film interviews several couples talking about what i t ’s like to be either pregnant or the father of an unborn baby. Several couples are interviewed who have decided not to have children and describe why. An actual childbirth is shown, with the baby sliding out of the mother. The film ends with several students asking questions., without giving them answers. Mrs. North takes her stool and moves it to the front of the room and begins the lesson by asking the class to recall some of the unanswered questions at the end of the film. One student replies: diabetes, "There was a question on if the mother has diabetes and is pregnant, will the baby necessarily have diabetes?" Mrs. North asks the class to answer it. One student says: "No, my mother had it and I d i d n ’t get diabetes." "Diabetes is an inheritable trait, but doesn't always show up until later." "Another question?" "Why does the woman have the baby instead of the man?" "Okay, what's the answer?" asks Mrs. North. "Because nature made it so," a student answers. "Yes, you can say that, or God made it that way, or 201 it's just our nature, but it is always true." A student disagrees, "In the seahorse, the male bears the young." Mrs. North and myself correct him and say that the female seahorse bears the young and then the male carries them in a pouch. "What other animals do things differently?" asks Mrs. North. "Certain fish chase females away and the males take care of the offspring." "Yes, sort of like the Dr. Seuss book, Horton Hatches the Egg." "Another question?" "Can a woman already pregnant get repregnated again?" "Okay, and what's the answer?" "No, because the woman doesn't produce more eggs." "Yes, another one?"/ "If a Japanese and an American mate, will the children be Japanese or American?" The students answered: "Japanese." "Both." "Combined." Mrs. North says, the two races." Mrs. North, "Yes it would be a combination of "I have always had a theory," says "that if all the races intermarried, we'd have one race that was beautifully tanned and golden. But certain traits are going to be lost, because other traits are dominant. Dominant and recessive genes means that if there is a mix of, say, brown eyes and blue eyes, the child will most likely be brown-eyed because brown eyes are dominant. "Another question?" A student replies: "If the mother is an addict, would her baby necessarily be deformed?" "Not whether deformed, but addicted," another student corrects him. "What's the answer?" "Yes, necessarily deformed." "No," replies Mrs. North, "the baby would not necessarily be deformed." "How about addicted?" asks Mrs. North. "No, not addicted." "Yes," another student disagrees. "Mrs. Hansen, help us out, would the baby be addicted if the mother were?" asks Mrs. North. "Yes," I explain, "the withdrawal just like an adult, baby would have to go through after (s)he were born." "How about cigarettes?" asks a student, "would there be an effect?" The students answer, "No effect." "Yes, there would be." "No effect, because it would stay in the mother's lu ng s." Mrs. North says, "Yes, it probably does affect the 203 baby, Mrs. Hansen, what do you think?” "Yes, I agree, the effect would be a diminished oxygen supply, because the mother's oxygen supply is affected by the smoke, which would affect the infant's air supply." "What about alcohol?" another student asks. "Yes, alcohol also affects the baby." "How about another question from the film?" "How do they get twins?" "Or only some people have twins?" Mrs. North explains and fraternal twins. the difference between identical A student tells about seeing Siamese twins joined at the head on television. Another student asks: "How do they get multiple births?" Mrs. North replies: "Most multiple births today are drug-induced via a fertility drug that women may take to in ­ duce the likelihood of pregnancy. Before the fertility drug, quintuplets were a marvel; now drugs can induce the egg to keep splitting." One student remarks was a test tube baby. that she heard about a baby who Mrs.North says that test tube babies were conceived in a test tube and then implanted in the mother's uterus, where it grows into a baby. I add that there are many parents who are waiting to have such a procedure done, but it is very new, and very expensive, and done only when the mother's Fallopian tubes are damaged or absent, and it is the only way for them to 204conceive a child. ’’Okay, one last question from the film?” "Why do the mo th e r ’s breasts start to make milk?" "You tell me," Mrs. North replies. "It's just like in a dog, when they have puppies, the milk comes." "It's because of chemicals in the body." "I read that by drinking milk when you're pregnant helps your milk to come." Mrs. your calcium North replies that milk is needed to supplement level, because the baby is growing bones and teeth and will take the mother's calcium. The vignette illustrated how the film used a new method to stimulate student participation regarding repro­ ductive health. The film featured students asking questions that all students of a similar age may wonder about, without answering them. This method allowed the instructor to ask the class to recall and answer the questions prompted by the film.As described in the vignette, the students didn't always agree with each other on some of the answers. When the question arose whether the baby would be addicted to drugs if the mother were, the students differed in their opinions. The film showed interviews with a series of people who have chosen different options regarding childbearing. By presenting different perspectives, and why they chose 205 them, the students were able to realize that sexual relations and child bearing requires decision-making and lifetime responsibility for their behavioral choice. The film also showed a graphic description of how fertilization occurs, as well as a clipping of an actual childbirth. When I interviewed four of the students after the unit was over, three out of four said that out of the entire unit, they best liked seeing a real child being born. By actually seeing what a child being born is like, the stu­ dents have a much clearer understanding of the results of their behavioral choices and decision-making. ADDITIONAL ANALYSIS OF THE HOBART HEALTH PROGRAM In addition to the vignettes, interview data and specific observations also contributed to the analysis of the Growing Up unit of the Hobart Health Education Program. The following section summarizes these findings. ORGANIZATIONAL STRUCTURE There were specific organizational structural de­ cisions that influenced the methods of instruction and con­ tent for the Growing Up unit. One of these decisions was to separate the genders of the class for separate film reviews. The girls of two classes assembled in Mrs. N o r t h ’s classroom and reviewed the film From Girl to W o m a n . The boys of two classes went to Mr. O l s o n ’s class and reviewed the comple­ mentary film From Boy to M a n . The theory behind this gender separation was to help the students to feel more comfortable discussing reproductive health issues and topics by having a girls or boys only class format. I interviewed four students as to whether or not they preferred this gender separation. following responses: but it saved time". The students had the "I didn't think it was a good idea, "Kind of yes, and kind of no, better to learn together the personal questions; it might help pr e ­ vent pregnancy". "The boys' classes dealt with boys, was good, but the filmstrips w e r e n ’t as good". student response.) 206 (Male that 207 Another component of the organizational structure was my presence as a participant observer. I feel that my participation as a resource person and/or guest speaker was also very well received and enjoyed by the students. The students asked lots of questions about my baby soon to be born, and during the lessons I partici­ pated in, some students even stayed in from their recess for a short time to ask me questions on a more personal level. Also, during the student interviews, students asked me more questions such as: being pregnant"? some of the "What is it like After my daughter was born, I returned to the class and gave a talk on what her childbirth was like. The students seemed very attentive and asked questions such as: "Did it hurt?" "How long did it take?" "Did the baby look around when she was born?" "Did her head come out first?" "What did she look like?" METHODS OF INSTRUCTION There were also several different teaching methods employed during the 6th grade Growing Up unit. Some of these methods were: 1. Films and filmstrips. 2. Using a game approach with teams and points. 3. Outlines of main points in the films. 208 4-. Letting students answer the questions in the film. 5. Health project notebooks. 6. Having the students tell stories of their personal experiences. 7. Bulletin board with health questions. 8. Resource persons, 9. Separating the genders. such as myself. 10. Anonymous question asking. 11. Special permission forms needed to be signed by the parents for students to be able- to participate in the reproductive health classes. The most enjoyable methods seemed to be (in my perspective) the end using the film with unanswered questions at asan incentive for discussion, and also myself as a resource person or guest speaker. The film with the un­ answered questions allowed the students to answer questions they themselves may have wondered about, but did not spontaneously ask. BEHAVIORAL CHOICE AND DECISION-MAKING Behavioral choices and decision-making seemed to be an integral part of the Growing Up unit for 6th grade. Stu­ dents were confronted with many decisions and behavioral choices during the teaching of the Growing Up unit. Some of the more important decisions that were discussed in the observed classes were: 1. The decision to breast or bottle-feed a baby. 2. Decision to respect other pe rso ns’ rights. 209 3. Decision of how to cope with depression and re j ection. A. Decisions to wear deodorant, keep clean. 5. Identify decisions they make that involve maturity and responsibility. 6. Realization that the decision regarding being able to have a baby and being ready to have one are two separate decisions. 7. Decision of marriage, and number of boyfriends/ girlfriends. Behind identifying a decision the students will need to make as they mature, is examination of the motivation for a particular decision. For example, the student who chooses to cope with rejection/depression by locking herself in the bathroom has a motivation for doing this behavior. it is to gain privacy, or to be able to wash away o n e ’s tears and have her crying go unnoticed. classes, Perhaps During the observed several motivations for certain decisions were also discussed. Some of these were: 1. To make their mother, father, brothers, sisters proud of them. or 2. To gain the respect of their peers. 3. Being able to earn money and be responsible as a prerequisite for having a baby. 4. To avoid pregnancy may be a motivating factor as to why parents may require girls to be in earlier than boys. 210 ISSUES For the 6th grade Growing Up unit, were discussed. Some of these issues were: not the same as love, test tube babies, several issues infatuation is the mother and baby make the baby born, not the doctor (unless it is a Caesarian birth), girls usually have to be in earlier than boys, age doesn't necessarily signify maturity, and most chores need to be non-sexist. The students' reactions to these issues varied from looking up a word in the dictionary (infatuation), a lengthy discussion about the issue. to having For example, during the discussion regarding whether a baby is necessarily af­ fected by the mother's use of drugs, of their own perceptions, several students told and disagreed that their health could be affected by their mothers who smoked during pregnancy. "What is infatuation?" the teacher asks. "If you don't like a person much, but you buy them something." Mrs. North then adds: "When I was in 5th grade, there was this red-haired boy, and I really thought he was neat. That was infatuation, not love." "Infatuation is when you give them attention when you don't really care," another student adds. Another student looks up infatuation in the dic­ tionary, and he tells the class: the dictionary." "It is foolish love, in 211 "Infatuation might be thought of as, I had a crush on him or her," Stella added. "Yes, you can have a crush on anyone, your teacher or doctor, or a girl or boyfriend," said Mrs. North. There were also some issues that were purposely not addressed. During an interview, a teacher acknowledged that abortion and venereal disease could not be mentioned at this time, and it really hindered the presentation of the full pi ct ure . The issue of the rights and privileges of others was also discussed in the 6th grade Growing Up unit. filmstrip entitled Growing and Learning it says: In a "We learn to be responsible and to respect the rights of others. learn responsibility through helping our families. twenty years old we stop growing, learning." We By but we d o n ’t stop In the discussion following the filmstrip, the teacher asked the class to recall a memory where they wanted to help their mothers. The students replied: "I remember wanting to help Mom wash the dishes." "I remember trying to vacuum the house, and I vacuummed the cat instead." "I remember trying to wax the floors while Mom was g o n e ." "I remember trying to make popcorn and spilled oil all over and made a mess." "I remember using my toy lawn mower to try and mow the lawn." 212 "I remember trying to help bake cookies." The teacher also asked the class to tell how they expressed respecting the rights of others. The students responded: "Do n't cheat!" "Don't steal from others, or take somebody else's mittens." The teacher adds, "Yes, part of growing up is learning to wait your turn. We all have to be able to wait for the things we want." One issue involved in the teaching of reproductive health is whether the level of material is appropriate for 6th grade students, Overall, and if so, how was this evidenced? the students seemed fairly comfortable with the concepts discussed in the Growing Un unit. During the discussion on prenatal development, students seemed quite comfortable. the They shared experiences of having seen animal births. During the baby's developmental stages, the students were asked to tell their own experiences and first memories— giving them considerable opportunity to apply it to themselves. During the discussion of male and female reproductive system physiology, the students seemed to feel comfortable. They were not asking many questions, but they did not behave uninterestedly either. During one of the student interviews, one student replied that learning about reproductive physiology and 213 prenatal development were the best parts. One student during the interview confided that he was a bit uncomfortable when the film showed the doctor cutting the umbilical cord of the newborn baby. student spent half of his recess (following this film) asking me to explain how the baby got food, water, the cord. This same and air through Ke thought it was directly "piped in" through the umbilical cord. Another female student replied she was a bit uncom­ fortable talking about developing in front of boys, but also said that maybe being in a mixed gender class will help prevent pregnancy. An interview with one of the 6th grade instructors gave the perspective that "the hardest part about teaching reproductive health to these students is that the students do not know each other. This year, they are coming together for the first time from all over town. Perhaps nudity in films was difficult for them, but they still need to have this information, even if they are uncomfortable at first." When asked whether the content level of the material presented seemed appropriate, the instructor replied, "Yes, these students are at a prime development point, and this information is very pertinent to what they are now ex­ periencing. Their understanding is observable in the class by their questions and answers." One of the leading psychologists in American education is of the opinion that the teaching of reproductive 214. health to young adolescents will encourage sexual experi­ mentation, increased unwanted pregnancy, veneral disease rate. Searching for and increased (Bettelheim, 1981.) evidence to this effect showed very little support of this theory. verify either support or non-support of this theory. I did ask the It would be impossible to instructor what she felt about this theory, and she replied, "The more they (the students) know, the more the students are allowed to choose. They are not trapped by not knowing what they are getting into. Some youths don't realize they can get pregnant from sexual re­ lations until it's too late. The students need to know that their bodies are their own, and they don't have to be touched in any way unless they want to be. In some years, we have also talked about sexual abuse in the home or family (not this year). It is a difficult subject, which may actually be interfering with home life. It is important for the stu­ dents to know they can c.ome to me, as their teacher, they are being touched in undesirable ways, that if that we can help." I also asked the instructor for any general comments she wished to make regarding the teaching of the Growing Up unit. She replied: "The students of today will still receive the stereotypical garbage of past generations as long as their uncles and family members--even teachers--keep telling the students the same false ideas they were raised on. An educational program like ours can only do so much to correct these false impressions." 215 PATHS NOT TAKEN (6TH GRADE) The role of reproductive health in the overall health education curriculum is in the researcher's view, essential. The students are bombarded with sexual messages everywhere they turn. of their decisions, consequences. If they do not understand the impact they are doomed to pay dearly for their Not only are the individual students going to pay, so will our society and the world at large. For a per­ son to engage in sexual relations because they are hungry for self-affirmation is often a tragic predicament. The students pay a price with their own lives, and the society pays a high price through social services and intervention measures. It is not enough that the student learns how they reproduce, they also must learn why the choice to engage in sexual relations is so appealing. Once they can see behind the motivations for their own decisions, they are more likely to make a choice with full knowledge of both the consequences and the reasons for doing/choosing their decisions. 216 SUMMARY The analysis and vignettes of the health program of Hobart focused on five key factors: ture, content, methods, organizational struc­ behavioral choice and decision­ making, and health education issues. The key factor iden­ tified as organizational structure enabled other factors or linkages to be present. The organizational structure was multi-dimensional in that it promoted comprehensive health education to the Hobart community through community inte­ gration, to the students through provision of a comprehensive health education curriculum, to the instructors through health education inservice training, and exchanged relevant health education information through state and national organizational networks. The content of the Hobart health education program was investigated in relation to the main themes generated by the curriculum, and the opportunities offered to the students to relate the content to their own personal experience. The content that was observed was recognized as meeting some of the Essential Objectives for Health Education in Michigan. The different methods used for instruction were examined in relation to what effect they had on student be ­ havior and learning. Certain methods, such as films with unanswered questions and hands-on experiences, encouraged more student participation than other methods, such as 217 watching a filmstrip. Behavioral choice and decision-making was investi­ gated as to whether the students recognized that their de ­ cisions and behavioral choices affect their health and the health of others. The presentation of health education con­ cepts in terms of the student's behavioral choice and de­ cisions allowed them to recognize that they are responsible for their own health and that their health choices affect the health of others. Issues that were investigated such as motivations for choosing non-healthful behaviors and certain aspects of reproductive health such as abortion and contraceptive health, and venereal diseases were not discussed in the ob­ served classes. Other .issues such as rights and privileges of others, double standards for curfew hours of boys and girls, and the issue of responsibility for one's health choices were observed. The five key factors of organizational structure, methods, content, choice and decision-making, and issues were interrelated in that some factors such as organizational structure and content enabled other factors of choice and methods and issues to be present. These five factors were identified as necessary for the students to learn compre­ hensive health education concepts in terms to the students' role and responsibility for their own health as well as the health of others. INTRODUCTION TO URBANDALE The next section is the analysis and ethnographic vignettes for the observations of the kindergarten health program at Urbandale. The main issues for this site center around the themes of organizational structure, methods of health instruction, and learning how to go to school. Also, the subsidiary factors of ethnic and cultural differences within the class, and sex-role stereotypes appear as minor themes affecting the students' ability to succeed in the learning of the health education curriculum. Issues that will be addressed in this section include: 1. The integration of school health services and community resources into the overall health education program. 2. The lack of health in the health education curriculum. 3. The prerequisites involved in learning how to go to school as a necessary ingredient for being successful in the health education curriculum. A- The merits and problems resulting from a teacherbased curriculum. 5. The effects on self-esteem and self-confidence that sex-role stereotyping plays. The first part of this section is a description of the background of the Urbandale kindergarten health program, followed by a description of the setting of the observations. The second part contains the ethnographic vignettes and commentary of the health program observations. Each vignette illustrates one or more main themes that were 218 219 -evident in the observations. Let us now turn to a brief description of the background of the Urbandale Health Education Program. URBANDALE SCHOOL DISTRICT The health education program in the Urbandale School District was divided into three components: a kindergarten health component, an elementary health component, and a high school component. My participation as an observer of the Urbandale School District was organized through a course on Participant Observation taught at Michigan State University by Profs. Buschman, Florio, and Erickson. I was a part of a three- person research team directed by Prof. Erickson to study and observe the Urbandale Health Education program. The director of the Urbandale Health Education program asked that each of the three researchers choose a different com­ ponent of the health project to observe. The component I observed was the Kindergarten health program. The following is a description of the Urbandale Kindergarten Health Education program. The Urbandale Health Education program for kinder­ garten students is based on two main assumptions: one, that health behavior is affected by self-esteem, and two, that health behavior is affected by health knowledge. The under­ lying assumption is that kindergarten students are in need of improved self-esteem, and health knowledge, and that the 220 Urbandale School District Health Program can contribute to improving a student’s sense of self-esteem and health knowledge. Several services were provided by the health program to improve the students’ self-esteem and health knowledge. Some of these services include: appraisal of the health status of students through regularly scheduled vision and hearing screening, health needs, counseling students and parents concerning clarifying to teachers the health needs of the students, providing a referral process for the correction of identified problems, prevention and control of disease. The mechanism in which the health program provided these services was through three main components: the teaching of a health curriculum, home visitation by student nurses, and inservice training for the kindergarten instructors. Each of these three components are discussed below. DISSEMINATION OF THE HEALTH CURRICULUM The health curriculum being implemented in the k i n ­ dergarten health program was developed by Eileen Earhart, Ph.D. This curriculum does not have a health content, but instead consists of a series of games and tasks to help the students improve their gross motor, auditory, and visual discrimination skills. This curriculum is theorized to help the kinder­ garten student improve her/his self-esteem by having success in completing the tasks of the curriculum. The students meet in groups of four or five students 221 and participate in the lesson for fifteen to twenty minutes. Because the kindergarten student's attention span is re­ latively short, the games or tasks in the curriculum do not last for more than five or ten minutes. The health lesson is organized so that half of the class of seventeen students had the health lesson on a given day. Four of the students met for fifteen minutes, and then switched with four other students after their turn was over. The teacher aide was the health instructor for all of the times I observed the health lesson. The teacher also worked with a small group of four students on reading skills during the health lesson. The remainder of the class was kept busy working at their tables. The main'issue regarding the dissemination of the health lesson was that the lesson did not have a health con­ tent. The content of the lessons were designated to help prepare the students for reading and math placement tests that are given to all of the kindergarten students. These placement tests were referred to as the IMS objectives, and the evaluation of the health project for kindergarten stu­ dents was previously based on how well students who had the health lessons compared to students who did not, on the IMS objectives. Neither the evaluation team hired by the Urbandale School District, nor the health program staff based their curriculum or evaluation on an actual health content. Therefore, to refer to this program as a "health education" program is somewhat misleading. 222 HOME VISITATION BY STUDENT NURSES The home visitation program is a joint effort of the Director of School Nurses, Coordinator. and the Health Education Program These individuals arranged for a team of stu­ dent nurses from a nearby college to conduct home visitations into the homes of kindergarten students identified as having developmental deficiencies. These visits were to obtain birth and developmental history in order to gain more under­ standing of the student's present health status, behavior, and performance. Reasons for ongoing visitation of students' homes were varied. Teachers were advised to refer students for home visits based on skill development, situations, or medical conditions. contact, behaviors, family Following a school nurse other support personnel within the school may also be summoned to assist the student. reading teacher, These personnel include counselor, bilingual specialist, community coordinator, and a multi-disciplined diagnostic team. One of the main issues regarding home visitations is the possibility of misidentifying students with developmental problems. What may be considered a developmental deficiency may actually be the teacher's misinterpretation of culturally learned pattern of performance. Once a student has been identified as being developmentally deficient, the imple­ mentation of remedial services may influence the student's self concept in undesirable ways. 223 INSERVICE HEALTH EDUCATION A second important component of the organizational structure of the health education program is the provision of health education inservice to instructors. The inservice education served to help the instructors learn how to iden­ tify students with developmental deficiencies and bonding problems between their peers and/or the instructor. Some inservice education sessions focused entirely on one student and what could be done to help the student improve her or his skills in the kindergarten classroom. Other sessions were round-table discussions where each of the health in­ structors shared their experiences with students in their classes who had developmental deficiencies. There were two main issues relevant to the inservice education sessions. One was motivation for the instructors to participate in the inservice sessions. The Urbandale instructors were compensated for their time and participation from the health project funds, and the sessions were always scheduled after the school day so the kindergarten teachers would not have to leave their classes and get a substitute. The financial compensation and the scheduling seemed to en­ courage the teacher's participation. The instructors who did participate regarded the sessions as worthwhile and enj oyable. A second issue regarding inservice education was the fact that although the instructors received the inservice education, the teacher aides were often the instructors for 224. the health lessons. Inservice education needs to be di­ rected toward whoever is doing the health instruction, whether it be the teacher or the teacher aide. Because of time and accessibility limitations, I was not able to equally investigate all three of these health program components. I instead focused my observations pri­ marily on one component: culum. the teaching of the health curri­ The other two components were investigated secon­ darily only in relation as to how they affected the imple­ mentation of the health curriculum. URBANDALE RESEARCH QUESTIONS 1. What evidences of health behavior does the health curriculum profess to teach? 2. How can these health behaviors be identified and measured? 3. Do the teacher training inservice programs for kindergarten teachers help them to identify health behaviors which may be affecting the student’s ability to learn? (self-esteem, bonding) 4. What additional factors seem to be affecting learning during the activities of the health curriculum? 5. Does the information from a school nurse visit change the manner in which the student is exposed to the health curriculum? 6. How do particular students who are identified as being target learners behave in the classroom? Do these students seem to be able to have a positive bond with the teacher? Other students? What is their behavior like during the health lesson? The different components and the expected outcomes of the Urbandale Health Education Program for kindergarten students is illustrated in the following diagram. fo s iriv t H caH h Bch/[\/ioft5 • selfesteem • leadership • Safety • Conceptoali-eati’o/v SKilh • ConfFioence HeAlfh Project • ObnpirM with teacher t StAFF EARHflRT students KlNpeR^ARTCN Carricolorti f U /P HfALTfl HFALT BEHAVIORS CLASSROOM ACTlV(Tit5 IMSERYICE Trt/ViNiNq N) ) A U i NURSES Ho me v is it s FIGURE M Urban4o./e Kindergarten Health Project 226 DESCRIPTION OF THE SETTING The field observation was conducted at an Urbandale School District elementary school situated in the center of a renewal project underway by the city of Urbandale. The community surrounding the school contained several low-income families who were being forced to move because their houses were condemned for renovation. The environment around the school also contained a large power plant which frequently expelled noxious smelling fumes to the area. The classroom I chose for study contained approxi­ mately 17 kindergarten students, teacher, teaching assistant, and a student teacher who was present occasionally. The racial content of the classroom consisted of: 3 Black 3 Hispanic 1 Oriental 10 White The teacher and teacher aide were both white women in their last year of teaching prior to retirement. teacher was a white woman, The student considerably younger. The classroom was set up as is shown in the diagram. The room contained six tables with approximately three stu­ dents to a table. Large group classroom activities such as seat work predominantly took place at the six tables, group discussion was often done on the carpet, and small group activities, two corners, including the health curriculum were done in the one with a table (A) and the other with chairs behind the piano (B). Z? -Q> C 50 m PI **30 StORAQE e a r e a 2 5 * $ tn S % o 50 T> m o rn -£ft 2t» 59 319*0. **gM 0 q atm ro o m VlMK <• CuUkuWDC TeACHeri Aioe DESK [ 227 r~ m > 228 The first vignette of the Urbandale Health Education Program illustrates what a typical day is like for a kin­ dergarten student. Throughout all of the Urbandale vignettes there are two target students who are featured: Carlos, and Raymond. These students were selected for pa r­ ticular focus because the kindergarten instructor requested additional information on these students. There are three key factors evident in this vignette. First, the wide range of kindergarten activities requires that the students understand verbal and non-verbal cues that signal appropriate behavior. In essence, the stu­ dents must learn how to go to school and what their roles and obligations are. Second, the methods in which the two teachers and students use to relate to each other show a strong sense of bonding. Third, the organizational structure of the health class enables only half of the students to get a health lesson on a single day. 229 A At DAY IN THE LIFE OF A KINDERGARTEN STUDENT 12:15 pm. the bell will ring, and just a minute before that Carlos comes in the front door from the hallway. Mrs. Smith, the teacher, reprimands Carlos and asks him to come in through the outside door with all the other students. For the next few seconds, Carlos gets a chance to tell Mrs. Smith what he did the night before. with very long, shoulder length hair. Carlos is small, He is wearing glasses, and is acutely cross-eyed. All of the children enter boisterously and im ­ mediately take their coats off and take their seats at one of the six round tables at the edge of the room. awaits their attention, Mrs. Smith and then goes over to the "leader chart" hanging on the wall and asks the class to tell her who thenew leader is new leader for the day. Each day the name of a is chosen, and the name of the student who will be the leader the following day are both placed on the chart. Each student gets a turn to be the leader. Mrs. Smith then goes over to Ronald and asks him to count with her the number of students who are present in class today. Together they count to 16, one student is missing; it must be Patty. Mrs. Smith then asks several of the students to practice counting to 16. Mrs. Smith then walks across the room to the chalk board, and awaits their attention for the lesson on the 230 number "8". Mrs. Smith, "Oh, how I like to see everyone's eyes," says calling for their attention. Mrs. Smith calls on several students during the next five minutes to help her draw the numbers they will be studying today. Mrs. White, the teaching assistant, begins to pass a worksheet to each student, with the numbers on it that they will be studying. For the next 20 minutes, the students all begin to color and work on their worksheets. As the students are finishing their papers, and b e ­ coming restless, Mrs. Smith goes over to the piano and begins to play. This music is a cue for the students to put away their papers, and to come and stand on their designated square surrounding the big carpet in the middle of the room. The students then march, skip, hop, to the appropriate music. jog, or walk according Carlos has not joined the group yet; he is still working on his paper with Mrs. White. After about five minutes of music, Mrs. Smith goes over to the ABC board next to the piano and asks the class to sit on the carpet in front of her (in their assigned spot). Mrs. Smith then takes a pointer and asks one of the students to point to the right letter as she goes back to the piano and plays the ABC song. The kids all sing, while the stu­ dent points to the right letter of the alphabet. Then the leader for the day goes over to the flag and the class all stands and says the Pledge of Allegiance. sit down and do a singing, of the alphabet board.' The kids again clapping exercise on the letters Each student with his or her name 231 beginning with that day's letter group gets up and puts his name tag on the letter board. After about fifteen minutes of questions about the alphabet, the students sing another song, and it is time for "show and tell". Three students get to give their "show and tell" each day. The rest of the class tries to guess the object. "Show and tell" lasts about fifteen minutes and then Mrs. Smith holds up an object cut out of construction paper (a house) and asks the class to tell her its shape. five minutes of questions, After it is time for milk and crackers. The class returns to their seats at the round table for snack time. Snack time lasts another fifteen minutes, and as they finish their snack, Mrs. Smith and Mrs. White hand out another worksheet. Not all of the students work on the worksheets. Four students go with Mrs. Smith, Mrs. White, and four students go with to have a small group work session. time for the health lesson. This is the For the next fifteen minutes, the two small groups and the remainder of the class each do a separate lesson. After fifteen minutes a shift change is called, and the students who were in the small groups go to their seats at the round tables, and the students who didn't have small group go to their lessons. typical day is as follows: The schedule of a 232 12:15 12:26 12:27 12:33 12:4.0 12:43 12:53 1:00 1:07 1:10 1:15 1:30 1:50 2:03 2:08 2:37 2:55 Bell rings, kids go to tables and do leader chart. Chalkboard exercise. Questions on the numbers. Students all work on papers for ’’numbers of the day” . Students busy working. Students getting restless. Students finish paper and line up around carpet. Students go to ABC board. Interruption--principal comes to door with new student. Pledge of Allegiance. Names are being placed on letter board. Kids sing a song, and "show and tell" begins. Milk and crackers--snack time. Students work on drawings. First small group is called. Shift change, second small group is called. Bell rings, end of the day. The strong level of bonding between the teacher Mrs. Smith, and the student Carlos, was evident in the way Carlos enters the classroom early from the hall in order to have a private talk with Mrs. Smith. The students are sup­ posed to enter the classroom from the outside door, but Carlos always enters from the hall. noon's activities, Throughout the after­ the students experience a continual series of rules and regulations, which guide their school-going behavior. Certain songs on the piano cue the students it is time to play a game, or sing their ABC song. The leader-for- the-day has particular roles and obligations by virtue of her/his position. The students go through a complex maze of verbal and non-verbal cues that help them know their appropriate behavior. The organizational structure of the health lesson 233 establishes that only half of the seventeen students have the health class on a single day. Each lesson has four or five students who attend the small group lesson for approximately 25 minutes. LEARNING HOW TO GO TO SCHOOL Learning how to go to school was identified as a main theme for the Urbandale health education program. All aspects of the health program: inservice education, home visitation, implementation of the health curriculum, and overall success in the classroom depend on the student’s ability to understand and perform the appropriate activities required in the classroom. The students must learn how to conform to the rules of the classroom, such as answering a question when called on, responding to non-verbal cues, being attentive, following directions, being socially ac ­ ceptable to o n e ’s peers, performing tasks when told to do so, etc. All of these behaviors must be learned for a child to have academic success in school. In kindergarten es­ pecially, learning how to go to school is a critical step in a student's future of academic success, trust in the school (teachers), self-esteem building, and optimal body functioning. When a five year old enters the classroom, par­ ticularly a multi-racial, the classroom observed, low-income, urban school such as the student comes in with a vastly different pre-school education. and some are very passive. Some students are aggressive, Some don't speak English, or have 234 proper nutrition, and some students, particularly minority students, have a culturally shaped interpretation of the world which is not comparable to the demands and behaviors expected of them from the school environment. The results of this enormous variety of student backgrounds is that some students find the roles and obli­ gations of school a totally alien world from what they have previously known. Some students are understandably insecure and have difficulty conforming to the requirements of the academic environment. The time it takes for these students to "bridge the gap" between themselves and their peers varies for each individual. Crucial to this process is the student's ability to bond with her/his peers, and with the instructor(s ). The students who can form positive esteem-building relationships with the others have an improved chance for learning how togo to school and ultimately improving their self-esteem. As will be seen in the vignettes, there were several students identified as having difficulty learning the appropriate school behaviors. In particular, my observations of Raymond and Carlos point to the conclusion that a student's ability to learn how to go to school is a critical step in the pro­ cess of being successful, both academically and socially, in the school environment. The response of the teacher and the health program staff seem to be to label these students deficient, when actually, the student's deficiencies are differences in 235 cultural interactional competencies. Having different cul­ tural and ethnic definitions of what is appropriate is not the same as having mental and physical deficiencies. The institutional response to these students however, has been to treat them' as deficient, and in need of special services. The impact on the students of these remediation efforts is unclear. The next vignette is an introduction to one of the target students: Raymond. Raymond has been identified by the instructor as being a possible retainee for repetition of kindergarten. Raymond has continually demonstrated that he does not understand several of the roles and obligations of kindergarten. In this case, Raymond doesn't follow the proper rules of hand-raising for answering a question. In his behavior, Raymond shows that he seeks teacher approval very intensely. however, Further analysis of Raymond's thinking shows that he may not follow all of the rules, but he is sophisticated enough to read behind the lines. 236 THE WEEKLY READER Mrs. Smith begins the d a y ’s work by discussing the Weekly Reader called "Zip". "And do you know who we are going to read today?" asks Mrs. Smith. They begin with the initials J.B." shouts. "What is his name? "Jelly Bean!!" the class "The name of this worksheet is Jelly Bean Jamboree. Can you say this?" asks Mrs. Smith. I am focusing on Raymond intensely; he is watching Mrs. Smith, and is following the discussion attentively. Raymond lips the words "Jelly Bean Jamboree" to himself while the other kids say it or think it aloud. Raymond is a tar­ get student by the observer because of comments from Mrs. Smith that she would like more information on him, as he is a potential retainee. His gross motor skills have been poor, he has not been able to write his name correctly or color and stay within the lines. students in the classroom. He is slower than other Raymond has tried to answer several questions but has not succeeded in saying the right answer. Mrs. Smith explains to the kids that this Weekly Reader can come to the students' house during the summer, if their mothers say it is okay. The students are asked to take home to their mothers a subscription notice, and maybe their mothers will let Zip visit them at home this summer. asks, "How much does it cost?" Raymond Mrs. Smith takes a second look at Raymond and replies somewhat hesitantly, "$3.00". 237 Raymond may not at all times be able to get the cor­ rect answer, but he has realized from Mrs. Smi t h ’s language that when she says "mother has to decide whether Zip can visit you at home", what it really means, is that it depends on whether or not mother is willing to pay for the subscrip­ tion. Raymond was the only one to verbalize this assumption. Mrs. Smith continues to quiz the students on the pi c­ ture on the cover of the Weekly Reader. the letter "T" in this picture?" and gets called on by Mrs. Smith. Mrs. Smith asks Raymond, with?" "What starts with Raymond raises his hand "Beaver", he says. "What letter does Beaver start Raymond shakes his head "no". Mrs. Smith points to a tennis racquet and asks, "What is this object?" "Tennis racquet", the kids' shout. Then Mrs. Smith points to the shoe on Z i p ’s foot and asks the students to tell her what about this object starts with the letter "T". shout: Raymond starts to "Socks!! Foot!!"..but doesn't get the right answer. Mrs. Smith has to tell them she wants to hear "tennis shoe". Next, Mrs. Smith points to the piece of luggage Zip is carrying. "What about this starts with a "T"?" guesses the right word, which is "tag". to his shoes?" "What begins with a "T"? after a few wrong guesses. on this question. Nobody "What does Zip do "Tie" they answer Raymond has answered correctly During the question and answer period b e ­ fore Mrs. Smith lets them color and circle the objects which start with a "T", I have noticed that Raymond keeps raising his hand to answer the questions asked by Mrs. Smith. When 238 Mrs. Smith calls on him, he doe s n ’t know the answer, yet he keeps raising his hand; he doesn’t take it down, even when he is called on. Raymond has shown that he does not understand that when he has an answer to the question being asked, when he must raise his hand to get called on. that is When he gets the "floor" he no longer needs to raise his hand. Raymond behaves like he is very anxious to get the floor, and to succeed by answering the questions correctly. Even when he does not know what is being asked of him, he still raises his hand to be called on. when it is appropriate Raymond has not learned to know (in the tea che r’s perspective) to raise his hand, and to subsequently get the floor, and to be prepared with an answer to the question. As could be seen from the vignette, Raymond demon­ strated that he doesn't understand the appropriate roles or format of question and answer time. Repeatedly, Raymond raises his hand to answer the teacher's question, and when he gets called on, he doesn't have the right answer, yet he does not take down his hand. Learning how to go to school is one of the main issues evident throughout the Urbandale Health Education Program. The kindergarten students must first learn how to go to school with all of its rules and cues, before the student can be successful in any subject content, including health. Although Raymond has difficulty being successful 239 during question and answer time, he shows conceptual superiority over his peers by understanding that when the teacher says "If your mother says it's okay, Zip can visit you at home this summer", what she really means is if your mother is willing to pay for a subscription, Zip's worksheet will be delivered to your house during the summer. Raymond understands this implicit meaning, and demonstrates it by asking Mrs. Smith "How much does it cost?" Raymond shows that he understands that money is involved in a subscription, and that Zip doesn't just appear if mother says it's okay; she must pay for it. Now let's take a look at how Raymond behaves in the health lesson. Two factors will be evident in the next vignette. First, the methods used to teach the health lesson allow a much less formal teaching format. Raymond had much more success in this format than in the methods used for the question and answer lesson. Second, the organizational structure of the health lesson is represented by the fact that the teacher aide, Mrs. White, is the instructor for all of the observed health education lessons. Third, the content of the health lesson is not a health content, and does not meet any of the Essential Objectives for Health Education. 240 RAYMOND IN THE HEALTH LESSON "What shape is this, Raymond?" answers correctly. "A square", Raymond There are four seated at the square table with Mrs. White and myself. Mrs. White goes over the design each student has before him or her, and asks each one of them "What color is this square?" questions correctly. Raymond answers his I am watching Raymond put his blocks on the design to the matched color; I notice he has done one row of his four rows incorrectly. "Can you look at that really close, Raymond, and find one that is a little dif­ ferent?" Raymond finds that one of his rows has a block with the wrong color up and corrects himself. On the next design, Raymond again has trouble getting the blocks to match the colors on the design. He is helped again by. Mrs. White, and gets them on correctly. Frequently Raymond is able to do his design correctly except for one small error, which he can usually figure out by himself after he has been told there is a mistake. In the health curriculum format, the children do not have to raise their hands, and get called on, but instead work openly with the teacher aide, and can ask and be asked questions without the formality of formal classroom "floor" space. Raymond seems to be more able to succeed in this format, although the content which is being asked is also different. He may simply be more comfortable with the in ­ formal small group format, or he may understand the 241 information better, or both. What is apparent in both for­ mats is that Raymond is trying to succeed. and seems eager to do his lessons correctly. He pays attention Perhaps what is more evident than his lack of content knowledge, is his lack of understanding of how to express what he does and does not know. As could be seen in the vignette, Raymond is more at ease in the small group format of the health lesson than in the question and answer time with the entire class. The small group format allows Raymond to show his abilities through his work in a non-competitive atmosphere. This con­ trasts to the question and answer time where he has to com­ pete openly with his peers for the "floor" and the correct answer. In the small group format, learning how to go to school is not as demanding a situation. The appropriate roles and obligations of the health lesson seem to be more easily understood and accomplished by most of the students. This allows more time to be spent on the content of the lesson, than on the mechanics of how to demonstrate mastery or understanding. The content of the health lesson is not health at all, nor are any of the health lessons for the kindergarten students. Instead, the curriculum consists of exercises for academic readiness. The curriculum is designed to allow the students to progress at their own pace, and be successful in achieving the tasks. This success is theorized to help the 2U2 student increase her/his sense of self-esteem. The teacher aide is the health instructor for all of the health lessons observed, yet, the teacher was the one who participated in the health education inservice education. The organizational structure of the health education and/or inservice may need to be adjusted so the inservice is given to the health instructor. The next vignette illustrates several major themes. First, the health lesson does not have a health content, i n ­ stead it is a lesson in visual discrimination and hand-eye coordination. Second, one of the students, Sonja, has little understanding of what she is supposed to do. Her lack of English comprehension prohibits her from knowing how to ful­ fill her roles and obligations in the kindergarten classroom. Third, the ethnic and cultural differences of both Sonja and Carlos may be a major reason for their lack of participation in the designated tasks. Fourth, the bonding level between the teacher aide and Carlos and Raymond seems to be quite positive. As can be seen in the vignette, both students seek Mrs. White's attention and approval in different ways. Fifth, the methods used to implement this curriculum re ­ quire a teacher for continuous coaching and encouragement. This "teacher-based" curriculum would not be as effective if the teacher or teacher aide were not present. For this curriculum to be successful in building student self-esteem, the teacher must give each student positive esteem-building 243 feedback. As can be seen in the vignette, this task can be quite difficult, particularly when the students are disrupting the lesson. 2U THE HEALTH LESSON The health lessons begin, and seated around the small table are Mrs. White, the teacher aide, Raymond, Sonja, and myself. us. Carlos, Clayton, A tape recorder is on behind The lesson is to take colored blocks and place the ap ­ propriate block on the design sheet in order to match the pattern. "First, will you take all the blocks out box?" Mrs. White asks. "Tell me what color this very top (of your design) "Re::d" says Carlos. this is? Carlos?" "Clayton, can you tell me what color Everyone try to find a different color". to fill in the colors. At first, good, there is not much talking. Raymond? is at the After a long pause, All four students get the same design to begin of the concentration is "What shape is this, What is this?" asks Mrs. White. replies correctly. "A square", he "What color is this Carlos?" answers "blue" correctly. copy and Carlos "Raymond, what color is this down here?" Mrs. White again asks. "Yel::low" Raymond drawls. "What color is down here Carlos?" "Purple" he responds. "Well, that's close to purple, but we are going to call that blue". "Can you real::ly put those blocks on very quietly for me?" Mrs. White asks. As I watch them do their work, of his rows wrong. Carlos has done one Raymond also has done one row incorrectly. 2 K5 "There's no need to talk, let's see who can get done really good". Clayton has also done one row wrong, but Mrs. White doesn't catch it. Mrs. White sees Raymond's mistake, and asks him to find it. it himself. Raymond finds his mistake and corrects Everyone but Sonja has finished his design, and Mrs. White hands out another design to work. "Will everyone take his red and white blocks? everyone got one?" Okay, "Can you find a red and white one Sonja?" "Okay, put the red on the left hand side, upper left hand side." "Sonja, honey, can you find a red and white block? Can you turn yours around so the red is up here?" Sonja is a Vietnamese child, and doesn't speak or understand English very well. She has been recommended for bilingual education, but her mother refuses to let her because of a domestic problem in the family. "Okay now, we are going to put the white side at the top, and right next to it the red, the top." Carlos is tuned out and is not paying attention to the exercise. at the top, so the white half is on "Carlos, Carlos.... you put the white side see if you can turn it around so the white side is on the top". "Can you do that Clayton?" (referring to Clayton's success). "He's got it!" Sonja is not understanding the task, and Mrs. White is directing her; meanwhile Carlos is busy making a tower out of his blocks, and not paying attention to the task. Raymond and Sonja are both having trouble and get help from Mrs. White. his tower, and then CRASH!! Carlos keeps building the blocks fall over on Carlos' and Clayton's design. "Carlos, you let those down quietly?" uh, uh, (a tonal no), car. Mrs. White then works with Carlos, block by block, and helps him finish his design. Sonja is also making her design different from the assigned one, but Mrs. White doesn't say anything to her. hands out a new design to everyone. Mrs. White The new design is to replicate a red cross on a yellow background. Mrs. V/hite wants to see if they can do the design without her coaching them. "I'm going to see if you can make your design just like this one, and I'm not even going to talk this time; I'm going to see if you can do it." Within a few moments, maybe A5 seconds, Mrs. White begins to prod Raymond and Sonja without paying much attention to Carlos. into his own world, ject. Carlos drifts off and is not working on the assigned pro­ Carlos is far behind the other students and decides to put his blocks away into the box in which they came. As he is halfway through doing this, Mrs. White asks all of the kids to start working on another design. Carlos then decides to take the blocks out of the box, and begins working on the assigned design. Mrs. White tells them this is the design that calls for using the blocks with the diagonals. Sonja decides she has had enough and starts to leave the table. She isn't sure of herself, and comes back to check and see if she can leave. "You all done, Honey?" "Yes, you can go, just put your blocks back in the box," said Mrs. White. Carlos meanwhile is playing with some leather pouches on the floor by the table. Raymond is working on his design and 247 seems to get it right with enough time. Carlos is the last one to finish, and he has taken approximately nine minutes to finish this design. The students have a few minutes left before the class is over, so Mrs. White lets them build towers and piles with their blocks. blocks away. Then it is time for them to put their Carlos has put all his blocks away in the box with the yellow side up except for one block. Mrs. White to look, and she responds: last one yellow too, Carlos?" He asks "Can you make that Carlos turns the one block around so now all are in the box with the yellow side up and shows it to the teacher. "That's very good, Carlos". Mrs. White turns to me regarding the tape recorder: "Did I do all right?" "Yes, that was great.... I hope taping it didn't bother you...." "No, No! I just hope it comes out alright." Throughout the lesson, Mrs. White carefully tries to encourage each of the students to succeed in their tasks. Carlos in particular frequently tunes out the lesson and drifts into his own world. Several times, Mrs. White has to speak to Carlos to encourage his participation. Carlos seems to succeed when he is coached on a one-to-one basis, but only works hard when he is being surveilled. Sonja understands very little English and does not grasp what she is supposed to be doing. These two students, Carlos and Sonja, demonstrate that their success in the health lesson, or lack of it, may be due to cultural and 24-8 ethnic differences in their perceived roles and obligations. Each of the students participating in this lesson have their own level of success at completing the assigned tasks. Clayton seems to be able to figure out what is ex­ pected of him and has little difficulty completing the tasks. Raymond is able to figure out what he is supposed to do, but has considerable difficulty succeeding. However, Raymond is persistent and is able to complete the.tasks with some assistance. Carlos seems to understand what he is supposed to do but is not able to remain attentive to the task. Eventually, with considerable assistance from Mrs. White, Carlos is able to complete the tasks. It seems as though Carlos repeatedly strays from his exercise and deliberately misbehaves, building a tower out of his blocks). (ie., This misbehavior usually results in one of the teachers giving him special attention to complete the task. My observations of Carlos suggest that he is able to figure out the tasks, but he craves teacher attention, and knows that his lack of atten­ tiveness will reward him with extra one-on-one attention. One of the teachers said that as she was reprimanding Carlos for being too slow, he turned to her and smiled and said: "I love y o u " . Perhaps some background information on Carlos would be helpful. Carlos is one of several children of an Hispanic family. His mother is pregnant with her fifth child, and in not very good health. Carlos has an older brother repeating 1st grade; Carlos is repeating kind er ­ garten. Carlos is often late or absent from school. severely cross-eyed, and needs surgery. wear glasses, long, He is He is supposed to but does not always do so. Carlos has very shoulder length hair which often gets in his eyes. Carlos' father is unemployed, well to people. Carlos' illiterate, and doesn't relate mother carries the burden of the family with her, and is the stronghold for the family. Carlos' mother was pregnant for Carlos, carrying the baby to term. if Carlos survived, When she had difficulty She made a promise to God that she would never cut his hair. The house Carlos lives in is condemned for urban r e ­ newal, and the family must move. However, luctant to move out of the neighborhood, the family is r e ­ because they like the school. Several of these details about Carlos' home life were obtained through a student nurse home visitation program that is part of a School Health Services and Health Education Program cooperative effort. This cooperative effort was initiated by the Health Education Program Coordinator, and the Director of School Nurses. These individuals arranged for a team of student nurses from a nearby college to con­ duct home visitations into the homes of kindergarten students identified as having developmental deficiencies. The stu­ dent nurse's role is to serve as a health resource for the s t ude nt ’s family, and to obtain background information on 2.S0 the stud ent’s home environment that may be helpful for the teacher. The student nurse works under the direction of the school nurse, and reports to the Health Program Coordinator, the student's teacher, and the school nurse during periodic inservice meetings. These meetings focus on the home en­ vironmental problems that may be contributing to the student developmental deficiencies, and what assistance the health program can provide to the student and her/his family. There are several issues that are evident in the home visitation program. The first issue is the process of identifying kindergarten students who have developmental d e ­ ficiencies or developmental lags. This process is initiated by the kindergarten instructor, who may refer the student to a number of school professionals such as bilingual spe­ cialists, speech therapist, reading aide, etc. One problem with this process is the misidentification of students with developmental problems. What may be considered a develop­ mental deficiency may actually be the teacher's misconception of the student's cultural definitions of appropriateness. The student's definition of what is appropriate is a cul­ turally shaped identification of learned roles and obli­ gations. The student's cultural definitions of appro ­ priateness may not match vhat, is expected of the student in the school classroom. Thus, the student must learn what is expected of her or him in order to succeed in school. essence, In the student must first learn how to go to school 251 before being able to be successful in school. A second issue evident in the home visitation pro­ gram is that once a student is labeled as having a develop­ mental lag, or as being deficient, when it is actually a misinterpretation of cultural interactional patterns, the treatment (s)he receives may severely alter the student’s sense of self confidence, and self-expectations in un ­ desirable ways. The student's self concept as deficient, slow, becomes rooted, and rewarded. or The treatments for the student with perceived developmental deficiencies may exacerbate the problem. A third issue regarding home visitation is the philosophical question regarding the limits of school res­ ponsibility for the student's well-being. The student's home environment may be a contributing factor to a student's academic deficiencies, but it is questionable how much a home visitation program can improve the home environment and/or the student's ability to excel in school. The possibility of negative consequences also must be examined. The following vignette describes an inservice education meeting between the health program staff, the Director of School Nurses, the student nurse who visited Carlos' family, and Carlos' teacher. The purpose of this meeting was to discuss the findings of the student nurse's visitation to Carlos' home. 252 The vignette will illustrate two main themes. First, the organizational structure of the health education pro­ gram has enabled this meeting to be organized. The teacher, school nurse, a student nurse, and the health program staff are trying to determine what community and program resources can be summoned in order to help Carlos' family cope with their difficulties. A secondary theme is how a student's home environment and cultural background can affect the student's ability to succeed in school. As will be seen in this vignette, Carlos' home environment places physical and emotional stresses upon Carlos and his family that affects his health, his ability to learn, and how he views the world. 253 INSERVICE EDUCATION: INTEGRATION OF SCHOOL HEALTH SERVICES "Mr. Altesco (Carlos' father) paralyzed," said June. seems to be totally "He cannot relate to people, he is very withdrawn to strangers. Mrs. Altesco is having to carry the burden of the whole family alone." is sick and needs rest." "Mrs. Altesco "Can't somebody step in and handle the family for her?" asks the Health Project Director. "Well," says June, "I don't think she would stop worrying unless she handled everything." "My role," said June, "is to help them get through this until the baby is born." they move away from the school, "If they will be unhappy." "Maybe Mr. Rose can help them get a house in this area," the school nurse says. June replies, "The houses next door, 203 and 204, have also been moved or sold. Mrs. Altesco says their house has been sold, and is scheduled to be torn down, but I checked the record of the city and the city did not acquire it. I also checked the register of deeds, and they did not have a record of acquiring it either. I asked Mrs. Altesco if I could ask the landlord what is going on, but she asked me not to. The family is supposed to be out of there before April 1, but they want to move before March 20, when the baby is due". The Health Project Director and the school nurse discuss how they can contact the urban renewal office and get some help. "The property is supposed to be divided up 254 to lower the population density," said June, nurse. the student "Bugs and roaches are still a problem in the home; the kids catch them and play with the roaches. The kids d o n ’t see it as a problem, but Mrs. Altesco says she d i d n ’t want them crawling on the new baby." asks, "Do they want to move?" kindergarten teacher says, The Project Director "Yes," June replies. The "It's going to be really impor­ tant to know which houses are going to be demolished. should get the names of the landlords, You Mr. Rose can help you. " During a time when Mrs. Altesco was in the hospital with eclampsia, June visited the family. Mr. Altesco's mother was taking care of the children, and Mr. Altesco was showing no signs of motivation. when I got there," June said. "All the kids were sick "They all needed throat cul­ tures and I suggested they all go to a doctor." "I also went to see Mrs. Altesco in the hospital and talked to her about getting the kids a doctor appointment. No appointment was available at the clinic." The school nurse asked if there was any equipment for the baby. June said no, and it was suggested that she contact the organization called "Operation Stork" and "Faith in Action", to help get the needed equipment for the baby. "This family certainly sounds beyond the take home toy stage" said a member of the Health Project Staff committee. June asserted that when she was at C a r l o s ’ home, both he and his brother were very well behaved, and urged very strongly that 255 the parents love their kids very much. June asked to speak to the teachers of the kids to find out how they were doing academically. She suggested there might be a language pr o­ blem, because Carl os ’ family speaks only Spanish at home, and this may be why the kids are slow academically. Mrs. Smith, head, Carlos' teacher, says as she shakes her "He's going to have trouble the whole way through." June says she will be'with the family until school gets out in June. "I've only had one visit without a crisis." The conversation then shifted to Mr. Altesco, and suggestions were made to help him improve his skills. him a third grade packet it will help." language problem?" asks June. replied Mrs. Smith. "Perhaps by giving "Do the kids have a "No, but gross motor skills," "Carlos wasn't toilet trained until Headstart." As the meeting was closing, June said, "Mrs. Altesco asked, me if she could have my phone number in case she moved." As could be seen in the vignette, Carlos' home en­ vironment places considerable constraints on his ability to relate to a kindergarten classroom. guage spoken is Spanish. In his home, the lan­ His mother is ill, and his father is unable to fill in for his mother and function adequately. The house Carlos lives in is condemned, and is considered a health hazard. The family seems to go from crisis to crisis and has not been able to meet their needs adequately, let 256 . alone provide a home environment conducive to academic achievement. The health program has provided an organizational structure that has enabled several community resources to be contacted and mobilized to help Carlos’ family overcome tre­ mendous social, physical, and emotional barriers. The stu­ dent nurses' visits have been a source of emotional support for Carlos' mother, as well as a mechanism for informing Carlos' teacher of his personal life circumstances. Carlos' lack of participation in kindergarten ac ­ tivities and his apparent developmental lag needs to be viewed in the context of his home environment, and physical, emotional, and social differences. mates, Compared to his class­ Carlos may seem slow and' apathetic. Yet, when his home life is considered, his achievement may be quite sub­ stantial. The organizational structure of the Urbandale Health Education Program has enabled a much more wholistic understanding and intervention into the health and education Of the kindergarten students. The last vignette for the Urbandale Health Education Program features three major factors or themes. First, the methods used to play the card game seem to generate conflicts between the students (regarding who will be chosen to play next), boredom, and discipline problems. Second, the in­ structor gives one of the students, Patty, a very strong sex-role message that is supposed to cue her on appropriate social-school behaviors. This message suddenly backfires when Patty begins to sing a song with strong sexual im­ plications. Finally, the instructor changes the rules of playing the game that motivates the students to improve their attention and participation. Third, as all of the health lessons in this curriculum, the content of the health lesson does not contain a health topic area. 258 ANOTHER DAY IN THE HEALTH LESSON I arrive a bit late to the lesson. table is Mrs. White, George, Seated at the Susie, Patty, and Harry. The game underway is to draw a card from a deck and if the two shapes on the card are alike, they go in the "alike" pile, if different, they go in the "different" pile. drawer chooses the next player. George picks two rectangles alike and puts them in the correct pile. triangles alike and does the same. to easily get the correct pile. "How many sides does "Three" Patty replies, as the kids keep Susie picks two spools on her card. are those called?" asked Mrs. White. answer. The students seem Mrs. White senses this, and asks some questions to stir interest. drawing cards. Susie draws two Harry draws two circles alike, and puts them in the correct pile. a triangle have?" Then the No one knew the right "Spools", Mrs. White finally answers. going to pick someone to go next..." sad," says Mrs. White. "What "Now Susie's "Harry, don't make me Harry was not paying attention and was looking around behind him. "Oh Harry, I'm sad, I don't think you want to play our game." Harry stops misbehaving. Patty didn't get chosen to pick a card and is upset. She says in a vicious voice: The "Harry already had a turn!" next round Patty got picked to draw a card and Mrs. White says: "See Patty, you were a little lady and he picked you." "That sounds like a lady now." looking our way." "Oh Harry, I'm glad you were "What is that object?" asks Mrs. White. 259 "Half a circle," George answers. says Susie. "What color?" "Yellow," Harry is looking anywhere but at the game. H e ’s looking at the wall behind him, then he talks about an ob­ ject on the floor. talk!" "Harry, we're having our game--don't Harry stands up and starts to lean over in his chair. "Harry, please sit down!!" says Mrs. White emphatically. don't want you to fall." Harry sits down. "Patty, how many sides to a square?" says. "I "You'd better look again." "Three" Patty It's Susie's turn and she gets her card right, then she chooses George. Patty turns around and starts asking a question about the rockets pasted to the wall. Mrs. White tells her to pay attention to the game instead of the wall. gets angry again. George chooses Harry and Patty "George already had a turn," Patty says. "We're all going to have lots of turns," says Mrs. White. Patty bows her head, turns away from the table, lips out, crosses her arms, and shrugs. on the next round, Harry chooses Patty she brightens up, pays attention, draws two lollypops alike. "Come here, sticks her and Patty then begins to sing: come here, my lollypop girl".... This song sounds like a sexual song and catches both my and Mrs. White's attention. Mrs. White looks twice at me with the type of look that says "Oh Oh,..." George is next and he chooses two boxes. do they go in, George?" "This one" he replies. "Cause they're different colors." "Right". "Which one "Why?" "Let's see who won," says Mrs. White, referring to the two piles. "Let's 260 count the cards." Mrs. White counts with the students up to fifteen in both piles. "They are tied, what's another word that means they are tied?" with an "E" says Mrs. V/hite. No answer.... "Equal", "It begins the students answer. The designed game was over with a few minutes left. Mrs. White took the deck of cards and dealt them out to everyone. Each of the students played their card into the correct pile, and the game moved around the table quickly, each student taking a turn. In this variation of the game, all students got the same amount of turns, there was no choosing of the next player, and everyone paid attention, and seemed to enjoy the game and not one mistake was made. The sex role message that Patty received twice from the teacher aide was that if she was a "lady" she would be chosen to have a turn in the card game. means in this context is not defined. What being a lady What Mrs. White is really asking, is for Patty to be quiet and patient, and not express her feelings of anger or disgust when the other students choose someone else to be the next player. Patty however, does not seem able to avoid expressing her resent­ ment. She feels it is not fair when she is not chosen as often as the others. When Patty is chosen, up and begins to sing a song "Come here, lollypop girl..." she brightens come here, my This song immediately triggers an un ­ usual response in both myself and Mrs. V/hite. Mrs. V/hite looks at me in a way that signals that she recognizes that 261 Patty has just repeated a sexual message she has learned, and it is not appropriate for a five year old -to be singing a song with a sexual proposition in it. Mrs. White does not say anything, but moves the game along. There was no definition to Patty what was being asked of her when she is asked to be a "lady". Perhaps Patty has interpreted it to mean that being a lady means behaving in a way that is sexually pleasing and provocative. The message behind the phrase of being a lady is loaded with stereotypical social rules. Both the male and female students are being socialized into a double standard of male and female acceptable behaviors. Learning what is acceptable behaviors for a classroom is essential for a student to succeed academically. However, the value system for appropriate gender behaviors is often used instead of academic behaviors. When Harry misbehaved, he w a s n ’t told to act like .a gentleman, he was told to stop misbehaving. When Patty was misbehaving, she was told to act like a lady, not to pay attention or wait her turn. This is an example of a stereotypical gender message that students receive that shape their self-image, self-esteem, and ultimately their choice of health behaviors, (ie., it improves their sexual image, choosing to smoke because or not excelling in school because boys won't be attracted if they are less academically successful). It was also important to note how a slight change in the methods of playing the game could result in all of the students' improved attention and participation. 262 CONCLUSION OF URBANDALE FINDINGS The analysis and ethnographies of the kindergarten health education program of Urbandale focused on three key factors: organizational structure, methods of instruction, and learning how to go to school. The organizational struc­ ture factor emphasized integration of school health services through a program of home visitation by student nurses. Al­ though this program seemed well received by the teacher and the student’s family, issues regarding the selection of students who warrant a home visitation, and the conse­ quences of this selection have been raised. Secondary components of the organizational structure are health education inservice training, and implementation of a health curriculum. The inservice education to teachers helped instructors learn how to identify students with de ­ velopmental deficiencies, and share classroom experiences and solutions toward helping these students. Although the health curriculum did not have a health content, the small group format allowed the teacher aide to closely observe the students' abilities. The methods of instruction emphasized helping the student to improve her/his self-esteem through having successful experiences with completing the tasks of the curriculum. The teacher aide taught all of the observed health lessons, however, the inservice education was only provided to the teachers. 263 The key factor of learning how to go to school was determined to be a prerequisite for any student success in the classroom. For minority students who have cultural and ethnic differences, learning how to go to school may take considerably more time and effort than for the non-minority students. A student's lack of cultural interactional com­ petencies may be misconceived as a developmental disability. When this misconception occurs, the institutional response of remedial services may affect the student’s self-concept in undesirable ways. The kindergarten health program of Urbandale is unique in its focus to consider the student's home environ­ ment as well as classroom performance, in its efforts to improve the student's self-esteem and ultimately improve the student's choice of health behaviors. INTRODUCTION TO BOTHAM CITY The next section is the analysis and ethnographic vignettes for the observations at Botham City. The main issues for this site center around the key factors of or­ ganizational structure of the health program, and the methods used to teach the health instruction. Issues that will be addressed in this section include: 1. The prioritization of time, funding, and re­ sources for the health instruction. 2. The integration of outside resources into the overall health program. 3. The issue of "turf-protectionism" expressed by the health instructors toward school nurses and parents. A. The use of certain methods to teach health, such as textbook, and closed circuit television. The first part of the section is a description of the settings observed at Botham School District, followed by the research questions used to guide my investigation. The vignettes tell the stories of what it is like in each of the classrooms where the key factors and main issues are evi­ denced. Following the vignettes are analytical commentaries that describe the main issues and factors found in each vignette. 26A 265 DESCRIPTION OF THE SETTING OF BOTHAM CITY The city of Botham is a large industrial town with a population of approximately 197,650. largest public schools in Michigan. Botham has one of the The district has over forty elementary and more than eight secondary schools, and serves a total student population of 22,350. Within the Botham school district, range of economic levels. there is a wide Some of the schools in the inner city are in low income neighborhoods, whereas the schools in the suburbs may be in neighborhoods that have considerable wealth. Botham schools have implemented anti-segregation bussing for the secondary schools, but this bussing is not done for elementary level students. The observations of the Botham school district took place at two schools. The first site was at Schultz school. Schultz school, founded in 18^8, is in a lower-middle class neighborhood. Schultz is a naturally racially integrated school in that the neighborhood surrounding Schultz comprises both blacks and whites. Schultz school was not originally in the city of Botham, however; as the city expanded its boundaries, Schultz school along with the neighborhood, became an annexed part of the city of Botham in I960. Be­ cause Schultz school was originally a rural independent school, it is equipped with a kitchen and cooking facilities. Schultz is one of two schools in the entire Botham School 266 District that still prepares its own hot lunches. The other schools in the district have their lunches catered. There are 106 students attending Schultz Elementary School. Schultz contains grades K-6, including two Special Education classes. I observed five classrooms at Schultz school and interviewed three instructors and the principal. The second school I observed in the Botham School District was Robin Hood School. Robin Hood School is lo­ cated on the city's south side, and is in an upper-middle class suburban neighborhood. Robin Hood is one of five "open” schools in the Botham School District. Instead of classrooms, there are four color-coded pods that contain three or more classes in each pod. A pod is a large car­ peted room which contains several areas designated for classes, library work, book shelves, and television watching. There are three classes and three teachers assigned to each pod. One pod is K-l-2, another 3-4> and one 5-6. The three teachers in the pod often rotate to other classes within the pod to teach their specialty subject such as health, math, or English. I observed three different classes and instructors at Robin Hood School. The school structure is shown in Figure 6 , and Figure 7 illustrates the layout of a typical pod. Robin Hood School has a large Vietnamese student population. than 100 students are Vietnamese, population of 270. More out of a total school For these students, there are special tutors and classes taught in Vietnamese. srf?ucn/z?E c *o 3 ’w -I. s; o vs ="8 vy •» *- Kr X) I V» c • cl * 1* V V* Vi* 7T !* ’£* w & «•*- v O cv HOOD "FrTnF school i/* o«K i >N v£T £ •ii 21 f oe- « ■j! " A ^• « a' H i F igure < c 6. ROBIV *i SiVl) O o -c 00 *0 0 0 0 «o ■t s oooooooo t! oooooooo 4 ]i rr— □ I -O C c£ A oS c u a> Is to 268 The following research questions were investigated in the observations at the Botham School District. BOTHAM CITY RESEARCH QUESTIONS - ORGANIZATIONAL STRUCTURE 1. What types of outside resources are included in the health education program? 2. What types of organizational structures are used to prepare for or assist in the teaching of health education? BOTHAM CITY RESEARCH QUESTIONS - METHODS 1. What types of methods were used in the observed health instruction classes? 2. What kinds, if any, of "hands-on" methods were used in the observed health education classes? BOTHAM CITY RESEARCH QUESTIONS - CONTENT 1. Were the instructors able to teach all ten topic areas recommended for a comprehensive health education curriculum? 2. What adaptations, if any, were used to teach the various health education areas? The first vignette, "Health Class in the Yellow Pod" combines observations of a 2nd grade open classroom at Robin Hood School, with an interview of the teacher. main issues are apparent in this vignette. Three First, the methods used to teach health using an open classroom are quite different from the traditional classroom. Second, the content of the health education textbook is seen by the instructor to be insufficient. Third, the organizational 269 structure components are viewed differently by the in­ structor. A subsidiary issue is also evident in this vignette; that is, the presence of a large proportion of foreign students expands the boundaries of acceptable or appropriate classroom behavior. 270 HEALTH CLASS IN THE YELLOW POD AN OPEN CLASSROOM OF K-l-2 There are approximately twenty students sitting on a carpeted floor around the teacher, Mrs. Johnson. Mrs. Johnson sits in a chair and begins to read them a story. Three students are seated, at their desks, coloring a picture as they listen. "This is a story about a girl named Edie, who didn't want to go to bed. Every time her mother would tell her it was time for bed, Edie would yell, Edie doesn't want to go to b e d !" "Have any of you stayed up really late before?" Several students reply, "yes". "How did you look when you didn't go to bed until really late?" "Grumpy" says one student. "Red eyes" said another student. "After being awake a long time, nobody looks very good," Mrs. Johnson replies. "So after Edie's mother got tired of her fussing, she decided that Edie didn't have to go to bed anymore. In fact, they took down her bed, disassembled it piece by piece, and put it in the garage. Edie was so glad, she said "I'm not going to bed ever again." That night, Edie's parents went to bed, and Edie was all alone. All she could hear was the tic, tock, tic, tock, 271 of the ..... , Mrs. Johnson stops reading and lets the students answer. "The clock" the students shout. Three other classes are ongoing in the same pod, yet the students are very attentive to the story. A student asks Mrs. Johnson, "Why do you get grumpy when you don't get enough sleep?" "What does sleep do for your stomach?" another student asks. Mrs. Johnson responds, need to rest. "All the parts of our body Our ears need to rest, and in daytime our mouths need to rest more than our ears. Our body will hurt if we don't get enough rest." Mrs. Johnson finishes reading the story, which ends with the fact that Edie is so tired the next day that she doe s n ’t want to go to the park and play with her Dad. she wants is to have her bed back. All Her father reassembled it and Edie goes right to sleep. After the story ends, Mrs. Johnson asks the .students to write her a story and tell her how they need sleep, and what they would be like without it. were working, While the students she came over to talk to me. Mrs. Johnson said the students generally learn health from the health text, but she expands it in order to have more material. "It is difficult to find time to round up all that is available for a single topic. dental unit in the text was expanded. For instance, the One of the students' 272 father is a doctor and he came and visited the class. We also had a dentist come in and advise the students on proper dental care. After that visit, the students brought in treats of celery and peanut butter instead of cookies. The students get health lessons through exercise and learning about their feelings," stated Mrs. Johnson. As she talked, I noticed that a young Cambodian girl was under one of the tables, clutching a Teddy Bear. student is coloring her pictures. Another Students seem to come and go out of the teaching area, while others continue working on their health assignment. The atmosphere is very informal. "Health is referred to as discovery time," says Mrs. Johnson. There is one teacher who does the health teaching for all the students in the K-2 pod. There are three or four classes ongoing in each pod, and four pods to the school. In addition, there is a special class of Vietnamese students. Mrs. Johnson said that health is taught both as a separate class, and integrated into the other courses. I asked Mrs. Johnson how she would improve on their health program if she could. She replied, ferent textbook. "The first thing I'd do is get a dif­ The way we do health now is interesting, but there needs to be expansion of the different subjects. The class does quite well with dental health, but there needs to be more stimulation with regard to other subject areas." 273 I asked Mrs. Johnson if there was any parent in­ volvement in the school's health program. She said, "no, there are a couple who have come in as a resource, but no direct involvement on the planning committee." Mrs. Johnson said that she has been teaching for twenty-seven years, and she "knew her job". She said, "I'd prefer that the parents leave the teaching and planning up to the teachers. job at home. They (the parents) can help by doing their That would be the best thing they can do. The ones who tend to participate in that kind of opportunity are the ones who have a greater need to be heard than ordinary ones, and that kind of social need will tend to be non-productive." Mrs. Johnson seemed to be quite emphatic as she continued, my job. "I don't want some parent telling me how to do I know how to do my job. Most parents are just a lot of talk, they don't have the expertise to make con­ structive changes. The participation of parents is given lip service in the planning committees, but they don't really participate." I asked Mrs. Johnson if there was any reproductive health taught to their students. She replied, not taught, but I wouldn't mind teaching it. parents' "no, it is Then, the involvement would be appropriate." Mrs. Johnson mentioned that there is a cable television station they watch that has health on it for 274 the students. "It had one program on about reproductive health entitled "All About You". They also had one on about elimination that was very well done. They had a show on about tornadoes, and showed all the students going into the womens' bathroom. A lot of the boys giggled a lot at that, which is a very dumb attitude. There is such stereotype about the genders that it's very hard to change. The parents aren't free enough themselves to change it." Mrs. Johnson says she has to get back to her class now--and collects the health materials. reading class. It is time for 275 There were several main themes evident in this vignette. First, the methods used to teach all classes including health, were different because of the open school format. The open school has "pods" instead of classrooms. A pod is a large carpeted room that contains several areas designated for classes, library work, book shelves, and television viewing. The teaching atmosphere in the red pod (K-l-2) seemed quite informal, yet structured. ongoing simultaneously, Three classes are but the students don't seem dis­ tracted by noise from the other classes. There is con­ siderable traffic or movement by the students in and out of the teaching areas. For example, while Mrs. Johnson was reading the story about Edie, three students were seated at a table coloring pictures as they listened, is seated underneath one of the tables, Bear. another student clutching a Teddy Other students are seated on the floor surrounding Mrs. Johnson. There are more than 100 students, or 3A% from southeast Asia attending Robin Hood School. students are Vietnamese, Most of the some are Cambodian, and Laotian. There are also Vietnamese tutors who help the students with their school work. The presence of these students had an impact on the overall health education program. Many of these students have difficulty adjusting to the American classroom. For example, as mentioned previously, one student sat under the table clutching her Teddy Bear during the 276 health lesson. The informal teaching format of the open classroom allows a larger margin of appropriate or acceptable behaviors than a more traditional classroom. A second methods issue evident in this vignette was the use of a health textbook for teaching health. When I asked Mrs. Johnson how she would improve their health pro­ gram she said: textbook. "The first thing I'd do is get a different The way we do health now is interesting, but there needs to be expansion of the different subjects. The class does quite well with dental health, but there needs to be more stimulation with regard to other subject areas." Other teachers in both Robin Hood and Schultz school also felt the textbook was inadequate. One teacher said she doesn't use the text at all, and another simply stated: text is a waste". "the Another teacher I observed at Robin Hood school used the text as an incentive for discussion, and then had his students copy down the main ideas, and answer the review questions at the end of the chapters. A second method, in addition to the textbook, is a one-hour health education program shown twice a week on cable television. This health education program often features students from within the Botham City School District and/or community resources, and is produced by the Botham School District Health Education Coordinator. The television show addresses various health education topics relevant to elementary students. Mrs. Johnson felt that many of the television programs were "very well don e". 277 An organizational structure issue was also evident in the vignette. This issue is the degree of parental in ­ volvement in the health education program. Mrs. Johnson seemed to feel very strongly against parental involvement. "I've been teaching for twenty-seven years and I know my job; I'd prefer that the parents leave the teaching and planning up to the teachers. job at home. Parents can help by doing their That would be the best thing they can do. The ones who tend to participate in that kind of opportunity are the ones who have a greater need to be heard than ordinary ones, and that kind of social need will tend to be no n­ productive. I don't want some parent telling me how to do my job; I know how to do my job. Most parents are just a lot of talk, they don't have the expertise to make constructive changes." It is evident from Mrs. Johnson's comments that parental involvement in the health program is not par­ ticularly welcomed. Mrs. Johnson also said that parental involvement is given "lip service" in the planning com­ mittees, but they don't really participate. The District Health Coordinator seemed to concur with this perspective. She indicated that parents were "not yet" on the Curri­ culum Planning Committee, but would be included at a later stage. The District Coordinator also said that "when the advisory board has been opened up to parent involvement, there hasn't been much of a response. If some parents do participate, it is usually the squeaky wheels who are 278 against reproductive health being taught." Mrs. Johnson seemed to feel differently about parental involvement if reproductive health was taught. Mrs. Johnson indicated that reproductive health was not being taught at the time of the observation, but that she wouldn't mind teaching it. "Then parental involvement would be appropriate," she said. Parental involvement in the health education pro­ gram seemed to be somewhat of a heated issue during my ob­ servations. For the Botham City School District, it is an issue that may warrant further resolution. The next vignette describes a 4-th and 5th grade health class at Schultz school. One of the most notable features in this vignette is how the student teacher is able to generate considerable student enthusiasm by having the students do a "hands-on" experience of "Name the Nutrient". The content of this lesson meets some of the Essential O b ­ jectives for Health Education in nutrition as well as enables the students to apply the content to their own personal experience. The organizational structure is also represented by the utilization of outside resources and materials. 279 NAME THE NUTRIENT "I am still waiting," the student teacher says to a very noisy classroom of 3rd and 4th graders. Finally, the multi-racial class of thirty students (ten boys and twenty girls) quiets down. The students are just returning from recess. "Today, we have a visitor. I ’ll introduce her to you. When you quiet down, I'd like to introduce Mrs. Hansen. She's here to watch our health class." "I brought a sack lunch today, and I'd like to find out if I brought a nutritious lunch. I'd like a volunteer to pull out one item, and tell me what food group it's in." "Me, me," the students enthusiastically wave their hands and lean out over their desks to be called on. The desks are arranged in clusters, with approximately five desks to a cluster. The regular teacher is not in the class­ room, and today is the first time the student teacher has taught the class by herself. "Okay, Rhonda, will you come up and choose one item from my lunch?" Rhonda comes up and pulls out an empty yogurt carton. "What group does yogurt belong in?" asks the student teacher. "Dairy." "Right, what else is in yogurt that may be in another food group?" 280 Several students try to guess but can't get the correct answer. The teacher finally says, is blueberry yogurt. Okay, "a fruit. This I need a meat; Steven, will you find one for me?" Steven comes up and looks a few seconds, and then pulls out an egg. "Right!" "What are the good things in foods?" asks the student teacher. No response. "It begins with an "N". "Nutrients" guess a couple of students after that clue. The entire class is very attentive and eager to be chosen to identify another food. After two more students find a banana from the fruit group, and a graham cracker from the breads and cereals, student teacher asks, the "did I have a balanced lunch?" "Yes," the class responds. One student goes up to the student teacher to ask her a question. The student teacher sends to his seat and says, the student back "this is teaching time". The student teacher then hands out a ditto sheet with one of the four food groups drawn in each of the four quadrants. The sheet is entitled "What did I eat today?" "I want you to fill in everything you've eaten so far, and then on the back I want you to write to me whether or not you ate a good lunch today. If you ate a good meal, 281 and i t ’s helping to build your body, then tell me, and tell me why you did or d i d n ’t have a good lunch today. Also, color the pictures." The students board on the side of get right to work. On the bulletin the class is a diagram with each of the four food groups on it. Adjacent to it, there is a "building blocks" display showing that proteins are the building blocks of our bodies. In the back of the room, there is an easel with a large sheet of paper on which is written, "Our Favorite Foods". The students have filled in their favorite food. While the students fill in their worksheets, student teacher mentions working on come from the that the materials the students the National Dairy Council book on n u ­ trition entitled: Food: lour Choice. text also used by the class, She shows me the health entitled: Being Heal th y. The health textbook has many pictures of students from all races. There are nine chapters in the book entitled: 1. 2. 3. A. 5. 6. 7. 8. 9. Ways to Keep Healthy. Families. Growing. Being Safe All the Time. Your Eyes and Ears. Eating Many Foods. Your Home. Safety and Medicine. Activities for Health. As the students finish their worksheet, the 27-minute health lesson is over; it is time for the math class to begin. are 282 There were several main themes evident in this vignette. First, the methods used to teach nutrition fo ­ cused on a "hands-on" experience. The student teacher was able to generate considerable student interest and en­ thusiasm by having the students pull an item out of her sack lunch and name the nutrient. The students seemed to highly enjoy this exercise as they waved their hands emphatically to be called on, saying "me, me". The hands-on method contrasted sharply to previous observations of using a textbook to teach health. The text­ book method generally consisted of having the students read a chapter aloud, and then answer the review questions at the end of the chapter. Both methods may be effective and n e ­ cessary for the learning of health education, but seemed to differ markedly in the students' expression of enjoyment. A second theme evident in this vignette is how the organizational structure of the health education program includes outside resources. In this case, the material the students worked on was from the Michigan Dairy Council. The Dairy Council provided both nutrition materials and inservice education to health instructors. The Botham City School District encourages outside resources being integrated into the health education program. The school district provides a directory compiled by Clark County Health Department that lists forty organizations and agencies involved in health education. Some of the entries on the list include: Advisory Center for Teens, Clark County Health Department, 283 Greater Botham City Epilepsy Center, Michigan Heart Asso­ ciation, Dairy Council. This list has been cross-referenced with the ten topic areas contained in the Minimal Perfor­ mance Objectives for Health Education in Michigan (MPO's). A third theme evident in the vignette is the use of a health textbook. One of the reasons the textbook was chosen by the Botham School District was because the pub­ lishers, Laidlaw, cross-referenced the text's content with the Minimal Performance Objectives. The publishers estab­ lished with the Botham School District that their text met the Minimal Performance Objectives and hence was selected for use throughout the school district. The Botham School District recognized that the teachers may not have time to address all ten of the health topics each year. Therefore, the Botham School District has selected certain health topic areas to be stressed at different grade levels. The fol­ lowing table shows the topic recommendations for each grade leve l. 284 Table 17. Botham City Health Topic Recommendations by Grade Level Grade Level Topic Recommendations Kindergarten Personal Health Practices Growth and Development Emotional and Mental Health Safety 1st Personal Health Practices Safety Community Health 2nd Nutrition Family Health Emotional and Mental Health Substance Use and Abuse 3rd Disease Prevention and Control Personal Health Practices Growth and Development Consumer Health 4th Growth and Development Emotional and Mental Health Safety Community Health 5th Disease Prevention and Family Health Consumer Health Safety 6th Personal Health Practices Nutrition Growth and Development Substance Use and Abuse Control 285 All ten of the topic areas for a comprehensive health education curriculum are eventually addressed by the end of the 6th grade year. Each of the ten topic areas is matched by a possible health activity, and appropriate media materials which can be used to supplement the health education lessons. One teacher I interviewed felt that the expectations of the school board with regard to health instruction, were still too demanding. with science. Ideally, this is a fine idea, however, it just doesn't work. address it all. time. "We are supposed to incorporate health The teachers aren't given enough time to There is too much to cover in too little Science and Health is given 150 minutes per week (30 minutes a day). Health should be taught separately, in ad­ dition to science. I have twenty-eight students who must share a science kit meant for six students, and I only have thirty minutes to do it, yet every student is supposed to get an opportunity to touch the contents and get an under­ standing of the subject. Simply not enough time! priorities are English, reading, and mathematics. The We have objectives to meet in those areas, too!" For this instructor and others I interviewed, there seems to be considerable differences between what is r e ­ commended by the school board, and what is actually taught in the classroom. Teachers are finding it very difficult to fit health instruction into an already bulging curriculum. 286 The lack of time to address all ten topic areas of health education has forced this teacher into selecting only "portions of the recommended portions" of health education for elementary students. This watering-down of the content may be one of the major reasons the District Health Education Coordinator expressed that health education needs to be integrated into other subjects, instead of being taught as an independent, separate subject. The instructors I interviewed also felt that health education should be both integrated into other subjects, and taught as an independent, separate subject. A fourth issue evident in the vignette was the con­ tent presented in terms of the student's choice and decision­ making. "I want you to fill in everything you've eaten so far, and then on the back, I want you to write to me whether or not you ate a good lunch today. If you ate a good meal, and it's helping to build your body, then tell me and tell me why you did or didn't have a good lunch today...," Through this exercise the student teacher is teaching the students that they must be responsible for their own n u ­ trition, and it is through their food choices that they help build their bodies. The content of the lesson is also put into terms of the student's own personal experience, thus improving the student's opportunity for future reference. 287 The following vignette will describe a dental health lesson in a special education class for J+th and 5th graders, and an interview with the instructor. represented in this vignette. Several themes are First, the teacher discusses how essential health education is for special education stu­ dents and how health education needs to be given a higher priority than it presently receives. Second, the organi­ zational structure is discussed in relation to bringing in outside resources, and the lack of participation by the school nurse. Third, behavioral choice and decision-making is seen as an essential component of health education for special education students because they have such high incidence of drug abuse, unwanted teenage and emotional problems. pregnancy , and other social As will be seen in this vignette, some of the students have difficulty being attentive to the health lesson and seem to have other concerns. 288 DENTAL HEALTH IN SPECIAL EDUCATION, GRADES 4-6 Today's lesson begins as the instructor, Mrs. Kaye, hands out a card to each of the eight students in her class. Written on these cards are answers to the questions she will ask the class. "A hard, bony material under the tooth," Mrs. Kaye says to the class. The student with the card replies, "dentin." "Right," says Mrs. Kaye as she takes the card with dentin written on it. "Having to do with teeth." "Dental." "Correct." "Hard like bone." "Enamel." "How many of you flossed your teeth since this time yesterday morning?" asks Mrs. Kaye. Five of the eight students raise their hands. "Today we are going to learn how to floss our teeth properly. I want each of you to take about eighteen inches of floss and pass the box on to your neighbor." One student opens his desk to take out a ruler to measure the floss. "A ruler isn't necessary, all you need to do is estimate by the length of your forearm." 289 The students begin to talk and clamor in their desks, as the dental floss is being passed around. "Almost everyone is resting their voice," Mrs. Kaye urged.... One student, a black female, says she doesn't want to do it, and she's not going to. "Some of your teeth are round and some are pointed," says Mrs. Kaye. Mrs. Kaye bends down and puts her face right in front of one of the students and shows him how to get the floss between the teeth. The other students are talking about how to get into a bar, "you need a fake ID," says one student. "This feels kind of funny doing it in public, doesn't it?" Usually you do this alone in the bathroom. There's no need to be embarrassed, we are all going to practice it." The girl who said she wasn't going to do it again says, "I'm not gonna do this ---- !" and says, "I'm all done, She flosses one tooth can I throw mine away now?" She throws the floss down on her desk and folds her arms on her chest, "I'm done." After flossing their teeth, Mrs. Kaye tells them they are going to work backwards from the cards with the dental definitions on them. Two of the students can't recall the definition of the word they had. .Mrs. Kaye answers the word for them as she signals for the other teacher to take over the class for the re­ maining five minutes until lunch; she spends the time talking with me. Mrs. Kaye says that teaching hygiene is remedial for these students, but necessary. "As you could see, their attention span is very short. The students learn dental health, washing their hands, foods they can eat without getting a lot of sugar, exercises, and the different parts of their body. Human growth and development is taught in accordance with the program developed by Lee Lipkey. also taught. Reproductive health is I teach them about the changes they encounter as adolescents, and very straightforward talk about sex." "For substance use and abuse, we usually bring in resource people; the students usually lack an appropriate role model, so we bring one in." "Fortunately, in this room, we have good facilities there is a drinking fountain, and a bathroom, make a big production of washing their hands. so we d o n ’t A shower is also available." "Because our students have problems, the health classes stress that they need to be aware of basic things such as hygiene, food on the table, and emotional problems. "The students really adore our hot lunch program, it may be the only hot meal they get. are obese, Two of our students so, we try to teach them how to interrupt the cycle of food as an answer to emotional problems." 291 The teacher does have contact with some of the parents--mostly concerning bathing and food. "There is a support system, but not as good as last year's. good, Last year we had a school nurse that was really she saw to it that some of the students got some den­ tal care they urgently needed. This year, the older nurse on staff isn't interested." "Drug abuse is a problem. need for positive self-concept, and in 4.th and 5th grade, they need to know who they are. parents who have no control, The students have a real Most of these students have or have pathological control over their lives, or exhibit manipulative behavior. is the kids' total environment. have money, knowledge, constructively. and exercise. That The parents often don't or experience on how to raise kids That is why we stress food, rest, hygiene, There is a rehabilitation center for mental and emotional problems, to which the students can be referred." "For these students, the human needs aren't being met, so, they compensate by having a high need for affection. This often results in teenage pregnancy. in the schools is very important, Reproductive health but it can only solve part of the problem." "A bigger problem is prioritizing the subjects in school. Often, the curriculum board listens to the one who is the loudest, and health isn't heard very loud." 292 As could be seen in the vignette, some of the stu­ dents in this class were not very receptive to the teac her ’s health lesson. While the instructor was trying to get the students to practice flossing their teeth, some of the 4-th and 5th grade students refused to participate and were in ­ stead discussing how to sneak into a bar. The instructor said these special education students seem to have a more urgent need for health education. "Drug abuse is a problem, the students have a real need for positive self-concept, and in 4th and 5th grade, they need to know who they are. Most of these students have have parents who have no control, pathological control over their lives, behavior. or or exhibit manipulative That is the k i d s ’ total environment." Mrs. Kaye went on to mention that "for these students the human needs a r e n ’t being met, so they compensate by having a high need for affection. This often leads to teenage pregnancy." Mrs. Kaye education may not pointed out that even the best health be sufficient tohelp these students the course of their lives. change This is why the health education content for special education students must start at the individual level of each student. For many of the students, this means learning basic hygiene, nutrition, rest, and exercise. One of the most important issues evident in this vignette is that for special education students, health is probably the most important subject they could learn. Yet 293 other subjects such as math, and reading and science are given higher priorities. As Mrs. Kaye points out: problem is prioritizing the subjects in school. "A bigger Often the curriculum board listens to the one who is the loudest, and health isn't heard very loud." The lack of health education as a priority subject is not just for special education students, but for all stu­ dents. The prioritizing of subjects as well as the time allotted for teaching, is decided by the upper levels of the Botham School District's organizational structure. In order to better understand the path such a change in policy would need to follow, let us take a brief look at the organizational structure of the Botham City School District. The highest authority over the entire district is the Botham City School Board. This group of elected officials is the top decision-maker in the district. Within the school board is an educational committee whose -main function is to review any new program, including health. This educational committee gives permission for any new program to be im­ plemented. In addition, there is an Instructional Council that operates district-wide. The functions of the In ­ structional Council are to review all programs within the school district and to keep the school board informed. This Council serves to avoid duplication of programs within the district. For specific health education matters, a District Health Education Coordinator functions to oversee all health 294education programs within the district. This includes monitoring all health education ongoing in more than fortyelementary, ten middle and high school buildings, education buildings, buildings, ten special and more than three alternative education giving a total of 22,350 students in the entire Botham City School District. For health education to be considered a higher priority subject, it would require approval and facilitation from all levels of the Botham City School District hierarchy. The District Coordinator would have to be a strong advocate and vocal proponent of health education as a priority sub­ ject. Even with this support, the bureaucracy and complexity of such a large district makes any new change in policy a long and difficult process. A second issue evident once again in this vignette is the lack of integration of school health services into the overall health education program. "There is a support system, but not as good as last year's," Mrs. Kaye explained. "Last year we had a school nurae who was really good, she saw to it that some of the students got some dental care they urgently needed. This year the older nurse on staff isn't interested." It is evident from Mrs. Kaye's comments that school health services and the health education program are not cooperating as is optimally possible. An additional issue evident in the vignette, Dental Health in Special Education, 4-6, is that in particular, special education students need to understand that they must be responsible for their own decisions and ultimate health status. Because problems such as drug abuse and unwanted teenage pregnancy are so high for special education students, more attention must be paid towards helping these students realize that their choices and behavioral decisions have serious consequences on their health and life course, as well as the lives of others. 296 CONCLUDING DISCUSSION ON BOTHAM CITY The main issues that were evident in the observations of the Botham City health education program centered around the main theme of organizational structure. More specifically, there seemed to be differences of perception between what the District Health Coordinator said about the health program, and what the health instructors said. The Health Coordinator said there were no problems seen between the school nurses and the instructors, and that the nurses could be resources for the teaching of certain health topics. The health instructors on the other hand, felt that the school nurses would not be interested in health in­ struction, or were not welcome in the classroom. The District Coordinator said the texts were chosen after careful evaluation which found the texts met the Minimal Performance Objectives for Health Education in Michigan (now termed Essential Objectives), were copyrighted, multi-ethnic, and avoided stereotypes. The health instructors who were interviewed said the text was "not used", "a waste", or "needed expansion". The District Coordinator said the teachers need more inservice health education, but it was too expensive, and the teachers probably wouldn't be willing to participate. The health instructors said there is not enough time to 297 teach health in an already bulging curriculum, and the ex­ pectations of the administration are too unrealistic. These differences in opinion lead to the conclusion that there is a lack of communication and understanding between the administration and the health instructors. This communication problem can only be remedied if both the ad ­ ministration and the health instructors are willing to sit down and hear each other's perspective. The first step to this process is the recognition that there is a communication problem between the two levels that not only hurts the ad ­ ministration and the health instructors, but is the most damaging to the students who, as a result, adequate comprehensive health education. do not receive 298 A COMPARISON OF PROGRAMS IN THE THREE SITES This section compares each of the three observed health education programs on three key factors: organizational structure, methods used in the health programs, and content of the health curriculum. These three factors were chosen because all three of the health programs were investigated in relation to these three variables. In addition, the ob­ served health education programs are compared on two dif­ ferent aspects: the major barriers seen in each program, and the major innovations of each health program. Finally, two additional factors are examined independent of any particular program site. First, let us look at the comparison of each of the three health programs on the key factors. ORGANIZATIONAL STRUCTURE The organizational structure of the three health education programs was markedly different. The organizational structure of Hobart Health Program is built upon the pr o­ gram providing a comprehensive health education curriculum to the students, and emphasizes integration of the program within the community. Components of the Hobart Health P r o ­ gram reflect this integration effort by the presence of a health education advisory board comprised of community pro­ fessionals, business people, clergy, teachers and parents; the providing of parent handbooks, parent review sessions, and frequent media coverage of the health p r og ra m’s activities. 299 The Urbandale Health P r o g r a m ’s organizational structure emphasizes integration of school health services into the overall health program. The home visitation by- student nurses, and the sponsoring by medical and edu­ cational authorities such as Dr. T. Berry Brazelton, MD., and Prof. Frederick Erickson, PhD., to provide inservice education to teachers also reflects this integration of health services into the health program. One of the more important aspects of the Botham City Health Program was its method of instruction utilizing closed circuit television to broadcast a bi-weekly health education show. This program addresses various grade levels on a variety of health topics and often features students from within the district, professionals and agencies in the community, and the district health coordinator. Figure 8 shows the formal organizational charts of the three health education programs. As can be seen from the diagram, the Hobart Health Education Program shows direct frequent communication of the district health co­ ordinator to the advisory board, the teachers, the parents, as well as to the school district superintendent. One reason this communication structure is possible is because of the small size of the school district. The district health coordinator meets regularly with the advisory board, parents, and teachers, which would not be so easy in a large district. The Urbandale Health Program organizational structure 300 shows a more complex communication flow. One notable a s ­ pect of the Urbandale Health Education Program structure is the communication ”triangle" between the superintendent, evaluation team, and the health program coordinator. the The health program is evaluated by the evaluation team, who re ­ ports directly to the superintendent. The staff of the health program, and the evaluation staff have had numerous conflicts over the evaluation of the program. These con­ flicts are one reason why the health program coordinator en­ listed the expertise of outside community professionals to assist in the provision of evaluation and inservice education. The health program coordinator of Urbandale has strong frequent communication with the school nurses, stu­ dent nurses, teachers, and the community professionals. The organizational structure of the Botham City Health Program is more hierarchial than the other health education programs. The district health coordinator has little or no direct contact with the health instructors, and only occasional communication with the building health co­ ordinators, the school nurses (who are frequently the same individuals), and the advisory board. One of the main reasons for this organizational structure is due to the large size of the district. Organizational structure differences and simi­ larities of the three health programs are better illustrated in Table 18, which compares the organizational structural components of each health program. Several main differences HOBART School B oard , URBAMDALE BOTH/*/^ SCHOOL BOARD SCHOOL I S up erintendent 4, (€.l6fvidn"tAry3 t \ I 1 Ni \i / In s tru c tio n ! Co unci I SuperiWTENDENT ; ^ re rrts * D is t r ic t h e a lth / Coorp»r/ATOR E/aIu Abort — » ri£Alfli_ + TfTA/A ScWool Worses r P1 P * C o o rd m o t o r V Omnumty ✓ profe«sw teachers ' / ' ! ADVisory O’ aonro " / I 1 j B u ild in g T eacher' s Students V School nurses \ 1 H e a l+ h /* '/ coordinator Student nurses i 60A R P \ J,/ Students / i \ 301 I AOVISORY board S u p e r in te n d e n t K\ D is tric t H c a l t h COOrd itYATOR. ✓ \ CITY t^ACHERS k- / / ^ Students * Students families Ke y 'StroM^ /Fr£QUBHT i ComnuntCATioN 1 infrecjjjcrrt Coy^AAtinicnKoM F ig u r e 8 . ‘ ' o r q a k iiz a t io w l charts of The 3 HEALTH w w b w 302 Table 18. Comparison of Organizational Structure for the Three Health Programs District Health Coordinator Building Health Coordinator Hobart Urbandale (K) Yes (1) Yes (1) Botham City Yes No No Yes School Health Advisory Board Yes N/A Yes Parental Involvement Yes No No Community Participation Yes Yes Inservice Training Yes Yes Yes Statewide Health Program Participation Yes Yes No Method of Health Instruction Validation by Michigan Department of Education Comprehensive Health Ed u­ cation Model Yes Manual Dexterity Skills No (1) Occasional Textbook and Closed Circuit Television No 303 Table 18. (Continued) Recognition byMichigan School Health Association Yes No No Yes Curriculum Guides for Comprehensive School Health Education approved by School Board Yes No Yes Same Curriculum Followed Within Grade Level Yes Yes Yes Some No No School Health Services Integration Student Involvement No Moderate 304can be seen from the table. First, as previously mentioned, there is a substantial size difference in the three health programs. Even more pertinent is the ratio differences between the program coordinators to the teachers. For the Hobart program there is one program coordinator to 37 health education instructors. For Urbandale, there is one health coordinator to 79 health instructors, kindergarten health program. six of whom teach the For Botham City, there is one health coordinator to 1,907 teachers, 4-50 of whom are elementary health instructors. A second notable feature is that both the health programs of Urbandale and Botham City are located in urban centers, have a multi-racial student population, with a wide variety of cultural and ethnic backgrounds. Hobart, however, is a small rural town, with a very homogeneous student population. In the two urban sites, the variety of cultural and ethnic backgrounds of the students makes the delivery of a health education content that is relevant to the student's personal experiences more difficult. wide diversity of the students' This is because the cultural and ethnic back­ grounds makes it quite difficult to have a universally ap­ plicable content. For example, nutrition education and practices may vary considerably along ethnic lines. Hispanic students may have tortillas with beans for breakfast instead of eggs and toast. Even though both are nutritious break­ fasts, the Hispanic students may not learn that their diets are equally nutritious and desirable. When the health 305 education content is not applicable to the student's per­ sonal experiences, it is less likely to influence the student's choice of positive health behaviors. A third difference in the three health programs is seen in the provision of health education inservice education to the health instructors. In Hobart, health inservice education was given to all instructors upon implementation of the curriculum (in 1979); also, health instructors re ­ ceive additional inservice on various topics such as cardio­ pulmonary resuscitation (CPR), dental health, etc. In addition, all instructors are given an instructional notebook containing student objectives, health activities, and sample test items. The observed inservice education at Urbandale focused on helping kindergarten instructors to identify students with developmental deficiencies who may warrant home visitations. This inservice emphasizes the home visitation program instead of the health instruction. The inservice education at Botham City was conducted by the Dairy Council for assisting the instructors' use of nutritional education packet provided by the Dairy Council. In addition, some health education inservice has been pro­ vided to the instructors through closed circuit television. None of the instructors I interviewed mentioned they had viewed the health education inservice programs. A fourth comparable aspect of the health programs' organizational structure is the presence and influence of a 306 school health advisory board. In the Hobart health program, the advisory board is comprised of community representatives from business and the professions, parents, and clergy. as well as teachers, The board meets regularly and makes recommendations on health education policies. All board meetings were open to the public, and any interested persons were welcome to attend. For the Hobart health program, the advisory board is a main structural tool for integrating the health program into the community. There was not an advisory board observed at the Urbandale program. There may have been one functional at some time, but not during the time of my observations. The advisory board at Botham City was originally formed to develop a reproductive health program. time of observation, During the the District Coordinator said this board was composed of representatives such as principals, nurses, administrators, and teachers. presently open to parents. The advisory board was not The District Coordinator men­ tioned that when it has been open for parent participation, there hasn't been much of a response, and if some parents do participate, it was usually those who were against repro­ ductive health being taught. It was unclear what role the advisory board played in overall health program policies. However, the District Coordinator did say that any academic program, including health, must be first approved by the educational committee of the school board, and/or screened by the instructional council. 307 The presence of an advisory board whose members represent community constituents, and which functions to examine and improve the health program is seen as an essential organizational component for the implementation of comprehensive school health education. A fifth organizational component compared between the three health programs is the integration of school health services into the health education program. school district, In the Hobart there was not a school nurse on staff at the time of the observations, nor were there any standard school health services. The public health department may work with the schools on a particular health issue, but there was not a school health services component observed in the Hobart health program. This contrasts sharply with the Kindergarten health program at Urbandale. The main emphasis in the Urbandale program was the integration of school health services into the health program. Through home visitation by student nurses, and the inclusion of school nurses in the inservice education sessions, the school health services was an integral part of the Urbandale health education program. The school health services for Botham City were not as well integrated into the health program as in Urbandale. School nurses could serve as resource persons for health instruction, but usually did not. Several of the teachers interviewed in the Botham City school district felt that the school nurses were not interested, or not welcome to be 308 involved in health instruction. The sixth organizational structure component that is compared in the three health programs is integration of the health program into the community. program, For the Hobart health community integration was one of the most important foci of the program. The coverage by the media, parent in­ volvement, parent handbooks, and open advisory board meetings, members of which represented the community, all served to integrate the health program into the community. The outcome of this process has been a wider acceptance by the community of health education as a priority subject, a source of community pride, and hopefully, a more health­ conscious community. Efforts to'integrate the Urbandale kindergarten health program into the community involved the families of students who were recommended for home visitations. There was not a public relations initiative to inform or involve the general public into the health program activities. Pr o­ fessionals such as the inservice education presenters were integrated into the program, but only to provide educational services. In Botham City, community integration consisted of a list of community agencies provided to the teachers for them to contact if they want additional resources on various health topics. Except for representation on the advisory board, no other efforts were observed to inform or involve the community with regard to the health education program. 309 In all three health programs, comprehensive health education curriculum guides were approved by the school board. All three health programs followed the same curri­ culum within a given grade level. Student involvement in the planning process was not observed at Urbandale or Botham City. However, Hobart's health program did have some stu­ dent participation in an anti-smoking presentation made to all 3rd and 4th grade students. As can be seen from this comparison of the organi­ zational structure components, the three health programs differed markedly in their organizational structures, and therefore, had resultant differences in their program em­ phasis. Now, let's look at how the three health programs compare on the key factor of health program methods. METHODS USED IN THE HEALTH PROGRAM The methods utilized in the health education pro­ grams are compared on three different levels; the methods of instruction, the methods used in inservice education, and the methods used in additional program activities. Each of these three levels is discussed below. Methods of instruction. The methods of instruction differed markedly in the three observed health programs. the Hobart health program, audiovisuals such as films, filmstrips with records, and several hands-on activities were predominantly used. The methods of instruction used in the Urbandale kindergarten health program were all small group hands-on In 310 exercises. During the health lesson, a group of four or five students would meet at small tables and complete a series of tasks or games for 15 to 20 minutes. The methods of instruction at Botham City were two-fold; a text book was used throughout the district and a closed circuit television health education program was broadcast twice weekly. All of the methods used in the three observed health programs had positive and negative attributes. Hands-on ex ­ periences where the instructors got the students involved seemed to be most enjoyable in the three sites. Other notable methods were the use of unanswered questions in the reproductive health films of Hobart, and visitation to com­ munity activities or businesses. These methods of learning also seemed to generate considerable student participation and enthusiasm. The use of closed circuit television was very well received by one of the instructors interviewed at Botham City. The potential a tool for health education for closed circuit television as instruction is yet to be explored in the Urbandale or Hobart health programs. Methods used for inservice education. The methods used for inservice education at the Hobart health education program were not observed; however, one of the instructors said that during the inservice education the teachers re ­ viewed all of the films and filmstrips, and discussed ways to complement the films with discussion. 311 There were two different types of inservice education meetings observed at the kindergarten program of Urbandale. One was directed to all of the teachers, the school nurses, and the health program staff. This inservice meeting focused on helping teachers identify and help students with develop­ mental deficiencies, and to distinguish these students from students who have cultural/ethnic interactional difficulties. The second type of inservice at Urbandale focused on one student and his family, who had received a home visitation by one of the student nurses. Education" on p. 252). (See vignette "Inservice At this meeting, different edu­ cational and social agencies that could be contacted to help the student and his family get needed medical, social, and economic assistance were discussed. The inservice education provided at the Botham City school district was not observed. Interviews with one of the instructors at Schultz School revealed that the Dairy Council had provided nutrition inservice education to their school instructors. The District Coordinator also mentioned that some inservice education had been broadcast over the closed circuit television health education program. Additional health education program activities. One of the additional programs receiving inservice education in the Hobart health program was the parent volunteer pro­ gram to help with the Hobart's dental health initiative program "Swish". "Swish" is a fluoride rinse program offered to elementary students as a preventive dental 312 health measure. Several parents have helped with the pro­ gram to prepare and distribute the fluoride rinse to the students. Another health education program receiving inservice education was the Hobart high school’s anti-smoking team. Inservice education was provided to the team in preparation and evaluation of the team's anti-smoking pitch presented to elementary students. In the Urbandale health education program, student nurses who were involved in the home visitation program re­ ceived special inservice education. This inservice education focused on preparing the student nurses to take family hi s­ tories, identify environmental social problems, and serve as resource persons to the family. There were no observed additional health education programs receiving inservice education at Botham City. CONTENT OF HEALTH INSTRUCTION The content of each of the three health education programs also varied considerably. The content of the Hobart health education program was certified by the Michigan D e ­ partment of Education (MDE), and recognized by the Michigan School Health Association as being a comprehensive health education program. chapter, As described in the review of literature comprehensiveness is defined by the Michigan D e ­ partment of Education as meeting all of the Essential O b ­ jectives for Health Education in Michigan in the ten topic areas of: nutrition, personal health, community health, 313 consumer health, family health, growth and development, emotional and mental health, disease prevention and control, stance use and abuse, and safety. sub­ In the Kobart school dis­ trict, these ten topic areas and essential objectives are represented in the health education curriculum in five units: Growing Up, My Healthy Community, Foods for Health, My Safety, and Decisions for Growth. All of the instructors in the Hobart district have implemented the health curriculum in their classes, with varying degrees of time spent on each unit. The Urbandale kindergarten health curriculum does not contain a health content. The content consists of a number of games or exercises the students complete that tests their listening skills, visual discrimination, manual dexterity. and The curriculum has been implemented for its ability to offer small groups of students an opportunity to improve their skills without competition from their peers, and have successful experiences completing the exercises. This success is theorized to help the student improve her/his sense of self-esteem, thus enhancing the chances of the student's choosing positive health behaviors. The students in the observed lessons seemed to enjoy the health lessons, but evidence of improved self-esteem was not observed. The content of the Botham City health education pro­ gram is based on a textbook by Laidlaw, "Being Healthy". The district coordinator said this text was selected on the basis of a variety of criteria, including the fact that it 3U met the Essential Objectives for Health Education in Michigan, that it was multi-ethnic, copyrighted, stereo­ types minimized, and that the reading level was appropriate for the students. Interviews with the instructors showed that many teachers felt the text was inadequate, needed ex­ pansion, and was not used. The televised health education programs also provided the students with a health content, but the content of these programs was not observed or available. MAJOR BARRIERS TO IMPLEMENTATION AND MAJOR INNOVATIONS IN THE THREE HEALTH PROGRAMS Barriers♦ In addition to the comparison of the three health education programs on the key factors, each health program is also compared with regard to -the program's major barriers and innovations observed in the three sites. According to interviews with the instructors, the major barriers to the implementation of comprehensive school health education in the Hobart health program was differences in implementation by various instructors. Some elementary health instructors in the Hobart school district do not teach health as extensively as others. Time constraints lead some instructors to feel unsupportive of fitting a d ­ ditional subjects into an already crowded curriculum. However, because the health program is strongly endorsed by the school board and the administration, and because all students must take a health test at the end of the unit that 315 is graded by the health education coordinator, the health instructors comply and teach health education regardless of their personal objections. This barrier of not enough time in the day to teach all that is expected by the school administration is also seen as the main barrier in the Botham City Health Education Program. Almost every teacher interviewed at Botham City complained that time was a major barrier to the teaching of health. High priority of reading, math, and science, has forced the teachers to treat health education as a lowered priority. A major difference in the health program of Botham City and Hobart is that in Botham City mandatory health tests are not being collected by the health program coordinator. The large size of the student population also makes it quite difficult to monitor the health education competence gained by the students. The Botham school dis­ trict has recognized that all ten topic areas of compre­ hensive school health education cannot be provided in all six grades every year. Therefore, the administration has recommended that each grade level emphasize two or three topic areas each year. The success of this recommendation was not observable. In the Urbandale kindergarten health program the major barrier observed was the lack of a health content being taught in the health lessons. Although health education is provided in later grade levels, the lack of health content in the kindergarten health program is seen 316 as a major barrier to implementing comprehensive school health education. At this level, kindergarten comprehensive health education curriculums are available, but they were not being used during the observations of the Urbandale health program. Innovations. The most important innovation ob­ served at the Hobart health education program was the in­ clusion of parents, professionals, and the general community in the activities of the health program. The open door policy of the advisory board, media coverage, parent review sessions, parent handbooks, newsletters, and the inclusion of professionals as health education resources all contri­ bute to the Hobart health program's major strength: community integration. This community integration is pr o­ vided through specific aspects of the organizational structure. The provision of regular advisory board meetings, parent handbooks, and other services has helped the Hobart health program to be implemented and maintained despite threats to the program such as budget cutbacks, opposition to reproductive health from various interest groups, teacher apathy and other problems. The most important innovation observed at the Urbandale health education program was the utilization of community professionals and resources to provide valuable health education services to the kindergarten students and instructors. Through contacting a nearby nursing college, the health program was able to provide student nurses to 317 serve as resources for the kindergarten student and her/his family. Both the student nurses as well as the families were able to benefit through the home visitation program. In addition, health education inservice was provided to the kindergarten health instructors through having medical and educational professionals share their expertise. These two examples illustrate that the Urbandale health program has been able to improve services through utilizing the resources available in their community. The main innovation observed in the Botham School District health education program was the use of closed circuit television for broadcasting health programs for students and health inservice education for teachers. The use of audiovisuals to provide supplemental health education information is seen as an important use of available technology. Because of -the large size of the Botham School District, the use of closed circuit television helps to overcome instructional problems such as lack of a uniform program content, the reaching of large numbers of students and teachers, and the maintenance of interest and creativity while teaching comprehensive health education. ADDITIONAL FACTORS INFLUENCING HEALTH EDUCATION There were also two additional factors identified as important and distinguishing in the three observed health education programs. The first factor was the presence of inter-district peer support for the health education coordinators within the health education professional 318 network. In Michigan, the main health education professional network stems out of the organizations of Michigan School Health Association (MSHA). Two of the three district health education coordinators were active members of Michigan School Health Association, and have attended their main fuctions. This organizational tie allows the district coordinators to share their personal frustrations and successes with col­ leagues throughout the state. Inter-district peer support is seen as an important ingredient for the implementation and maintenance of a comprehensive health education program. The second factor is the quality of relationship between the district health coordinator and the teachers. The observations of the three health education programs can in no way compare the quality of this relationship between any of the three programs. However, certain attitudes towards the coordinators and administration in general were observed. Candid conversations with the teachers in all three of the programs indicated that colleagial cooperative relationships between teachers and the administration (in­ cluding the district health coordinator) tends to foster the most productive and constructive participation by the teachers and the district coordinator. Comments such as: "the co­ ordinator needs to be a squeaky wheel to get some grease", "the teachers really resent being ordered to teach or do anything", "we are sick of getting it (health) pushed down our throats". cooperative, All voiced resentment that they are not on a mutual goal-oriented relationship with the 319 district coordinator. In these instances, the district co­ ordinator and the administration were viewed by the teachers with animosity. These attitudes do not improve the teacher's ability to teach health education in a positive and in­ teresting way. Instead, health is seen as just one more subject to cram into an already overloaded curriculum. Eventually, the students are the ones who often receive this message, and instead of fostering interest and participation, health education becomes just another subject for the students to contend with. The observations of the three health programs iden­ tified several rules or practices that did seem to be positively received by the teachers. Some of these were: • Inclusion of the teachers in the decision-making process regarding the health education program. • Provision of health education inservice training that provides the teachers with an opportunity to share their experiences and frustrations in the classroom. e The provision of health education inservice that suggests new ways or methods for health education instruction. • Maintaining personal relationships between the district coordinator and the teachers. • Providing financial or time compensation for health education inservice. • Strong support from the administration and dis­ trict coordinator to the teachers in the wake of any community disruption regarding the teaching of reproductive health as a content area of comprehensive health education. These administrative rules were observed in at least one of the three observed health education program, and were 320 very positively regarded by the health instructors. SUMMARY This chapter has compared three main factors: or­ ganizational structure, program content, and program methods between the three observed health education programs. It was found that each program had a different organizational structure, and thus a different program emphasis. Hobart's health program emphasized integration of the health program into the community, while the Urbandale health program em­ phasized integration of school health services into the health program. Botham City's health program emphasized the utilization of closed circuit television to supplement the health education being provided in the health textbook. The three observed health programs were examined in the light of what particular organizational components fos­ tered their respective program emphasis, and how these com­ ponents shaped the overall health program's structure. Differences in implementation by various health in­ structors, lack of sufficient time in the day to teach all required subjects, and the lack of a health content were identified as the major barriers to the implementation of comprehensive school health education in the three sites. Integration of the health program into the community, utilization of community resources into the health program, and the use of closed circuit television to teach health education were identified as the major innovations of the three sites. 321 In addition, peer support for the district coordinator, and the quality of relationship between the district coordinator and the teachers were identified as important administrative practices for the improvement of comprehensive school health education. CHAPTER VII CONCLUSIONS AND RECOMMENDATIONS The results and recommendations of this disser­ tation address several main themes of comprehensive school health education. These themes include the organizational structure, program content, methods of instruction, pro­ fessional preparation of instructors, selected health education issues, and research methods for health education. The recommendations generated by this thesis are directed toward school health program administrators, health instructors, college and university administrators, and health educators. The conclusions and recommendations are divided into two sections. The first section includes conclusions and recommendations that are derived directly from the data and findings of this dissertation. The second section includes conclusions and recommendations that go beyond the actual findings of the dissertation, and suggest future directions that health education should pursue. The conclusions and recommendations based directly on the dissertation findings are discussed below. ORGANIZATIONAL STRUCTURE The results of this study reveal essential infor­ mation regarding the organizational structure of school 322 323 health education programs. The findings of the health education survey indicate that there is a lack of a welldeveloped organizational structure to implement compre­ hensive school health education in Michigan public schools. Some of the major findings from the survey that point to this conclusion are (1) a majority (70.2$) of the elementary principals responded that there was no building health coordinator to help develop, coordinate, implement, and evaluate the comprehensive school health education program, (2) 35.1$ of all principals responded that school health services were not integrated into the overall health pro­ gram, and (3) a majority (62.7$) of principals from all grade levels responded that their school board had not ap­ pointed a school health advisory board made up of parents having children attending the district schools, educators, local clergy, community health professionals, and other interested citizens. The observations of the three health education pro- . grams also generated several conclusions regarding the or­ ganizational structure of school health education. The ob­ servations of the kindergarten health program at Urbandale showed how the integration of school health services and community re -ources into the health program can be used to provide additional information on selected students through a home visitation program. Inservice education sessions with the teacher, student nurse, school nurse, and the health project staff provided valuable information and 324 insight into the home environment of students who demon­ strated poor achievement in the classroom. The publication of parent handbooks, and the pa r­ ticipation of parents on the advisory board and as volunteers for the Hobart health program illustrated how parent in ­ volvement can serve to improve and maintain a comprehensive school health education program. In addition, the health program at Hobart was able to sustain considerable op­ position by a vocal minority to the reproductive health component because of a sound organizational structure. The observations of the Botham City health program indicated how outside resources can be used to supplement the health program content. The Dairy Council provided curricular materials as well as inservice education to instructors to supplement the nutrition education of the health program. Based on these findings regarding the organizational structure of the health program, the following recommendations are made: 1. A sound organizational structure of comprehensive school health education programs should be estab­ lished before the implementation of the program. This structure should include: a. Appointment of a qualified health education coordinator. b. A health education advisory board made up of parents having children attending the district schools, local clergy, community health pro­ fessionals, students, teachers, administrators, school nurses, and other professional staff. _c. Integration of school health services into the overall health program. 325 d. Community health agencies and community health professionals as resource providers to the school health program. e. A needs assessment of the status of the com­ prehensive school health education program already being taught in the school district and local community. f. An assessment of the current health needs and concerns of the local community. 2. A continuous evaluation mechanism should be on­ going during the planning and implementation of the program. 3. Health instructors, school health services per­ sonnel, and school district administrators should be involved in the planning and implementation of the health education program. 4-. Health program administrators should improve their skills in implementing educational change program s. HEALTH PROGRAM CONTENT The results of this dissertation indicate that com­ prehensive school health education is fragmented, and in­ consistent or non-existent in Michigan public schools. The major findings of the statewide health education survey i n ­ dicated that community health and consumer health were the least frequently taught health areas in all grade levels. In addition, 36.5% of the elementary principals responded that teachers within the same grade level did not follow the same health curriculum. The observations of the three health education pro­ grams also indicated several findings pertaining to the con­ tent provided in the health education programs. The Botham City health program recognized that the teachers in their 326 school district did not have enough time to teach all ten topic areas contained in the Essential Ob.iectives for Health Education in M ichiga n. The school district responded to this curricular overload by recommending that only certain health topics be taught at each grade level, and that all ten topic areas be covered at least once by the time the student reaches the end of 6th grade. This adaptation of the Essential Objectives by the Botham City School District indicates that the standards developed by the Michigan Department of Education for pro­ viding a comprehensive school health education program may need to be modified by school districts that are already experiencing an overcrowded curriculum. In the kindergarten health education portion of the Urbandale program, none of the content areas of compre­ hensive school health education were provided. Instead, the curriculum focused on academic readiness skills and improving the students' sense of self-esteem. The content of the health program provided in the Hobart School District contained all topic areas listed in the Essential Ob.iectives for Health Education in Michiga n. In addition, discussed, several health education issues and topics were such as anti-health messages in the media, sex- role stereotypes, and the presence of a double standard for boys and girls to have opportunities for personal choice and decision-making. Based on the findings relevant to the program content in comprehensive school health education, the following recommendations are made: 1. The content provided in the health education pro­ grams should be based on the Essential Ob.iectives for Health Education in Michigan. 2. The content of the health program being provided should be relevant to the students' personal experiences. 3. The content of health instruction should be presented in terms of the students' personal responsibility, choice, and decision-making. U. The content of health instruction should be re­ assessed to include cultural differences present in the Michigan student population. Each of the ten topic areas of comprehensive school health education should discuss cultural patterns and differences within each topic area. For example, the nutritional diet of Hispanic Americans may be quite different from that of native Americans, yet be equally nutritious. 5. Within each school district, teachers within the same grade level should teach from the same health curriculum. 6. The content of health instruction should discuss anti-health messages in the media, in stores, and in advertising. These anti-health messages need to be identified as gimmicks used to sell material products. 7. Sex-role stereotypes should be eliminated from all health instruction content areas, and be identified as undesirable aspects of teacher attitudes in health education professional preparation courses. METHODS OF INSTRUCTION There were several different types of methods of instruction observed in the three health education programs. One method of teaching health that appeared to be effective in all three observed programs was the use of hands-on 328 experiences for teaching different health topics. The teachers as well as the students seemed to participate more actively and to enjoy hands-on health exercises more than any other observed methods of instruction. Each of the three health programs also used dif­ ferent methods of health instruction. The Hobart health program used audiovisuals for most of its health instruction. One of the films showed students asking questions about re­ productive health. the film. These questions were not answered in Following the film, the teacher asked the class to recall the questions and to try to give the appropriate answer. This technique generated considerable discussion about reproductive health topics that might not have occurred otherwise. Another method of instruction used at the Hobart health program was the separation of genders for the dis­ cussion and film From Girl to Woman (for females) and From Boy to Man (for males). This separation of the genders may have given the students a message that reproductive health should not be discussed openly, or that it is embarrassing, or that it should only be discussed with members of the same sex. Separation of the genders for certain reproductive health topics is seen by the researcher as a method of in­ struction that may give the students undesirable perceptions about reproductive health education. The methods of instruction used to teach the kinder­ garten health program at Urbandale consisted of small group 329 interactions with four or five students and the teacher aide. Teaching small groups of students helped the teacher to give each student more individualized attention than would be possible in a larger group. The Botham City schools supplemented their text­ book method of instruction with a health education television program shown twice weekly. This method of instruction was well received by the teacher whom I interviewed, and was an effective way of teaching health to a large number of students. Based on the findings relevant to the methods of instruction observed in the three health programs, the following recommendations are made: 1. The methods of health instruction should include more hands-on experiences. 2. Kindergarten health instruction should include as much small group interaction as is possible. 3. The instructional method of using films with unanswered questions is recommended as an ef­ fective tool for stimulating discussion. 4. Closed circuit televised health programs is re­ commended as an effective method of teaching health to a large population of students. 5. Using a film showing an actual childbirth that also discusses personal responsibility and decision-making is recommended as an effective method of teaching about human childbirth. 6. The inclusion of outside resources is recom­ mended as an effective method of teaching health and involving the community in the health education program. 330 PROFESSIONAL PREPARATION OF INSTRUCTORS There were two main results from the health education survey that indicated that instructors of health have had little or no professional preparation in general health education. First, only 19.5$ of the elementary principals responded that health teachers had at least four semester hours of professional preparation in general health education. Second, 8/. 8$ of the elementary principals res­ ponded that health education inservice is not being re ­ ceived by the teachers on a yearly schedule. These two findings point to the conclusion that health instructors in Michigan public schools have had little or no preservice (college) or inservice training in general health education. Based on these findings, the following recommendation is made: Colleges and universities that provide elementary teacher education should require at least four semester hours of general health education for elementary teacher certification. SELECTED HEALTH EDUCATION ISSUES Several health education issues and concerns were observed and/or generated during the observations of the three health education programs. In the observation of the Hobart health program, a major issue regarding lack of public confidence in comprehensive health education was evident in the health education advisory board meeting. During the meeting, there was considerable debate about the appropriateness of three reproductive health films. Although 331 the advisory board recommended the films be included in the 6th grade curriculum, the discussion indicated that the general public lacks confidence in and knowledge of the need for comprehensive school health education. Also observed in the Hobart health program were discussions about anti-health messages in the media. The observations of the health program at Botham City indicated that there was a substantial difference of opinion between the elementary health education instructors and the administrators of the school district. These dif­ ferences of opinion were about such issues as health edu­ cation content, methods of instruction, time allotment for health instruction, inservice education, and parent involvement. The main issue evident in the observations of the Urbandale health program was the possible misidentification of students as being developmentally deficient, when in fact their deficiencies might have been due to differences in cultural patterns of communication and behavior. The re­ medial efforts for these. mi.sidentified students may serve further to exacerbate the problem. Based on these health issues and concerns observed in the three health programs, the following recommendations are made: 1. Health education professionals should disseminate research findings and professional perspectives to the general public via the media, local forums, and community and school meetings. These per­ spectives should be in lay persons’ terms so that 332 the general public can be reassured of the essential nature of comprehensive school health education. 2. Health educators should work together with other health professionals, such as physicians and nurses, to increase current knowledge and share perspectives on health issues and concerns. 3. Health educators should take a more active role than simply being available to local school dis­ tricts. Local school boards should be encouraged to conduct a health education needs assessment and to implement a comprehensive school health education program. 4. Health education administrators should involve more health education instructors in their efforts ' to establish realistic health education program criteria. RESEARCH METHODS FOR HEALTH EDUCATION One of the more unusual aspects of this disser­ tation has been the utilization of two different methods to assess the status of comprehensive school health education and program criteria.in Michigan public schools. By using both a quantitative method to obtain a general overview and .program criteria frequency count, and a qualitative'research method to obtain an inside analysis of different functions of three health programs, the study goes beyond the limitations of using either of these two methods alone. The qualitative research method has the distinct advantage of being able to illustrate what the participants of a health education program see, do, and confront in their day-to-day activities. The qualitative research in this dissertation tells the story from the participant's point of view, and "brings to life" the implementation of 333 educational programs and policies enacted at higher levels of educational administration. Particularly when evaluating educational policies, there needs to be more information beyond frequency count data. There also needs to be qualitative information on how the educational program or policy implementation is working and the various adaptations needed or used in certain settings or circumstances. As could be seen in the narrative vignettes des­ cribing the health programs, qualitative research methods can present new information and findings that would not be possible by using quantitative research methods alone. Both the qualitative and quantitative research methods used in this dissertation were necessary to give a balance of perspective that includes a broad overview of health education status throughout Michigan, and a detailed focus of the inside structures and functions of a health education program. Based on these findings and conclusions, the following recommendations are made: 1. Qualitative research methods as well as quanti­ tative research methods should be included whenever evaluating public educational policies. 2. More qualitative research studies should be conducted on individual components of compre­ hensive school health education. Some of these components should include investigation of: a. The effectiveness of different methods of health education inservice to health instructors. 334 b. The effectiveness of various methods of in­ struction used to teach health education to students. c. The role personal responsibility and behavioral choice and decision-making plays in health education presently being taught in Michigan public schools. d. The importance and necessity of certain health education organizational structure components such as integration of health services, ad ­ visory board, outside resources, district and building health coordinators, health curri­ culum planning committees, parental involve­ ment, participation of health professionals, participation of students, etc. The following section of conclusions and recommen­ dations are not based directly on the dissertation findings. Instead, these conclusions and recommendations have been developed in response to what was found to be absent from the observed health education programs. These suggestions and conclusions reflect a general educational phenomenon that seems to occur in a variety of subjects where contro­ versial or value-laden issues are omitted from the academic curriculum. Because this omission happens in such a wide variety of academic subjects, it suggests that schools have organi­ zational structures in place to measure and respond to outside political pressure by deleting controversial topics from the curriculum. This omission of controversial topics may serve to protect the schools from political conflict, however, the students are forced to pay the price by being less informed 335 of critical health issues affecting their lives. This conclusion also suggests that school adminis­ trators should examine the consequences of omitting these controversial issues, and seek creative ways to endure out­ side political conflicts yet provide the students with a realistic understanding of the various issues. Some of these issues include the ethics and rights of abortion, toxic waste contamination and responsibility, the threat of nuclear war, conservation of dwindling natural resources, and the causes and remedies of world hunger and poverty. Based on these considerations, the following recommendations are made: 1. The content of health instruction should stress the interdependent nature of life. Students must learn that their health and well-being necessarily affects the health and well-being of others, and vice-versa. 2. The content of health instruction should include more emphasis on current health issues affecting peop les ’ lives, such as toxic waste pollution and responsibility, the threat of nuclear war, the reasons and remedies for world hunger and poverty, and the diminishing of natural resources. 3. The content of health instruction should include information regarding why the public has been deliberately uninformed or misinformed about health-threatening circumstances or pollutants affecting their lives. A. Health educators should take a more active role to combat health-threatening issues and circum­ stances that affect human lives, such as toxic waste contamination, the threat of nuclear war, anti-health messages in the media, conservation of dwindling resources, and the reasons and possible solutions to world hunger and poverty. 336 SUMMARY In order for our future society to understand and make knowledgeable■choices about the multitude of health issues and concerns facing our lives, comprehensive school health education must be included in the educational curriculums of Michigan public schools. However, as this disser­ tation has pointed out, comprehensive school health education is either non-existent, or inconsistent throughout Michigan public schools. This dissertation has described five main themes of school health education that comprise a comprehensive school health education program: organizational structure, program content, methods of instruction, behavioral choice and decision-making, and selected health education issues. Each of these five factors has been identified as necessary but not sufficient components of a comprehensive school health education program. These five themes or constructs were also identified as having an interdependent nested spiral relationship, with more focused and specific constructs at the center, and more broad and global constructs on the fringes. The spiral nesting effect of the five factors has allowed the articulation of a conceptual scale of health education program quality. The more a health program re ­ flects each of these five factors, the better the program quality seems to be. 337 A statewide health education survey of public school principals and a participant observation study of three health education programs has provided only a small part of the total picture of comprehensive school health education ongoing in Michigan. The total picture of com­ prehensive school health education is beyond the scope of this study. However, this dissertation does provide valid information, and recommends a framework upon which future research in health education can be based. APPENDIX 338 a project of MICHIGAN SCHOOL HEALTH ASSOCIATION MICHIGAN HEALTH COUNCIL April 2, 1981 Dear Principal, Your school 1s being asked to participate in a survey to assess the status of health education in Michigan Schools. The Michigan School Health Assoc­ iation and the Michigan Health Council through a grant from the W.K. Kellogg Foundation is surveying a ll public schools 1n Michigan to determine the status of th eir school health education program. Enclosed is a survey to assess the current school health education program of your building. Please f i l l out the survey and return i t no late r than April 24, 1981 to: MSHA Survey Suite 340, Nisbet Building 1407 S. Harrison Road East Lansing, MI 48823 Phone (517)3378413 The results of this survey w ill be used to identify existing health educat­ ion programs and to identify schools which desire assistance for developing or expanding th eir health education program. With the exception of this assistance re ferra l, all answers to the survey w ill be held in strictest confidence by the Michigan School Health Association. The statewide statistics resulting from this survey w ill be shared with the Michigan Department of Education, the Michigan Department of Public Health, and any other interested school health groups. I f you desire a copy of the final report, please check the Final Report Box on page 4 of the survey. Your prompt attention and personal assessment of your school is extremely important to the success of this survey. Thank you in advance for your cooperation. Sincerely, Mamra DuShaw Project Director 339 a project of MICHIGAN SCHOOL HEALTH ASSOCIATION MICHIGAN HEALTH COUNCIL April 2, 1981 Dear Superintendent, This 1s to Inform you that a ll school building principals 1n your d is tric t are being asked to participate 1n a survey to assess the status o f health education 1n Michigan schools. The Michigan School Health Association and the Michigan Health Council through a grant from the W.K. Kellogg Foundat­ ion 1s surveying a ll public schools 1n Michigan to determine the status of th e ir school health education program. The results of this survey w ill be used to Identify existing health educat­ ion programs and to id en tify schools which desire assistance for developing or expanding th e ir health education program. With the exception of this assistance re fe rra l, a ll answers to the survey w ill be held 1n s tric te s t confidence by the Michigan School Health Association. The statewide s ta tis tic s resulting from this survey w ill be shared with the Michigan Department of Education, the Michigan Department of Public Health, and any other Interested school health groups. I f you desire a copy o f the fin a l report, please w rite to: MSHA SURVEY Suite 340, Nlsbet Building 1407 S. Harrison Road East Lansing, MI 48823 Phone (517)337-8413 Thank you fo r your attention. Sincerely, Martha DuShaw Project Director 340 SCHOOL HEALTH EDUCATION RESOURCES COORDINATION SCHOOL HEALTH EDUCATION SURVEY ■ ------------------------------- PHONE mrnm. --------------------- GRADE LEVELS QAtE PLEASE CHECK APPROPRIATE ANSWERS AS THEY RELATE TO YOUR BUILDING 1. Yes Is health education taught as an id e n tifie d (separate) subject?___________ No ___ N/A ___ 2. Is health education integrated into other subjects? ___ ___ ___ 3. In grades 1-6, do the teachers have at lea st 4 semester hours of professional preparation in general health education, i . e . personal health/community health, and school health problems? ___ ___ ___ 4. I f the answer to question 3 is "no", what percent o f teachers do have a t least 4 semester hours o f professional preparation in general health education? ______ % 5. In grades 7-9, are the health education teachers c e rtific a te d teachers holding majors or minors in health education?_________________ ___ ___ ___ 6. I f the answer to question 5 is "no", what percent o f teachers do have a major or minor in health education? % 7. Has a person been appointed as the building health coordinator to help develop, coordinate, implement, and evaluate the comprehen­ sive school health education program? ___ ___ ___ I f the answer to question 7 is "yes", does th a t person (the building health coordinator) have a major or minor in health education? ___ ___ ___ Do the school health service personnel ( i . e . school nurse, public health nurse, school health workers, school psychologist) help plan and implement the program? ___ ___ ___ Do you, as p rin c ip a l, provide instructional leadership by working with s t a ff in planning, organizing, implementing and evaluating the health education program in your building? ___ ___ ___ Do the teachers o ffe r study options, extra c re d it and/or choice fo r students on projects?______________________________________________ ___ ___ ___ Do teachers receive health education inservice train in g on a yearly schedule? ___ ___ ___ Have curriculum guides fo r grades K-9, that include the 10 areas, as defined by tne "Minimal Performance Objectives fo r Health Education in Micnigart*, been cevelooed by tne taacners? ___ ___ ___ 3. 9. 10. 11. 12. 13. 341 14. 15. 16. Yes No N/.' Has the local school board approved curriculum guides and policies fo r implementing a comprenensive health education program? ____ __ ___ Are the state guidelines r e la tiv e to drug education, sex education and comprehensive health education being followed? ___ ___ ___ How many minutes o f health in stru ctio n are provided per week, and per year in your school building? Please f i l l in the chart below. GRADE 1 2 3 4 5 6 7 8 MINUTES PER WEEK WEEKS PER YEAR 17. Do a ll teachers w ithin a grade level follow the same curriculum? 18. Is the teacher-student ra tio in health education classes consistent with school d is tr ic ts contract policy? 19. Does your school d is t r ic t have a health curriculum planning committee to provide leadership in the development and implementation of the comprehensive health education program? 20. Are the health education knowledge tests suited to the grade level where they are administered? 21. Does your school d is t r ic t have a p lan/p olicy fo r f ir s t - a id and emergency care? 22. Are students involved in planning health in struction al a c tiv itie s ? 23. Has the school board appointed a school health advisory board made up o f parents having children attending the d is t r ic t 's schools, educators (e.g. adm inistrators, teachers, professional s t a f f ) , local clergy, community health professionals, and other interested citizens? 24. Are current health education periodicals and health reference m aterial available fo r classroom use? 25. Is the school health services comoonent integrated into tne to tal comprehensive health program? 25. Do community resource persons p a rtic ip a te in the health education program? -2- 9 342 27. Please check the appropriate boxes in the following graph where the 10 topical health education areas are taught in your school (fo r further c la rific a tio n as to what is included in each area, refe r to the "Mini­ mal Performance Objectives fo r Health Education in Michigan document). GRADE 1 2 3 5 4 7 6 3 9 Disease Pre­ vention and Control Personal Health Nutrition Growth and Development Family Health Emotional and Mental Health i ! i Substance Use and Abuse i Cons'umer Health i ;Safety 1 • ! ! i !Community 'Healtn ! !; i 1 . I i1 ! l i "Your school building has been identified as containing grades 9-12. Please answer questions 5, 15, 27, 23 and 29 of part I, and question 1 of part II as they apply to your school "building. Thank you. - 3- 343 Yes 28. Does the "minimum Performance Objectives fo r Health Education In Michigan" serve as a guide fo r your school d is t r ic t 's health curriculum? 29. Are pre-tests and post-tests given in a ll 10 areas (as defined by the "Minimal Performance Objectives fo r Health Education In Michigan") of the health education curriculum? The results of th is survey w ill be used to deter­ mine the statewide status of school health educat­ ion in Michigan. Individual school buildings w ill not be id e n tifie d , with the exception of assistance re fe rra l (Question #3 Part I I ) , a ll answers w ill be held 1n s tr ic te s t confidence by the Michigan School Health Association. PART I I Please answer the following open ended questions as they pertain to your school building. Be as s p e cific as possible, and attach additional pages as required. 1. ,2 . 3. Do you consider the "Minimal Performance Objectives fo r Health Education In Michigan" applicable to your school d is tr ic t? I f not, why? What do you believe are the major improvements which could be made within your school d is t r ic t to enhance the development of a comprehensive school health education program? ( i e . needs assessment, inservice tra in in g , curriculum development, in teg ration with community professionals, health­ fu l school environment, e tc .) Do you believe your school d is t r ic t would l i k e assistance from the State of Michigan Department of Education in expanding or developing a compre­ hensive school health education program? I f so, in what areas? (see above) I f you would l i k e a copy o f the MSHA Survey Final Report, please check the box below. Thankyou. T FINAL REPORT BOX Return a ll surveys to : MSHA SURVEY Suite 340, Nisbet 3 u ild in g 1-C7 3. Harrison Road East Lansina, MI 43823 Phone (517)337-3413, No N/A BIBLIOGRAPHY BIBLIOGRAPHY BOOKS Anderson, C. L., and Wm. H. Creswell. School Health Practice. St. Louis: C. V. Mosby C o ., 1976. Boston Women's Health Collective. Our Bodies. Ourselves: A Book by and for W o m e n . New York: Simon and Schuster, 1976. Byrd, Oliver E. School Health Administration. W. B. Sanders C o ., 1 9 & 4 • Philadelphia: Daly, Mary. Gynecology. The Meta Ethics of Radical Feminism. Boston: Beacon Press, 1978. Earhart, Eileen. Manual on Kindergarten Manipulative Skills. Lansing: Lansing School District Health Project. Ehrenreich, Barbara, and Deidre English. For Her Own Go od : 150 Years of the Experts' Advice to W o m e n . Garden City: Anchor Books, 1979. Emrick, J., S. Peterson and Rogers R. Agarwala. Evaluation of the National Diffusion N e t w o r k , Vol., I, Finding and Recommendations. California: Stanford Research Institute, 1977. Gordon, Raymond L. Interviewing Strategy, Techniques, and Tactics. 3rd ed. Homewood: The Dorsey Press, 19t>9, 1975, 1980. Green, Lawrence, et al. Health Education Planning: A Diagnostic App roach. Palo Alto: Mayfield Pub. Co., 1980. Greenburg, J. Student-Centered Health Instruction: A Humanistic Appr oac h. Reading: Addison-Wesley, 1978. Havelock, Ronald G. The Change Agent's Guide to Innovations in Education. Englewood Cliffs: Ed. Technology Pub. Co., 1974. Hays, William L. Statistics for the Social Sciences. 2nd ed. New York: Holt, Rinehart & Winston, Inc., 1973. Herriott, Robert, and Neal Gross of Educational Change. 3U (ed.). The Complex Nature 345 JBF Associates. Adolescent Childbearing. JBF Associates, 1980. Washington, D.C.: Kagan, Norman. Interpersonal Process Recall: A Method of Influencing Human Interaction. East Lansing: Michigan State University, 1975. Lindsay, Peter H., and Donald A. Norman. Human Information Processing: An Introduction to Psychology. New York: Academic Press, 1972. Mussen, P., J. Conger and J. Kagan. Child Development and Personality. New York: Harper & Row, Publishers, 19& 9. Schatzman, Leonard, and Anselm L. Strauss. Field Research Strategies for a Natural Sociology. Englewood Cliffs: Prentice-Hall, Inc., 1973. Sliepcevich, Elena M. School Health Education: A Call to Acti on . Washington, D.C.: Samual Bronfman Foundation, 1965. ________ . School Health Education Study: A Summary Rep or t. Washington, D . C .: Samual Bronfman Foundation, 19&4Statewide Health Coordinating Council. Michigan State Health Plan 1980-1984. Statewide Health Coordinating Council, 1980 . Swartz, Howard, and Jerry Jacobs. Qualitative Sociology: A Method to the Madness. New York: The Free Press, Div. of MacMillan Pub. Co., Inc., 1979. United States Department of Health, Education and Welfare. Healthy People: The Surgeon G e n e r a l s Report on Health Promotion and Disease Prevention. Washington, D.C.: U. S. Gov't. Printing Office, 1979. ARTICLE IN JOURNAL Anderson, Elaine J. ".Preinstructional Strategies and Learning Outcome of Teachers in a Series of ITE Workshops," A E R A , Round Table Session. April 4-8, 1977. Argyris, Chris. Research," "Some Unintended Consequences of Rigorous Bettelheim, Bruno. "Our Children are Treated Like Idiots," Psychology Today. July, 1981. pp. 38-40. 346 Engiel, Elizabeth. "Health Education in Schools - A Philosophical Dilemma," Health Education J o ur na l. XXXVII, 4 (1978), 231. Francome, C. and C. Francome. "Towards an Understanding of the American Abortion Rate," Journal of Biosocial Science. XI, (1979), 303-313. Green, L. W. "Toward Cost-Benefit Evaluations of Health Education: Some Concepts, Methods, and Examples," Health Education Monographs I I , (Supplement I), (1974), 34-64• Hoch, L. L. "Attitude Changes as a Result of Sex Education in the Schools," Journal of Science Teaching, VIII, 4 (1971). Kanter, J. F . , and M. Zelnik. "Contraception and Pregnancy: Experience of Young Unmarried Women in the United States," Family Planning Perspectives, 5 (1973). Kapp, L., B. A. Taylor and L. E. Edwards. "Teaching Human Sexuality in Junior High School: An Interdisciplinary Approach," Journal of School H e a l t h , February, 1980. Kirby, D. "The Effects of School Sex Education Programs: A Review," Journal of School Heal t h , December, 1980. pp. 559-563. Kolacki, Eugene. "How to Plan Inservice Health Education for Elementary Classroom Teachers," Health Educatio n, March-April, 1981. LeCompte, Margaret D., and Judith Preissle Goetz. "Problems of Reliability and Validity in Ethnographic Research," Review of Educational Research. LII, 1 (1982), 31-60. McAlister, Alfred. "Social .and Environmental Influences on Health Behavior," Health Education Quarterly, VIII, 1, (1981), 25-31. McGuffin, S. J. "Knowledge of Reproduction and Child Care Possessed by 16-Year Olds in Northern Ireland," Public Health. LXXXXIV (1980), 261-263. McNab, Warren L. "Advocating Elementary Sex Education," Health Ed uc ati on, September-October, 1981. p.22. "New Definitions: Report of the 1972-73 Joint Committee on Health Education Terminology," Journal of School Health, XXXXIV, (1974), 33-37. 34 7 Newman, Ian. "Integrating Health Services and Health Education: Seeking a Balance," Journal of School H e al th, L I I , 8, (1982), 498-501. Ojemann, R. H. "Should Educational Objectives be Studied in Behavioral Terms?" Educational Leaders hip, 1968, pp. 223-31. Parcel, E. S., and 0. Luttman. "Evaluation in Sex Education," Journal of School H e a l t h . LI, 4 (1981). Pincus, J. "Incentives for Innovation in the Public Schools," Review of Educational Res ear ch, XXXXIV, 1 (1974), 113-143. Reid, Donald. "School Sex Education and the Causes of U n ­ intended Teenage Pregnancies - A Review," Health Education J o u r n a l . X X X X I , 1, (1982). "Report of the 1972-73 Joint Committee on Health Education Terminology," Journal of School H e a l t h . January, 1974* p. 33. Scales, P. "How We Guarantee the Ineffectiveness of Sex Education," Siecus Rep or t. VI, (1978). Sliepcevich, E.. "The Responsibility of the Physical Educator for Health Instruction," Journal of Health, Physical Education Recreation. J a n u a r y , 1961. p"I 32. Taub, Alyson, and Vivian P. J. Clark. "Training Elementary School Leadership Teams for Health Education," Journal of School H e a l t h . XXXXVII, December, 1977, p. 615. Watson, G., and R. S. Rogers. "Sex Instruction for the Mildly Retarded and Normal Adolescent," Health Education J o urn al . XXXIX, 3, (1980). Zelnik, M., and J. F. Kanter. "Sexual and Contraceptive Experience of Young Unmarried Women in the United States, 1971 and 1976," Family Planning Perspectives, IX, 2 (1977). Zimmerli, Wm. H. "Organizing for School Health Education Programs at the Local Level," Health Education Quarterly, VIII, 1 (1981), 39. ARTICLE IN BOOK Argyle, Michael. "The Social Psychology of Social Change," Social Theory and Economic Chan ge . Borns, T. B., and S. B. Saul, e d s . London: Tavistock, 1967. 34 8 Becker, Howard S., and Blanche Geer. "Participant Obser­ vation and Interviewing: A Comparison", Issues in Participant Observation: A Text and Rea de r. Reading: Addison-Wesley Pub. C o ., 19 6 9 • Berman, P., and M. McLaughlin. Federal Programs Supporting Educational Change. Vol. IV, The Findings in R e vi ew . Santa Monica: Rand Corporation, 1975. Carlson, R. "School Superintendents and the Adoption of Modern Math: A Social Structure Profile". Miles, M. B . , ed., Innovations in Education. New York: Teachers College Press, 1964. Geer, Blanche. "First Days in the Field: A Chronicle of Research in Progress". Issues in Participant Observation: A Text and Rea de r. Reading: Addison-Wesley Pub. C o ., 19^9. Leavitt, Harold J. "Applied Organizational Change in In­ dustry: Structural Technology and Humanistic Approaches". March, James, ed., Handbook of Organizations. Chicago: Rand McNally, 1965. McCall, George J. "Data Quality Control in Participant Observation". McCall, George and J. L. Simmons, (eds.) Issues in Participant Observation: A Text and R e ad er. Reading: Addison-Wesley Pub. C o ., I n c . 1969• Phillips, Susan. "Participant Structures and Communicative Competence: Warm Springs Children in Community and Classroom". Rogers, R. S. "The Effects of Televised Sex Education at the Primary School Level". Rogers, R. S. (ed.). Sex Education Rationale and Reactio n. England: Cambridge University Press, 1974. Zelditch, Morris, Jr. "Some Methodological Problems of Field Studies". McCall, George, and J. L. Simmons (eds.). Issues in Participant Observation: A Text and Re ad e r . Reading: Addison-Wesley Pub. C o ., I n c . 1969. STATE DOCUMENTS Education Commission of the States. State Policy Support for School Health Education: A Review and An aly si s. Michigan Department of Education. Michigan Program Criteria. Lansing: Michigan Department of Education, 1981. 349 Michigan Department of Education. Guidelines for a Compre­ hensive School Health Education Progra m. Lansing: Michigan Department of Education, 1979. ________ . Michigan Essential Ski lls. Department of Education, 1979. Lansing: Michigan _________. Support Materials for Health Education. Michigan Department of Education, 1980. Lansing: Michigan School Health Association. 1979-80 Michigan Ed u­ cational Assessment Program Health Education Interpretive Report, Grades 4, 7, and 1 0 . Lansing: Michigan School Health Association, 1980. Michigan State Board of Education. Position Paper on the Michigan Comprehensive School Health P r og ram. Lansing: Michigan State Board of Education, 1980. Myers, Frank H. Patterns and Features of School Health Education in Michigan Public Schools. Lansing: Michigan Department of Education, 1969. Office of Health and Medical Affairs. Recommendations for Comprehensive School Health Education. Lansing: 1982. Tremor, M. A Model for Managing Comprehensive Health' Ed u­ cation Programs in Schools (draft). Tallahassee: Florida Department of Education, 1979. VanPatten, Muriel. Keynote address to Michigan School Health Association Annual Meeting. May, 1981, Southfield, M i . REPORTS Erickson, Frederick. "On Standards of Descriptive Validity in Studies of Classroom Activity". Institute for R e ­ search on Teaching. Occasional Paper No. 16, 1979. School Health Education Study. Synthesis of Research in Selected Areas of Health Instruction. SHES Study, 1964. Sliepcevich, Elena. A Summary Report: School Health E d u ­ cation Stud y. Washington", D. C.: S H E S , 1964-. NEWSPAPER Giordiano. "Emotional Problems May Grow on Your Family Tree," The Detroit Free Press, November 10, 1982. p. 1-B. Pawsey, James, M. P. "The Sex Education That I s n ’t Working." London Daily Mail, August, 1980. 350 CONFERENCE PAPERS Bensley, Loren B. "A Study of Health Teaching in J+9 Selected Public Junior and Senior High Schools in Michigan." Mt. Pleasant: Central Michigan University, 1970, (unpublished report.) Lewis, Charles E., and Mary Ann Lewis. "Teaching Children Self Care: A Counter Cultural Proposal." Paper pre­ sented at the "Learning for Life" Conference on the Future of Health Education. Vancouver, British Columbia, Canada, April 29-May, 1982. Parent-Teacher Association, National. Matters and Awareness." n.d. "Health Education World Health Organization, Geneva, Switzerland. DISSERTATIONS Romas, John A. "A Study of Health Instructional Practices in Michigan Public Schools." Unpublished Doctoral Dissertation, University of Michigan, 1976. Sophiea, Kathleen M. "A Study of the Health Education R e ­ quirements for Elementary and Middle/Junior High School Teachers Set by Teacher Preparation Institutions Within the State of Michigan." Unpublished Master's Project, Wayne State University, 1981. Stoddard, Susan Clay. "The Search for an Ideal Multi­ cultural Environment: An Ethnography of Two Overseas American Schools." Unpublished Doctoral Dissertation, Michigan State University, 1980. 351 GENERAL REFERENCES Bowen, Eleanor Smith. Return to Laughter. of Natural History, 1964. American Museum Brown, Carol A. "The Division of Laborers: Allied Health Professionals, International Journal of Health Services, Vol. 3, No. 3, (1973), p. 435. Dewey, John. Democracy and Education. MacMillan Company, 1931. New York: The Etziowi, Amatai. Modern Organizations. Englewood Cliffs, New Jersey: Prentice Hall, Inc., 1961. Glass, Gene V. and Julian C. Stanley. Statistical Methods in Education and Psychology. Englewood Cliffs, New Jersey: Prentice Hall, Inc., 1970. Hopkins, Kenneth D. and Gene V. Glass. Basic Statistics for the Behavioral Sciences. Englewood Cliffs, New Jersey: Prentice Hall, Inc., 1978. Illich, Ivan. Medical Nemesis: The Expropriation of Hea lt h. Pantheon Books (Random House, I n c .), 1976. LaPiere, Richard T. Book C o ., 1965. Social Change. New York: McGraw Hill McCall, George, and J. L. Simmons (ed.). Issues in Participant Observation., A Text and R e a d e r . Reading, M a .: Addison-Wesley Pub. C o ., 1969. Malinowski, Bronislaw. Argonauts of the Western Pacif ic . New York: E. P. Dutton, 1961. Pelletier, Kenneth R. Mind as Healer, Mind as Sla ve r. New York: Dell Publishing Co., 1977. Simon, Herbert A. Administrative Behavior. The Free Press, 1976. New York: 352 Waller, Willard. The Sociology of Teaching. Russel and Russ el, 1961. New York: Watkins, Dillingham, Martin. Practical English Handbo ok, ith ed. Boston: Houghton & Mifflin Co., 197A. Wheelis, Allen. The Quest for Identity. W. W. Norton & Co., Inc., 1958. New York: