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Promoting teenage health : Some observations from a study tour of the USA
Lynda Finn and Lynda Finn Health Education Journal 1986 45: 99 DOI: 10.1177/001789698604500212 The online version of this article can be found at: http://hej.sagepub.com/content/45/2/99

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Promoting teenage health

Some observations from
Lynda
a

study tour of the USA

Finn

HEALTH education and health promotion were examined in three settings: schools (and curriculum development agencies), adolescent health centres, and youth projects. Provision is uneven: it varies from the highly innovative and comprehensive to the nonexistent. However, it is important to note that of the three services, only the first - school health education has been developed to a comparable (and in some respects, supenor) extent in the UK.
-

School health education Although 43 states address health education in their education legislation, there are enormous variations in the way in which it is delmered Some school distncts limit their health education provision to a small number of uncoordinated one-off health instruction lessons taught by non-specialist staff, whereas others offer a comprehensive curriculum taught by health education teachers with relevant credentials. Three states - Oregon, Indiana and West Virgmia - require a full year course of health education in order to graduate from high school. But out of 15,500 school districts in the USA, under 1000 have a comprehensive health education curriculum. The scale of the country and of its population, the vast number of school districts, the high degree of state autonomy, and the absence of a national curriculum development or dissemmation agency have, perhaps inevitably, resulted in an absence of national or regional co-ordination. This, in turn, has meant that good practice is not necessarily disseminated throughout the school system. Neighbouring states indeed, neighbouring school districts - can have very different strategies. For some teachers, health education itself is under threat. In certain states the prevailing political climate has encouraged conservatme pressure groups to argue for an instruction-based, mformation-imparting approach. Such groups view health education itself and values clarification in particular - as highly undesirable and wish to exclude it from the curriculum. Health education practice was observed in two schools one in California and one in New York. Although the students were of a similar age, they were different in most other respects. Huntington Park Senior High, near Los Angeles, is in a poor, largely Hispanic district. Ninety per cent of the students are Hispanic, and many have language difficulties in Spanish as well as in English. Students are in the 14 to

17 age range and are relatively low academic achievers. There has been a sharp increase in the number of teenage suicides in the past five years, and this has encouraged the school to employ two therapists. However, health education is a separate, timetabled, compulsory subject taught, not by the schools therapists, but by specialist health education staff. The academic level of the students, combined with their economic and social circumstances, has resulted in the design of a specific health education curnculum intended to meet their needs. The curnculum is imaginative and broad, and a wide variety of teaching strategies is used - group discussion, use of visitors, role play, projects, case studies, display work, and so
on.

Student involvement

is seen as an

essential

com-

ponent of health education. A glossary of health education terms, known as Healthy Words is offered as a way of introducing new vocabulary. The glossary, which consists of 150 core vocabulary words, each illustrated mth an explanatory drawing or cartoon,

designed by a student. Using overhead transparencies, the glossary is the major means by which
was

mtroduced to students. Students are of their most valuable learning tools was student-designed and are, similarly, encouraged to create their own learning tools. A major feature of Huntmgton Park is that Youth Gives a Damn, now a nationally known health education project, started here. In 1971, some 60 students were taken into the mountains north of Los Angeles, for a weekend camp of health education activities. The camping weekends grew in popularity and diversity. Their aim, according to the YGAD constitution, was to &dquo;encourage and promote better health through involvement in health education and health service programs and activities.&dquo; YGAD also tries to motivate participants toward health-related careers and to encourage them to become involved in community activities. The underlying philosophy is that through involvement in its activities students increase their own personal health education. Although initiated and co-ordinated by teachers, YGAD has a high degree of student involvement. The votmg membership of the board of directors is limited to those between 13 and 18 years of age, and this ensures that the programme of activities is relevant to the needs of teenagers. The weekend camps continue, and the programme includes films, speakers, small group discussion, seminars and demonstrations. YGAD particinew terms are
aware

that

one

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99

pants have examined such issues

as

smokmg,

sex-

16 modules and has

strong emphasis on skill acqui-

uality,

assertiveness defence for women,

training, death education, selfdrugs, environmental pollution,

sition. Fme basic health skills are covered - self-

and diet. They have seen a demonstration of acupuncture, and have learned how to check blood pressure and to undertake cardio-pulmonary massage and diabetic testing. YGAD now takes place in ten states and is a highly regarded, voluntary, comprehensive health project which complements and supplements health education in school. Staff and students give their time freely. In addition to the camping weekends, YGAD mcludes weekend and evening activities in the community Participants test blood pressure, check for heanng impairment and diabetes, act as mterpreters for people for whom English is a second language, and lobby local and national politicians on health issues. They appear at concerts, parents evenings, health fairs, and vanous other public events. Pnvate mdustry and voluntary organisations such as the American Cancer Association, Red Cross and the March of Dimes are eager to donate money and equipment. Such is the success of YGAD that it is now able to insist that money is donated without stnngs. Youth Gives a Damn has demystified health. It serves to reinforce and to put into practice knowledge, attitudes, and behaviours learned in school, and has enabled young people to engage directly with their commumty. For YGAD volunteers, health education is not just another timetabled school subject, but is seen as something alme and real and very much part of their hves. Formal evaluation has shown the followmg:I ~ YGAD participants had a significantly better selfconcept than others. ~ YGAD participants were significantly less afraid of death and dying than others. ~ YGAD participants were more interested in protecting their environment than others. ~ YGAD participants were significantly more sexually responsible than others. ~ YGAD participants were significantly more negative in their attitude toward alcohol, tobacco and marijuana, and they showed a significant decrease in consumption of the above. ~ YGAD participants were twice as likely to select health-related careers.

assessment, communication, decision-making, health advocacy, and healthy self-management. The wide range of health topics offered is presented as content through which skills can be acquired and rehearsed. Health topics mclude diet, stress, health and safety in the workplace, creating a healthy environment, fitness, living with feelmgs, and pre-

venting injuries.
THTM have been widely acclaimed by educationalists in the USA and the UK Family and community mvolvement are essential components of the mod-

ules. Environmental and economic factors are tackled, as are the social determinants of health. THTM are extremely popular with both staff and students in Uniondale. For students, lessons are invariably exciting and enjoyable, and they have a very real connection with out-of-school activities. Staff strongly advocate THTM because the matenals are studentcentred and interactive, and lend themselves to small group-based participative learning methods. This, in turn, leads to a high level of student involvement and a significant shift in relationships between staff and students. The modules are currently being evaluated by the Centers for Disease Control. A recent evaluation of four school health curnculum programmes studied in the School Health Education Evaluation identified ten elements important in the delivery of a comprehensive school health education

programme:&dquo;: ~ Sound, well-planned, sequentially developed curncula which provide opportunities for students to learn about their personal, family and community
health. Content to be appropnate to age, level of development, and needs of students. ~ Opportunities for students to learn about health in its larger social context. 0 A co-ordinated curnculum. ~ In-service training for staff. ~ Rich teachmg/learnmg resources that support curnculum objectives and are relevant to cultural, ethnic, geographical and environmental realities. ~ Outreach activities which inform and involve parents and families. ~ Regular review of the school environment to ensure that the hidden curriculum does not contradict health education messages. ~ Active involvement by the community,. ~ Regular re-assessment of the curnculum. ~ Good management within the school. The authors feel that &dquo;the vibrant interaction of at least a majonty&dquo; of the above elements is essential to a successful, lasting and flexible school health education programme. In their different ways, Huntington Park and Uniondale offer many of these elements and can bd said to provide a comprehensive programme.

Uniondale Public High School, Long Island, has a long history of teaching health education. Semor members of the administration are strongly in favour
and the school has a health education co-ordmator. Students are mostly from skilled working class families and the level of unemployment is low. In New York State, one semester of health education is compulsory in secondary school. This usually takes the form of a half semester in Junior High and a half semester in Senior High. The curriculum vanes from district to district, and Uniondale offers the Teenage Health Teaching Modules. THTM is a comprehensive curnculum package for the 12 to 17 age range. Initiated by the Centers for Disease Control in Atlanta, it was researched and developed by the Education Development Center in Massachusetts. It consists of

Adolescent health centres Adolescent health centres are virtually unknown in the UK. They provide an important service which complements school health education. Their existence is based on the promise that the needs of teen-

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100

agers are specific and are different from those of either adults or children. Adolescence is a time of rapid change when young people are strugglmg to estabhsh their identity and to form relationships unllke those of childhood. It is also a time of growing independence when the development of self-esteem is of great sigmficance. Although based in a medical setting, adolescent health centres provide a broad and comprehensive service of which medical care is but one small part. Mount Sinai, the oldest adolescent health centre, on which many others were modelled, is based in New York City and was founded in 1969. Its staff are from varied backgrounds - social work, medicine, family therapy, education, nursing, educational psychology and the diversity of provision reflects this Six major programmes are offered: an adolescent health care unit; a family life education programme, an alternative school; a mental health counsellmg programme, an in-patient unit; and a counsellmg programme. Young people can visit the unit with a medical complaint, to obtain contraceptive advice, or sexuality counselling, to talk to a social worker, because they are having difficulty with school work or with family relationships, or with just about any other adolescent problem. The alternative school provides an opportunity for those who have difficulties with the public school system to study for equivalent qualifications. The atmosphere is warm and friendly, and although young people are encouraged to involve their parents, confidentiality is assured for those who choose not to do so. The staff aim to demystify the health process. They emphasise choice. Young people are encouraged to make mformed decisions wherever possible they can choose male or female staff, whether to take a certain drug, whether one form of treatment is preferable to another. The teenagers are encouraged to become actively involved in issues surroundmg their health. they are encouraged to ask questions, to make mformed decisions, and to develop skills of assertiveness. Staff at the Mount Sinai Hospital are reported to have little difficulty in recognising former patients of the adolescent health centre, as these patients ask the most questions and are the most actively involved in their health. The centre provides an extensive outreach service. Staff work with local schools complementing the health education programme, with groups of parents, and with other agencies. &dquo;One definition of an adolescent is a person who comes late for appointments! We try to teach them that arriving on time is part of being an adult. Our job mcludes helping teenagers make the transition to adulthood. They learn its okay to ask whats in a prescription We help them to 3 register to vote. We are empowering them. &dquo;3 Gouverneur Adolescent Clmic, also in New York City, was modelled on Mount Sinai. It is located in a pubhc hospital in a poor, largely black area of the City, and is much smaller, with fewer resources than Mount Sinai. Nevertheless, it provides a comprehensive range of services for young people between 13 and 19, mcluding medical exammations, guidance and counsellmg on a range of issues - nutrition, sexuality, relation-

ships, school or work problems, weight control, family violence, and substance abuse. Young people are encouraged to involve their parents but, if they refuse,
is assured. The Adolescent Health Centre in the National Medical Centre in Washington DC provides a similarly wide range of services and sees over 10,000 patients each year. Although the centre is non-profit-makmg, uninsured people cannot be seen. The poorest sectors of the community, who are most likely to be uninsured, are required to attend the local state hospital, and even emergency services are not open to them at the National Medical Centre. Local schools frequently request speakers, but their staff tend to have a very narrow conception of what health education has to offer. Speakers are usually invited to talk on pregnancy prevention or pre-natal counselhng. Staff of the National Medical Centre, however, are aware of the limited nature of these requests and, wherever possible, attempt to broaden the scope of health education.. <-

confidentiality

Youth projects Youth projects than

a

can

provide

similar, though less

educational rather medical setting. The Door in New York City provides a comprehensive, multi-faceted service for teenagers It opened in 1970 and is funded by the City, the State, the Federal Government, and a variety of pnvate and voluntary organisations. It offers, free to young people, a health awareness programme, prevocational and employment training, careers guidance, a wide variety of recreational activities, a learning centre (which is virtually an alternative school), a food and nutntion programme, a mobile performing arts unit which operates in the city, legal advice, confidential counselling, and much more Based on the principle that an effective service for young people has to involve participants fully and make available a wide range of services from which they are encouraged to choose, it has proved to be immensely successful and has been the model for other such projects, such as The Hub in the Bronx. The Door provides a non-threatening environment, a supportive yet challenging atmosphere, and a hohstic philosophy. It allows young people to explore new patterns of relationship and enables them to gain confidence and discover an authentic means of self-expression. The Centre for Youth Services in Washington DC was modelled on The Door, but adapted its provision to meet the needs of a poorer, almost entirely black, less mobile and less sophisticated chentele A large number of young people are living through domestic upheavals and there is a high level of poverty and unemployment. The centre caters for young people in the highest nsk categories. All chents are assigned a primary counsellor, and a joint decision is made as to which combination of services to use. Faclities include educational, pre-vocational, vocational, recreational or medical programmes. Thorough health screening is compulsory for all new chents - for some, this is the first health screening they have ever had. The staff see pregnancy prevention as a major objective. The high level of teenage pregnancy is seen to be

medically-focused

service in an

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101

poverty and unemployment, and

environment of fatalistic attitude with little to plan for. It is not surprising that staff have a very clear view of the relationship between the health status of their clients and the surrounding political and economic climate. Health education is designed to demystify the health process and create a supportive yet challenging environment in which young people can develop to their full potential. consequence of low self-esteem,
an
a

ment made some contribution, by far the most important source of fundmg was private - industry and commerce, voluntary organisations, charities. As projects such as Youth Gives a Damn grew in success,

Conclusions School health education appeared to be most effective when it was comprehensive and co-ordinated. Strong support from senior administrators was a prerequisite. The most progressme programmes brought with them the need for participative, interactive teaching and learning strategies. Perhaps the most exciting example of health education was Youth Gives a Damn, a wide-ranging, holistic project which reinforced and extended school health education so that it became truly multisectoral. However, the absence of a national curnculum development/dissemination agency, perhaps inevitable in a country as large and as diverse as the USA, has implications for the overall level and quahty of health education in the curriculum. Adolescent health centres can provide an equally comprehensive, though different, service for young people Staffed by adults who positively choose to work with adolescents, their very existence acts as a recognition of the specific needs of teenagers. But it seems unlikely that the British health system could provide such a broad-based non-medical service within a medical setting, desirable though this might be. Youth projects can take health education out of an entirely medical or entirely educational setting. In the USA they provide mnovative and imagmative responses to community need. Unconstrained by the bureaucratic and philosophical limitations of the education and medical systems, they offer an atmosphere where, in the words of one of their staff, young people

and private mdustry became and more eager to be associated with them. But the less obviously successful projects, those less in the public eye and those located in poor communities, found fund-raising more difficult. Many projects were severely hampered by the insecurity of a perpetual search for funds and the commercial marketmg of the product which fund-raising necessitates. One project worker was required to spend 70 per cent of her time fund-raising - time which could be better spent working with young people. She was most impressed with the British youth service and its system of local education authority funding, even though this resulted in a service which was severely limited in comparison with such imaginatme projects as The Door and the Centre for Youth Services. Some people in health promotion in the UK still argue that health education for young people is not legitimate unless large-scale, statistically relevant changes in health behaviour can be demonstrated. This is at vanance with the view of health education which advocates the acquisition of assertiveness, confidence, increased personal effectiveness, and so on, as desirable health education goals in themselves. The young people observed in the USA, the consumers of health education, were quite unmoved by this tension between what can be crudely charactensed the medical and educational models. They had no doubt at all that the most effective health education was that which recognised and responded to then needs - mental, physical and social.

voluntary organisations
more

References 1 LoyaR Youth gives a damn &mdash;itfinal is worth the project effort? report, 1981 (unpublished)
2
3 Davis R et al Comprehensive school health education a practical definition, Journal of School Health. October 1985 Mount Sinai Medical Center Annual Report 1984, Quote from staff member

grow healthfully. Many of these projects depended on a variety of funding sources. Although federal and local governcan

&bul et; Lynda Finn is

assistant education officer schools/further education 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;Where there is need to improve the health knowledge and practice of the American people, and whereas a comprehensive programme of health instruction is an essential in meeting this need, and whereas the effectiveness of health instruction depends to a great extent on content and the time available for instruction, therefore, be it resolved that schools throughout the country be urged to provide appropriate health instruction in both elementary and secondary schools. Be it further resolved that such instruction in secondary schools be given five periods a week for at least two
semesters.
&dquo;

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

102

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