Abstract
The purpose of this article is to outline the process, content, and evaluation of a 14-week health education program for 6th, 7th, and 8th grade students in an inner city Catholic grade school who are at risk for multiple health problems. The process includes a needs assessment with findings, followed by construction of an age-appropriate program. A content outline displays the topics and information presented to the students. In conclusion, an evaluation presents the results and effectiveness of the program.
INTRODUCTION
School nurses play a vital role in reducing health disparities for at-risk populations by implementing targeted health education programs in the early school years. Unfortunately, many schools in such at-risk communities cannot afford programs to help children avoid the consequences of these disparities because they have neither the staff nor the resources for health education curricula. This is true of the inner-city Catholic elementary schools in the District of Columbia (DC). To give students the information needed to make healthy choices in their lives and decrease the risks identified in the health disparities research, one inner-city school principal invited three Georgetown University School of Nursing and Health Studies senior nursing students to implement a semester-long health education program in grades 6 through 8. The student nurses had previously completed a public health clinical rotation in the DC school system and welcomed the opportunity to implement a health education program as an independent study. The focus of the program was to educate students in an attempt to reduce future health disparities common to this population.
BACKGROUND
Useful teaching techniques for school-based health education programs include the following: (a) the program must be culturally sensitive and age-appropriate; (b) accessible for all students in terms of location and having little or no expense; and (c) involve the use of teaching aids such as videos, activities, handouts, and posters. Information should be presented on a basic level first, then move toward increased complexity with important points reiterated several times to increase retention (Bauer, Geront, & Huynh, 2001; Hall-Long, Schell, & Corrigan, 2001; MacDonald, 1999). Conveying large amounts of complex information to children in a brief amount of time is ineffective (Luria, Smith, & Chapman, 2000; Manios, Moschandreas, Hatzis, & Kasatos, 1999). Research shows that peer-led sessions are highly beneficial and can be more effective than health programs delivered by parents, teachers, or health specialists (Early et al., 1998; Gibson, Shah, & Mamoon, 1998; Higgs, Edwards, Harbin, & Higgs, 2000). Peers include older students or persons the students look up to. Teachers facilitate classroom discipline and play a vital role in reviewing and reinforcing the material presented, as well as providing a supportive environment. Group discussions prove to be an invaluable component of programs because students are free to ask questions and can be given correct and concise answers. It is critical that health professionals teaching health education strive to elicit motivation for change by communicating the short-term consequences of risky behaviors, because some research shows that long-term consequences are more difficult for children to visualize (Higgs et al., 2000).
The most essential component of a health education program is parental involvement, because parents have a major impact on their children’s habits. The best kind of involvement happens when parents are provided with health information through parental discussion groups and information pamphlets sent home with their children. Parents who show interest in the education of their children offer better long-term protection to children raised in low socioeconomic areas (Roberts, 1997). Parents can role model healthy behaviors and provide support for those behaviors taught in a school-based health education program (Luria et al., 2000; Manios et al., 1999).
SETTING AND DEMOGRAPHICS
The elementary Catholic school system in DC enrolled 25,369 children during the 2001–2002 school year. Forty percent were minorities, mostly African American, and 23% were non-Catholic (Archdiocese of Washington, 2002). The St. Thomas More School, with 194 students, is in the Southeast region of DC, in a community called Anacostia. This community was home to Frederick Douglass and traditionally middle-class African Americans since the 19th century. It is still predominantly African American and is now significantly impoverished. Not surprisingly, Anacostia has marked health disparities when compared with the rest of the DC population, including a high prevalence of diabetes mellitus, heart disease, cancer, HIV/AIDS, homicide, and suicide-related deaths (State Center for Health Statistics Information, 1998). The St. Thomas More School had no school nurse and no health education program in place.
NEEDS ASSESSMENT
The initial step taken in the development of the health education program was a needs assessment. This was done as a stepping-stone to assess the educational needs of the students, their risk factors, and the topics of interest that they desired to learn about. The results of the assessment were used in the development and planning of the program. The programs developed are often generated from specific health disparities of a community, including risk factors, common health problems, and needs identified by the community itself (Swinney, Anson-Wonkka, Maki, & Corneau, 2001). The content of the program developed was based on the information gathered from teachers and administrators, parents, and student body. Open-ended questions were asked of teachers, administrators, and parents to determine topics that would most benefit the students, types of student lifestyles, and major risk factors for the students. A 13-question survey was distributed to students (N = 42) in grades 6 through 8. The survey questions were selected in response to the data collected from teachers, administrators, and parents. The survey elicited information about the students’ knowledge of nutrition, exercise, personal safety, substance use, and other topics. The survey was also structured to give students a chance to express personal concerns or specific topics of interest. In addition, an informal discussion was held with the students to identify their ideas on health-related topics.
The results of the needs assessment disclosed a large amount of helpful information. Input from teachers and administrators revealed that the students lacked knowledge of the fundamental principles of body functioning and healthy living and needed information pertaining to
Puberty and human reproduction. Human anatomy and physiology. Personal hygiene. Self-esteem issues. Nutrition. Smoking and substance use issues.
During a PTA meeting held at the St. Thomas More School, parents discussed the health education program and stated their children needed to have information about
Puberty and reproduction. Basic first aid. Basic cardiopulmonary resuscitation (CPR). Heimlich maneuver.
The results of the student surveys revealed a knowledge deficit on all topics covered in the survey, including nutrition, anatomy, drugs, smoking and alcohol, exercise, and puberty. For example, 46% of the students reported eating fruits and vegetables less than three times a week.
THE HEALTH EDUCATION PROGRAM
All sources of input were taken into consideration when topics for the program were selected. There were only 8 weeks during which lessons could be taught. As a result of the needs assessment, the following curriculum was devised:
Anatomy and Physiology of the Cardiovascular System. Anatomy and Physiology of the Digestive System. Anatomy and Physiology of the Reproductive System. Puberty and Development Issues. Basic Nutrition and Nutrition-Related Diseases. Smoking and Substance Use.
The health education program was designed according to the cognitive theory of education. Cognitive theory maintains that “by changing thought patterns and providing information, learners’ behavior will change” (Stanhope & Lancaster, 2000, p. 269). The educator should deliver this information using a variety of methods. Educational cues, such as videos, diagrams, posters, models, handouts, and handson exercises, should be used to relay content and to help influence the change of thought patterns (Stanhope & Lancaster, 2000). Repetition was used when information was presented to allow for fundamental principles to be heard and for sufficient time on basic concepts so that each student had opportunity to understand the information. The lessons were succinct and specific. Each lesson was constructed using a basic sequence of steps to maximize the learning experience of the students (Stanhope & Lancaster, 2000). These steps are defined in Table 1.
Because the students had the opportunity to provide ideas for lesson topics, they were immediately attracted to the program. One week ahead of time they were told about the upcoming lesson to stimulate thought. At the beginning of each class, students were informed of the content and activities for that class. Open-ended questions were used to guide discussion and to promote critical thinking. Key concepts were defined at the beginning of each class and visual aids were used to enhance understanding. Students were then asked to relate each topic to their personal lives. Each lesson began with an open-ended discussion in which students could share their knowledge of the topic, including past experiences or personal reactions. This discussion often revealed many myths and misunderstandings that could then be corrected. Weekly quizzes gave students a chance to recall information from the previous lesson. The quizzes were then corrected in class to provide feedback and to address any confusion about the material.
The health education program was given over a 14-week period, with 8 weeks of teaching, 7 topics, and 40 minutes allotted for each lesson. Students were required to have health education permission slips signed by their parents before attending any health education classes. Three students were excluded because their parents believed that they should be the only source of health education for their children. The principal allocated $100 from school funds for teaching aids/materials. Details of the health education programs are listed here.
The Cardiovascular System
The anatomy and physiology of the cardiovascular system were taught first as grounding for the lessons to follow. “Cardiovascular knowledge is one of the predisposing factors that influence cardiovascular health behavior and lifestyles and one of the prerequisites to making healthy heart choices” (MacDonald, 1999, p. 86). Basic anatomy of the heart and cardiovascular system was taught, including the heart, veins, arteries, and lungs. Students were taught why blood, the heart, and the heartbeat are essential to all body functions. They were shown how to find a pulse, how to count it, and how to listen for heart sounds. They participated in an activity that demonstrated the rapid rise in heart rate due to physical activity to illustrate the body’s oxygen demand and the heart’s involvement during this process. Basic information was introduced pertaining to heart diseases such as hypertension and arteriosclerosis. Students were taught the basic etiology of how these diseases develop and how they can make an effort to keep their hearts healthy through exercise, good nutrition, and not smoking.
The Digestive System
The digestive system was presented by describing how food travels through the body after it has entered the mouth. The lesson focused on the role of digestion and the various organs involved in the digestive process. To increase understanding of this process, students were repeatedly asked to demonstrate the pathway of food through the digestive system and articulate the processes that occur in each location. For example, students were asked to explain the process of chewing and swallowing and then describe what was happening in the stomach and in the small intestine.
Students had multiple questions about gastrointestinal disturbances such as flatus, constipation, and food intolerances. These gastrointestinal problems were discussed in basic terms and related to dietary intake and lifestyle choices. For instance, students were taught that if a person consumed a diet with little or no fiber and rarely moved around to get exercise, then constipation might develop.
Nutrition
Nutrition was a priority for several reasons. First, obesity is one of the most prevalent health conditions among American children. One out of five children is overweight, and children from low-income families living in urban areas are at increased risk for obesity (Covington et al., 2001). Second, good nutrition is essential to proper growth, development, and learning. Third and most important, because this group of students is at high risk for chronic diseases such as diabetes mellitus, hypertension, heart disease, atherosclerosis, osteoporosis, obesity, and some cancers (Juhn et al., 1999; Rogers, 1997), a nutrition lesson focusing on the Food Guide Pyramid and healthy versus unhealthy food choices was designed. Students were asked to do a diet recall by listing the foods they had eaten for breakfast and lunch. The different food groups were then discussed, and students were asked to categorize the foods they had eaten into the appropriate groups.
Students were educated about good versus bad fats and the health effects of each. The anatomy of the heart was used to describe how plaque begins to form in the vessels when too many bad fats are consumed. The results of eating a diet high in saturated fat were discussed at great length and then related to the cardiovascular lecture. The students then did an activity that involved planning a healthy dinner with all of the food groups.
Reproductive Health
A health education program on sexual and reproductive health should be implemented during early adolescence, before puberty. The reason for early implementation is that children are becoming sexually active at younger ages, and they are more likely to retain information and are more easily influenced at a younger age (Aarons et al., 2000; Juhn et al., 1999; Manios et al., 1999). The content for this lesson plan focused on the physical and emotional changes that occur during puberty and maturation. To educate within the guidelines of the Catholic Church, the puberty program was paired with a program taught by the church pastor. Whereas the pastor addressed issues such as marriage, respect, morality, and responsibility in puberty, the health lesson focused on the anatomical and physiological aspects of the reproductive tract, along with emotional changes that occur during this process.
One week before this lesson, students were asked to anonymously submit questions they would like to have answered. These questions were used to develop the lesson plan. The module began with a lesson on anatomy and physiology of the male and female reproductive organs and then went into further detail by focusing on the changes that occur during puberty. To keep the lecture basic, only a few specific organs, including the ovaries, fallopian tubes, uterus, vagina, penis, scrotum, testicles, and prostate, were discussed. The students were educated about location and function of these organs and the role they play in maturation and reproduction. Also included was information about estrogen and testosterone and how these two hormones play a role in physical and emotional changes that occur during puberty. Multiple visual aids were used during the two reproductive lectures, including a video, posters, and handouts.
Drugs, Smoking, Alcohol
The topics of drugs, smoking, and alcohol were taught after the puberty and maturation lesson to display the relationship among peer pressure, self-esteem, and personal choices that may arise during this time. Jessor’s theory of problem behavior suggests that “personality and perceived environment are essential components of a problem behavior complex” (Huang, Unger, & Rohrbach, 2000, p. 249). Therefore, by presenting the benefits and disadvantages resulting from interaction among the individual, the social, and the physical environments, one would hope to see a decrease in risk taking. Smoking was the target for emphasis, chosen because of its frequent identification as the precursor to more serious drug use (Huang et al., 2000). Research suggests that education about tobacco use is more effective when short-term consequences are identified because they are easier for students to visualize (Higgs et al., 2000).
The lesson focused on why some people choose to do drugs and why others do not. Students were split into two groups: One group was responsible for giving five reasons why people choose to do drugs, and the other group gave five reasons why people choose not to do drugs. Students were then asked to explain to classmates why they had chosen these responses. Students then took time to share personal experiences related to drugs and alcohol. Focusing on social and peer reinforcement has proven to be most successful (Higgs et al., 2000). Students were asked to identify situations that may lead a person to choose drugs and then to provide creative answers that could be used to say “no.” For example, short-term consequences of tobacco use focused on bad breath, stinky clothing, and the inability to breathe easily during increased physical activity. Long-term consequences, such as lung cancer, liver disease, high blood pressure, and other diseases, were presented but not described in great detail.
EVALUATION
Evaluation of the health education curriculum took place continually and consisted of teacher feedback, student feedback, in-class questions, quizzes, and attention to student body language. Evaluation from teachers was deemed a priority because they are experts in teaching methods and know the students best.
The students showed an eager desire for the weekly lessons. They participated fully. They were attentive, asked questions, and were especially captivated by the models, demonstrations, and diagrams that were brought to class. They enjoyed doing hands-on learning activities most. The teaching style emphasized open-ended discussions after lecture content was given. These discussions created a more relaxed atmosphere and an enhanced learning environment.
The most helpful evaluation tool used during the project was the weekly written quiz. The quizzes were given at the beginning of each class over the information covered during the previous class. The quiz results were used to evaluate knowledge retention. Many of the students scored above 70% on the quizzes. At the end of the program, a comprehensive education evaluation was done in the form of a Jeopardy game. The game questions were content from all lessons taught throughout the program. The game revealed positive results. Groups would compete for the best answer, and when in doubt they would collaborate to make the best response. The game stimulated reiteration of past lessons and also sparked opportunity for new education when new questions arose. Overall, the game was a success and all questions were answered.
The students also had an opportunity to critique and evaluate the health education program. A questionnaire was distributed that allowed students to rate and comment on the content, effectiveness of lessons, and the teaching and evaluation methods. Results were positive, indicating that the students had both enjoyed and benefited from the material. For example, all students (n = 39) answered that they enjoyed the classes, and 38 of the 39 respondents stated that the information would help them to make healthier lifestyle choices. All students stated that they felt comfortable with the student nurses teaching and would be interested in learning about other health topics. The most popular topics that students showed interest in adding to the program included cancer, high blood pressure, more anatomy and physiology, and exercise. Students stated that they enjoyed group exercises, handouts, and informal discussions the best.
IMPLICATIONS FOR SCHOOL NURSING PRACTICE
One implication for school nursing practice is related to the shortage of nurses in the school system. The cause of the shortage is twofold: (a) a lack of nurses entering the field and (b) a lack of funding to support the role in the school system. Those school nurses who provide services devote much time to the physical needs of the children and to screening and follow-up. This leaves minimal time for health education in the classroom.
With the assistance of a preceptor, nursing students can provide health education to children in schools that do not have a school nurse or where the school nurse does not have the time to provide health education in the classroom. The preceptor assists the students by providing guidance and direction during the development phase of the health education program. At the St. Thomas More School, a preceptor pointed out the appropriate steps to take during the construction phase and then encouraged the student nurses to present the classes independently.
In the health education program described in this article, the school principal and teachers were integral for program success. The principal was the liaison between the nursing students and the parents; all teaching material had to be approved by the principal before the presentation. Teachers remained in the classroom while lessons were presented to manage student behavior if needed. Teachers also added input and feedback about lesson plans to continually improve the effectiveness of the teaching. This article demonstrates that with assistance and guidance, nursing students can successfully teach health education to schoolchildren.
CONCLUSION
The impact that school nurses can have on the health of school-age children is substantial. Through health education, they can influence students to reduce their risk for serious illnesses. The health education program implemented at the St. Thomas More School in Washington, DC, showed that there was a need for and a desire to learn about healthy lifestyle choices. Health disparities affecting the African American population, such as teenage pregnancy, hypertension, heart disease, and drug use, may begin to be decreased through effective health education. The principal requested that future Georgetown University nursing students come to the school to continue this work. Thus this program will be the basis for future classes in which other types of disparities and risk behaviors can be addressed.
Footnotes
ACKNOWLEDGMENTS
We would like to thank our preceptor, Professor Judith Baigis, RN, PhD, FAAN, Georgetown University School of Nursing and Health Studies, and the principal and teachers of St. Thomas More Catholic School.