Health education for youth of the 21st century

In the early 1980s my daughter came to me with a career decision that was quite surprising. She declared that she wished to become a health educator. The news was surprising in that teaching had always been outside her realm of interest, possibly because she had grown up in a household in which teaching and education, in general, were a part of daily conversations. Needless to say, any definite life's goal would have been received with pleasure, but for her to have chosen her mother's profession was even more gratifying. Nevertheless, I asked myself, ``Could she not have selected a more traditional subject to teach? At the time, health science was not a required subject in California's secondary schools. Not all universities oserex nea_tb science protessional preparation programs. In many districts where health science appeared in the curriculum health classes were taught by persons without a teaching credential in the subject. No one outside of the field appeared particularly distributed by this condition because "health" was not considered a basic, core subject like mathematics or English. Since anyone with a remotely related teaching credential could teach health, I wondered whether there would be employment for my daughter when she finished her preparation. Not to be deterred she obtained a Health Education Secondary Teaching Credential, and subsequently, a Masters Degree in Special Education, and a California Administrative Services Credential. In spite of all this "preparation" her daily life as a teacher and administrator in today's schools is a formidable challenge. We have both come to realize that her background in health science has been invaluable in coping with these challenges. This will become increasingly clear as one reads the vignettes collected over the last six years from middle schools in which she has worked. Of particular note is the fact that these experiences have been in rural schools with no particular ethnic or racial composition; rather the youth in these vignettes are from lower socio-economic families with limited education.

Even in the early eighties HIV-AIDS among middle and high school students had appeared on the horizon, substance abuse among youths had persisted, teen pregnancies had begun to skyrocket, school violence was on the rise, and other societal problems associated with poverty, single parent families, and growing urban isolation predicted that the health of America's youth might well become a major responsibility of the public school.

While public schools are reluctant recipients of more and more of the larger society's responsibilities, we must consider health education to be an inescapable responsibility. This should become clear as we explore what is meant by health education in today's schools, what role it plays in the daily life of teachers and administrators; and how teacher educators are approaching the task of preparing and providing continued professional development for teachers. Let us take the case of Leah:

I first met Leah, an 8th grader, walking back from gym to the office. She said she was sick and wanted to lie down. She told me she had suffered a miscarriage two weeks ago and had an infection. Her mother's boyfriend had punched her in the stomach so hard that she lost the baby. She said he did it because he thought it might have been his baby. I kept my composure and made a report to Children's Protective Services when I returned to my office. Leah rested in the office then returned to class. Later that day, a student reported to me that Leah had marijuana in her backpack. I called Leah in and searched her backpack only to find a switchblade. Our school has a zero tolerance policy for weapons. Leah was faced with an automatic five day suspension and a recommendaton for expulsion. 1 called Leah's mother; Leah begged me not to tell her mother about the pregnancy. She said she had the life because she feared her mother's boyfriend would kill her; and that he was in jail for having tried to do so the previous night. I called the police department and found that a male had been arrested at Leah's residence for assault. I called the mother, explained the knife situation and took Leah home. The mother invited me in and we talked. She was feeling frustrated with Leah's attitude. She knew Leah was out of control but didn't know what to do about it; she asked me for resources in the community that could help. I gave her names of the appropriate social agencies and strongly emphasized the need for family counseling. Since I had made a report to Children's Protective Services, I know they would be out to see the family relatively soon. The mother agreed to seek counseling. The next week I received a call from Leah's mother. There had been an episode with drugs and sex involving several boys. The mother had thrown Leah out of the house. Two days later Leah had been admitted to the adolescent psychiatric hospital for observation after cutting her wrists in an attempted suicide. The mother said Leah would be placed in foster care when was released from the hospital; she wanted me to know what happened so I could work with Leah more effectively when and if she returned to our school.

How can a teacher or administrator be prepared to handle Leah's and her family's problems? How can teachers and administrators help students reach academic standards when these kinds of environments exist within the home and community? What can the school do in such a serious case as this? Should Leah be "written off" as a "lost cause?" One might think so; however, there are more Leahs than we wish to admit.

Even more typical "health" cases have their complications. Take for example the case of Kelly:

My administrator's role is difficult to define. Since we have no resident school nurse, Kelly was sent to my office to be checked for head lice. As official "lice inspector" I had seen Kelly many times before. I asked for a print-out of her attendance record. Kelly had been out over a third of the school year because of lice. This day her head was full of nits and live bugs. The nape of her neck was covered with infected sores from repeated scratching. The look in her eyes and her flushed cheeks told me she already knew she would be sent home. I called down to her room for her things and asked the secretary to call her home.

The phone at home and the numbers on the emergency card had been disconnected. I had no choice but to drive her home. We talked during the drive about why she was continuing to have this problem. Kelly told me that her mother used the medicated shampoo on herself and her boyfriend and only used rubbing alcohol on the children. When we arrived at the house, I asked to talk to the mother. I explained why I was bringing her daughter home again. I told her she must use medicated shampoo, comb the nits out Kelly's hair, wash and dry all bedding, and vacuum the house to get rid of the lice. The mother looked away from me; she said she didn't have any money, and medicated shampoo was too expensive. They did not own a dryer or a vacuum. When I told her that the child had developed infected sores on the back of her neck, she said she would take her to the clinic when she could find a ride. I left the home knowing that the steps needed to win the battle against lice was overwhelming. I felt our school was ill equipped to help this family in their health needs. I knew I would not see the student back in school for quite awhile.

One can see from these vignettes that health education is much more than a study of food classes to promote nutritious eating habits or demonstrations on how to brush one's teeth to ensure dental hygiene. Health education is working with parents, families and whole communities. Health education is being sensitive to the social stigma faced by children like Kelly. Health education involves teaching students to make choices based upon critical thinking; to understand self and protect self; to develop values that are conducive to personal growth and wholesome activities; to understand interpersonal relations and to develop satisfying human relationships; to develop the ability to think beyond self with concern for others, for family, for school and the extended community.

Health Education an Integral Part of Education Reform

While schools and schooling are undergoing tremendous scrutiny and demands for change from multiple constituencies, two very potent movements in education reform speak to the role of health education in pre-service teacher education and continued professional development programs for certified teachers, as well as instructional program delivery in the classroom. The first involves a school linked comprehensive services model for school organization and instruction. The second involves the development of specific subject matter standards for student achievement. As in other subjects, health education standards provide a foundation for assessment of student learning, organization of curriculum content, instructional emphasis, and, indirectly, focus for teacher preparation programs. Each of the reform movements in its own right is complex and is the subject of much of the current professional literature. We can only touch upon their relevance for our purposes.

School linked comprehensive services is a model for schooling that places students and families at the center of the educational enterprise with the service professionals working together with each other and parents to meet the needs of learners, their families, and communities. The model has given legitimacy to previously informal arrangements in which professionals and families conferred to approach a specific problem. Most important, the model is providing a theoretical knowledge base for professionals to use in the evaluation and assessment of student progress. For the health educator who works with other health professionals, social workers, psychologists, teachers, and parents, it is an opportunity to learn, to teach, and to be central to student success in a larger context. In reality, however, it is a complex model in which the distinct cultures of each profession, the family, and the community often make it difficult to create a truly integrated service program. For this reason there is considerable effort to create preservice and graduate programs that bring professionals in training together in seminars and internships to experience cooperative work under supervision.

The teachers and administrators in the field, however, cannot wait for all the difficulties to be worked out. They have to meet the needs of students like Sherie:

Our district has formed a team we call IMPACT. The team consists of a representative of the police department, a social worker from Children's Protective Services, an intake worker from the Community Counseling Center, the school psychologist, a nurse and an administrator from the school district. Children referred to IMPACT must be accompanied by their parents. Sherie was referred to IMPACT by her classroom teacher because of poor attendance. She was a bright 8th grader who stopped coming to school. Her teacher expressed concern about how far she was falling behind academically. She also said Sherie had lost weight, and had developed dark circles under her eyes, and appeared "spacy" when in school. The teacher was worried about Sherie's physical and emotional health.

The IMPACT meeting was set. Five minutes before the appointed time Sherie's mother called to say she had no transportation and could not attend the meeting. I got in my truck and drove to their house to pick them up only to find that the mother had left town. I found Sherie at her grandfather, whom I knew to be a registered child molester; he was drunk. Because I had developed a trusting relationship with Sherie, I convinced her to come with me and share with the team what had been happening in her life. As it turned out Sherie's mother was a drug dealer. A deal went sour and as a result, someone stole all of Sherie's school clothes and shoes. Sherie and her mother were homeless and sleeping in different houses every night. Sherie was having unprotected sex with an adult acquaintance of her mother and experimenting with drugs. Sherie had no concept of the possible consequences of her behavior. She was, in fact, adapting to her environment. The situation was overwhelming for the classroom teacher. IMPACT enabled us to assist Sherie immediately by utilizing the resources represented.

What will have to happen by way of follow up in order to ensure continuea protection tor Sherie? Who will fund the kind of services needed by children like Sherie who are born into these environments? What will be the effects upon society as these conditions are repeated in ever increasing numbers? What kinds of academic expectations are appropriate for children in crises? How flexible can teachers be as they struggle to meet children's needs and society's expectations, such as calls for returning to basics or increasing S.A.T. scores or meeting "world class" standards?

As we look at the development of curricular and achievement standards as a means of curricular and instructional reform, we see that those developed for health education embody many of the concepts central to the team approach or comprehensive school linked services. Though the National Health Education Standards focus on the student and her/his performance, they also speak to family and community.

National health Education Standards

1. Students will comprehend concepts related to health promotion and disease prevention.

2. Students will demonstrate the ability to access valid health information and health promoting products and services.

3. Students will demonstrate the ability to practice health-enhancing behaviors and reduce health risks.

4. Students will analyze the influence of culture, media, technology, and other factors on health.

5. Students will demonstrate the ability to use interpersonal communication skills to enhance health.

6. Students will demonstrate the ability to use goal-setting and decision-making skills to enhance health.

7. Students will demonstrate the ability to advocate for personal, family and community health.

(National Health Education Standards, developed by a Joint Committee on National Health Education Standards: Association for the Advancement of Health Education, American School Health Association, American Public Health Association and sponsored by the American Cancer Society: 1995)

Teachers and administrators who use these standards as guides to curriculum selection and development are able to include the normal content areas: community health, consumer health, environmental health, family life, mental and emotional health, injury prevention and safety, nutrition, personal health, prevention and control of disease, and substance use and abuse. However, an interesting instructional approach is suggested by the Centers for Disease Control and Prevention. It is to organize the units of study for adolescents around risk behaviors: tobacco use; dietary patterns that contribute to disease; sedentary lifestyle; sexual behaviors that result in HIV infection and other sexually transmitted diseases; unintended pregnancy; alcohol and other drug use; behaviors that result in intentional and unintentional injury. This may be a more realistic approach when one considers cases like Mike:

Mike began the year in sixth grade, but he didn't fit in. His voice was deeper and was already growing facial hair. Many of his comments were inappropriate for his age, and he had many tales to share about his gang days in New York. He talked about having brought guns to school for protection and about selling drugs for his parents. When his school records arrived, I reviewed them. I found that he had been retained and was more than a year older than his classmates.

Due to his size and "street experience" we made a team decision to place him in seventh grade. During the ensuing months I spent many days with Mike due to his inability to control angry outbursts. He was easily provoked and used violence as a way to solve problems. I held a parent conference to brainstorm ways to help Mike. The grandparents had been awarded custody of Mike; they seemed supportive. Mike was "given" to them by the father because Mike was drinking heavily at age 10 and was "`causing too much trouble." Mike's background included physical abuse at the hands of a violent, alcoholic father and a drug addict mother who had disappeared several years before. An older brother and younger sister had been left behind in New York, but recently had moved into the area with the father. Mike lived within a mile of his father's new house but was not welcome. The grandmother faced open heart surgery; the prognosis was not good. After a fight on the playground, Mike sat in the office crying because he did not know who was going to take care of him. He reeked of alcohol. I talked to him for quite awhile about his substance abuse. He was open to talking about the type and extent of drug use. He didn't admit to the extent of his problem, but was willing to see a counselor. Unfortunately, our resources at the school and in the community for low income citizens are limited; we have one counselor for one day each week. The community counseling center has a three week waiting list for an intake appointment. I made a referral to our counselor with the hope that she can see him this week.

Assuming schools were to follow the suggestion of the Centers for Disease Control and Prevention and organize health education instruction so that it is relevant for all students, but particularly for student like Mike, one can anticipate some of the barriers to implementa.tion of relevant studies in health education. Barriers to Relevant Health Education The nation is beginning to realize that adolescents as a group have been under served by society in general, and schools in particular. A recent article in Education Week announcing a new report from the Carnegie Council on Adolescent Development, Great Transitions: Preparing Adolescents for a New Century, characterizes the problem as follows: "The nation has neglected the basic needs of its young adolescents, too often scrambling to fix one teenage problem at a time rather than working to prevent them. The entire age group is at risk, not just lowincome or disadvantaged young adolescents -" (Education Week, October 18, 1995, p.7)

The new report builds upon a previous Carnegie report, Turning Points: Preparing Youth for the 21st Century, in which smaller schools-within-schools, stable relationships between students, their peers and teachers, and cooperative learning techniques were recommended. The new report stresses the need for schools "to provide an understanding of human biology; to instill in them (students) the skills, knowledge, and values to foster good health and help them avoid sexually transmitted diseases, pregnancy, drug abuse, and violence. They need to have access to health providers trained for their needs, have medical insurance, and have health facilities on or near school campuses." (Ibid.)

Great Transitions: Preparing Adolescents for a New Century's key recommendations have considerable significance for those engaged in health education:

1. Developmentally appropriate schools for adolescents should be small and safe, promote cooperative learning, play down academic tracking and offer primary healthcare services either in or near the school.

2. Schools should work to keep parents engaged in their children's education, creating parent support groups, parent education programs, and education for prospective parents.

Under special circumstances, parents of young adolescents should get child-care tax credits so their children can be enrolled in high quality after-school programs.

Communities should provide more places and activities for young adolescents to use in their out-of-school hours, and national and local youth-serving organizations should expand their reach to that end.

Spending for adolescents should be redirected to fundamental, comprehensive approaches that focus on preventing problems. It is clear that reports such as the ones quoted above give direction to professionals, policy makers, and parents. Yet, relevant health education remains one of the most controversial subjects in the curriculum. There is great debate over who has the right to give instruction about such personal matters as sexual behavior. There is great divergence among parents and communities about whether values of any type should be discussed outside of the family. It is not uncommon for these differences of opinion to be decided in a court of law. In Massachusetts a federal district judge recently dismissed a suit brought against high school administrators for sponsoring and AIDS prevention program without notifying parents. The parents claimed that the presentation violated their privacy rights and their right to "direct and control the upbringing of their children."

A U.S . Court of Appeals upheld the dismissal, ruling that "upbringing does not `encompass a broad-based right to restrict the flow of information in the public schools - if all parents had a fundamental constitutional right to dictate individually what the schools teach their children, the schools would be forced to cater a curriculum for each student whose parents had genuine moral disagreements with the school's choice of subject matter."' The case currently is being appealed to the U.S. Supreme Court. (Education Week, December 13, 1995, p.7 referring to the case, Brown v. Hot, Sexy and Safer Productions)

While the debate goes on, teachers and administrators are making decisions about subject matter and instructional techniques. At the school site they must rely upon the wisdom of their school boards, superintendents state policy makers, state education agencies, and parents to create the context for teaching and learning. Most important, they must rely upon each other to do the best they can, to support one another in order to avoid the "burn out" that accompanies daily contact with these severe human problems. Teachers and administrators must take the initiative to develop a school organization with alternative structures and schedules which can accommodate the types of students described in the real cases presented above.

Documents like the Health Framework for California Public Schools Kindergarten Through Grade Twelve provide a basis for the content and sequence of learning. Teacher educators in colleges and schools of education through preservice and continued professional development programs are assisting practitioners develop the content knowledge, as well as define and refine approaches to teaching controversial issues. In California, specialized courses in health education for teacher candidates are mandated by law. Nevertheless, it falls to the classroom teacher and his/her ingenuity to build the trust, the knowledge, and the commitment to teach sensitive issues which comprise relevant health education. Researchers in the U.S. Centers for Disease Control and Prevention and the National Network of Runaway and Youth Services have found that teachers are much more important in preventing teenage problems than we might have suspected. For example, in the area of AIDS prevention adolescents believe most the information presented by health clinic professionals, persons with HIV, and educational videos. Nevertheless, "Teenagers trust their teachers more as a source of AIDS information than they do their family, friends, sexual partners, television, and even trained out reach workers -" (Education Week, October 18, 1995, Teachers, Trust, and AIDS Information, p. 32.)

Students have given teachers an awesome responsibility. Teachers must be prepared for this responsibility. However, neither state mandated courses, frameworks, or standards can "teach" teachers to have compassion and empathy, nor the disposition to work with all kinds of children and families. In the words of my teacher-administrator daughter, "Only a genuine relationship between a knowledgeable teacher and the student can make the difference."

"We may erect skyscrapers of silver that rise from streets paved with gold, but if our inner cities resemble Beirut, our children pass through metal detectors into schools that are war zones, and one out of every four high school graduates cannot read his diploma, then we will have failed ourselves, failed our nation, and failed our God."

Copyright Project Innovation Summer 1996
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