Baseline data on coordinated school health programs in the state of Ohio.

Abstract: Many Ohio agencies encouraged school districts to adopt coordinated school health programs. Baseline data to assess the success of these efforts was collected. Two hundred and twenty-five surveys were mailed to randomly selected Ohio public school districts. Results demonstrated that many districts had been exposed to the coordinated school health concept. Many had some components in place, but few had well established/coordinated programs in all eight areas. Data collected will assist in measuring the success of efforts in Ohio to promote coordinated school health by providing a benchmark against which future programs and statewide efforts can be evaluated.

**********

Since the 1990's, the term "comprehensive school health" has been replaced by the term "coordinated school health" to demonstrate the cooperation and joint planning between the eight components needed for successful school health programs to occur. The definition of an effective coordinated school health program included: school health services, school health education, school health environment, integrated school and community health promotion efforts, school physical education, school food service, school counseling, and school site health promotion for faculty and staff (Allensworth & Kolbe, 1987).

Coordinated school health programs were deemed necessary for two main reasons. First, children could not be expected to be ready to learn if they were not healthy and well cared for. Educational goals could not be met because of the poor health of students and their families (Auter, 1993). Henderson (1993) stated that schools were obligated to ensure that students had a basic health status that would enable them to learn and to provide them with the skills necessary to participate fully in society. Second, the current major health problems facing our nation today were largely preventable and could be attributed to changeable behaviors, many of which began in youth (Jackson, 1994). In Ohio, many efforts were initiated to encourage school districts to adopt coordinated school health education programs that encompassed the eight components listed above.

BACKGROUND

Several different efforts in Ohio had been designed to promote statewide coordinated school health education. These efforts were spearheaded by groups such as the Ohio Department of Health (ODH), the Ohio Department of Education (ODE), the State Planning Committee for Health Education in Ohio (SPCHEO), and the Ohio Division of the American Cancer Society. Each of these efforts used different approaches that targeted different groups.

The Ohio Comprehensive School Health Conference held at Salt Fork State Park in southeast Ohio, was modeled after other such conferences held nationwide. School districts sent teams composed of board members, administrators, teachers, professional staff, clerical and support staff, parents, and business and community leaders to this conference. While at the conference, these teams were responsible for developing an action plan to aid in the establishment of coordinated school health education in their districts. The ODH and ODE provided support to teams before, during, and after the conference (Cottrell, Capwell, & Brannon, 1995).

The State Planning Committee for Health Education in Ohio (SPCHEO) was a group of state level professionals dedicated to improving the health status of youth. Since their inception, they had developed a model plan to assist school/health community teams in developing programs through systematic planning. The model consisted of six phases: team building, needs assessment and analysis, setting priorities, goals and objectives, implementation, and evaluation. Other efforts by SPCHEO included attempts to influence health education legislation, allocation of block grant money, minimum standards for school, and conferences aimed at influencing teachers, administrators, and community health representatives, (Cottrell et al., 1995; Capwell, 1988).

The Ohio Division of the American Cancer Society (ODACS) developed an action plan and regional workshops. The aim of the action plan was to promote the institutionalization of coordinated school health education in all of Ohio schools by the year 2000. The action plan was structured around six core issues: policy; awareness; goals and objectives; professional preparation; resources; and parent; family; and community (American Cancer Society, 1993). Regional workshops were conducted for school/community coalitions. A manual entitled Health for Success was developed for use by the coalitions (American Cancer Society, 1995). In addition, ODACS developed a mini grant program to help districts initiate coordinated school health programs. An award program was in developmental stages to recognize districts with outstanding programs (Rooney, L., personal communication, June, 1999).

Considering many groups in the state of Ohio had put forth efforts to encourage school districts to adopt coordinated school health education programs, the remaining question was, "How effective were these efforts?"

PURPOSE

The purpose of this project was to gather baseline data on coordinated school health programs in the state of Ohio. Gathering baseline data was important because it provided a yardstick against which success in promoting this type of program could be measured. The specific questions directing the study were:

1. What percent of school districts had exposure to the concept of coordinated school health education?

2. What percent of districts had committed resources to a coordinated school health education program?

3. In which of the eight components of coordinated school health education were districts most likely to have strengths/weaknesses?

4. What barriers existed that prevented schools from adopting coordinated school health education programs?

5. Did factors such as district size, per pupil expenditure, or location (rural, urban, suburban) have any impact on whether a school district adopted a coordinated school health education program?

The data collected by this project helped establish the current level of coordinated school health programming in Ohio public school districts. The data will be used to evaluate ongoing and future efforts to promote coordinated school health programming statewide.

METHODS

PROCEDURES

This study was conducted in the state of Ohio. At the time of the survey there were 612 public school districts in Ohio. Two hundred and twenty-five surveys, representing 37% of all Ohio public school districts, were randomly selected. Materials were prepared and mailed to superintendents of these school districts throughout the state of Ohio. Self-addressed, stamped, return envelopes were included in each mailing. The instructions asked that the superintendent or designee complete and return the survey. A cover letter from the researcher included with the instrument assured complete confidentiality to participants, explained the need for the survey, and provided the deadline for returning the survey. Definitions to ensure consistent understanding of the terminology specific to coordinated school health and directions for completing the survey were attached to the instrument. A reminder notice was sent to the superintendents of all of the selected districts one week after the survey was mailed out. A follow-up phone call to all selected districts was placed during the second week after the original mailing.

INSTRUMENTATION

The instrument used for this project was a mailed assessment survey. The survey consisted of a total of 109 questions which were of a yes-no forced choice format. Space was left for expanded answers where applicable. In addition, specific information regarding demographics (per pupil expenditure, size of district, and whether the district would characterize itself as urban, rural, or suburban), was requested for comparative purposes.

The survey was divided into sections, each focusing on a specific area of a coordinated school health education program. The breakdown of questions were: administration, 11 questions; food service, 13 questions; health services, 12 questions; counseling/psychology, 10 questions; health instruction, 16 questions; physical education, 15 questions; environment, 8 questions; faculty/staff wellness, 14 questions; family, school, community partnership, 10 questions.

Questions on the initial instrument were developed from the results of a Delphi study completed in Ohio (Cottrell et al., 1995). The Delphi study asked 30 experts in coordinated school health education from the state of Ohio to identify "key indicators" of a coordinated school health education program. After three rounds of review, the items above the mean in importance were appropriately worded and included on the initial instrument. The use of Ohio's coordinated school health experts to establish content for the instrument was important in establishing validity of the instrument.

To further establish content validity, ninety-six questions on the initial instrument were cross-referenced to at least one other instrument previously developed to measure coordinated school health efforts. These instruments included the Texas Instrument, Idaho State

Comprehensive School Health Programs Assessment, School Health Policies and Programs Study, Maryland's Public School Health Education Specialist Study, and the Ohio Department of Health/Ohio Department of Education Survey (Survey of Attitudes, 1991; Girvin, J., personal communication, January 12, 1995; Journal of School Health, October, 1995; Mansky, 1991; Cottrell, R.R., personal communication, January, 1999). The remaining 13 questions were selected solely on the results of the Delphi study.

To further establish content validity, the initial instrument was then submitted to a panel of experts including two representatives from the Ohio Department of Health, two faculty members from the Health Promotion and Education Program at the University of Cincinnati, and one public school health education teacher. The panel was asked to modify existing questions, suggest additional questions, and eliminate unnecessary questions. Input from the panel was incorporated into the instrument.

A test/retest procedure was used with four Ohio public school districts to establish reliability of the instrument. School districts for the test/retest were randomly selected from the same sampling frame from which participants for the final survey were selected. None of the pilot districts were included in the final sample. After the initial test was administered, a second test was administered to the same district two weeks later. A correlation coefficient was run comparing the total score on both sets of tests. Three of the four randomly selected districts returned both sets of surveys. The correlation coefficient for the test/retest was .9685. This high degree of correlation indicated that the instrument was stable and reliable.

SAMPLE

The target audience for this project were the superintendents or their designees in the 612 public school districts in the state of Ohio. Two hundred and twenty-five surveys were mailed to randomly selected Ohio public school districts. This number represented 37% of the total number of districts in the state at the time of the survey.

Of the 225 surveys mailed out, 116 surveys were returned. The 116 surveys returned represented a 52% response rate or 20% of the total number of districts in the state. The districts were asked to provide information regarding the size of their district, their per pupil expenditure, and whether they would describe their district as rural, urban, or suburban. They were also asked to identify who in the district completed the survey.

Five percent of the districts failed to provide the demographic information requested. Of the districts providing demographic information, 62.1% described themselves as rural, 25% as suburban, and 7.8% as urban. These data correspond with state-wide statistics. Of the 612 Ohio public school districts, 359 or 58% were rural, 150 or 25% were suburban, 103 or 17% were urban (Ohio Department of Health, Brown, J., personal communication, April 2001). The size of the districts varied greatly, from 374 to 38,000 students, with a mean number of 3,062.24 students. The median was 1,800. The per pupil expenditure reported by the districts ranged from $2,800 to $10,000, with a mean per pupil expenditure of $4,961.86.

Fifty-eight percent of the surveys were completed by the superintendent of the district, 12% were completed by the school nurse, 6% by the assistant superintendent, 2% by the health education coordinator, 17% by others. Eleven percent of the districts failed to provide this information.

RESULTS

SURVEY RESULTS

Research questions 1-4 were answered by means of frequency analysis. Only 47% of the districts sampled reported that they had previously been exposed to the concept of coordinated school health education. Twenty-two percent had sent teams to the Ohio Comprehensive School Health Conference and 27% had applied for outside grants to support district-wide coordinated school health education programs.

Ninety-two percent of the districts sampled stated that developing and implementing a coordinated school health education program has not been a priority within the district. Further, 545 do not see priority being given to this within the next two years. Table 1 outlines the barriers to coordinated school health education programs cited by the responding districts. Many different barriers were cited by responding districts, the most common barrier being that of low priority, with priority being given to academic achievement and passing state mandated proficiency exams. Other barriers cited were: lack of funding, lack of personnel, lack of time, and lack of leadership.

Of the eight components of coordinated school health education programs, a majority of responding school districts reported having food service programs, health service programs, counseling/psychology services, health instruction, physical education classes, and established environmental policies in place. Eighty percent of these districts reported having no formal faculty/staff wellness programs or school/community task force, coalition, or advisory committee in place.

COMPARISON ANALYSIS

Research question 5 was answered by means of comparative analysis. Data were analyzed to determine if the total score on the survey was in any way related to whether the districts described themselves as rural, urban, or suburban. One hundred and seven districts provided this information while six districts declined.

A one-way ANOVA was run to determine whether differences between the groups existed. A score of .261 on the Levine test for homogeneity of variances indicated that the three groups (urban, rural, and suburban) had equal variances. Since the variances were equal, the groups could be directly compared to one another. An ANOVA indicated statistically significant (alpha = .05) differences between the three groups (p = .0249, F (2,107) = 3.8228). This indicated that differences existed between districts identifying themselves as urban, rural, or suburban. Further analysis using the Bonferroni test was conducted to determine exactly where differences between the groups were located.

Significant differences (p < .05) were found in total scores on the survey between those districts describing themselves as rural and those describing themselves as suburban. The mean score on the survey for rural districts was 57.42, while the mean score for suburban districts was 66.03 (Table 2). These data indicated that suburban districts had stronger coordinated school health programs than rural districts. No significant differences existed between urban and rural school districts or between urban and suburban school districts. The mean for urban school districts was 59.11.

The data were then analyzed to determine if the size of the district had an effect on the total score of the survey. The smallest responding district had a total of 347 students while the largest had 38,000 students. Seven districts failed to report this data.

The districts were ranked ordered according to size and then divided into thirds. Data were then analyzed to look for a relationship between size of the district and the total score on the survey. The Levine test for homogeneity of variance was .872 which indicated that the three rank ordered groups had equal variances. The one-way ANOVA was statistically significant at the .05 level of significance, p = .0175, F (2, 113) = 4.1914. This indicated that differences existed between the groups. Because a positive relationship existed between the size of the district and the total score on the survey, post-hoc analyses were run.

A Tukey-HSD test with a significance level of .05 was run to determine where the differences were located. Significant differences were found between the largest third of the districts and the other two groups (Table 2). Based on these data, the largest districts had better coordinated school health programming than the middle or small sized districts. It is important to note that outliers may have affected these results. The means (64.92, 57.24, and 56.86 respectively) of all the groups were close together, however group two has a district reporting a very low level of coordinated school health programming while group three had two districts with coordinated school health programming in place.

To examine the relationship between per pupil expenditure and the total score on the survey, a correlation coefficient was run. One hundred and two districts provided their annual per pupil expenditure. Fourteen districts declined to provide this data. The range of spending was $2,800 to $10,000, with a mean of $4,962.

The correlation between per pupil expenditure and total score was statistically significant (alpha = .05, = .006). The correlation between per pupil expenditure and total score was .2682.

Higher per pupil expenditure was related to higher levels of coordinated school health programming in the district.

CONCLUSIONS

Results of this study may be limited by the number of surveys returned and the demographics of the responding districts. Findings may also be limited by the honesty of the respondents and their personal perceptions and biases regarding coordinated school health education. The effects of these limitations on the study's outcomes must be considered when interpreting results.

Most school districts had some of the eight components of a coordinated school health education program in place, but there was little or no coordination of their efforts. The components most likely to be present within the districts were: school health services, health instruction, physical education, and counseling. The majority of the responding districts also had a food service program that provided meals that met the U.S. dietary guidelines and had environmental policies in place that covered drug and alcohol usage, violence and weapons, and a safe and clean environment. The districts were least likely to have the components of faculty/staff wellness and integrated school and community efforts in place within their districts.

Overall, most of the districts had portions of one or more of the eight components of a coordinated school health education program in place. However, only 13% of the responding districts felt they had a coordinated program that included all eight components.

When demographic data were examined, statistically significant relationships could be found between the variables of size of the district, per pupil expenditure, and description of the district as rural, urban, or suburban with the total score on the survey. A relationship was found between the size of the district and the total score on the survey instrument. Larger school districts were more likely to have coordinated school health education programs in place than were small or medium sized districts. A school district that described itself as rural was less likely to have a coordinated school health education program in place than a district that described itself as suburban. There were no significant differences in programming, however, between urban and suburban districts or between urban and rural districts. The per pupil expenditure reported by the school districts had an effect on their level of coordinated school health programming. Schools reporting larger per pupil expenditures were more likely to have increased levels of coordinated school health programming. Positive relationships were found between the variables of size of the district, per pupil expenditure, and description of the district with the total score on the survey. No one of these factors, however, had a strong enough relationship to be named a definitive factor in determining whether a district implemented a coordinated school health education program.

DISCUSSION

Overall, there was little coordination of the eight components of a coordinated school health education program within Ohio public school districts. Most districts had some of the eight components in place. These tended to operate independent of each other with no vision of an overall coordinated school health program.

Coordinated school health education programs have a greater likelihood of becoming a reality once specific barriers have been addressed. Districts did not perceive health programs to be of high priority. The message they were receiving from the state and from their comments emphasized the passing of state mandated proficiency exams. Health education needs to be regarded as an academic subject with its own proficiency exam, health education needs to be mandated by law, and funding needs to be made available to establish and maintain programs.

Given the amount of effort the Ohio Department of Health, the Ohio Department of Education, the State Planning Committee for Health Education, and the American Cancer Society have put forth to promote coordinated school health programs, it is disturbing that only 47% of the districts reported being exposed to the concept. The message has not been effectively disseminated to the schools. Future efforts should be directed at strategies to directly inform school boards, superintendents, and principals about coordinated school health education programs. Speaking directly to these groups at state and regional conventions may be one way to get the message out. In addition, articles need to be written and published in journals that these professionals read. One-on-one contacts with local decision makers by advocates of coordinated school health programs may well prove to be the most effective way to promote this cause.

Table 1. Barriers to Coordinated School Health Programs (N = 116)

                                                   Number of Districts
                     Barriers                        Citing Barrier

Low priority for leadership (non-specific)                 29
  Priority given to passing proficiencies,
    student achievement                                     5
  Not a state mandate, only do what is required             2
Lack of funding                                            11
Lack of personnel to take on additional work               10
Lack of time                                                8
Lack of leadership                                          6
The families in the district are responsible for
  the health of the children                                1
Health concerns are addressed by individual
  departments                                               1
Made an attempt 3 years ago, poorly received/
  used by staff                                             1
                                                   Total   75
Table 2. Relationship of Score to Physical Description and Size
of School District (N = 110).

Description   Total Possible Score   Mean score

  Suburban            109              66.03
  Urban               109              59.11
  Rural               109              57.42

  Size
  Small               109              56.86
  Medium              109              57.42
  Large               109              64.92

REFERENCES

Allensworth, D.D., Kolbe, L.J. (1987). The comprehensive school health program: Exploring an expanded concept. Journal of School Health, 57, (10) 409-412.

American Cancer Society. (1995, October-December). Health for Success.

American Cancer Society. (1993, May). Working Together for the Future.

Auter, J. (1993). Closing comments: Making it work. Journal of School Health, 63, (1) 38-39.

Capwell, E.M. (1988). The state planning committee for health education in Ohio. Journal of School Health, 58, (1) 12-15.

Cottrell, R.R., Capwell, E.M., Brannon, J. (1995). Comprehensive school health conferences: The Ohio evaluation model. Wellness Perspectives: Research, Theory, and Practice, 11, 55-63.

Henderson, A.C. (1993). Healthy Schools, Healthy Futures: The Case for Improving School Environment. Santa Cruz, CA: ETR Associates.

Jackson, S.A. (1994). Comprehensive school health programs: Innovative practices and issues in standard setting. Journal of School Health, 64, (5) 177-179. Journal of School Health, 65, (1995).

Mansky, K.E. (1991). The current status of Maryland public school health education: A 1990 survey of district specialists. Unpublished manuscript: University of Maryland at College Park.

TSCHI. Survey of attitudes toward comprehensive school health. 1991.

Jann Greenberg is a Masters Degree Candidate, Randall Cottrell, D.Ed., CHES and Amy L. Bernard, Ph.D., CHES are both faculty in the Division of Health Services in Health Promotion and Education at the University of Cincinnati. Address all correspondence to Ms. Greenberg at 12120 Village Woods Drive; Cincinnati, OH 45241; (PH) 513.769.0507; Email: [e-mail].