gram decisions based on sound education theory, research-mediated standards for student outcomes, effective health education programs, and behavioral change theories and knowledge (Allensworth, DeGraw, English), and

  • from a focus on teaching skills in isolation through categorical areas to a focus on teaching generic skills identified as promoting adoption of health-enhancing behaviors. Generic personal and social skills that should be taught include refusal skills, problem-solving, decisionmaking, media analysis, assertiveness skills, communication, coping strategies for stress, and behavioral contracting (Allensworth, Degraw, English).

Cost-Effectiveness

Rigorous experimental studies have not been undertaken to establish the cost-effectiveness of school health education. However, Rothman and coworkers (1993) have developed mathematical models to predict what benefit-cost ratio might possibly be achieved from exemplary state-of-the-art health education programs dealing with smoking, other substance abuse, and sexual behavior leading to unplanned pregnancy and STDs, including HIV or AIDS. For their analysis, the authors examined studies of selected exemplary programs that had been reported in the literature to produce positive behavior change among adolescents. Criteria for program selection in this analysis included the following: outcomes were measured longitudinally (12 or more months of behavioral data); the program was classroom based and offered during school hours; results had been reported since 1982; and a control or comparison group was used. Program costs included such variables as instructor salary and benefits, teaching and training time, and curriculum materials. Program effectiveness included both the initial effectiveness rates and the decay effects found in the actual studies. Direct and indirect benefits involved estimates of avoided morbidity and mortality. Highlights of their calculations are described below.

Substance Abuse: Substance abuse in the Rothman et al. (1993) study refers primarily to alcohol abuse. Benefits were defined as averted costs associated with adolescent avoidance of substance abuse. Direct benefits were those associated with avoidance of hospitalizations for which the primary or secondary diagnoses were related to substance abuse, and indirect benefits included the avoidance of such events as motor vehicle injuries and crime-related loss of productivity and social expenditures. The benefit-to-cost ratio was 5.69 for substance abuse education.

Smoking: Benefits involved averted costs associated with the lifelong treatment of smoking-related diseases. The benefits of tobacco avoid-



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