Schools and Health Our Nation's Investment (1997) / Chapter Skim
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6 Challenges In School Health Research and Evaluation
6 Challenges In School Health Research and Evaluation
Pages 271-295
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From page 271... ...
First, these programs comprise multiple, interactive components, such as classroom, family, and community interventions, each employing multiple intervention strategies. Therefore, it is often difficult to determine which intervention components and specific messages, activities, and services are responsible for observed treatment effects.
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From page 272... ...
Types of School Health Research Research and evaluation of comprehensive school health programs can be divided into three categories: basic research, outcome evaluation, and process evaluation. Basic Research An ultimate goal of CSHPs is to influence behavior.
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From page 273... ...
This type of evaluation in its most basic form resembles the randomized clinical trial with experimental and control groups, along with the requisite null hypothesis assumptions and concern for internal and external validity. Outcome evaluation can further be divided into three stages: efficacy, effectiveness, and implementation effectiveness trials (Flay, 1986~.
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From page 274... ...
The goal of process evaluation is not to determine the basic impact of an intervention but rather to determine whether a proven intervention was properly implemented, and what factors may have contributed to the intervention's success or failure at the particular site. Implementation and/or participant exposure can be used as proxies for formal outcome evaluation.
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From page 275... ...
It would be desirable to stimulate and support research and evaluation alliances among colleges of education, schools of public health, and colleges of medicine. Bringing together the expertise from all three sectors in school health research and evaluation centers may enhance the understanding and interaction between these sectors and produce research and evaluation methods that can address cross-sector issues more accurately.
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From page 276... ...
All three types of evaluation can contribute to the development and dissemination of comprehensive school health programs, although it is important that they be applied in their proper sequence. Process evaluation studies are inappropriate for demonstrating intervention efficacy or measuring cost-effectiveness, just as basic research approaches may go beyond what is necessary for local program evaluation.
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From page 277... ...
However, interventions associated with individual program components should be developed and tested by using rigorous methods that involve experimental and control groups, with the requisite concern for internal and external validity. In this section, some of the methodological challenges of demonstrating program impacts are examined.
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From page 278... ...
Is a reduction in absenteeism a proxy for improved health status and a reasonable indicator of health outcomes? Dependent variables used to measure effectiveness of school-linked health services have included linking students with no prior care to health services, decreased use of the emergency room for primary care, identification of previously unidentified health problems, access to and utilization of services by students and families, perceptions and health knowledge of students and their parents, decreasing involvement in risk behaviors, and health status indicators (Glick et al., 1995; Kisker et al., 1994; Lewin-VHI and Institute of Health Policy Studies, 1995~.
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From page 279... ...
Schools should be held accountable for conveying health knowledge, providing a health-promoting environment, and ensuring access to high-quality services; these are the reasonable outcomes for judging the merit of a CSHP.1 Other outcomes improved attendance, better cardiovascular fitness, less drug abuse, or fewer teen pregnancies, for example may also be considered, but the committee believes that such measures must be interpreted with caution, since they are influenced by personal decisionmaking and factors beyond the control of the school. In particular, null or negative outcomes for these measures should not necessarily lead to declaring the CSHP a failure; rather, they may imply that other sources of influence on children and young people oppose and outweigh the influence of the CSHP.
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From page 280... ...
The national evaluation plan for the Healthy Schools, Healthy Communities Program provides helpful information for the evaluation of school health services (Lewin-VHI and Institute of Health Policy Studies, 1995~. This plan is facilitated by a standardized data collection system and marks the first time that health education and health services will be systematically analyzed with a management information system that records different types of health education interventions, utilization of health services, and outcomes.
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From page 281... ...
This section focuses on some of the challenges and unresolved questions in classroom health education and suggests issues that merit further study. Effects of Comprehensive Health Education The preponderance of school health education research has consisted of outcome evaluations focusing on categorical risk behavior, such as smoking, drug use, sexual behavior, and nutrition.
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From page 282... ...
One of the first major studies to demonstrate a dose-response effect was the School Health Education Evaluation project (Cornell et al., 1985~. Students from classrooms in which health programs were implemented more fully demonstrated significantly greater improvements in attitude and behaviors, compared to the entire intervention cohort.
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From page 283... ...
With regard to specific policy recommendations, there are insufficient data to delineate a requisite number of lessons across content areas and grades. There is, however, some evidence to suggest that at least 10 to 15 initial lessons, plus 8 to 15 booster sessions in subsequent years, are required to produce lasting behavioral effects (Botvin et al., 1983, 1995; Connell et al., 1985~.
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From page 284... ...
Lasting Effects of School Health Education In several long-term follow-up studies of substance prevention programs delivered in grades 5 through 8 (Bell et al., 1993; Flay et al., 1989; Murray et al., 1989) , positive program effects observed one to four years following the intervention had decayed by grade 12, or shortly after graduation from high school.
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From page 285... ...
While initial results were encouraging and skills training has become an integral component of many school health education programs (Botvin et al., 1980; CDC, 1988, 1994; Flay, 1985; Glynn, 1989; Kirby, 1992; Pentz et al., 1989b; Schinke et al., 1985; Walter et al., 1988) , many "skills-based" programs include other intervention strategies, such as modifying personal and group norms and outcome expectations, which also may have contributed to the reported intervention effects (Botvin et al., 1984; Ellickson and Bell, 1990; Murray et al., 1989; Pentz et al., 1989a; Walter et al., 1987~.
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From page 286... ...
The authors suggest, however, that skills practice may be effective only when clear values or norms are emphasized or when skills focus specifically on avoiding undesirable sexual behavior rather than on developing more general communication skills. Given the limited funding and classroom time available for health education, it is important that school health education programs include primarily those approaches known to influence health behavior.
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From page 287... ...
Additional research, particularly studies examining the effects of interventions addressing traits that may underlie clusters of risk behaviors, is needed before health education is restructured toward a more targeted model of health behavior change. Realistic Outcomes for School Health Education It can be argued that previous studies reporting weak or null behavioral outcomes employed health education interventions of insufficient dose and breadth.
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From page 288... ...
. Therefore, although health education delivered in isolation may not be able to produce lasting behavioral effects, when combined with other activities or implemented within a comprehensive school health program, significant enduring changes in behavior as well as physical risk factors can be achieved.
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RECOMMENDATIONS In order for CSHPs to accomplish the desired goal of influencing behavior, the committee recommends the following: An active research agenda on comprehensive school health pro grams should be pursued in order to fill critical knowledge
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From page 290... ...
Since the overall effects of comprehensive school health programs are not yet known and outcome evaluation of such complex systems poses significant challenges, the committee recommends the following: A major research effort should be launched to establish model comprehensive programs and develop approaches for their study. Specific outcomes of overall programs should be examined, including education (improved achievement, attendance, and graduation rates)
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From page 291... ...
This information will require overall consensus about the criteria to use for determining the quality of school health programs. It is also important to know how best to influence change in the climate and organizational structure of school districts and individual schools in order to bring about the adoption and implementation of CSHPs.
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1994. Guidelines for school health programs to prevent tobacco use and addiction.
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1987. School health education: A foundation for school health programs.
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Journal of School Health 61~1~:35-38. Pentz, M.A., Dwyer, J.H., MacKinnon, D.P., Flay, B.R., Hansen, W.B., Wang, E.Y., and Johnson, C.A.
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From page 295... ...
Journal of School Health 60~2~:6066. Telch, M.J., Miller, L.M., Killen, J.D., Cooke, S., and Maccoby, N
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