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http://hej.sagepub.com/ Health Education Journal

http://hej.sagepub.com/content/45/2/99The online version of this article can be foun d at:

DOI: 10.1177/001789698604500212

1986 45: 99Health Education Journal Lynda Finn and Lynda FinnPromoting teenage health : Some observations from a study tour of the USA

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Promoting teenage healthSome observations from a study tour of the USA

Lynda Finn

HEALTH education and health promotion were exam-ined in three settings: schools (and curriculumdevelopment agencies), adolescent health centres,and youth projects. Provision is uneven: it varies fromthe highly innovative and comprehensive to the non-existent. However, it is important to note that of thethree services, only the first - school health education- has been developed to a comparable (and in somerespects, supenor) extent in the UK.

School health education Although 43 states address health education in

their education legislation, there are enormous vari-ations in the way in which it is delmered Some schooldistncts limit their health education provision to asmall number of uncoordinated one-off health

instruction lessons taught by non-specialist staff,whereas others offer a comprehensive curriculumtaught by health education teachers with relevantcredentials. Three states - Oregon, Indiana and WestVirgmia - require a full year course of health educationin order to graduate from high school. But out of15,500 school districts in the USA, under 1000 have acomprehensive health education curriculum. Thescale of the country and of its population, the vastnumber of school districts, the high degree of stateautonomy, and the absence of a national curriculumdevelopment or dissemmation agency have, perhaps

inevitably, resulted inan

absence of national orregional co-ordination. This, in turn, has meant thatgood practice is not necessarily disseminatedthroughout the school system. Neighbouring states -indeed, neighbouring school districts - can have verydifferent strategies.

For some teachers, health education itself is underthreat. In certain states the prevailing political climatehas encouraged conservatme pressure groups to arguefor an instruction-based, mformation-impartingapproach. Such groups view health education itself -and values clarification in particular - as highlyundesirable and wish to exclude it from thecurriculum.

Health education practice was observed in twoschools one in California and one in New York.

Although the students were of a similar age, they weredifferent in most other respects. Huntington ParkSenior High, near Los Angeles, is in a poor, largelyHispanic district. Ninety per cent of the students areHispanic, and many have language difficulties inSpanish as well as in English. Students are in the 14 to

17 age range and are relatively low academicachievers. There has been a sharp increase in thenumber of teenage suicides in the past five years, andthis has encouraged the school to employ two thera-pists. However, health education is a separate, time-tabled, compulsory subject taught, not by the schoolstherapists, but by specialist health education staff.The academic level of the students, combined withtheir economic and social circumstances, has resultedin the design of a specific health education curnculumintended to meet their needs. The curnculum is imag-inative and broad, and a wide variety of teachingstrategies is used - group discussion, use of visitors,role play, projects, case studies, display work, and soon.

Student involvement is seen as an essential com-

ponent of health education. A glossary of health edu-cation terms, known as Healthy Words is offered as away of introducing new vocabulary. The glossary,which consists of 150 core vocabulary words, eachillustrated mth an explanatory drawing or cartoon,was designed by a student. Using overhead trans-parencies, the glossary is the major means by whichnew terms are mtroduced to students. Students areaware that one of their most valuable learning toolswas student-designed and are, similarly, encouragedto create their own learning tools.

A major feature of Huntmgton Park is that Youth

Gives a Damn, now a nationally known health edu-cation project, started here. In 1971, some 60 studentswere taken into the mountains north of Los Angeles,for a weekend camp of health education activities. Thecamping weekends grew in popularity and diversity.Their aim, accordingto the YGAD constitution, was to&dquo;encourageand promote better health throughinvolvement in health education and health serviceprograms and activities.&dquo;YGAD also tries to motivate

participants toward health-related careers and toencourage them to become involved in communityactivities. The underlying philosophy is that throughinvolvement in its activities students increase theirown personal health education. Although initiatedand co-ordinated by teachers, YGAD has a highdegree of student involvement. The votmg member-ship of the board of directors is limited to thosebetween 13 and 18 years of age, and this ensures thatthe programme of activities is relevant to the needs ofteenagers. The weekend camps continue, and theprogramme includes films, speakers, small group dis-cussion, seminars and demonstrations. YGAD partici-

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pants have examined such issues as smokmg, sex-uality, assertiveness training, death education, self-defence for women, drugs, environmental pollution,and diet. They have seen a demonstration of acupunc-ture, and have learned how to check blood pressure

and to undertake cardio-pulmonary massage and dia-betic testing.YGAD now takes place in ten states and is a highly

regarded, voluntary, comprehensive health projectwhich complements and supplements health edu-cation in school. Staff and students give their timefreely. In addition to the camping weekends, YGADmcludes weekend and evening activities in the com-munity Participants test blood pressure, check forheanng impairment and diabetes, act as mterpretersfor people for whom English is a second language, andlobby local and national politicians on health issues.

They appearat concerts,

parents evenings,health

fairs, and vanous other public events. Pnvate mdustryand voluntary organisations such as the AmericanCancer Association, Red Cross and the March ofDimes are eager to donate money and equipment.Such is the success of YGAD that it is now able toinsist that money is donated without stnngs.

Youth Gives a Damn has demystified health. Itserves to reinforce and to put into practice knowledge,attitudes, and behaviours learned in school, and hasenabled young people to engage directly with theircommumty. For YGAD volunteers, health education isnot just another timetabled school subject, but is seenas something alme and real and very much part of theirhves.

Formal evaluation has shown the followmg:I

~ YGAD participants had a significantly better self-concept than others.

~ YGAD participants were significantly less afraid ofdeath and dying than others.

~ YGAD participants were more interested in pro-tecting their environment than others.

~ YGAD participants were significantly more sex-ually responsible than others.

~ YGAD participants weresignificantly

more nega-tive in their attitude toward alcohol, tobacco andmarijuana, and they showed a significant decreasein consumption of the above.

~ YGAD participants were twice as likely to selecthealth-related careers.

Uniondale Public High School, Long Island, has along history of teaching health education. Semormembers of the administration are strongly in favourand the school has a health education co-ordmator.Students are mostly from skilled working class fam-ilies and the level of unemployment is low. In New

York State,one

semester of health educationis com-

pulsory in secondary school. This usually takes theform of a half semester in Junior High and a halfsemester in Senior High. The curriculum vanes fromdistrict to district, and Uniondale offers the TeenageHealth Teaching Modules. THTM is a comprehensivecurnculum package for the 12 to 17 age range. Initi-ated by the Centers for Disease Control in Atlanta, itwas researched and developed by the EducationDevelopment Center in Massachusetts. It consists of

16 modules and has a strong emphasis on skill acqui-sition. Fme basic health skills are covered - self-assessment, communication, decision-making,health advocacy, and healthy self-management. Thewide range of health topics offered is presented as

content through which skills can be acquired andrehearsed. Health topics mclude diet, stress, healthand safety in the workplace, creating a healthyenvironment, fitness, living with feelmgs, and pre-venting injuries.

THTM have been widelyacclaimed by educational-ists in the USA and the UK Family and communitymvolvement are essential components of the mod-ules. Environmental and economic factors are tackled,as are the social determinants of health. THTM areextremely popular with both staff and students inUniondale. For students, lessons are invariably excit-

ingand

enjoyable,and

theyhave a

veryreal connec-

tion with out-of-school activities. Staff stronglyadvocate THTM because the matenals are student-centred and interactive, and lend themselves to smallgroup-based participative learning methods. This, inturn, leads to a high level of student involvement and asignificant shift in relationships between staff andstudents. The modules are currently being evaluatedby the Centers for Disease Control. A recent evaluation of four school health curnculum

programmes studied in the School Health EducationEvaluation identified ten elements important in thedelivery of a comprehensive school health educationprogramme:&dquo;:~ Sound, well-planned, sequentially developed cur-

ncula which provide opportunities for students tolearn about their personal, family and communityhealth. Content to be appropnate to age, level ofdevelopment, and needs of students.

~ Opportunities for students to learn about health inits larger social context.

0 A co-ordinated curnculum.~ In-service training for staff.~ Rich teachmg/learnmg resources that support cur-

nculum objectives and are relevant to cultural, eth-nic, geographical and environmental realities.

~ Outreach activities which inform and involve par-ents and families.

~ Regularreview of the school environment to ensurethat the hidden curriculum does not contradicthealth education messages.

~ Active involvement by the community,.~ Regular re-assessment of the curnculum.~ Good management within the school.

The authors feel that &dquo;thevibrant interaction of atleast a majonty&dquo;of the above elements is essential to asuccessful, lasting and flexible school health edu-cation programme. In their different ways, Hunt-ington Park and Uniondale offer many of theseelements and can bd said to provide a comprehensiveprogramme.

Adolescent health centres Adolescent health centres are virtually unknown in

the UK. They provide an important service whichcomplements school health education. Their exis-tence is based on the promise that the needs of teen-



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agers are specific and are different from those of eitheradults or children. Adolescence is a time of rapidchange when young people are strugglmgto estabhshtheir identity and to form relationships unllke those ofchildhood. It is also a time of growing independencewhen the

developmentof self-esteem is of

great sig-mficance. Although based in a medical setting, ado-lescent health centres provide a broad andcomprehensive service of which medical care is butone small part.

Mount Sinai, the oldest adolescent health centre,on which many others were modelled, is based in NewYork City and was founded in 1969. Its staff are fromvaried backgrounds - social work, medicine, familytherapy, education, nursing, educational psychology- and the diversity of provision reflects this Six majorprogrammes are offered: an adolescent health careunit; a family life education programme, an alterna-tive school; a mental health counsellmg programme,an in-patient unit; and a counsellmg programme.Young people can visit the unit with a medical com-plaint, to obtain contraceptive advice, or sexualitycounselling, to talk to a social worker, because theyare having difficulty with school work or with familyrelationships, or with just about any other adolescentproblem. The alternative school provides an oppor-tunity for those who have difficulties with the publicschool system to study for equivalent qualifications.

The atmosphere is warm and friendly, and althoughyoung people are encouraged to involve their parents,confidentiality is assured for those who choose not todo so. The staff aim to demystify the health process.They emphasise choice. Young people are encour-aged to make mformed decisions wherever possible -they can choose male or female staff, whether to takea certain drug, whether one form of treatment ispreferable to another. The teenagers are encouragedto become actively involved in issues surroundmgtheir health. they are encouraged to ask questions, tomake mformed decisions, and to develop skills ofassertiveness. Staff at the Mount Sinai Hospital arereported to have little difficulty in recognising former

patients ofthe adolescent health

centre,as these

patients ask the most questions and are the mostactively involved in their health.

The centre provides an extensive outreach service.Staff work with local schools complementing thehealth education programme, with groups of parents,and with other agencies.

&dquo;Onedefinition of an adolescent is a person whocomes late for appointments! We try to teachthem that arriving on time is part of being anadult. Our job mcludes helping teenagers makethe transition to adulthood. They learn its okay toask whats in a prescription We help them toregister to vote. We are empowering them. &dquo;33

Gouverneur Adolescent Clmic, also in New York City,was modelled on Mount Sinai. It is located in a pubhchospital in a poor, largely black area of the City, and ismuch smaller, with fewer resources than Mount Sinai.Nevertheless, it provides a comprehensive range ofservices for young people between 13 and 19, mclud-ing medical exammations, guidance and counsellmgon a range of issues - nutrition, sexuality, relation-

ships, school or work problems, weight control, familyviolence, and substance abuse. Young people areencouraged to involve their parents but, if they refuse,confidentiality is assured.

The Adolescent Health Centre in the National Med-ical Centre in

WashingtonDC

providesa

similarlywide range of services and sees over 10,000 patientseach year. Although the centre is non-profit-makmg,uninsured people cannot be seen. The poorest sectorsof the community, who are most likely to be unin-sured, are required to attend the local state hospital,and even emergency services are not open to them atthe National Medical Centre. Local schools frequentlyrequest speakers, but their staff tend to have a verynarrow conception of what health education has tooffer. Speakers are usually invited to talk on pregnancyprevention or pre-natal counselhng. Staff of theNational Medical Centre, however, are aware of thelimited nature of these requests and, wherever poss-ible, attempt to broaden the scope of healtheducation..


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a consequence of low self-esteem, an environment ofpoverty and unemployment, and a fatalistic attitudewith little to plan for. It is not surprising that staff havea very clear view of the relationship between thehealth status of their clients and the surrounding pol-itical and economic climate. Health education isdesigned to demystify the health process and create asupportive yet challenging environment in whichyoung people can develop to their full potential.

ConclusionsSchool health education appeared to be most effec-

tive when it was comprehensive and co-ordinated.Strong support from senior administrators was a pre-requisite. The most progressme programmes broughtwith them the need for participative, interactiveteaching and learning strategies. Perhaps the mostexciting example of health education was YouthGives a Damn, a wide-ranging, holistic project whichreinforced and extended school health education sothat it became truly multisectoral. However, theabsence of a national curnculum development/dis-semination agency, perhaps inevitable in a country aslarge and as diverse as the USA, has implications forthe overall level and quahty of health education in thecurriculum.

Adolescent health centres can provide an equallycomprehensive, though different, service for youngpeople Staffed by adults who positively choose towork with adolescents, their very existence acts as a

recognition of the specific needs of teenagers. But itseems unlikely that the British health system couldprovide such a broad-based non-medical servicewithin a medical setting, desirable though this mightbe.

Youth projects can take health education out of anentirely medical or entirely educational setting. In theUSA they provide mnovative and imagmativeresponses to community need. Unconstrained by thebureaucratic and philosophical limitations of the edu-cation and medical systems, they offer an atmospherewhere, in the words of one of their staff, young peoplecan

grow healthfully.Many of these projects depended on a variety offunding sources. Although federal and local govern-

ment made some contribution, by far the most import-ant source of fundmg was private - industry andcommerce, voluntary organisations, charities. As pro-jects such as Youth Gives a Damn grew in success,voluntary organisations and private mdustry becamemore and more

eagerto be associated with them. But

the less obviously successful projects, those less inthe public eye and those located in poor communities,found fund-raising more difficult. Many projects wereseverely hampered by the insecurity of a perpetualsearch for funds and the commercial marketmg of theproduct which fund-raising necessitates. One projectworker was required to spend 70 per cent of her timefund-raising - time which could be better spent work-ing with young people. She was most impressed withthe British youth service and its system of local edu-cation authority funding, even though this resulted ina service which was severely limited in comparisonwith such imaginatme projects as The Door and theCentre for Youth Services.

Some people in health promotion in the UK stillargue that health education for young people is notlegitimate unless large-scale, statistically relevantchanges in health behaviour can be demonstrated.This is at vanance with the view of health educationwhich advocates the acquisition of assertiveness,confidence, increased personal effectiveness, and soon, as desirable health education goals in themselves.The young people observed in the USA, the consum-ers of health education, were quite unmoved by thistension between what can be crudely charactensedthe medical and educational models. They had nodoubt at all that the most effective health educationwas that which recognised and responded to thenneeds - mental, physical and social.

References1 LoyaR Youth gives a damn itis worth the effort?final project

report, 1981 (unpublished)2 Davis R et al Comprehensive school health education a

practical definition, Journal of School Health. October 19853 Mount Sinai Medical Center Annual Report 1984, Quote from

staff member

&bullet;Lynda Finn is assistant education officer schools/furthereducation at the Health Education Council.

40 YEARS AGO

Schools health education in the USA Joumal readers will be interested to learn that at the twentieth annual meeting of the Society of State Directors of Health and

Physical Education, held recently in Washington, DC, the following resolution on health education was passed.&dquo;Wherethere is need to improve the health knowledge and practice of the American people, and whereas acomprehensive programme of health instruction is an essential in meeting this need, and whereas the effectiveness ofhealth instruction depends to a great extent on content and the time available for instruction, therefore, be it resolvedthat schools throughout the country be urged to provide appropriate health instruction in both elementary andsecondary schools.

Be it further resolved that such instruction in secondary schools be given five periods a week for at least twosemesters.

&dquo;

Taken from the Health Education Journal, Vol 4, 1946.


99.fullpromoting teenage health : some observations from a study tour of the usa

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