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HEALTH EDUCATION RESEARCHTheory & Practice

Vol.4 no.l 1989Pages 111-124

The diffusion of school-based tobacco-use preventionprograms: project description and baseline data

Guy S.Parcel, Michael P.Eriksen1, Chris Y.Lovato, Nell H.Gottlieb,Susan G.Brink and Lawrence W.Green2

Abstract Introduction

Evaluation studies indicate that school-basedsmoking prevention programs can be effectivein preventing the initiation of smoking byadolescents. However, the potential impact ofthese programs has been limited because fewschools use programs which have been shownto be effective. Efforts to increase adoption ofthese programs by schools are needed. Thispaper presents the rationale, theoretical basis,intervention strategies and initial findings fromone of two federally funded studies to develop andevaluate interventions to enhance the diffusion oftested prevention programs. Survey results atbaseline indicate that school administrators andteachers have a high receptivity for adopting atobacco-use prevention program, but the reporteduse of evaluated curricula was low. The majorityof school districts develop their own teachingprograms which may not contain importantelements of successfully evaluated programs. Mostschool districts had smoking policies, but fewapplied restrictions to groups other than students.These data and other conditions indicate asupportive climate as well as the need to developand evaluate strategies to encourage the diffusionof tobacco-use prevention programs.

Center for Health Promotion Research and DevelopmentSchool of Public Health, University of Texas HealthScience Center at Houston, PO Box 20186 and 'TheUniversity of Texas M.D.Anderson Cancer Center,Houston, TX 77225, USACurrently, Vice President for Health PromotionPrograms, Henry J. Kaiser Family Foundation, MenloPark, CA, USA

National priorities and objectives for healthpromotion and disease prevention have been clearlyestablished (USDHEW, 1979; USDHHS, 1980,1986). To pursue these objectives, many riskreduction and disease prevention interventions havebeen developed, implemented, and their effectivenessevaluated through research and demonstrationprograms. Unfortunately, the diffusion of programsbeyond the demonstration sites is often slow. As aconsequence, the potential for significant publichealth benefit is lost. This situation is particularlyevident for programs aimed at preventing the use oftobacco among adolescents.

Schools are the logical site in which to conducttobacco-use prevention programs. Nearly 95% of allchildren and youth are in elementary or secondaryschools (Iverson and Kolbe, 1983), and most schoolseither mandate or endorse school health education(Kolbe and Iverson, 1984). Many of these programsinclude tobacco as an integral component. TheNational School Board Association (1987) estimatesthat anti-smoking education programs are part of thecurriculum in the majority of school districts in thecountry and are present in nearly two-thirds ofmiddle and junior high schools. The 1987 SchoolHealth in America Study found that 20 states (40%)mandate tobacco-use prevention education and that22 states (44%) have a law or regulation that restrictssmoking in public schools (Lovato et al., 1989). Un-fortunately, many school-based smoking preventionefforts often are didactic, one-shot efforts, are notintegral to the curriculum or to school policies, anddo not reflect state-of-the-art behavior changestrategies.

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Recent smoking prevention programs havedemonstrated an ability to keep 'baseline neversmokers' abstinent (Luepker et al., 1983) and toprevent the onset of smoking by up to 50% instudents exposed to the program (Perry et al., 1987).These programs have also been shown to reduce theprevalence of tobacco use in students who hadexperience with smoking at baseline (Flay et al.,1985).

Although these programs have been shown to beeffective and appear to have long-lasting impact, theyhave been conducted only among a small proportionof students and the techniques have not been diffusedto the larger at-risk population. Clearly, the greatestpublic health impact can be achieved by increasingthe number of students exposed to currently effectiveprevention programs. The current challenge is toinvestigate the factors associated with the successfuldiffusion of effective programs. The National CancerInstitute (NCI) has acknowledged this problem andhas recognized that, in spite of a number of NCI-funded research and demonstration programs thathave resulted in effective programs to preventadolescent smoking, the actual number of studentsreached has been relatively small (Best et al., 1988).In 1987, NCI funded two research projects designedto study the process of influencing the diffusion oftobacco-use prevention programs to schools. Theseprojects are designed to determine factors that relateto the diffusion of tobacco-use prevention and to testinterventions designed to influence the diffusionprocess. The purpose of this paper is to present theconceptualization, design and initial baseline charac-teristics for one of the two NCI-funded researchprojects. The major goals of the project are: (i) todevelop and evaluate intervention strategies toincrease the diffusion of a demonstrated effectivetobacco-use prevention program into school districts;(ii) to analyze the diffusion process to determinefactors that influence adoption and implementationof the tobacco-use prevention program; and (iii) todecrease the percentage of students who use or beginto use tobacco products.

This paper will provide an overview of thetheoretical foundations of the project and describethe project design and interventions in relation to the

first two goals. The project's impact on studenttobacco-use is being measured, but is not reported, inthis paper. This paper will also present baseline datato document existing conditions for program adoptionand demonstrate the need for interventions to furtherthe diffusion of school-based prevention programs.

Theoretical foundations

Diffusion theory and social learning theory providethe overall conceptualization for this project and areused to design the intervention strategies.

Diffusion theory accounts for the pattern ofadoption of a new idea or innovation by a population.It provides a predictive model of what to expect, adescriptive model of what is happening, and anexplanatory model of what transpired in the processof change by a population (Mohr, 1982; Rogers,1983; Green and McAlister, 1984; Green et al.,1989).

Diffusion is conceptualized as a staged process ofadoption of a specific intervention among individualsor organizations over time. The resulting pattern isdepicted by a cumulative logistic or S-shaped curveas shown in Figure 1 (Rogers, 1983; Green et al.,1989). A population of individuals or organizationscan be characterized as innovators, early adopters,

ao•a

a>a.

100 r

80

60

40

20

Adoptors

Diffusion Curve

• InnovatorsB Early Adopters0 Early MajorityS Late MajorityI1D Late Adopters

Laggards

Time

Figure 1. The S-shaped curve of diffusion showing the stagedprocess of adoption of a specific innovation over time.

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School-based tobacco-use prevention programs

early majority, late majority or laggards based ontheir point of adoption of the innovation relative toothers on this curve (Rogers, 1983).

Attributes of the innovation, decision-makers'perceptions of them and organizational characteristicsare key to all phases of the diffusion process.Whether the intervention is perceived: as needed, asan improvement over existing practices, as easy toimplement, as compatible with existing values andpractices and whether it is easily communicated, willinfluence the decision process (Graham, 1973; Baschand Sliepcevich, 1983; Moss, 1983; Rogers, 1983;Kolbe and Iverson, 1984; Roberts-Gray, 1985;Orlandi, 1986; Scheirer, 1986; Ottoson and Green,1987). Other factors such as expectations, perceivedavailability of resources, willingness to make changesin the status quo, support and reinforcement, andself-efficacy have also been identified as factors thatinfluence adoption of an innovation (Morrish, 1976;Pincus, 1976; Louis and Rosenblum, 1981; Scheirer,1981, 1986; Mohr, 1982; Basch and Sliepcevich,1983; Rogers, 1983; Basch, 1984; Kolbe andIverson, 1984; Roberts-Gray, 1985; Basch et al.,1986; Gottlieb et al., 1987; Ottoson and Green,1987; Green et al., 1989). In addition, organizationalcharacteristics, such as size, slack resources,professionalism, decentralization and informal socialnetworks, have been found to be positively associatedwith innovativeness (Mohr, 1982; Rogers, 1983).

Social learning theory (Bandura, 1977, 1986)offers a framework for designing interventions toinfluence diffusion through all four phases of thediffusion process. Modeling (i.e. the observation ofothers experiencing the innovation) can informpotential adopters about the relative benefits ofan innovation, influence expectations and valueexpectancies for the outcome of adoption, andprovide vicarious reinforcement for adoption. Theprovision of incentives for adoption and enhancedself-efficacy for decision-making and implementationof the innovation can facilitate diffusion. The designof such interventions should be grounded in thecontext of the targeted organizations or individuals.

The interventions developed for use in this studywill make extensive use of modeling and incentivesto influence the dissemination, adoption, implemen-

tation and maintenance of the tobacco-use preventionprogram in the schools. For example, in thedissemination intervention, we will use the 'dual-link'model which includes both media channels andinterpersonal channels to provide symbolic modelingand observation (Bandura, 1986). It may not bepossible or cost-effective to transport schoolpersonnel from several school districts to observe thesuccessful use of the tobacco-use preventionprogram. Thus, from district to district, the inter-personal channel would be difficult to use. However,media such as video tape or print material can beused to model the use of the program by one districtfor observation by several other districts. Once themedia reaches a school district, the further dis-semination can make use of the interpersonalchannels such as demonstrations, meetings, anddiscussions to continue further exposure to mediamaterial. In both channels, the essential componentsof the intervention strategies include modeling thebenefits, effective use and positive outcomes fromusing the tobacco-use prevention programs in theschools.

According to Bandura (1986), environmentalinducements serve as regulators of the adoption ofan innovation, and adoptive behavior is highlysusceptible to the influence of incentives. Thus, twomajor strategies that can be used to influence schoolsto adopt innovative health promotion programs are:(i) demonstrate how the program will benefit theusers and fit effectively into current activities andgoals of the organization; and (ii) create incentivesthat will provide social or economic benefits toteachers, administrators or the school district.

The application of social learning theory can alsobe extended to the implementation of a school-basedhealth promotion program by applying the principlesof skill training for the program implementors.Empirical studies of the implementation of innovativeschool programs have demonstrated the importanceof teacher training in influencing program successincluding implementation and student learningoutcomes (Huberman and Miles, 1984; Connell etal. 1985). Following the initial implementation ofthe program, maintenance and eventual institutional-ization within the schools will be influenced by

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feedback on success in meeting program objectivesand by incentives for continued implementation.

Project description

The study is being conducted in the state of Texaswhich has 1057 independent school districts locatedwithin 20 education service regions. The regions aresupported by two teacher training centers—one in thewestern half of the state, the other in Houston. Thelarge number of districts in the state required thatthe study have a geographic focus. The decision wasmade to select our study regions from the 11 regionsin the eastern half of the state. This decision enabledus to control for teacher training site.

Of these 11 regions, three were selected forintensive data collection (Figure 2), two of whichwere also to be targets of the diffusion intervention.The third region serves as a comparison region. Thedecision to use three of 11 regions was based on theneed to limit the study to a manageable number ofschool districts while having sufficient numbers tomeet the experimental conditions for evaluating theimplementation and maintenance interventions.

The criteria used to select the three educationalservice regions participating in the study were: (i)the region was densely populated and (ii) a majortobacco-use prevention program was not planned orcurrently under implementation in the region.Additionally, each region selected for the diffusionintervention must have a health education specialistassigned to the regional education service center.

The innovation that will be disseminated to theTexas schools is the Minnesota Smoking PreventionProgram (Perry et al., 1987), modified to fit regionaldifferences and renamed 'Smart Choices'. Theprogram includes both curricular and policy com-ponents. School districts in the 18 non-interventionregions will receive a brochure announcing theavailability of the 'Smart Choices' program. Schooldistricts in the remaining two regions will be exposedto a series of diffusion interventions designed toinfluence the rates of dissemination, adoption,implementation and maintenance of the 'SmartChoices' program by school districts. Data onprogram adoption will be collected from school

Comparison 38 DistrictsTraatnwnt 29 DistrictsTr«atm*nt 99 District!

Figure 2. The state of Texas. Three eastern regions wereselected for intensive data collection.

districts in all 20 regions over a three-year periodto construct an adoption curve.

Intervention and evaluation methodsThe diffusion intervention uses the existing edu-cational structures within the state. The contentof the intervention is partly guided by the conditionsfor adoption described by baseline data and byconstructs derived from diffusion theory and fromsocial learning theory. Each phase—dissemination,adoption, implementation and maintenance—includesmultiple intervention strategies. These strategies aresummarized below and in Table I.

Dissemination

The intervention strategies in the dissemination phasehave two purposes: (i) to provide information aboutthe tobacco-use prevention program and (ii) toincrease the motivation of potential users to adoptthe program. This phase has three components:development of district opinion leaders to shareinformation within districts, a diffusion network toshare information across districts, and use of mediachannels to facilitate exposure to the innovation. Eachdistrict is asked to appoint a representative to serveas an opinion leader. A one-day workshop prepares

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Table I. Diffusion intervention strategies

Diffusion phase Target level Strategies

Dissemination Administrators Diffusion networkTeachers Opinion leaders

Video-based modelingInterpersonal

communication channelsVicarious reinforcement

Adoption Administrators Print material for modelingTeachers Incentives

Vicarious reinforcement

Implementation Teachers Video-based trainingModelingSkill of trainingReinforcement

Workshop-based trainingModelingSkill trainingReinforcement

Maintenance Administrators IncentivesTeachers Feedback for reinforcement

these opinion leaders for the role of disseminatinginformation about 'Smart Choices' in their schooldistrict. District representatives who do not attendare mailed a 'Smart Choices' diffusion informationpacket or receive a personal visit from the RegionalHealth Education Specialists. To help with the dis-semination process within the school district, eachopinion leader is given a videotape which models theadoption and use of 'Smart Choices' in a Texasschool. The diffusion network is created by use ofa newsletter that goes to key personnel in districtsin the intervention regions. Information aboutactivities related to program dissemination occurringin school districts is reported in the newsletter.

The dissemination intervention will be evaluatedby a survey instrument designed to measure keyvariables likely to influence program adoption.The survey will be administered pre- and post-intervention to school administrators and teachers tomeasure the impact of the intervention. Selectedresults from the pre-intervention survey are presentedin the results section of this paper.

Adoption

A newsletter mailed to all intervention region schoolsis the major element of the adoption phase inter-vention. The print material provides examples ofadministrators and teachers deciding to adopt 'SmartChoices' and offers incentives to adopt, includingbenefits of the program and reductions in programand training costs. Adoption will be measured by thedistrict superintendent completing a programadoption form required for ordering copies of theprogram and enrolling in training.

Implementation

The implementation phase tests the efficacy of twoapproaches to train teachers in conducting the tobaccoprevention program: an in-service workshop and aself-instructional video package. Both methods usethe three-faceted approach of modeling, guidedpractice and self-directed application of acquiredskills suggested by Bandura (1986). Self-reports ofteacher implementation will serve as the primaryoutcome measure to determine the completeness andfidelity of program implementation. These data willbe validated by comparing teacher reports withstudent reports of what was implemented in theclassroom.

In addition to these measures, instrumentation fromthe Concerns-Based Adoption Model (Loucks et al.,1976; Hall et al., 1977; Hall and Loucks, 1978) willbe used to assess: (i) various operational forms ofthe innovation that result as teachers adapt theprogram to their particular situation, (ii) teachers'comfort and skill in implementing the program and(iii) teachers' attitudes regarding involvement withthe program.

Maintenance

The maintenance phase intervention is designed torequire a minimal amount of input from externalsources but to provide sufficient attention toencourage continuation of 'Smart Choices'. Threetypes of incentives include: (i) reinforcement throughrecognition; (ii) feedback on student learningoutcomes; and (iii) special attention to the teachers.Focus groups will be used to determine the specifictypes of incentives which are needed to be applied

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Year One- 1987/88S«p . „ Jan . Jun . „ Aug

DIFFUSION PROOfl/UI

Inta/vntion

Comp.ri.on

Year Two- 1888/89-_ J«n Fab Mat Ape May Jui Jul .

Ytar Four - 1980/91• - M a y Aufl

O . ,

Figure 3. Research design for diffusion interventions and evaluations. O—ID = baseline measure of teachers' andadministrators' receptivity toward the prevention program, X—ID = dissemination intervention, O—2D = follow-up measure ofreceptivity, X - 2 D = adoption intervention; 0 - 3 D = measure of program adoption, X-3D = workshop teacher training,X—4D = video-based teacher training, O—4D = measures of program implementation, X—5D = maintenance intervention,C—5D = control treatment for maintenance phase, O—5D = measure of program implementation during maintenance phase,R = random assignment to treatment groups.

in each of these categories. To evaluate the impactof the maintenance intervention, program continu-ation will be monitored, as well as implementationcompleteness and fidelity, as conducted for theimplementation phase.

As part of the development and evaluation of thediffusion interventions, baseline data were collectedon the prevalence of tobacco-use prevention curriculaand policies, as well as on relevant teacher andadministrator characteristics. In addition, districtorganizational data, including size, wealth (taxablevalue per average daily attendance),- populationdensity of district and student socio-economic status(percentage of students on federal lunch subsidy)have been obtained from TEA. In subsequentanalysis, these district level variables and teacher/administrator characteristics, including receptivityattitudes, professional cosmopolitanism, priortraining in health education and years of teaching,will be used to specify models of adoption,implementation and maintenance.

Research designAs shown in Figure 3, the research design is aseries of studies conducted within four separate butinterrelated phases. The series begins with thedissemination phase which uses a pre-test—post-testquasi-experimental design with 128 districts assignedto the intervention group and 38 districts assigned

to the comparison group. The assignment tointervention and comparison groups is by TEAregion rather than by random assignment because thediffusion interventions are based on geographicproximity of districts and application within existingstructures of the state department of education. Theintervention districts are exposed to the disseminationintervention ( X - ID in Figure 3) and a comparisonof change in receptivity toward program adoption(O-1D and O-2D) is made between the inter-vention and comparison districts. The interventiondistricts are then exposed to the adoption intervention(X—2D) and a comparison of program adoption ratesis made between the districts in intervention andcomparison groups (O—3D).

The implementation phase involves only thoseschool districts in the intervention group who adoptthe 'Smart Choices' prevention program. Adoptersare randomly assigned to two types of teachertraining formats: workshop face-to-face training(X-3D) and video-based, self-paced training(X-4D). Program implementation (O-4D) is thencompared between districts receiving the twodifferent types of training to determine if video-basedtraining can be more cost effective than traditionalworkshop training. The maintenance phase alsoinvolves an experimental study with districts whichimplement the program randomly assigned to receivethe intervention (X-5D) or to a non-intervention

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control group (C-5D). The maintenance inter-vention is evaluated by a comparison of programimplementation (O-5D) between districts in theintervention and control groups. Also, at the end ofthe maintenance phase a survey will be conductedin the comparison districts (O—5D) to determine theextent to which program adoption and implemen-tation have taken place without exposure to any ofthe diffusion interventions.

Not shown on Figure 3 is the design for deter-mining the impact of the 'Smart Choices' programon students' tobacco-use behavior. During theimplementation and maintenance phases, self-reported behavior will be measured in participatingdistricts in the intervention and comparison groupsto determine tobacco-use at baseline, followingintervention and at one year follow-up.

In addition to monitoring program adoption in theintervention and comparison districts, all theremaining school districts in Texas will be monitoredfor program adoption over the four-year period ofthe study to construct adoption curves for a minimaldissemination intervention (a program announcementbrochure). Organization characteristics of districtswill be used to distinguish differences in adoptionstatus over time.

These interrelated series of studies are designedto address the following outcomes of interest: (i) ratesof adoption by districts according to treatment,(ii) environmental, cognitive, organizational andbehavioral factors related to adoption, (iii) complete-ness and fidelity of program implementation and (iv)rates of maintenance of the program by districtswithin treatments, and student cognitive and (v)behavioral outcomes related to prevention of tobaccouse.

Method

SubjectsThe data described in this paper represent twoseparate surveys. A prevalence survey was mailedto each school district, and a receptivity survey wasmailed to teachers and school administrators withindistricts. Data on the status of school policies andprograms (prevalence survey) were collected from

144 of the 166 school districts (87%) after twofollow-up mailings. Of those surveys returned, 61 %were completed by the district superintendent or anassistant superintendent, 11 % by principals, and 10%by curriculum coordinators. The remaining 18%were completed by other district administrators,counselors, teachers and school nurses.

Data on relevant administrator and teachercharacteristics (receptivity survey) were collectedfrom 118 of the 166 school districts in the three studyregions. Survey respondents included 483 district andschool level administrators and 277 seventh-gradescience and health education teachers. Within thesurveyed districts, a response rate of 87% wasobtained for administrators and 82% for teachersafter two telephone follow-ups.

Of administrators comprising the receptivitysurvey sample, 74% were male and 26% female.The teachers' sample was 51% male and 49%female. Mean ages were 48 years and 40 years foradministrators and teachers respectively. Eighty percent of administrators and 88% of teachers werecurrently non-smokers.

ProceduresA one-page survey containing 13 questions wasdeveloped to assess the prevalence of tobacco-useprevention curriculum and policy among schooldistricts in the three study regions. A cover letterand the survey instrument were mailed to thesuperintendent of schools in each of the studydistricts. All questions were closed-ended anddesigned to assess the current prevalence of tobacco-use prevention curricula and policies, as well as theirrelevant characteristics. A tobacco-use preventioncurriculum was defined as a 'series of instructionallessons with stated learning objectives and plannedstudent learning activities'. In addition to prevalence,the name of the curriculum, grade levels taught andindividual with primary responsibility for instructionwere identified. The prevalence of written policiesthat restrict or prohibit tobacco-use was also assessed,including other policy characteristics such as type ofindividuals affected, locations included, compliance,enforcement and communication techniques.

Separate surveys were developed for teachers and

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Table U. Comparison of teacher and administrator responses to items indicating their receptivity to curriculum

Disagree Neither agreenor disagree

Agree

1. Commitment/perceived needTobacco-use prevention should be taughtin schools

2. LegitimacyOfficials view tobacco-use as importantpriority

3. SupportAdministrators/teachers view tobacco-useprevention important for seventh-grade students

4. Organizational fitTobacco-use prevention curriculum will fitwith seventh-grade science classes

5. Resistance to change/degree of changeAdding a tobacco-use prevention curriculumto seventh-grade classes would interfere withscience curriculum already established

6. Social reinforcementTobacco-use prevention would contributeto a good evaluation

7. Self-efficacyCan teach effectively to prevent students'use of tobacco products

Can ensure effective use of tobacco-useprevention curriculum in my school/district

8. Competition/perceived needAlready enough tobacco-use preventioncurricula available for seventh-grade classes

9. TimelinessTime is right for introduction of seventh-grade tobacco-use prevention curriculum

10. ResourcesSchool does not have resources to purchasematerials, for a new tobacco-use preventioncurriculum

A1

T*

AT

AT

AT

AT

AT

ATAT

AT

AT

AT

21

44

41

64

6262

1812

_

7

5-

5557

74

3031

43

3346

2926

1717

2427

5157

_26

22-

3430

3529

2737

9496

6350*

6773

7779

1412

3131

—67

73-

1113

5867*

4332*

"Administrators—sample size ranged between 476 and 482 for individual items due to missing data.'Teachers—sample size ranged between 269 and 273 for individual items due to missing data.*P <, 0.05; **P <, 0.01.

administrators to assess the level of receptivity to atobacco-use prevention program that includes: (i) acurriculum for seventh-grade science classes and(ii) tobacco-use policies for students and schoolemployees.

To develop the survey, key concepts from theliterature on diffusion and social learning theoryrelated to the adoption of an innovation wereidentified. From these concepts, items with a five-point Likert Scale were developed (i.e. strongly

disagree to strongly agree) and pretested on a sampleof science teachers (n = 69) and administrators(n = 28). Reliability of the revised instruments wastested at baseline using Cronbach's alpha. For theteachers' survey, total alpha was 0.86 and for theadministrators' survey, total alpha was 0.87.

Data from the survey will later be used to evaluatethe impact of the dissemination intervention. In thispaper, a subset of 16 items is presented that wereselected to provide information that would guide

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development of the dissemination and adoptioninterventions. These items were selected because theyare most logically associated with receptivity to theinnovation, are related to important theoreticalconcepts in social learning, and are most amenableto intervention.

Results

The following is a description of results from theprevalence and receptivity surveys. Results fromitems related to curriculum are presented first,followed by results of items related to policies. Thereceptivity data in Tables II and IV represent anaggregation of the responses of individual teachersand administrators in all of the responding districts(118) in the three study regions. These data arepresented to provide an overview of initial teacherand administrator receptivity to tobacco-useprevention curricular and policy innovations and arenot intended to provide a baseline receptivity measureof school districts (the unit of analysis) in theintervention and comparison regions. Subsequentanalysis will use the district as the unit of analysisto determine the effectiveness of the diffusion inter-ventions.

Prevalence of curriculumFewer than one-half of the school districts (42%)currently have a tobacco-use prevention curriculum.Of those that have a tobacco-use preventioncurriculum, 46% reported that it has been developedinternally within the school district. Less than 12%of districts use nationally recognized and/or testedcurricula such as the American Heart Association's'Putting Your Heart Into the Curriculum' or theAmerican Cancer Society's 'Help Myself program.

Tobacco-use prevention curricula are taught inmultiple grades within a district but most frequentlyin the seventh grade (85%), and less often in sixthgrade (63%), eighth grade (53%) and ninth grade(46%). Thirty-six per cent reported that the topic istaught in a grade level other than sixth through ninth.When used in the seventh grade, it is almost alwaystaught by either science (56%) or health teachers(35%).

Receptivity to curriculumData from the receptivity survey were aggregatedaccording to administrators and teachers andcollapsed into three response categories: (i) an'agree' category which combines 'strongly agree' and'agree', (ii) 'neither agree nor disagree' and (iii) a'disagree' category which combines 'stronglydisagree' and 'disagree'. Frequencies and chi-squareswere carried out on the 10 items described in Table

n.Commitment/legitimacy/support

Over 90% of teachers and administrators agreed thattobacco-Use prevention should be taught in schools.However, a significantly lower proportion of teachersthan administrators felt that school district officialsview tobacco-use prevention as an important teachingpriority [50% versus 62%, x2 = 12.40 (2 d.f),P < 0.01].

Both administrators and teachers tend to agree thateach group considers tobacco-use prevention to bean important topic for seventh-grade students. Nearlythree-quarters of teachers (73%) felt that admin-istrators view tobacco-use prevention as an importanttopic with about two-thirds of administrators (67%)reporting that teachers view the topic as important.

Organizational fit/resistance to change

Over 75 % of administrators and teachers felt that atobacco-use prevention curriculum could fit in wellwith the seventh-grade science classes at their school.Similarly, 62% of both administrators and teachersdid not believe that the introduction of a curriculumwould interfere with the currently established scienceinstruction.

Social reinforcement

Over one-half of teachers (57%) and administrators(51%) neither agreed nor disagreed that eitherteaching a tobacco-use prevention curriculum orassuring that a curriculum be taught would contributeto a good performance evaluation.

Self-efficacy

The majority of administrators (73%) agreed thatthey felt confident in ensuring the effective use ofa program in their district. Sixty-seven per cent of

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Table ID. School district tobacco-use policies

Students Faculty/staff

Campusvisitors

Restricts or prohibitsIn buildingsOn school groundsAt extracurricular events

Level of complianceExcellentGoodFairPoor

(n = 142)999992

(n = 142)553590

(n = 142)715025

(n = 111)652942

(n = 142)693421

(n = 108)4741102

teachers agreed that they can teach effectively toprevent student use of tobacco.

Competition/timeliness/resources

Over one-half of teachers (57%) and administrators(55%) tended to agree that there are not enoughtobacco-use prevention curricula available for use inseventh-grade classes. Teachers (67%) weresignificantly more likely than administrators (58%)to believe that the time is right for introduction ofa curriculum [x

2 = 7.76 (2 d.f.), P < 0.05]. Thetwo groups also differed significantly in theirperception of resource availability [x2 = 11 06 (2d.f.), P < 0.01]. Teachers are as likely to agree(32%) as to disagree (31%) that resources will beavailable to purchase the required materials for a newcurriculum, while administrators are more likely toreport concern that resources are not available(43%).

Prevalence of policiesAs seen in Table EQ, nearly all surveyed districtsreported that they restrict student tobacco-use inbuildings (99%), on school grounds (99%) and atextracurricular events (92%); however, less than halfof the districts control the tobacco-use of faculty, staffand visitors on school grounds and < 25 % at extra-curricular events.

District administrators reported a mixed level ofcompliance with tobacco-use policies. School districtadministrators are more likely to rate faculty and staffcompliance as 'excellent', compared to students orvisitors.

Receptivity to policiesThe same methods used to analyze the curriculumquestions were used to analyze the policy questions.Of the six items related to policy receptivity shownin Table IV, three were asked only of administrators,therefore teacher-administrator comparisons werenot made for these items.Commitment

The overwhelming majority of respondents (98% and97%) in both groups believe that a non-smokingpolicy for students should be strictly enforced.

Expected outcomeOver two-thirds of both administrators and teachersbelieve that a non-smoking policy for schoolemployees would make student educational effortsmore effective.

Support/commitment

A significant difference was found for the perceivedlevel of employee support for a non-smoking policyrestricting employee smoking, with administratorssignificantly more likely to believe that employeeswould support such a policy [x2 = 8.93, (2 d.f.),P < 0.01]. Approximately one-third of adminis-trators are in favor of a non-smoking policy foremployees, and a similar number believe thatemployees would support such a policy. Only 24%of teachers agreed that school employees wouldsupport a non-smoking policy that restricts theirsmoking.

Self-efficacy

Nearly one-half of administrators (47%) are

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Table FV. Comparison of teacher and administrators responses to items indicating their receptivity to a tobacco-use policy fortheir school

Disagree Neither agree nor disagree Agree

CommitmentSupport a strictly enforced

non-smoking policy for studentsExpected outcome

non-smoking policy for employeeswould make educational efforts toprevent tobacco-use among studentsmore effective

SupportEmployees would support a non-smoking policy that would restricttheir smoking

CommitmentIn favor of a non-smoking policyfor employees

Self-efficacyConfident that school/district couldeffectively implement a non-smoking policy for employees

TimelinessTime is right for introductionof a non-smoking policy thatincludes employees

A1

T*

AT

AT

AT

AT

AT

11

1010

3240

16-

21-

16-

12

1719

3336

9897

7371

3524

17

32

48

66

47

36

'Administrators—sample size ranged betewen 476 and 482 for individual items due to missing data.'Teachers—sample size ranged between 266 and 269 for individual items due to missing data.**P S 0.01.

confident that their school district could effectivelyimplement a non-smoking policy for employees, withone-third reporting that they are uncertain and 21 %not being confident of the district's ability to imple-ment such a policy.

Timeliness

Thirty-six per cent of administrators agree that thetime is right to introduce a non-smoking policy thatincludes employees, with nearly half neither agreeingnor disagreeing.

Discussion

The results of these baseline surveys suggest that bothteachers and administrators are receptive to teachingtobacco-use prevention in schools and to adoptingnon-smoking policies for school employees.However, the current level of practice, particularly

the use of tobacco-use prevention curricula forstudents and non-smoking policies for teachers andstaff, is exceedingly low. Fewer than one-half of thedistricts surveyed report using a formal tobacco-useprevention curriculum and nearly one-half of thosethat do use a curriculum, use one that they havedeveloped themselves.

Because teachers and administrators appear to bereceptive to adopting effective prevention programs,it is necessary to develop individual and organiz-ational interventions that lead to increased diffusionof Effective programs. To develop effective diffusioninterventions, it is important to understand whydistricts are not already utilizing proven programsand what steps in the diffusion process need to betargeted. For example, should interventions bedirected at disseminating the characteristics andavailability of effective programs, or directed atassisting school districts in the implementation and

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maintenance of these programs?These initial survey results have already influenced

the development of the videotape and newslettercomponents of the dissemination and adoptioninterventions and will be used to develop theimplementation intervention for the tobacco policycomponent. A further analysis of our baseline dataprovides some information that will be useful in thedevelopment of other diffusion interventions. Forexample, not only are teachers and administratorsvery receptive to tobacco-use prevention programs,they tend to share similar views on the subject. Thus,a school-district-wide appeal may be more costeffective than developing and directing separateinterventions to teachers and administrators.

The data suggest generally high receptivity,although there are specific areas which can betargeted for intervention. Only one-half of theteachers believe that school district officials considertobacco-use prevention to be an important priority.Because administrators are significantly more likelythan teachers to agree with this statement, anappropriate intervention is likely to be effective inincreasing teacher perceptions in this area. Similarly,the majority of both teachers and administrators areuncertain as to whether adoption of a tobacco-useprevention program would contribute to a goodindividual performance evaluation. An interventiondirected at supervisors to include prevention activitiesin appraising job performance may affect perceptionsin this area.

Lack of resources may be a serious barrier towidespread program adoption. Our data, however,do not indicate whether this concern is actual orperceived, and whether teacher and administratorconcern related to resources will predict adoption ofthe program by the school. Strategies to address thisbarrier would differ depending on its nature andwould range from program subsidies and informationabout program costs and benefits to steps that wouldmake cost less of an issue.

Successful program diffusion is not solely depen-dent upon analyzing or manipulating characteristicsof the individual or of the innovation. Environmentaland organizational factors are also critical indetermining whether programs are diffused or

impeded. In Texas, several organizational factorsprovide an opportunity to test specific diffusioninterventions. Texas educational standards requiretobacco education for the seventh grade. Most schooldistricts will meet this requirement through theseventh grade life science class. Thus the teacher ofseventh-grade life science is confronted with teachingin a new area and needs either to adopt or to developcurricula to address the tobacco education require-ments. Because the diffusion intervention in Texaswill build on existing state structures and resources,the diffusion model will have a high probability ofbeing transferable to other regions of the state andto other health education programs. The regionalservice centers located throughout the state functionas a resource to local school districts in curriculumdevelopment, staff development and instructionalsupport services. The approach will be to demon-strate the feasibility of implementing a theory-baseddiffusion intervention to move health promotioninnovations from research and demonstration statusto widespread use in school settings.

In summary, the results of this study suggest thatwhile school district receptivity to tobacco-useprevention programs is high, the current level ofpractice is relatively low, particularly regarding theuse of proven tobacco-use prevention curriculum.Because effective educational interventions havebeen developed, the public health challenge is todisseminate these programs widely to school districtsthroughout the nation and to encourage theiradoption, implementation and maintenance. Thefindings of this project will contribute to a betterunderstanding of factors that influence the diffusionof school-based health promotion programs. Theapplication of established theoretical frameworks willadd to our understanding of how to develop diffusionprograms that will result in increased use andcontinuance of effective health promotion inter-ventions in schools as well as in other settings.

Acknowledgements

The authors gratefully acknowledge the assistanceof Jack Franklin of the Texas Cancer Data Centerfor assisting in data collection, and Chris Harvey and

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Frances Chan for overall support in data collectionand analysis. This work was supported by grant NCICA45970-1.

References

Bandura.A. (1977) Social Learning Theory. Prentice Hall,Englewood Cliffs, NJ.

Bandura.A. (1986) Social Foundations of Thought and Action.Prentice Hall, Englewood Cliffs, NJ.

Basch.C. (1984) Research on disseminating and implementinghealth education programs in schools. Journal of School Health,54, 57-66.

Basch,C.E. and Sliepcevich.E.M. (1983) Innnovators, innovationsand implementation: a framework for curricular research inschool health education. Health Education, 14, 20-24.

Basch,C.E., Eveland.J.D. and Portnoy.B. (1986) Diffusionsystems for education and learning about health. Family andCommunity Health, 9, 1-26.

BestJ.A., Thomson.S.J., Santi,S.M., Smith.E.A. and Brown.K.S.(1988) Preventing cigarette smoking among school children.Annual Review of Public Health, 9, 161-201.

Connell.P.B., Tumer.R.R. and Mason.E.F. (1985) Summary ofthe findings of the school health education evaluation: healthpromotion effectiveness, implementation, and costs. Journal ofSchool Health, 55, 316-323.

Flay.B.R. (1985) Adolescent smoking: onset and prevention.Annals of Behavioral Medicine, 7, 9—13.

Flay.B.R., Ryan.K.B., Best.J.A., Brown.K.S., Kersell.M.W.,d'AvemasJ R. and Zanna.M. (1985) Are social-psychologicalsmoking prevention programs effective? The Waterloo study.Journal of Behavioral Medicine, 8, 37—59.

Gottlieb.N.H., Lloyd.L.E. and BoundsJ.N. (1987) The adoptionof health promotion programs by state agencies. Journal ofPublic Personnel Management, 16, 235-242.

Graham,S. (1983) Studies of behavior change to enhance publichealth. American Journal of Public Health, 63, 327-334.

Green,L.W. and McAlister,A. (1984) Intervention to support healthbehavior: some theoretical perspectives and practical reflections.Health Education Quarterly, 113, 323-339.

Green.L.W., Gottlieb.N.H. and Parcel.G.S. (1989) Diffusiontheory extended and applied. Advances in Health Education andPromotion, JAI Press, in press.

Hall.G.E. and Loucks,S.F. (1978) Innovation Configurations:Analyzing the Adaptations of Innovations. (Available from TheResearch and Development Center for Teacher Education, TheUniversity of Texas, Austin.)

Hall,G.E., George.A.A. and Rutherford,W.L. (1977) MeasuringStages of Concern About the Innovation: A Manual for Use ofthe SoC Questionnaire. (Available from The Research andDevelopment Center for Teacher Education, The University ofTexas, Austin.)

Hansen.W.B., Johnson.C.A., Flay.B.R., GrahamJ.W. andSobeU. (1988) Affective and social influences approaches tothe prevention of multiple substance abuse among seventh gradestudents: results from project SMART. Preventive Medicine,17, 135-154.

Huberman,A.M. and Miles,M.B. (1984) Innovation Up Close.Viking Penguin, New York.

Iverson.D.C. and Kolbe,L.J. (1983) Evaluation of the nationaldisease prevention and health promotion strategy: establishinga role for the schools. Journal of School Health, 53, 294-302.

KoIbe.L.J. and Iverson.D.C. (1981) Implementing comprehensiveschool health education: educational innovation and socialchange. Health Education Quarterly, 8, 57-80.

KolbeX.J. and Iverson.D.C. (1984) Comprehensive school healtheducation program. In MatarazzoJ.D., Weiss.S.W., HerdJ.A.et al. (eds), Behavioral Health: A Handbook of HealthEnhancement and Disease Prevention. Wiley Interscience, NewYork.

Loucks.S.F., Newlove.B.W. and Hall.G.E. (1976) MeasuringLewis of Use of the Innovation: A Manual for Trainers,Interviewers, and Raters. (Available from The Research andDevelopment Center for Teacher Education, The University ofTexas, Austin.)

Louis,K.S. and Rosenblum.S. (1981) A Program and itsImplications for Dissemination and School Improvement Policy(Contract No. 400-78-0002). National Institute of Education,Washington, DC.

Lovato.C.Y., Allensworth.D.D. and Chan.F.A. (1989) SchoolHealth in America: An Assessment of Stale Policies to Protectand Improve the Health of Students, 5th edn. American SchoolHealth Association, Kent, OH, in press.

Luepker.R.V., Johnson.C.A., Murray,D.M. and Pechacek.T.F.(1983) Prevention of cigarette smoking: three-year follow-upof an education program for youth. Journal of BehavioralMedicine, 6, 53-62.

Mohr.L.B. (1982) Explaining Organizational Behavior. Jossey-Bass, San Francisco.

Morrish.l. (1976) Aspects of Educational Change. George Allenand Unwin, London.

Moss.N. (1983) An organization-environment framework forassessing program implementation. Program Planning andEvaluation, 6, 153-164.

National School Boards Association (1987) No Smoking: A BoardMember's Guide to Nonsmoking Policies for Schools. NationalSchool Board Association, Alexandria, VA.

Orlandi.M.A. (1986) The diffusion and adoption of worksite healthpromotion innovations: an analysis of barriers. PreventiveMedicine, 15, 522-536.

Ottoson.J.M. and Green,L.W. (1987) Reconciling concept andcontext: theory of implementation. In Ward.W. (ed.), Advancesin Health Education and Promotion, Vol. 2, JAI Press.

Perry.C.L., Murray,D.M. and Klepp,K.I. (1987) Predictors ofadolescent smoking and implications for prevention. Morbidityand Mortality Weekly Report. 36, 415-455.

Pincus,T. (1976) Incentives for innovation in the public schools.In Williams,W. and EJmore.R. (eds), Social ProgramImplementation. Academic Press, New York.

Roberts-Gray,C. (1985) Managing the implementation ofinnovations. Evaluation and Program Planning, 8, 261 —269.

Rogers,E.M. (1983) Diffusion of Innovations, 3rd edn. Free Press,New York.

Scheirer.M.A. (1981) Program Implementation, the OrganizationalContext. Sage Publications, Beverly Hills.

Scheirer.M.A. (1986) Program theory and implementation theory:implications for evaluators. In Bickman.L. (ed.), New Directionsin Program Evaluation, Volume on Program Theory andProgram Evaluation. Sage Publications, Beverly Hills.

US Department of Health, Education and Welfare (1979) HealthyPeople, the Surgeon General's Report on Health Promotion and

123



ownloaded from


G.S.Parcel et al.

Disease Prevention Background Papers 1979. Washington, DC. Health Objectives for the Nation: A Mid Course Review. PublicUS Department of Health and Human Services (1980) Promoting Health Service, USDHHS.

Health—Preventing Disease: Objectives for the Nation.Bethesda, MD.

US Department of Health and Human Services (1986) The 1990 Received on October 25, 1988: accepted on December 15, I98S

124



ownloaded from


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