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Effectiveness of a Health Education Curriculum for Secondary School Students -- United States, 1986-1989

Risk behaviors that affect the health of young persons in the United States include drug use, alcohol consumption, tobacco use, imprudent dietary patterns, physical inactivity, unsafe sexual practices, and injury-related behaviors (1,2). Because these behaviors are usually established during youth, since 1977 CDC has supported the development, evaluation, and implementation of comprehensive school health education curricula to reduce these behaviors among young persons. This report describes the impact of one of these curricula (Teenage Health Teaching Modules (THTM)) on student knowledge, attitudes, and selected health-risk behaviors.

During 1979-1983, THTM was developed (3) for use at the secondary level initially by school systems already using the comprehensive elementary school health education curriculum, Growing Healthy. THTM consists of 16 instructional modules, each of which addresses a separate developmentally based health task (e.g., Eating Well and Handling Stress). Teachers are encouraged to add supplementary activities and materials to the module's core materials. All modules are intended to develop five skills: self-assessment, communication, decision-making, advocacy, and self-management (3).

During 1986-1989, to assess the effects of THTM on selected student health-risk behaviors, a large-scale controlled evaluation was conducted by a private research organization with technical oversight from an external committee of health education research experts (4). The evaluation employed a quasi-experimental pretest/posttest control group design (5) to determine whether selected modules of THTM could improve student health knowledge, attitudes, and self-reported behaviors and to suggest how to implement the curriculum more effectively. The effectiveness of THTM was assessed in two settings: 1) an "experimental" setting, involving new users recruited for the study; and 2) a "naturalistic" setting, involving users who had adopted THTM independent of the study.

Junior high/middle schools were required to use four modules (Being Fit, Having Friends, Living with Feelings, and Preventing Injuries) and senior high schools five different modules (Eating Well, Handling Stress, Protecting Oneself and Others, Promoting Health in Families, and Planning a Healthy Future). Teachers in the experimental setting were to use all four or five required modules (and no others) and were urged to implement the curriculum as prescribed. Teachers in the naturalistic setting were to use a minimum of three of the required modules and had the option of using additional modules. Students were exposed to THTM for 36-38 45-minute classes (approximately 27 hours) during a 16- to 18-week semester.

The evaluation included 4806 students from 149 schools in seven states. Pretest and posttest self-administered questionnaire responses were analyzed for 2530 students who received THTM and 2276 same-school controls. By education research convention, standardized effect sizes greater than 0.25 were considered educationally important and further characterized as small (0.20-0.49), moderate (0.50-0.79), and large (greater than or equal to 0.80) (6,7). From pretest to posttest, students in THTM-exposed classes were more likely than those in control classes to report larger knowledge gain scores (p less than 0.01; 2-tailed t-test) and larger attitude gain scores among senior high school classes (p less than 0.05). The standardized effect sizes were moderate to large for knowledge (0.64-1.12) and moderate for attitudes (0.69-0.76) among senior high classes.

From pretest to posttest, THTM-exposed students in 39 experimental senior high school classes were more likely than those in control classes (p less than 0.05; 2-tailed t-test) to report, for the preceding 30 days, fewer cigarettes smoked (standardized effect size: 0.47) and fewer instances of illegal drug use (standardized effect size: 0.58) (Table 1).

From pretest to posttest, THTM-exposed students in 40 naturalistic senior high school classes were more likely than those in control classes (p less than 0.05; 2-tailed t-test) to report, for the preceding 30 days, abstinence from cigarettes, smokeless tobacco, and illegal drugs and fewer alcoholic drinks consumed (Table 1). The standardized effect sizes ranged from 0.49 to 0.65.

For senior high school classes in both experimental and naturalistic settings, THTM had no statistically significant effect on two other behaviors that were measured (i.e., wearing seatbelts and eating fried foods). In addition, THTM had no discernible effects on any self-reported behaviors of junior high/middle school classes. Reported by: JG Ross, MT Errecart, Macro Systems, Inc, Silver Spring, Maryland. Office of Program Planning and Evaluation, Office of the Director, Surveillance and Evaluation Research Br, Div of Adolescent and School Health, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The THTM evaluation confirmed that specific modules of a school health education curriculum designed for secondary school students can have educationally important effects on student knowledge, attitudes, and selected self-reported health-risk behaviors. However, the self-reports of tobacco, alcohol, and drug use were not physiologically verified, and the limited (4-month) follow-up period precluded determining whether THTM had a sustained impact on knowledge, attitudes, and self-reported behavior. Nonetheless, these findings support other research that suggests that carefully designed and implemented comprehensive school health education programs can reduce risks for disease and injury among young persons (7,8).

Several possible explanations exist for the lack of statistically significant effects on the self-reported behaviors of junior high/middle school students; possibly the most important is that the behaviors addressed in the modules to which these students were exposed did not specifically correspond with the behaviors measured in the evaluation.

Findings from the THTM evaluation can support education and health professionals, parents, and other community members in achieving the year 2000 national health objective to "increase to at least 75 percent the proportion of the nation's elementary and secondary schools that provide planned and sequential kindergarten through 12th grade quality school health education" (9). Because quality school health education can improve important health-related knowledge, attitudes, and behaviors for persons both during school years and in later life, health and education agencies, parents, and other concerned community members together should consider intensifying efforts to implement comprehensive school health curricula.


  1. CDC. Results from the National Adolescent Student Health Survey. MMWR 1989;38:147-50.

  2. Kolbe L. An epidemiologic surveillance system to monitor the prevalence of youth behaviors that most affect health. Health Education 1990;21:44-8.

  3. Education Development Center. Health is basic: an introduction to the THTM Program for Teachers and Students. Newton, Massachusetts: Education Development Center, 1983.

  4. Errecart MT, Walberg HJ, Ross JG, Gold RS, Fiedler JL, Kolbe LJ. Effectiveness of teenage health teaching modules. J School Health 1991;61:26-30.

  5. Cook TD, Campbell DT. Quasi-experimentation: design and analysis issues for field settings. Boston: Houghton Mifflin, 1979.

  6. Cohen J. Statistical power analysis for the behavioral sciences. New York: Academic Press, 1977.

  7. Connell DB, Turner RR, Mason EF. Summary of findings of the school health education evaluation: health promotion effectiveness, implementation, and costs. J School Health 1985;55:316-21.

  8. Walter HJ. Primary prevention of chronic disease among children: the school-based "Know Your Body" intervention trials. Health Educ Q 1989;16:201-14.

  9. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: US Department of Health and Human Services, Public Health Service, 1990.

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