Enhancing Teacher Health Literacy Through Evidence-Based Learning

Presenters: Fred L. Peterson, Tammy J. Jordan, and Erin Floyd-Bann, The University of Texas at Austin; J. Terry Parker, Waxahachie Independent School District, TX

This session is presented in separate parts. Use the buttons at the end of the transcription to navigate between each part.

I. Fred Peterson

FRED PETERSON: The title of our session is Enhancing Teacher Health Literacy Through Evidence-Based Learning. My name is Fred Peterson. I am from the University of Texas at Austin. I am a professor in child, adolescent and school health.

My co-presenters tonight include Tammy Jordan, who is a doctoral student in health education at the University of Texas; Dr. Erin Floyd-Bann, who recently received her doctoral degree in health education from the University of Texas at Austin; and Dr. Terry Parker, who is an adolescent health promotion specialist and counselor in the Waxahachie Independent School District of Waxahachie, Texas.

We thank you for your participation this evening, and let's start our presentation. The purpose of our presentation is multifold. Number one, to illustrate selected trends in youth risk-taking; to present a broad overview of the bio-cycle sociology of adolescent risk-taking; to present an evidence-based vision and philosophy for teacher training in pre-service child, adolescent and school health education; to bridge the gap between research and practice in addressing the challenges of youth risk-taking with a special focus on sexual behavior.

For the first time in the history of our country, young people and less healthy and less prepared to take their places in society than were their parents. This was a statement in 1990 from a document entitled "Code Blue: Uniting for Health for our Youth." And I would suggest that, in the year 2002, the statement is certainly as appropriate and as on target in terms of the issue at hand — the health of kids.

School professionals and educational leaders need to be fully prepared to address the complex issues and social morbidities that youth present in the classroom and clinic in the 21st century. Thus, a need for evidence-based approaches for child, adolescent and school health promotion.

[READS QUOTE]

"We live in a decadent age. Young people no longer respect their parents. They are rude and impatient. They frequent taverns and have no self-control."

Now, look at that statement, and tell me when you think that was written.

AUDIENCE MEMBER: The 1600's.

MR. PETERSON: The 1600's? Any other ideas or suggestions?

AUDIENCE MEMBER: 1800's.

MR. PETERSON: The 1800's? When I present this slide in my teaching, in presenting this idea of teacher training to other groups across the country, many people think it's sort of new graffiti in the new millennium and something very recent, but you have sort of captured it.

[NOTES THAT QUOTE WAS FROM 3,000 B.C. GREECE]

It has been suggested that this was probably chiseled in a cave or along a brick wall or on a tomb probably as late as 5,000 years ago. And probably the message is that adolescents today, in the 21st century, aren't a lot different than adolescents were 5,000 years ago, and that adolescence may be a time for testing one's limits, for experimenting, for engaging in selected risk behaviors, and the only difference being that, in the new millennium, some of the risk behaviors are more intense, more profound, and perhaps more deadly in nature than ones possibly 5,000 years ago, but adolescents have always been adolescents.

Current trends and outlooks of risk-taking. You have in your handout packet a blue set of pages that looks at the Youth Risk Behavior Survey. It's a trend analysis of risk behaviors from 1991 through 1999. You can see what risk behaviors have stayed the same, what risk behaviors have improved in terms of lessened, and what risk behaviors have actually gotten worse in the last 9 or 10 years.

In terms of leading causes of mortality in adolescents, number one is accidents, number two is homicide, number three is suicide, number four is cancer, number five is heart disease, number six includes congenital issues and birth defects, number seven respiratory ailments, and number eight, and rising, HIV disease. This will give you a sense of the new kinds of things that may be apparent in the new millennium.

The Centers for Disease Control has actually categorized adolescent risk-taking into six broad categories. These six categories, cumulatively, explain about 80 percent of morbidity and mortality in young adults and other adults. The six categories of risk behavior include physical inactivity, poor dietary habits, tobacco use, behaviors that result in unintentional and intentional injuries, alcohol and other drug use, and sexual behaviors.

As you can see, all of these are referred to collectively as social morbidities or socially based behaviors that may lead to illness, trauma and death, to differentiate from child and adolescent health issues we were dealing with in the 1940's and 1950's and 1960's, which were more biologically oriented rather than socially oriented. But we pretty much have taken care of the biological morbidities through immunizations, vaccines and a lot of primary health care.

Looking at data from the 1999 Youth Risk Behavior Survey, you can see what kinds of behaviors appear to be at the forefront. The Youth Risk Behavior Survey is a biannual risk behavior survey conducted by the Centers for Disease Control and Prevention that is done nationally as well as on a state-by-state local option basis. This is 1999 Youth Risk Behavior Survey data that we have on the screen now. And you can see some of the things that are causing us a lot of concern.

For example, almost 50 percent of students report having had sexual intercourse. And this is data collected from grades 9, 10, 11, and 12. This is cumulative data across four grades. If we were to take the data, 9, 10, 11, and 12, the frequencies would actually get higher as we got into older kids.

Thirty-five percent of students report not having vigorously exercised or participated in physical activity for the past seven days. Almost 43 percent of students report currently trying to lose weight. Seventeen percent of students report having carried a weapon on one or more occasions within the past 30 days. That's 17 percent, which should be an alarm for all of us in terms of those of us who are interested in youth violence prevention efforts. And 70 percent of students report having tried cigarette smoking. Thirty percent of students have reported having someone offer, sell or give them an illegal drug on school property during the past 12 months. Again, this is data just from 1999 that should capture all of our attentions today.

This is a trend analysis of sexual experience and violent behaviors amongst 9th to 12th-graders from 1991 to 1997. You can see the trends, from the baseline in 1991 through 1997. First, the red bar includes sexual behaviors. The yellow bar is fighting. The green bar is carrying weapons.

Substance use amongst young people, grades 9 through 12. Again, 1991 through 1997. You can see the baseline, 1991, on the left side of the graph. On the right side is 1997 data. In terms of alcohol use, you see some peaks and some valleys there. Binge drinking, which is on an upward trend, and is currently a major epidemic source of concern not only in high school but on college campuses today. And marijuana use, tobacco use and cocaine use. Cocaine use is relatively small in comparison to the other substances but of course is certainly a major concern to all of us.

Risk behaviors that have worsened include frequent cigarette use. The baseline data is 12.7 percent; 1999 data is 16.8. Episodic heavy drinking, i.e., binge drinking, around 31-32 percent. Lifetime marijuana use has really, really climbed. As you can see, in 1991 it was 31 percent, as reported in the Youth Risk Behavior Survey. In 1999 it's up to almost 50 percent. Current cocaine use is now low at around 4 percent. Lifetime illegal steroid use, which we see is of course a major concern for those young people participating in sports and athletics, almost 4 percent. This data is in your handout.

In terms of sexual behaviors, one that has gotten worse is the use of birth control pills at last sexual intercourse. Almost 21 percent reported using birth control pills in 1991, and it has dropped to 16 percent in 1999. So less people who are sexually active are using protection in terms of birth control.

In terms of physical activity, attendance in 1991 was almost 42 percent. It dropped to about 30 percent in 1999. There are all kinds of issues relating to why that is going on, to include in some States, including Texas, if you are participating in other activities like band, cheerleading and other kinds of things, you are allowed to opt out of physical education, which is a real policy issue. And it's not only Texas but in lots of other States.

Now we get to risk-taking. We define risk as any action for which there is some possibility of failure as well as some opportunity for success. Looking at that definition — some opportunity for success as well as some possibility of failure — would anyone like to volunteer an example of a risk they may have taken in the last week?

AUDIENCE MEMBER: I flew on a plane in very inclement weather conditions. The plane had to be deiced.

FRED PETERSON: I see the lady's name in the second row is Diane, from Canada. She said she flew here in icy and snowy weather and they had to deice the plane. So that raises our emotional level. And of course flying, although statistically the safest form of traveling long distance, certainly is not devoid of potential trauma and problems. And when that trauma occurs, when a crash occurs, of course it is terrible and horrific and usually few survive and it really catches the medias attention.

Any other risks? Yes, the gentleman in the first row, from Texas.

AUDIENCE MEMBER: I ate food I probably shouldn't have eaten in terms of it being healthy for me.

FRED PETERSON: In food selection sometimes what appears to be good, healthy food, sometimes we get a response that is less than healthy in nature.

We could ask several others, but let's move on. Why do young people engage in risk? What motivates risk-taking? We're going to get into some of the research and theoretical basis that helps us to explain sort of the bio-cycle sociology of risk-taking today. Risk-taking, as we define it, is something that can be both positive or negative, constructive or destructive in nature. As we look at the research from Richard Jessor, from the University of Colorado, among others — and these are developmental psychologists — they would suggest that risk-taking is essential for growth and development. It is necessary, but it certainly needs to be channeled in positive and healthy directions.

Risk-taking can include the traditional things such as engaging in sexual behavior, consuming alcohol, tobacco and drugs, using illegal drugs, or even recreational kinds of things such as amusement parks and these wild and crazy roller coaster rides, bungee jumping, water skiing. Risk-taking can be biological, psychological, social, or financial in nature. Any of us who invest in our State lotteries in the United States, that is sort of a financial risk-taking, with an opportunity for success and possibly for failure. The stock market has been kind of crazy lately, so that is probably not guaranteed success. We can go on and on with the kinds of risks that we all take.

Now we get into the bio-cycle sociology of risk-taking, where we are going to try to give you some information that is evidence-based, based on research theory and evaluation, and then show you applications in professional practice. Some risk-taking theories include Zuckerman's sensation seeking model, which is a biological model to explain risk, and it is diagramed in your handout today; problem behavior theory by Richard Jessor, University of Colorado; the causal model of adolescent risk-taking from Irwin and Milstein, from the University of California at San Francisco.

Now we get to the sensation seeking scale. This is a biologically based theory that approaches risk-taking from a biological motivated approach and measures one's propensity for risk-taking. So we would like you to take out the yellow sheet of paper — it should be the bottom piece in your handout — and do the sensation seeking scale. This is part of our audience participation today, so we will take a couple of minutes here and fill out the scale. And then we will interpret the scale for you. This is just one measure of predicting one's propensity towards risk-taking.

For each of the 13 items on your survey, select the choice that best describes your likes or dislikes or the way that you feel. Select only one statement for each item. The directions are on your handout, and I will also put them on the screen. Give yourself one point each time your answer matches the following choices.

[PAUSE FOR PARTICIPANT ACTIVITY]

FRED PETERSON: Let's see how we did. Let me just suggest that Zuckerman has done a lot of research in this field. This is the simplest, quickest survey he has. So this is the one we use because it takes less than five minutes. He has surveys that have up to 140 items, using five-point Lickert scales that are more intense, more predictive. This is the short version just to give you a feel for a tendency toward sensation seeking which is connected to risk-taking.

Notice that the ranges go from 1 to 3, which is very low in sensation seeking. Is there anyone in the audience that scored that?

The young lady in the first row looks like she is another Texan in the audience. Thank you.

Anyone score 4 to 5?A couple of people there in the fifth row.
Now, average, in the middle? We have a cluster over here. Very good. Anybody score 10 or 11? A few young people in the back row. There is another Texan who is a sensation seeker. Very good. And 12 to 13?

You people in the back must be bungee-jumpers. Okay.
Let's interpret this now. Again, this is sort of an estimated measure of a propensity towards risk-taking. High sensation seekers, if you scored high in this survey that would suggest that you perceive less risk in many activities. And that even when the perceived risks are equal between high sensation seekers and low sensation seekers, the high sensation seekers are likely to anticipate more positive potential outcomes. So we can all look at something together and some of us might choose to do it because we see it as exciting and fun, and the same behavior some others of us may choose to not participate in because we anticipate possible danger.

High sensation seekers are associated with substance abuse, reckless motor vehicle use, delinquency and pathological gambling. High sensation seekers generally enjoy seeing horror movies and even the possibility of erotic films. So there seems to be a connection with horror and sexuality perhaps. High sensation seekers may be more impulsive regarding life choices. High sensation seekers are more likely to choose participation in activities such as mountain climbing, motorcycling, hang gliding, whitewater kayaking, water skiing, downhill skiing, high diving, racecar driving, et cetera.

Yes, a question.

AUDIENCE MEMBER: So are these behaviors age-specific? Have you done research related how middle-aged people like myself would score as opposed to teenagers?

FRED PETERSON: That is an excellent question. The answer is that the scores generally are higher in younger audiences. And if they track the same people, doing longitudinal cohort kind of research, track the same person, and give them various equivalent surveys, over time older people tend to become a bit more conservative in their risk-taking.

In some cases, the early and young sensation seekers, when they get older, say in their forties or fifties and sixties, may still engage in some kind of risk behavior, but their choices are different. They are not taking the more physical kinds of behaviors. They may be risk-taking in terms of things in their environment, financial risk-taking, social, and so on. Generally, it is a function of age. As with many of us, we tend to mellow and become a bit more conservative in terms of some things in our decisions as we get older.

This is the Zuckerman theory, or the Zuckerman sensation-seeking model that is referred to in the literature. You have this in your handout. As you can see, it is very biological in nature. The origins are at the level of the neurons in the brain. We are looking at levels of dopamine and epinephrine in terms of neural transmitters. We are looking at monoamine oxidase, which is an enzyme that regulates the transmission of chemicals in brain cells.

We are looking at hormones interacting in different complex ways in the brain, in the arousal center in the brain, in the pleasure center, to eventually express itself in different behaviors such as perhaps involving sex, drugs, alcohol, partying, traveling, risky sports, a search for variety, and other kinds of things. It has its origins biologically. This would suggest that when we design interventions to address risk-taking, we have to take into consideration the biological aspects. And there are some approaches to curbing risk-taking that do not address the biology of risk-taking.

This slide, which is called the principle factors that contribute to risk-taking — you also have this as a full slide in your handout — is very complex, is very busy. We will not go over everything that is on this slide. This would suggest that there are many, many things that seem to interact. Some are endogenous, or internal, in nature. Some are exogenous, or come from the outside inwards, that interact in predisposing ways to influence our participation in risk behavior.

And we get into such issues as cognition, how we think, how we view the world; gender, male versus female differences; hormones, and particularly testosterone in boys; our perception of risk whether we have what is called an optimistic bias, where we engage in things and have no sense of danger, we think we are immortal and invulnerable; self-esteem issues; aggressiveness. And in terms of exogenous factors, to include parenting styles, parental denial, low parental support, peer behavior, transitions in school.

The transition from elementary to middle school can be hard on some young people, and then again, from middle school to high school. The data would suggest that for those who drop out of school, many of them will drop out during these key transition periods, either from elementary to middle school or middle school to high school. We lose a lot of kids around 8th and 9th grade. So one key intervention is to get them involved in meaningful activities and keep them in school somehow in constructive behaviors while they are transitioning across the school cycle.

And then of course are precipitating factors, things in the immediate environment, how we perceive risk, are drugs readily accessible and available, are peers using drugs, and so on.

This slide, of and by itself, should suggest that simplistic solutions — which I call magic bullets — simply will not work to address adolescent risk-taking. Quick, magic bullets are doomed to failure because they cannot address all of these factors that are interacting. When we look at risk-taking, there is biological, psychological and sociological factors that all intertwine in strange matrices and webs and simplistic solutions cannot possibly address everything. So we need to identify risk-taking as very complex in nature, and our interventions must be multidimensional and complex.

This is the causal model of adolescent risk-taking, another popular theory. We won't take time in this presentation to dissect it, but you can see it involves some biology, some psychology, some perception of one's environment, and they interact in various ways. This is also in your handout. You can see that, over time, a lot of things interact to predict possible involvement in risk.

This is Richard Jessor's adolescent problem behavior theory, which you also have in your materials today. Similar to the other two theories we presented and, again, a little different. Dr. Jessor was the first to suggest, maybe 25 years ago, that risk-taking was normative in nature and was essential to growth and development, but it had to be channeled in positive ways.

We have given you our definition for risk: Any action for which there is some possibility of failure as well as some opportunity for success. We have given you Zuckerman's definition of sensation seeking: A trait defined by the seeking of varied, novel, and complex and intense sensations and experiences, and the willingness to take such physical, social, legal, and financial risks for the sake of such experience, which evolves into a biological — i.e., physiological — arousal, euphoria, and psychological excitement. And you took the Zuckerman sensation seeking scale today.

And then this final definition, which I will not take time to read. You have it in your handout today. The notion is that risk-taking being volitional — i.e., voluntary — with an uncertain outcome, either positive or negative, and being bio-cycle social in nature.

Any questions?

We are getting into the meat of some selected concepts. And I have the adolescent risk-taking, behavior-training module as part of your materials. This is a module we use in training both undergraduate as well as graduate students at the University of Texas, both in pre-service education, health education, health psychology, and other areas. We know that in adolescence there are a lot of changes going on that contribute to the possibility of risk, including biological, physiological, cognitive, and social changes, and that these developmental changes may interact in some ways and trigger complex responses that involve engagement in risk.

We know that risk-taking appears to fulfill certain psychosocial and developmental needs that are essential for growth and development. Risk-taking may facilitate personal growth during adolescence and adulthood, to include self-improvement, commitment and self-disclosure. I have given you examples of these in the handouts, which shows that risk-taking is part of growing as a person. These would be the more positive kinds of risk-taking, to improve ourselves, to step forward and support a cause that is important in our lives, to perhaps disclose our desires, our likes, our weaknesses and so on.

In any of these kinds of risk behaviors there is a possibility of success as well as the possibility of disappointment, rejection, failure, and so on. So risk-taking is a normal, healthy dimension of adolescent growth and development. It builds self-confidence, enhances self-esteem, promotes autonomy, builds self-identity, and helps to gain peer acceptance and respect.

Risk-taking allows young people to explore their boundaries, test their limits and gain confidence in themselves. And adolescents have a proclivity due to biological, psychological and sociological forces for taking risk. We know risk-taking generally moves in what is known as a developmental trajectory. It usually does not occur in isolation; they sort of cluster together in predictable ways and related to various psychological and environmental antecedents. For example, young people who are sexually active may also be driving while drunk or riding in a car while drunk. They may also be smoking cigarettes, and so on and so on. They tend to cluster together.

This slide shows a developmental trajectory of risk-taking, which means basically that as one gets older, it increases. You can see the data from grades 7 and 8, both male and female, and grades 9 and 10, and grades 11 and 12, that it is an upward slope of things gradually increasing. This data includes risk behaviors such as tobacco use, regular alcohol use, binge drinking, marijuana use, other illicit drug use, fighting, weapon carrying, suicidal thoughts, suicidal attempt, and unprotected intercourse.

One last comment about that last slide. This would suggest, in terms of primary prevention, that we need to begin our interventions earlier rather than later.

Risk-taking is necessary for healthy functioning. Health, for more people, is a matter of balancing risk rather than taking none at all. The challenge is to channel risk-taking in positive, health-enhancing ways.

The goal of our presentation today is to link research to best practices. We know that research theory-based approaches are more likely to result in best practices than interventions not based on scientific evidence. We see ourselves as having a great disconnect. There is a chasm. There are researchers doing their things and presenting their research at scientific meetings, sort of singing to the choir, and the practitioners are working hard in the classrooms and the community centers. And sometimes the researchers don't connect well with the practitioners and so forth. So we need to work harder to build a bridge to connect research with practice. And both ends of that continuum, research and practice, can benefit from each other.

That is our vision for the future, to build a steel bridge that connects research and practice. We should use evidence-based approaches. We should enhance what I will term health literacy, which we are going to define very quickly and then move on to our application to a specific risk behavior. We should use prevention theory. We should implement programs that have demonstrated effectiveness.

What are the skills and competencies of a health-literate teacher? This is part of connecting research to practices to train young people. Teacher health literacy was an area that we looked at, and then conducted some research and published a paper in the Journal of School Health April 2001, of which you have a copy of that paper in your handout. It looks at health literacy from a teacher perspective rather than a student perspective.

Traditionally, health literacy has focused on what we expect young people to accomplish and learn in terms of health concepts and skills if they have been exposed to high-quality training. Of course, in order to do that, our providers, the teachers, must also have health literacy. So this is our definition. And we see a relationship between teacher health literacy and student health literacy, in which the teacher is viewed as the provider of health information and the student is viewed as the consumer. And we are suggesting that provider health literacy, i.e., teachers, is as important as consumer, i.e., student, health literacy.

Maximizing both sides of this provider/consumer relationship should improve the quality of teacher preparation as well as the quality of instruction in the classroom. Teacher health literacy is viewed as containing a wide array of attributes important in school health education practice. And in our teacher training and preserve at the University of Texas, this is the philosophical foundation upon which we do preserve education.

What does teach health literacy include? It certainly includes having strong pedagogical skills, being able to communicate and teach effectively, being able to utilize a wide variety of teaching methods, learning strategies, multimedia technology, and cyberspace resources. There is a lot of great stuff going on at this conference this year on the integration of technology into the classroom. And certainly that is part of my view of teacher health literacy.

Being a facilitator of learning rather than simply an information giver is part of teacher health literacy. Being able to engage young people in their own learning of health information and using discovery learning techniques and so on. Expecting students to move far beyond rote memorization. If we think of Bloom's Taxonomy of Learning, memorization of knowledge is the lowest level and the higher levels include comprehension, application, analysis, synthesis, and evaluation. And we view that we should bring the kids as high as we can in our teaching, to go far beyond simply knowledge in terms of final outcomes.

We certainly view teacher health literacy and teacher training that one should have a passion for teaching as well as compassion for students. And one should be able to motivate students to care about their health and the health of others.

In terms of staff development, of course one of the reasons of many great reasons of coming to the ASCD Conference is to upgrade your knowledge, listen to interesting speakers, gain new information, and continuing education, so we can keep up with the information. I think it is a really important part of teacher training. You have to become professional, become members of ASCD and other education organizations to keep with the flow of information.

Another view of health literacy is to be an advocate for kids and actively lobby and participate in activities to support student health education and health care services in the local community, and to proactively support the importance of child and adolescent health in the political arena. And finally, to deliver science-based — i.e., evidence-based — health information in our teaching. Which simply means that whatever we do, we should ask the question: What is the scientific evidence to support that information? And if there is no scientific evidence to support what we are doing, perhaps we need to rethink what we are doing.

I would like now to hand the microphone over to Tammy Jordan, to begin talking about evidence-based health promotion.

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