A Perspective on International School Health Education Research
School health education stimulates research, either to ascertain the base for curriculum development or to evaluate educational outcomes. In 1987, members of the American School Health Association's Council on International Health explored the scope and content of school health education research being conducted in countries outside the U.S. The results of that exploration with the aim of increasing intercountry communication and cooperation are reported. During the project's development, Diane D. Allensworth, RN, PhD, FASHA, Associate Executive Director for Programs, American School Health Association, Loren Bensley, EdD, FASHA, Professor of Health Education, Central Michigan University, and Dean Miller, HSD, FASHA, Professor of Health Education, The University of Toledo, served as consultants.
METHOD
Letters requesting abstracts or copies of published or unpublished research studies performed since 1984 on school health education were sent to ASHA members in other countries who receive the Journal of School Health (n = 110). Similar letters were sent to all international colleagues of International Health Council members, and to the 50 World Health Organization regional offices. All but 12 individuals contacted replied, although not all provided research studies. Several respondents provided names of other individuals to contact; each contact was followed up. In several instances, copies of the same research were received from different individuals. Respondents were helpful and resourceful, often taking time to photocopy articles from their national journals.
Journals from bahrain, Chile, Japan, People's Republic of China, and Sweden regularly provide English translations of the research abstracts; in five other countries, this was not the case. Fortunately, students from these countries attending Loma Linda University volunteered to make the English translations.
Studies on school health education presented in 1988 at the XIII International Conference on Health Education in Houston also were included. This review is not comprehensive because the methodology used omits countries where Council members had no contracts. In addition, some research in countries where Council members have contacts may have been missed.
FINDINGS
Individuals from 31 countries forwarded 188 research studies, all but 10 of which had been published or presented. Table 1 lists the countries responding, the number of studies received from each country, and the source of publication. The largest number of studies (30) evaluated health education curricula in broad areas; for example, the National Health Foundation of Australia supports and evaluates comprehensive health education in schools as part of its overall strategy to reduce death and premature disability from cardiovascular disease. Other studies evaluated specific curriculum areas such as drug, alcohol, smoking, or human sexuality education.
The other major category of studies was that of knowledge, beliefs, attitude, or behavior in areas such as alcohol use, sexual or reproductive health, tobacco use, AIDS, dental health, exercise, and nutrition. These studies focused not only on students but on parents, teachers, physicians, nurses, and, in one instance, journalists. The 1988 Canadian Youth and AIDS indepth survey of 50,000 Candian youth ages 12-18 represents an example of this type of study.
The contribution of school health services to education also was the focus of research in several countries. Three studies explored the contribution of school nurses, two the role of the nurse-teacher, and one the contribution of primary care centers.
Table 2 lists the categories and number of studies reviewed.
CROSS-COUNTRY COMPARATIVE STUDIES
One of the most promising trends in international research in school health education is cross-country comparative studies. One cross-national survey intitiated by the World Health Organization in 1982 began by studying health behaviors among schoolchildren in England, Finland, Norway, and Austria. [1] The study was expanded in 1985-1986 to include more than 10 European countries, resulting in proposals for national adolescent health behavior surveillance systems.
A second study, by Miller and Huang in 1987, using Fishbein's model of reasoned action [2] to identify attitudinal and social factors to predict behavioral intentions, compared 10th grade students in Toledo, Ohio, and Taipei, Taiwan. [3] Ajzen and Fishbein define a person's subjective norm as 'his perception that most people who are important to him think he should or should not perform the behavior in question.'
In both Toledo and Taipei, the attitudinal component had greater influence on intention of cigarette smoking than did the subjective norms (p = .001). Students in Toledo had more positive attitudes toward cigarette smoking than did the students in Taipei (p = .001). The same phenomenon occurred in the subjective norms (p = .001).
Perry and colleagues [4h conducted a four-country pilot study on the efficacy of school-based alcohol education. The goal of educational programs in Australia, Chile, Norway, and Swaziland was to delay onset and minimize involvement of alcohol use among adolescents ages 13-14. Twenty-five schools were assigned randomly to peer-led alcohol education, teacher-led education, or a control condition. Outcome data converge on the finding that peer-led education appears to be efficacious in reducing alcohol use across a variety of settings and cultures.
Country Comparison Studies: Smoking
Smoking prevalence studies, although not planned as cross-national studies, lend themselves to cross-national comparisons. For example, a study in Bahrain among 1,000 physicians, journalists, and intermediate and secondary school teachers (response rate = 49.2%) revealed the percentage of smokers was 60.1%, 77.4%, and 80.6%, respectively. [5] There were more smokers among non-natives (77.7%, p [is less than] .001), among males (71.1%, p [is less than] .001), and among single individuals (90.8%, p [is less than] .001). Because Bahrain's highest rate of smoking is among school teachers, smoking prevention education may be more difficult than in countries with lower rates among teachers.
Minagawa [6] surveyed 368 school physicians in Niigata Prefecture, Japan. The percentage of current regular smokers is 33.9% male and 0% female. The percentage of those giving up smoking was 50.8% increasing with age classes. Three percent of physicians were engaged in anti-smoking education for students. It is possible that female physicians might be more effective role models for students.
A 1986 study in Spain [7] revealed that 51.9% of physicians, 45% of nurses, and 47% of teachers smoked. The prevalence of youth smokers decreased between 1982 and 1986 surveys, with a prevalence of 52.1% as compared with 61.7% earlier (p < .005).
Yang [8] surveyed smoking among fivve rural villages in Beijing City. He found 83.5% of males had ever smoked, of whom 79.8% were current smokers, and 60.9% were heavy smokers. The corresponding proportions for their wives were 4.3%, 3.8%, and 2.5%, respectively. He also found the number of cigarettes smoked consistently increased with age. Those with high school of higher education had the lowest proportion of ever smoking and were smoking the least number of cigarettes. Gong-shao [9] studied cigarette smoking among Beijing high school students, finding the smoking rate among boys was 8.2% in the first year of junior high, rising to 34% by senior class II. Most started smoking one to two years after entrance into high school, where smoking was prohibited. Smoking rates among those whose parents smoked were significantly higher than among those whose parents did not smoke.
Li [10] studied the prevalence of smokers in senior middle and junior middle schools in Shanghai. Smoking prevalence was highest among occupational schools, followed by senior middle and junior middle schools, with prevalence of smokers at 45.7%, 21.9%, 5.0%, respectively.
In Greece, a study of secondary school students showed 21% of students smoked, with 7.7% smoking regularly. [11] Forty percent of males smoked while only 11.8% of females smoked. The percentage of students who smoked from towns (27.5%) differed markedly from that of smokers from villages (13%). In comparison with two studies conducted in the past 17 years, smoking rates have reduced gradually in Greece (39.1% in 1971, 28.9% in 1980, 21% in 1987).
In Tijuana, Mexico, Elder and colleagues [12] studied the onset of cigarette use among public school students. Fifty-four percent of males and 34% of females had experimented with smoking. rates of smoking behavior among Mexican-American school children in nearby San Diego more closely resembled the higher rates of their Tijuana counterparts than those of their Anglo-American counterparts.
Maternal smoking was more strongly associated with smoking among girs, while peer smoking had a relatively stronger association with future intentions to smoke among boys.
In a Bristol, england, [13] study, 1% of youth age 11 smoked regularly compared with 27% of adolescents age 16. A similar study in Trent [14] revealed that one in five of teens ages 15-16, with more girls than boys, smoking regularly in the region. A study of smoking among teachers in England [15] found the prevalence to be relatively low and showing signs of a downwards trend, particularly among women. Nutbeam reported that teachers who smoke cigarettes tend to have a lower consumption than is normal in the general population. Cigar and pipe smoking is a common alternative for men. A slightly higher is proportion of primary and middle shcool teachers smoke than do secondary school teachers.
These studies suggest several options for smoking education programs:
1) An educational focus on intermediate and secondary school teachers designed to emphasize role modeling aspects of their position, following england's example,
2) A concertrated effort in urban schools, and occupational and trade schools,
3) Educational programs that involve joint efforts by parents and students to reduce smoking rates, and
4) Peer-le education in areas where peer influence shows the strongest association.
Borrowing and adapting educational strategies between countries with similar behavioral and demographic characteristics, such as in the People's REpublic of China and Japan, where smoking rates among women remain low, should prove beneficial.
EFFECT ON NATIONAL SCHOOL HEALTH
POLICIES AND PROGRAMS
Reporting the results of all 188 studies is not feasible. The listing of research topics does reveal that research in other countries is similiar to that being conducted in the U.S. It would apear, however, that some countries use nationwide studies more effectively to direct health education. For example, a collaborative relationship between Canada's federal Education and Training Unit and the Social Program Evaluation GRoup at Queen's University continues a study begun in 1982, in which information on health attitudes and behaviors of students is collected regularly. 16' Particularly relevant for future interventions are findings such as a common pattern of risk-taking among young people in the areas of diet, safety, dental care, and drug use. The Canadian group also found that when young people have positive relationships with their parents, they are more likely to have lifestyles. Canada is associated with 11 member countries of the World Health Organization's European Regional Office in surveying the health attitudes and behavior of youth ages nine, 12, and 15, with surveys being conducted in 1984, 1989, and 1994. Survey results have sparked changes in Canadian policies and programs such as inservice programs for teachers in several provinces, health education teaching packages for public health nurses in Newfoundland and Ontario, development of family life or human sexuality education programs in Prince Edward Island and Alberta, and policy regulating milk and snacks available in schools in Newfoundland.
DISCUSSIon and recommendations
Countries that publish one or more journals devoted to school healt offered more opportunity for publishing research. Some researchers used other publications, such as medical society journals, as avenues for sharing research findings. Several researches successfully submitted articles to journals in other countries; this occured frequently within nations of the British Commonwealth and in the Scandinavian countries. In many areas of the world, however, there are few ways to publish.
The Journal of School Health, which does not have a separate category exclusively for international papers, publishes relevant international manuscripts related to the health of children and adolecents K-12. The Journal also published a 96-page issue on international health programs in February 1983.
Because more that 500 college and university libraries in other countries subscribe to the Journal of School Health, the Journal could provide greater opportunities for publication of studies of regional or worldwide interest. Other U.S. health education journals could follow the example of the United Kingdom's Health Education Journal and accept manuscripts from other countries. In addition, editors or volunteers among reviewers can assist health professinals from other countries to express their thoughts in English and demonstrate applicability to the U.S.
The American School Health Association's Council on International Health has search for ways to utilize the international experience and research of ASHA members and to make the results available for faculty, graduate students, and practitioners on an ongoing basis. The Council recommended the formation of an International Resource Center at the University of Toledo, under the direction of Dean Miller, HSD, FASHA, in which collections of materials, program descriptions, and research could be archived and accessed. All studies collected for this article are being archived at the University of Toledo.
These research studies revealed that individuals involved in school face similar problems regardless of the country in which reside. People working with immigrant and refugee populations in the U.S. would find the task much easier if studies done in country of origin were more accessible. The world of school health is a small one. Perry's study emphasizes that knowledge, educational approaches, and research methodology is transferable to widely disparate countries. It is time all school healt professionals profited from the collective wisdom.
References
[1] Nelson GD, et al. Cross-national surveys of adolescent health behaviors. Panel presentation at XIII World Conference on Health Education, Houston, Texas; September 1988.
[2] Ajzen I, Fishbein M. Understanding Attitudes and Predicting Social Behavior. Englewood Cliffs, NJ: Prentice-Hall; 1980.
[3] Huang Song-yuan, Miller DR. A cross-cultural study of cigarette smoking beliefs among tenth grade students in the US and Taiwan. Paper presented at XIII World Conference on Health-EDucation, Houston. September 1988.
[4] Perry CL, et al. WHO collaborative study on alcohol education and young people: Outcomes of a four-country pilot study. Int J Addict. In press.
[5] Al-Khateeb M. Trends of tobacco smoking among physicians, journalists, and teachers in Bahrain. Bahrain Med Bull. 1986;8(1):19.
[6] Minagawa K. Conciousness of school physicians toward anti-smoking education. Jpn J Sch Health. 1986:28(11)
[7] Plans-Rubio P, et al. Effectiveness evaluation of the smoking prevention and control in Catalonia, Spain. Paper presented at the XIII World Conference Health Education, Houston, Texas. SEptember 1988.
[8] Yang H. The prevalence of smoking in rural Beijing, People's Republic of China. Paper presented at XIII World Conference on Health Education, Houston, Texas. September 1988.
[9] Gong-shai Y, Wan-sheng L. Cigarette smoking among Beijing high schoolers. Hygie. 1983;(2):21-24.
[10] Li Wan X. Prevalence in middle school and health education. Paper presented at XIII World Conference on Health Education, Houston, Texas. September 1988.
[11] Martoudis SG. The habit of smoking among the undergraduates of the secondary schools in the region of Nicosia. Medical-Surgical Cyprus. 1987.
[12] Elder JP, Molgaard CA, Laborin RL. Patterns and predictors of cigarette use among public school children in Tijuana, Mexico. Int Q Comm Health Educ. 1987-88:8(2);129.
[13] Nelson SC, Budd RJ, Eiser JR. The Avon prevalence study: A survey of cigarette smoking in secondary children. Health Educ J. 1985;44:12-14.
[14] Gillies P, et al. An adolescent smoking survey in Trent, and its contribution to health promotion. Health Educ J. 1987;46:19-22.
[15] Nutbeam D. Smoking among primary and secondary school teachers. Health Educ J. 1987;46:14-18.
[16] Beasley RP, King AJC. Research findings lead to improvements in health education for Canadian youth. World Yearbook of Education. 1989.
Joyce W. Hopp, PhD, MPH, RN, FASHA, Dean and Professor, School of Allied Health Professions, Loma Linda University, Loma Linda, CA 92350.
