Abstract
Background
The School Health Education Program (SHEP) is a collaboration of the John A. Burns School of Medicine and the State of Hawai‘i Department of Education that was founded to improve the health of Hawai‘i's youth. This program allows premedical and medical students (collectively referred to as “medical students” from here on) to serve as health educators for high school students in six priority areas of health education.
Objectives
To confirm the efficacy of this community health partnership program and to determine the factors resulting in its success.
Methods
A total of 1714 students from seven of Hawai‘i's public high schools were surveyed for improvement in their content knowledge and decision-making confidence after participating in SHEP presentations. A sub-group of 235 high school students were asked about their comfort level and trust in their interactions with medical students as compared to their health teachers.
Results
The knowledge content and confidence in decision making increased significantly after participation in SHEP activities (p<.0001). High school students were found to be more comfortable and more trusting in learning about health topics from medical students as compared to health teachers (p<.0001). Reasons given included the medical students' content knowledge as well as their presentation methods and positive attitude.
Conclusions
The unique dual role of medical students as future physicians and as students allowed them to retain their credibility as health educators while developing a strong rapport with the high school students. Through SHEP, medical students can gain valuable experience through researching and teaching health topics while high school students receive additional health knowledge through this teaching.
Introduction
The School Health Education Program (SHEP) is a collaboration of the John A. Burns School of Medicine and the State of Hawai‘i Department of Education.1 This program was originally founded in 2002 for premedical and medical students (to be referred to collectively as “medical students” from here on), high school students, and faculty to work together to improve the health of Hawai‘i's youth. By allowing medical students to serve as health educators for high school students, both benefit: the medical students gain valuable experience through researching and teaching health topics while high school students receive additional health knowledge through this teaching.
The chosen health topics focus on six priority areas, directly comparable to those cited in the Youth Risk Behavior Surveillance System (YRBSS): “injury and violence prevention; alcohol and drug use prevention; sexual health and responsibility; tobacco use prevention; nutrition and physical activity; and personal and consumer health.”2 The YRBSS was developed by the Centers for Disease Control and Prevention (CDC) to monitor health risk behaviors of 9th through 12th grade students. These behaviors contribute to deaths of adolescents, most commonly through motor vehicle crashes, other unintentional injury, homicide, and suicide before the age of 25. They also contribute more chronically to the deaths of adults through cardiovascular disease and cancer at older ages.
The current mainstay of educating public high school students about these health risk behaviors is their health education curriculum. Health education, however, is lacking in both quantity and quality. The High School Transcript Study from 2000 revealed that the amount of time devoted to health and physical education averaged to 2.2 credits for high school graduates in year 2000.3 This number may be compared to the mean total course credits of 26.2 earned by this same group of graduates. These credits are measured in Carnegie units, a standardizing factor that equates one credit to a 40 minute class period that occurs once per day across the entire school year. The High School Transcript Study from 2005 noted that these data from 2000 were not significantly different in 2005.4
In addition to the limited quantity of time devoted to health education, the quality of this infrequent health education is questionable. Health teachers who have had no training in the basic sciences may lack confidence in teaching a more complex curriculum. For the 1999–2000 school year, only 74.8% of health education teachers had proper certification to teach health education. Of those certified, only 56.6% possessed an undergraduate or graduate degree in the field of health education.5
This current health education system is clearly not sufficient, a fact made apparent by the adolescent health education crisis in the United States. Additional resources are needed. One editorial in The Lancet addressed sex education in particular and noted that “the median age at first intercourse increased significantly with educational level.”6 With the current rates of unwanted pregnancy, it is clear that more education is needed. In the editorial, the question then arose of “how, and who will do the teaching?” One suggestion was the use of medical students who could use their clinical knowledge to take part in an education program as a way of giving back to the community.
Numerous programs with this particular service-learning model of medical students and interns serving as teachers to younger students have been reported in the literature. These programs have proved beneficial to the teachers by increasing their efficacy as communicators,7 improving their confidence by dealing with the subject at hand (e.g., sexual health issues),8 and allowing them to develop “teaching and relationship-building skills with adolescents.”9 More importantly, these programs have met their educational goal and proved beneficial to the students. The programs generally involved sensitive topics such as AIDS education,10–14 sex education,15–17 breast feeding,18 and substance abuse.19
These current data show benefit to both students and teachers who participate in service-learning programs. They create a compelling case for the establishment of additional programs of a similar vein in the context of a national adolescent health crisis.
The efficacy of SHEP has already been established in an earlier study.20 The objectives of this current study are not only to reinforce the efficacy of this service-learning model, but also to determine the etiology of its success. This study proposes that medical students are in a unique position to teach high school health classes; they have a dual role as both health care providers and as students. Because high school health education typically addresses issues of a more personal nature, a trusting relationship must be established between teacher and student for effective learning to take place. The medical students' role as health care providers enables them to provide trustworthy information to the high school students while their role as students allows them to foster a peer relationship rather than assume an authoritarian role when teaching.
The results suggest that medical students are more highly rated as health education instructors than health teachers among high school students. Such a finding would yield a new effective option in aiding to alleviate the current adolescent health crisis.
Methods
Pre-clinical medical students and undergraduate pre-medical students (collectively referred to as “medical students” in this paper) were divided into three student groups with each group randomly assigned to two high schools. A monthly presentation format was developed, allowing the student group to form a longitudinal relationship with the assigned schools.
Prior to the monthly presentations, each group worked with medical school faculty to develop content expertise and outcome measurements tools. Each group practiced their presentation with clinical faculty members, allowing for direct oral feedback prior to the actual school presentation. Presentation methods were chosen by student groups and included the use of PowerPoint presentations, poster board presentations, small-group discussions, interactive games, and role-playing scenarios. These presentations were created to maximize the interaction and minimize one-sided lecturing.
In creating these presentations, the seven areas of the National Health Education Standards21 were kept in mind. Some methods by which these standards were applied to the presentations can be seen in Table 1.
Table 1.
National Health Education Standards as Applied to SHEP Presentations
| 1) Core Concepts: The high school students were taught the basic information about the health topic at hand. |
| 2) Accessing Information: The students were given contact information about local health resources that could answer any further questions they had about the health topic. The students were also informed about situations in which it would be appropriate to talk to an adult, and the appropriate adults to contact within their environment (e.g., school nurses, teachers, and parents). |
| 3) Self Management: In addition to core concepts, the students were taught techniques on how to continuously apply these core concepts to their daily lives, such as in reading nutritional facts labels and condom use. |
| 4) Analyzing Influences: Students were made aware of the media influences on the foods they eat, their body images, smoking and alcohol usage, sexual activity, and violence. |
| 5) Interpersonal Communication: This was addressed in the role-playing activities when students were placed in a position where they had to counsel a friend who was considering suicide or speak with a relative who was thinking about quitting smoking. |
| 6) Decision Making & Goal Setting: Students participated in role-playing activities that offered skills on how to make decisions in scenarios such as peer pressure or sexual advances. They were also given materials that allowed them to keep track of their diet and exercise activities with the goal of achieving a healthy lifestyle. |
| 7) Advocacy: Students were encouraged to teach others about the health content they had learned in the presentations. As in the role-playing exercises mentioned in Interpersonal Communication, students had to counsel others using the concepts they had learned. |
To determine the efficacy of these presentations, a one-group pretest-posttest design with mixed analysis of variance was used, with time and school as additional variables. These pre- and post-tests were used to determine if the high school students gained content knowledge and confidence in decision-making after the presentations. The participating public high schools included: Castle, Nanakuli, McKinley, Kailua, Farrington, Waipahu, and Roosevelt High Schools. Data collection continued from the school years of 2003–04 and 2004–05. A total of 1714 students participated. IRB exemption was obtained for this study.
Three of these schools were singled out to receive additional questions related to the high school students' attitudes toward being taught by medical students. These schools were chosen due to their accessibility to the primary researcher. These additional questions were directed toward their comfort level in receiving health education from medical students and their trust in the information presented to them. The participating schools included McKinley, Castle, and Kailua High Schools. A total of 235 students participated in this arm of the study.
The test questions used to measure content knowledge consisted of multiple choice questions with four possible answers. The pretest and posttest questions remained the same. During the presentations, the answer to each of the multiple choice questions was included in the health content. In the survey questions used to measure the students' decision-making confidence, comfort, and trust, a 5-point Likert scale was used to measure student opinion.
Students were also asked to comment on why they felt more comfortable learning about health topics from medical students, or why they felt that the medical students' information was more trustworthy if they had marked “Slightly agree” or “Strongly agree” on the Likert scale. After review of all comments in aggregate, six main categories of comment type were created, and each comment was placed into one of the six categories by the lead author of this paper after the categories were well defined. The categories included Medical Knowledge, Presentation Method, Presentation Attitude, Fellow Students, Medical Experience, and Confidentiality (further defined in Table 2). Placement of comments into the categories was straight-forward, with comments clearly falling into one of the six categories. Interestingly, no comments were made about the interactive and engaging nature of the presentations themselves.
Table 2.
Definition of Categories Defined by High School Students
| A. Medical Knowledge: This category included comments about medical students having a greater understanding and more accurate knowledge of health topics because they are specializing in that field and studying it at the time of presentation. It also includes comments about how medical students are medical professionals and it is their interest and duty to provide health education. |
| B. Presentation Method: This category included comments about how medical students tend to give more detailed answers than parents or teachers and explain their ideas more thoroughly, rather than holding back information. It also includes comments about how medical students use facts to back up their arguments rather than relying on opinions. |
| C. Presentation Attitude: This category included comments about how medical students are less judgmental and more objective than parents and teachers. Comments focused on how, for example, a parent would think that his child smokes if his child asks him a question about smoking, whereas a medical student would not make such an assumption. Also, some comments mentioned that the medical students would treat the high school students with respect, as equals, rather than talking down to them. |
| D. Fellow Students: This category included comments about how medical students are students in school, just like the high school students. The medical students are closer to their age, more familiar with substance abuse experiences, and have a greater understanding of their high school woes since the medical students experienced it more recently than their health teachers. Also, the medical students were noted to be more “fun” due to their energy and interaction. |
| E. Medical Experience: This category included comments about how medical students have seen the diseases and issues surrounding substance abuse and unsafe sex in patients, so they are better able to argue against substance abuse and unsafe sex based on their knowledge of the later consequences. |
| F. Confidentiality: This category included comments about medical students being complete strangers to the high school students and thus, being seen as confidants to whom the high school students could tell their secrets and ask questions. |
Results
Over the course of two school years during which the high school students received approximately one SHEP presentation per month, the students scored significantly higher on the posttests as compared to the pretests in content knowledge. When examining all schools combined, (n=1714), it was found that knowledge content increased from pre- to post-test for healthy living, substance abuse, and sexual health, with p< .0001 for all three categories. The confidence in decision-making was also significantly higher from pretest to posttest for all three categories as well, with p<.0001.
In the subgroup study looking at students at McKinley, Castle, and Kailua High Schools, it was determined from an increase in the Likert scale that students are more comfortable learning health education from medical students rather than their health teachers. It was also shown that students trusted the information they received from medical students more than from their health teachers (Figure 1).
Figure 1.
High School Students' Comfort and Trust with Medical Students
After categorizing the students' comments into one of the six categories (see Methods section), it could be seen that nearly half the comments generated by the high school students suggested that they felt more comfortable learning from medical students because of their Medical Knowledge. From pretest to posttest, there was also a minor increase in the Presentation Method category. The other five comment types also made up approximately half of the comments (Table 3, Figure 2).
Table 3.
High School Students' Reasons for Comfort: Percentage of Comments by Topic
| A | B | C | D | E | F | |
| Pre-Test | 47.2 | 8.3 | 22.2 | 9.72 | 1.4 | 11.1 |
| Post-Test | 48.1 | 18.5 | 12.0 | 15.7 | 0.9 | 4.6 |
Figure 2.
High School Students' Reasons for Comfort: Percentage of Comments by Topic
The high school students were also asked for their comments about why they trusted the information from medical students more than that from their health teachers, and believed this information to be more accurate (Table 4, Figure 3). The same six categories were used. It is evident that the majority of the comments, both pre- and post-test, fall in the Medical Knowledge category.
Table 4.
High School Students' Reasons for Trust: Percentage of Comments by Topic
| A | B | C | D | E | F | |
| Pre-Test | 89.9 | 3.8 | 2.5 | 3.8 | 0 | 0 |
| Post-Test | 72.7 | 22.2 | 2.0 | 2.0 | 1.0 | 0 |
Figure 3.
High School Students' Reasons for Trust: Percentage of Comments by Topic
Discussion
This study confirms that, as discussed in prior literature,20 the School Health Education Program is effective both in increasing health content knowledge of high school students and in increasing their confidence in decision-making skills related to the health content. Such results suggest that the high school students retain the information they are taught in the health presentations and that after the presentations, they feel better prepared to make real world decisions based on this newly-learned knowledge.
More importantly, this study brings some insight into why SHEP has been successful in conveying health information to the high school students. One essential aspect of effective teaching is the rapport between student and teacher, particularly when addressing sensitive health topics. In SHEP, medical students had the opportunity to develop this rapport while teaching high school students about healthy living, substance abuse, sexual health, and teen violence. As evidenced by the current data, the high school students felt more comfortable with the medical students than with their own health teachers.
Another aspect of effective teaching is the information content. There must be an element of trust before the student is willing to accept the teachings of the teacher as fact. At times, this trust can be generated by the aforementioned rapport that the student has with the teacher. An authoritative figure who specializes in the topic at hand may also generate trust that he or she is knowledgeable enough to provide trustworthy teachings. The data in this present study shows that the high school students felt that the information from the medical students was more accurate, and thus, more trustworthy, than that of their own health teachers.
This overall preference for medical students poses many questions. What are the necessary qualities of an effective health educator? Certainly these would be the qualities necessary to develop a rapport with the students, and create an environment of comfort and trust while efficiently communicating accurate information. What qualities do medical students possess that allow them to do this more effectively than health teachers? Could this success in health education be replicated by a nurse or physician who has background knowledge and experience in such health topics? How can a high school health teacher use this information to improve his or her rapport with the students?
The comments generated by the high school students gave some indication as to which qualities they preferred. In those students who felt more comfortable with medical students than with their health teachers, approximately half of their comments focused on the Medical Knowledge of the medical students as the reason for their comfort. This focus suggests that it was the functional aspect of the medical students, such as their knowledge and their role as medical authorities that was important to these commenters. The other half of the comments focused more on the subjective aspects of the medical students, such as the presentations they created or their teaching attitudes and methods.
In analyzing the set of comments generated by high school students who felt that the medical students presented more accurate information than their health teachers, the large majority felt that way because of their Medical Knowledge. This is not surprising because medical students are specializing in medicine, studying to become physicians, so they are perceived as presenting accurate medical information. However, there is an increase in comments from pretest to posttest that cite the Presentation Method as another reason why medical students present accurate information. This suggests that the content of the presentations and the teaching method contributed to the credibility of the medical students.
In essence, it was a combination of their teacher-like role and their student-like demeanor that allowed the medical students to retain their credibility while still developing a rapport with the high school students. The high school students saw the medical students as being almost physicians and this gave them an air of authority that contributed to the trust and rapport. At the same time, the medical students were still students themselves. They saw the medical students as being closer in age to them and presenting these health topics in engaging and interactive ways. This contributed to the comfort and trust levels as well.
Thus, the very unique position of medical students allows them to make excellent health educators to high school students. As well as improving their own teaching and communication skills, as mentioned in the introduction, the use of medical student teachers can benefit the community. The creation of additional such programs nationwide in which medical students educate high school students on health topics is a step in the right direction to address the adolescent health education crisis.
Acknowledgements
SHEP is funded by the Fund for the Improvement of Post-Secondary Education (FIPSE), US Department of Education, and the Pfizer Corporation. The authors would like to thank Mike Fukuda MSW, for his assistance in the preparation of this manuscript.
References
- 1.Naguwa GS, Kramer K, Fukuda M, Kasuya R. Students teaching students: community health's School Health Education Program (SHEP) Hawaii Med J. 2004;63:89–90. [PubMed] [Google Scholar]
- 2.Centers for Disease Control and Prevention, author. Youth Risk Behavior Surveillance — United States, 2005. Surveillance Summaries, June 09, 2006. [April 29, 2008];MMWR. 2006 55(SS-5) http://www.cdc.gov/mmwr/PDF/SS/SS5505.pdf. [Google Scholar]
- 3.National Center for Educational Statistics, author. The High School Transcript Study: A Decade of Change in Curricula and Achievement, 1990–2000. Statistical Analysis Report, March 25, 2004. NCES 2004455. [April 29, 2008]. http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2004455.
- 4.National Center for Educational Statistics, author. America's High School Graduates: Results from the 2005 NAEP High School Transcript Study. Statistical Analysis Report, February 22, 2007. [April 29, 2008]. http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2007467.
- 5.Qualifications of the Public School Teacher Workforce: Prevalence of Out-of-Field Teaching 1987–88 to 1999–2000 (Revised) Statistical Analysis Report, August 15, 2004. [April 29, 2008]. http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2002603.
- 6.Sex education in schools: peers to the rescue? The Lancet. 1994;344(8927):899–900. doi: 10.1016/s0140-6736(94)92260-8. [DOI] [PubMed] [Google Scholar]
- 7.Olm-Shipman C, Reed VA, Jernstedt GC. Teaching children about health, part II: the effect of an academic-community partnership on medical students' communication skills. Education for Health. 2003;16(3):339–347. doi: 10.1080/13576280310001607640. [DOI] [PubMed] [Google Scholar]
- 8.Faulder GS, Riley SC, Stone N, Glasier A. Teaching sex education improves medical students' confidence in dealing with sexual health issues. Contraception. 2004;70:135–139. doi: 10.1016/j.contraception.2004.03.010. [DOI] [PubMed] [Google Scholar]
- 9.Spears N, Ham K, Duncan C. A science learning initiative with urban junior high school students. Academic Medicine. 1999;74(5):601–602. doi: 10.1097/00001888-199905000-00076. [DOI] [PubMed] [Google Scholar]
- 10.Johnson JA, Sellew JF, Campbell AE, et al. A program using medical students to teach high school students about AIDS. J Med Edu. doi: 10.1097/00001888-198807000-00003. [DOI] [PubMed] [Google Scholar]
- 11.Morton M, Nelson L, Walsh C, Zimmerman S, Coe RM. Evaluation of a HIV/AIDS education program for adolescents. J Community Health. 1996;21(1):23–35. doi: 10.1007/BF01682761. [DOI] [PubMed] [Google Scholar]
- 12.Short RV. Teaching AIDS. IPPF Med Bull. 1989;23(3):1–4. [PubMed] [Google Scholar]
- 13.Campbell E, Weeks C, Walsh R, Sanson-Fisher R. Training medical students in HIV/AIDS test counselling: results of a randomized trial. Med Educ. 1996;30(2):134–141. doi: 10.1111/j.1365-2923.1996.tb00731.x. [DOI] [PubMed] [Google Scholar]
- 14.Sunwood J, Brenman A, Escobedo J, et al. School-based AIDS education for adolescents. J Adolesc Health. 1995;16(4):309–315. doi: 10.1016/1054-139x(94)00091-r. [DOI] [PubMed] [Google Scholar]
- 15.Jobanputra J, Clack AR, Cheeseman GJ, Glasier A, Riley SC. A feasibility study of adolescent sex education: medical students as peer educators in Edinburgh schools. Br J Obstet Gynaecol. 1999;106(9):887–891. doi: 10.1111/j.1471-0528.1999.tb08425.x. [DOI] [PubMed] [Google Scholar]
- 16.Cora-Bramble D, Bradshaw ME, Sklarew B. The sex education practicum: medical students in the elementary school classroom. J Sch Health. 1992;62(1):32–34. doi: 10.1111/j.1746-1561.1992.tb01217.x. [DOI] [PubMed] [Google Scholar]
- 17.Tsurugi Y, Yamamoto M, Matsuda S. Peer education by medical students in a public health course. J UOEH. 2002;24(3):257–269. doi: 10.7888/juoeh.24.257. [DOI] [PubMed] [Google Scholar]
- 18.Frew JR, Taylor JS. First steps: a program for medical students to teach high school students about breastfeeding. Med Health R I. 2005;88(2):48–50. [PubMed] [Google Scholar]
- 19.Davis TC, George RB, Long S, et al. Sophomore medical students as substance abuse prevention teachers. Davis J La State Med Soc. 1994;146(6):275–278. [PubMed] [Google Scholar]
- 20.Lam L, Lee R, Nip I. Comparing need between health occupation and health education schools: which students benefit most from the School Health Education Program. Hawaii Med J. 2004;63:268–277. [PubMed] [Google Scholar]
- 21.Pateman B. Hawai‘i's “7 by 7” for School Health Education: A PowerPoint Presentation on Integrating the National Health Education Standards With Priority Content Areas for Today's School Health Education in Grades Kindergarten Through 12. [April 29, 2008];Prev Chronic Dis. 2006 3(2):A63. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1563955. [PMC free article] [PubMed] [Google Scholar]