Progress in Education: V. 17

PROGRESS IN EDUCATION, VOLUME 17

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PROGRESS IN EDUCATION EDITOR: R. NATA Progress in Education, Volume 16 2008. ISBN 978-1-60456-098-5 Progress in Education, Volume 15 2007. ISBN 978-1-60021-673-2 Progress in Education, Volume 14 2007. ISBN 978-1-60021-545-2 Progress in Education, Volume 13 2004. ISBN 1-59454-090-X Progress in Education, Volume 12 2003. ISBN 1-59033-781-6 Progress in Education, Volume 11 2003. ISBN 1-59033-690-9 Progress in Education, Volume 10 2003. ISBN 1-59033-579-1 Progress in Education, Volume 9 2003. ISBN 1-59033-539-2 Progress in Education, Volume 8 2002. ISBN 1-59033-439-6 Progress in Education, Volume 7 2002. ISBN 1-59033-429-9 Progress in Education, Volume 6 2002. ISBN 1-59033-321-7. Progress in Education, Volume 5 2002. ISBN 1-59033-251-2. Progress in Education, Volume 4 2001. ISBN 1-59033-089-7. Progress in Education, Volume 3 2001. ISBN 1-59033-016-1. Progress in Education, Volume 2 2001. ISBN 1-56072-934-1. Progress in Education, Volume 1 ISBN 1-56072-836-1.

PROGRESS IN EDUCATION, VOLUME 17

ROBERT V. NATA EDITOR

Nova Science Publishers, Inc. New York

Copyright © 2009 by Nova Science Publishers, Inc.

All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Available Upon Request

ISBN: 978-1-61470-624-3 (eBook)

Published by Nova Science Publishers, Inc.  New York

CONTENTS Preface Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Chapter 7

Chapter 8

vii Why Theory is Failing in the African American Community: The Battle to Reduce HIV/AIDS A. Celeste Farr

1

Against Science Education: The Aims of Science Education and Their Connection to School Science Curricula Peter Davson-Galle

31

Becoming Different: Perspective Transformation Through PostRegistration Baccalaureate Nursing Studies Melanie Birks, Ysanne Chapman and Karen Francis

61

Perspectives on Health Education Research – Vulnerable Populations Lisa M. Jamieson and Gloria C. Mejía

79

Health and School Attendance Among Immigrant Children in United States Cecilia Obeng

105

Accessing the General Physical Education Curriculum for Students with Sensory Deficits Roseanna Davidson, Effie Laman and Michael Shaughnessy

115

Conformance Evaluation of Standards for the Professional Practice of Internal Auditing: An Assessment of an Instrument’s Validity and Reliability Mohd Ariff Bin Kasim, Siti Rosmaini Bt Mohd Hanafi, Asmah Abdul Aziz, Isahak Bin Kassim and Dawson R. Hancock

187

At-Risk Preschoolers Become Beginning Readers With Neurologically Integrated Alphabet Instruction Donita Massengill Shaw and Mary Lou Sundberg

213

vi Chapter 9

Chapter 10 Index

Contents Learning From Differences. The Masters Study-Course in Education Management at Ludwigsburg Pedagogical University Ulrich Müller Teachers, Learners And Curriculum John Chi-Kin Lee, Michael Williams and Leslie Nai-Kwai Lo

227 239 255

PREFACE This series presents substantial results from around the globe in selected areas of educational research. The field of education is consistently on the top of priority lists of every country in the world, yet few educators are aware of the progress elsewhere. Many techniques, programs and methods are directly applicable across borders. This series attempts to shed light on successes wherever they may occur in the hope that many wheels need not be reinvented again and again. Chapter 1 - This article is a review of the theoretically based and ethnocentrically relevant behavior change interventions presented to the African American community. This summary demonstrates that scholars have used theory to increase knowledge, intentions to change behavior, and other variables, but have not been successful in attempts to increase safer sexual practices such as abstinence or condom usage. The messages presented to the community which encourage condom use in hopes of preventing HIV/AIDS, are not sufficient to inspire behavior change. A brief discussion about the history of the African American community with medical practitioners provides support for the idea that doctors are not always effective spokespersons for this population. Given some of the current discussions which are flourishing within the African American community, it is suggested that future interventions must deal with community myths or exaggerations such as the epidemic of men on the "down low." Also, exemplars such as Magic Johnson are acknowledge as the work considers the idea that members of the African American community may not fear HIV/AIDS. This suggestion leads to the later recommendation that more information should be presented to the community relating to the threat and effect of living with HIV/AIDS. The overall argument of this chapter leads to the conclusion that the question of safe sex within the African American community is a complicated one, for which a more compelling solution is required. The call to action from this chapter encourages scholars to spend more time exploring the attitudes, beliefs, and feelings of the African American community so that messages can be created which will inspire behavior change and ultimately reduce the number of new cases of HIV/AIDS within this population. Chapter 2 - To clarify: in this chapter I will speak only of compulsory science education in schools; much of what I say will not transfer across to either science electives in schools or to undergraduate science. Such science education, like all compulsory education, is an exercise in force against students. Overriding individual autonomy in this way is not to be lightly done and should involve appeal to aims that are of sufficient importance for the individual, or the

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group/society, to outweigh such loss of freedom over one's own mind's contents. Moreover, the loss of freedom is guaranteed; in order to outweigh it, the benefits aimed at should not just be of sufficient moral importance but be attainable with sufficient probability for a suffient proportion of students. Finally, to justify the imposition of science education requires not just the probable achievement of ends that are of sufficient importance to outweigh the loss of freedom that is their cost but the absence of better candidates that might occupy the same "time-slot" of lost freedom. All very vague, admittedly, and it is the burden of this chapter to examine this issue in further detail as an exercise in sustained argumentation. My contention will be that such argumentation in justification of compulsory science education cannot be satisfactorily advanced at the moment and, in any event, does not seem to have been yet advanced in the extant literature. Accordingly, as compulsory school science education is without a satisfactory available warrant, it should be excised pending the provision of one. Chapter 3 - Education has the potential to transform. For nurses employed in complex, constantly changing health care environments, continuing education is essential. Postregistration baccalaureate courses are an important means by which certificate and diploma qualified nurses can upgrade their existing qualifications to degree level. Often nurses who wish to pursue tertiary education are constrained by geography, work and personal commitments. The increasing number of courses offered by international universities provides a mechanism for accessing higher education that would otherwise be unobtainable for nurses. This paper reports on the experience of change that accompanied a postregistration degree course undertaken in off-campus mode by nurses in Malaysian Borneo. As part of a larger study employing grounded theory methodology, these findings are discussed in the context of the development of professional identity through perspective transformation. Chapter 4 - Health education research is a predominantly Western construct. Problems frequently arise in regards to idea communication and project ownership when investigations are implemented among vulnerable populations, particularly when researchers are from nonvulnerable backgrounds. Participatory Action Research (PAR) is a relevant methodology in health education research involving vulnerable populations because of its fundamental tenets that power be equally shared between the researchers and the researched, that data and information not be removed from their contexts, and that the data collection process be directly influenced by history, culture and local environment. Contemporary health behaviour models, such as the PRECEDE-PROCEED planning model and the Diffusion of Innovation model, suggest that health education interventions among vulnerable populations have much to gain from embracing more holistic, PAR approaches, which in turn are more likely to result in a sustained reduction in harmful health behaviours among vulnerable populations. Chapter 5 - The study explores the interconnectedness between health, and school attendance among immigrant school-aged children by examining illnesses that their parents consider prevalent, ‘serious,’ or ‘ordinary’ and how such perceptions influence their decision to allow their children to miss or attend school. The data for the study were collected in Virginia and Indiana between 2005 and 2007 by the author and three research assistants. A total of one hundred and five families took part in the research, answering closed and open-ended questions about their two hundred and forty children.

Preface

ix

Results indicate that a majority of the immigrant parents surveyed in the study ensured that their children’s illness did not interrupt their school attendance. Most participants scheduled their children’s doctor’s appointments during non-school hours. Missing school was viewed as being a failure or inability on the part of a parent to properly socialize their child to enjoy hard-work. Some participants viewed missing school as not taking advantage of the opportunity they have in their new environment (USA). The study concludes that the immigrants’ cultures have considerable impact on their perceptions about health and school attendance. The study could form the basis for studying the link between health and schooling among different immigrant groups. Chapter 6 - Students in a regular physical education program typically learn skills through observation and practice. Teachers and specialists working with students who are sensory impaired with multiple disabilities face unique challenges. Because such students make up a small percentage of the population, physical education texts on adaptations, instructional strategies and activities for groups give only minimal information about working with them. Physical education teachers and activity leaders in the trenches are always on the lookout for appropriate, appealing games and activities for their students. It is apparent that even for students who are blind, multiply disabled or deafblind, no special curriculum and few, if any; specific activities exist only for them. Activities for these students are basically the same activities that have attracted students since time immemorial. These games are adaptations of familiar activities found in virtually every good physical education or motor-development curriculum. Even though the implementation of these activities results in specialized programs or special classes, the actual content and practice are easily accomplished, common-sense adaptations and accommodations that make the application of familiar activities appropriate for integrated and mainstreamed classes. These activities are educational and have both general goals and specific objectives. The authors are aware, however, that learning is accomplished most effectively in environments of enjoyment, pleasure and fun – we should all focus on the learner and learning (not the teacher and teaching). Chapter 7 - The internal audit profession has become more important after the collapse of various giant corporations. In fact, it is mandatory for public companies in Malaysia to have an internal audit function. The effectiveness of these internal audit functions is significant to ensure proper discharge of responsibilities by internal auditors. The best measure of internal audit effectiveness is through the level of conformance towards the Internal Audit Professional Practice Framework (PPF). The present study concludes that most of the existing instruments measuring internal audit effectiveness suffer major weaknesses that limit its value. The development process of the new instrument to quantitatively measure the effectiveness of internal audit functions was clearly highlighted. The PPF was utilized in the development of the new instrument. A new approach of measurement was used as a solution to existing instruments. The results indicated that the new instrument was highly reliable and conforms to the existing framework suggested by IIA. Chapter 8 - The purpose of this study was to determine the effectiveness of a neurologically integrated approach in teaching 22 at-risk preschoolers their letter sounds by comparing the results to preschoolers who received traditional ball-and-stick letter-naming. Three sequential phases to teaching the experimental method include imagery, auditory, and

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integration and sound blending. Students received pre-, mid- and post-tests for sound recall and word blending. Analysis of covariance and descriptive statistics measured growth. Results indicate that significant changes occurred in the experimental students’ knowledge of letter sounds and word blending compared to students who received the traditional approach. Reasons for their superior performance are mentioned. It is recommended to explicitly teach at-risk children their alphabet knowledge through a neurologically integrated approach that mirrors brain development. Chapter 9 - New challenges in the education sector require competent leadership of educational institutions as well as professional personnel management and development. Since the winter semester 03/04 the Pedagogical University of Ludwigsburg has been offering a further-training Masters course in education management which qualifies participants for managerial functions in the education sector. In the study-course attention is focused on the acquisition of holistic and general managerial competence through self-guided, interactive and process-oriented learning, closely adapted to individual professional requirements in daily practice and the occupational biography of the participants. A special feature of the project: Participants come from three distinct walks of educational life: school, adult and further education, and from business companies: "Learning from the differences". This paper reports on the background to the project and describes the curricular and methodological architecture of the study course. Chapter 10 - In a traditional, technical paradigm of school management, schools are often perceived as bureaucracies implementing carefully specified curriculum and instructional procedures to produce standardized products known as students. This paradigm is compatible with a behavioristic view of learning in which both curriculum and instruction are broken down into small, sequential steps dictated by teachers (Darling-Hammond, 1998). Educational reform in the new century calls for a different approach to school improvement in which teachers are encouraged to employ a wide repertoire of teaching strategies in order to enable students to construct their own knowledge. Using this approach, teachers seek to change teacher-proof curricula into bridges between, on the one hand, learners’ diverse conceptions, interests, motivations, learning modes and experiences, and, on the other, their goal of teaching for understanding. Some scholars, including Darling-Hammond (1998), argue that more attention needs to be given to "the development of schools as inquiring, collaborative organizations…to strengthen teacher education and certification processes, to create knowledge-building institutions such as professional development schools, to decentralize school decision-making, to support collegial teacher development, to redesign local assessment practices, and to create learning networks among teachers and schools" (p.646).

In: Progress in Education, Volume 17 Editor: Robert V. Nata

ISBN 978-1-60692-505-8 © 2009 Nova Science Publishers, Inc.

Chapter 1

WHY THEORY IS FAILING IN THE AFRICAN AMERICAN COMMUNITY: THE BATTLE TO REDUCE HIV/AIDS A. Celeste Farr North Carolina State University, Raleigh, North Carolina 27695, USA

ABSTRACT This article is a review of the theoretically based and ethnocentrically relevant behavior change interventions presented to the African American community. This summary demonstrates that scholars have used theory to increase knowledge, intentions to change behavior, and other variables, but have not been successful in attempts to increase safer sexual practices such as abstinence or condom usage. The messages presented to the community which encourage condom use in hopes of preventing HIV/AIDS, are not sufficient to inspire behavior change. A brief discussion about the history of the African American community with medical practitioners provides support for the idea that doctors are not always effective spokespersons for this population. Given some of the current discussions which are flourishing within the African American community, it is suggested that future interventions must deal with community myths or exaggerations such as the epidemic of men on the "down low." Also, exemplars such as Magic Johnson are acknowledge as the work considers the idea that members of the African American community may not fear HIV/AIDS. This suggestion leads to the later recommendation that more information should be presented to the community relating to the threat and effect of living with HIV/AIDS. The overall argument of this chapter leads to the conclusion that the question of safe sex within the African American community is a complicated one, for which a more compelling solution is required. The call to action from this chapter encourages scholars to spend more time exploring the attitudes, beliefs, and feelings of the African American community so that messages can be created which will inspire behavior change and ultimately reduce the number of new cases of HIV/AIDS within this population.

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For anyone who is interested in the portrait of HIV/AIDS within the United States, statistics present an alarming story of infection. The subpopulation which has sustained the highest levels of infection is the African American community. “According to the 2000 census, African Americans make up approximately 13% of the US population. However, in 2005, African Americans accounted for 18,510 (49%) of the estimated 38,096 new HIV/AIDS diagnoses in the United States in the 33 states with long-term, confidential namebased HIV reporting” (CDC, 2006a). African Americans also accounted for “22,030 (50%) of the estimated 44,198 AIDS cases diagnosed in the 50 states and the District of Columbia” (CDC, 2006a). While monitoring the spread of the virus over time, scholars have noted that in the years 1999 through 2002, “the south accounted for the largest proportion of AIDS diagnoses among Black women in the 50 [states] and DC, with an estimated 54.5% compared with 32.1% (8,870 [women]) in the northeast, 8.9% (2,420 [women]) in the midwest and 4.6% (1,261 [women]) in the west” (Whitmore, Satcher, & Hu, 2005, p. 22s). Although the focus of this work is on the adult population, it is also terrifying to note that “of the estimated 18,849 people under the age of 25 whose diagnosis of HIV/AIDS was made during 2001–2004 in the 33 states with HIV reporting, 11,554 (61%) were African American”(CDC, 2006b). Considering the horrible nature of these statistics, it is not difficult to understand why reducing HIV/AIDS within the African American community is of such urgent importance. HIV can be transmitted through various methods, although men and women tend to receive the virus in different ways. African American men tend to contract the virus primarily through sexual contact with other men, followed by injection drug use and high-risk heterosexual contact (CDC, 2006). For African American women, the primary method of contraction is overwhelmingly through high-risk heterosexual contact, followed with considerably fewer numbers of women infected by injection drug use (CDC, 2006). Another factor which increases the spread within the African American community is the high rates of STDs within the subpopulation. Physicians have found that due to physical changes caused by STDs, such as genital lesions that can serve as an extra point for bodily fluids to be exchanged, chance of contracting HIV can be increased by as much as 3 to 5 times (Fleming, & Wasserheit, 1999). Gonorrhea and Syphilis have often been listed among the STDs that ultimately increase risk (Fleming, & Wasserheit, 1999). Sadly, “the highest rates of sexually transmitted diseases (STDs) are those for African Americans. In 2005, African Americans were about 18 times as likely as Whites to have Gonorrhea and about 5 times as likely to have Syphilis” (CDC, 2006c). Various scholars understand the vast importance of reducing the new cases of HIV within the African American community. With a sincere desire to effect change, scholars have applied various theoretical interventions to the community. Unfortunately, to this point, most the theoretical attempts to effect change have failed. It is the purpose of this work to explore the theories that have been used, and then reflect on the nature of the African American community with an eye toward understanding the reasons that theory has failed in the past. Ultimately, with further consideration of this reflection, scholars can use all of the theoretical tools at our disposal to correct a society effecting problem.

Why Theory is Failing in the African American Community

3

USE OF THEORY Various scholars have attempted to understand and explain the risky sexual behaviors, injection drug use (IDU) behaviors, and correlated behaviors which facilitate HIV/AIDS transmission. Others strive to design interventions to prevent the spread of HIV/AIDS throughout the at-risk African American population. Doctors and Nurses seek to explain the phenomenon from a practitioner perspective. Health Communication and Public Health Scholars seek to prevent risky behaviors by applying theory to their selected context. Psychologist and Social Workers strive to understand the cognitive, sociological, and societal functions driving risky behaviors. All of these attempts to understand, explain, predict, and control risky behaviors within the African American community have created a rich literature, although one that has had little demonstrative success in slowing the HIV/AIDS epidemic within the African American community. Various theories have been applied during the development of interventions for the African American community. Among the theories used are the Health Belief Model (HBM) (Brown, & Van Hook, 2006; Oliva, Reinks, Udoh, & Smith, 2005; Neff & Crawford, 1998; Williams, Ekundayo, Udezulu & Omishakin, 2003; Winfield, & Whaley, 2002), Sexual Health Model (Robinson, et al., 2002), Transtheoretical Stages of Change Model (TTM) (Collins, Kohler, DiClemente, & Wang, 1999; Oliva, et al., 2005; Williams, et al., 2003), Social Cognitive Theory (SCT) (Collins, et al., 1999; Koniak-Griffin, et al., 2003; Oliva, et al., 2005; Williams, et al., 2003; Wingood, & DiClemente, 2006), Information-MotivationBehavior Skills Model (Oliva, et al., 2005), Structural Ecosystems Therapy (SET) (Prando, Szapocznik, Mitrani, Mauer, Smith, & Feaster, 2002), Person Centered Approach (Prando, et al., 2002), AIDS Risk Reduction Model (ARRM) (El-Bassel, et al., 2001; Winningham, Corwin, Moore, Sargent, & Gore-Felton, 2004), Theory of Reasoned Action (TRA) (KoniakGriffin, et al., 2003), Protection Motivation Theory (Oliva, et al., 2005), General Ethnographic and Nursing Evaluation Studies in the State (Genesis) Assessment model (Brown & Hill, 2005), Sisters Informing Sisters About Topics on AIDS (SISTA)(Prather, et al., 2006; Wingood, & DiClemente, 2006), Women Involved in Life Learning From Other Women (WILLOW) (Wingood, & DiClemente, 2006; Wingood, et. al, 2004), Sistering, Informing, Healing, Living and Empowering (SiHLE) (Wingood, & DiClemente, 2006; Wingood, et. al, 2004), African Centered Behavior Change Model (ACBCM)(Gilbert, & Goddard, 2007), Leininger’s Culture Care Diversity and Universality Theory (Plowden, Fletcher, & Miller, 2005), and Women’s Empowerment Theory (Wechsberg, Lam, Zule & Bobashev, 2004). Despite use of theory, most interventions have not successfully changed or reduced risky practices within the African American population. The HBM is one of the most used behavior change theories (Janz, Champion, & Strecher, 2002). The main components of the HBM are perceived susceptibility, perceived severity, perceived benefits, and perceived barriers (Janz, et al., 2002). The theory suggests that an individual will engage in preventative behaviors, cease risky behaviors, or otherwise involve themselves in behavior change if they feel that they are susceptible to an illness, in this case HIV/AIDS, that the disease would have severe consequences, effect their life, health or well being, and if the benefits of engaging in behavior change would, in their perception, outweigh the barriers to change that they anticipate experiencing.

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Despite the overall success of the theory when applied to other groups, while applying the HBM to the African American community, scholars have found the model to be ineffective (Brown & Van Hook, 2006; Neff & Crawford, 1998; Oliva, et al., 2005; Winfield & Whaley, 2002). Perhaps one of the reasons that the theory fails within the African American community is the inability to convince community members of their susceptibility. There are also problems reducing perceived barriers to condom use. Scholars have observed that “the effects of barriers and susceptibility appear more salient among Anglos and Mexican-Americans than among African-Americans" (Neff & Crawford, 1998, p.292). Another study found that "there was no clear pattern between perceptions of risk regarding HIV and condom use or between perceptions of risk and general sexual behavior despite 33% to 50% of respondents engaging in sexual behavior that increased their risk of acquiring HIV"(Brown & Van Hook, 2006, p. 48). The disturbing lack of relationship between perceived risk, knowledge, or perceived susceptibility and sexual practices is not a unique finding within the literature (Neff & Crawford, 1998; Winfield & Whaley, 2002). Winfield and Whaley (2002) when studying college students using the HBM, found that "our current conceptualization and approaches obviously have not been effective in reducing the frequency of unprotected sexual intercourse. Students are engaging in risky sexual behavior regardless of high levels of knowledge about the potential risks” (p. 342). It seems clear that the relationship between perceived risk and behavior change, as expressed by the HBM, does not function as predicted within the African American population. In frustration, some scholars have even gone as far as to express that “social cognitive models are limited in their ability to explain HIV/AIDS preventative behavior” (Winfield & Whaley, 2002, p.342). The idea that knowledge is unrelated to prevention behaviors is not a finding that is exclusive to the HBM. Scholars using the SCT and TTM have expressed similar thoughts (Williams et al., 2003). Social Cognitive Theory predicts that individuals symbolize behavior, learn by observing others, develop a degree of confidence in performing the behavior, anticipate the outcomes of that behavior, which then leads to the determination to behave or to regulate behavior, and once performance of the behavior has occurred, they reflect upon the entire experience to make determinations about future behaviors (Baranowski, Perry & Parcel, 2002). As related to HIV/AIDS, most scholars have used the SCT to predict condom use. According to the theory, individuals would gain knowledge about the manner in which condom use can reduce their opportunity to contract HIV. From this knowledge base, the individual will learn how to use condoms, at times through training, previous experiences, or watching their sexual partners apply the device. The individual will then gain a degree of confidence with applying condoms, which again may be facilitated through training. The individual would affirm that condoms are easy to use, as well as easy to obtain and decide that the use of condoms will reduce their risk of disease. Next, they would determine that they intend to use condoms in future sexual experiences. After the occurrence of a sexual experience which involved a condom, the individual should reflect upon the entire experience and make a determination about their future condom use. If all has proceeded smoothly, the individual should at least intend to use condoms in the future. Although the SCT is a clear predictive model, when applied it has often been paired with the TTM. The Transtheoretical Stages of Change Model predicts that change involves a process of progressing through six stages (Prochaska, et al., 2002). In the precontemplation stage, the

Why Theory is Failing in the African American Community

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individual would not intend to take action or change their behavior within the upcoming six month period. In the contemplation stage, the individual intends to take action or alter their behavior at some point within the upcoming six month period. During the preparation phase, the individual not only intends to take action within the next thirty days, they have also taken some behavioral steps in the direction of their intended behavior change. The action phase begins with the onset of behavior change and is characterized by continued behavior change for a period of less than six months. The maintenance stage is the stabilization of the new behavior, and marked by the individual continuing their behavior change for more than six months. The termination stage is the point at which the “new” behavior becomes more fixed behavior. The individual is not as easily tempted back to their previous behaviors, but now considers their “new” behavior as their natural behavior (Prochaska, et al., 2002). When using this model in an HIV context, most scholars are encouraging their target population to wear condoms or to replace risky sexual behaviors with safer sexual behaviors. Despite the fairly straightforward predictions of both the SCT and the TTM, when applied to the African American community, once again we find that theory fails. While using the SCT and TTM with a sample of African American women, scholars found that "women's respective knowledge did not translate into positive health attitudes or behaviors, although the urban women in this study indicated significantly higher level of knowledge about HIV/AIDS and related high/risk behavioral factors than their rural counterparts" (Williams, et. al., 2003, p. 120). Another study which also used a combination of the SCT and TTM continued to support the disconnect between knowledge and behavior (Collins, et al., 1999). Collins and colleagues (1999) determined that most of their African American respondents, when considering the use of condoms with their “main sex partner,” were in the precontemplation stage. For “other partners” or sex partners with whom they were not in a committed relationship, the respondents were in the maintenance stage. In essence, it seems that African Americans are not willing to use condoms with their main partner, but may reluctantly use them with their “other” partners (Collins, et al., 1999; McCoy, et al., 1989). Despite using the SCT and TTM through three rounds of data collections, Collins and colleagues (1999) were unable to demonstrate an HIV prevention effect within their African American drug using sample. Given the SCT’s success with other populations, some have used the theory in combination with another successful theory, the TRA. The TRA suggests that the best predictor of an individual’s behavior is their behavioral intentions (Montano & Kasprzyk, 2002). Behavioral intentions are formed by an individual’s attitude toward a behavior and their subjective norms regarding the behavior. Attitudes toward a behavior are created by an individual’s beliefs about the behavior and their evaluation of the outcomes of engaging in the behavior. Subjective norms are developed through consideration of normative beliefs and the individual’s motivation to comply. The TRA is another extremely successful theory in other contexts, yet despite being paired with the SCT, the theories were not able to product behavior change within the African American community (Koniak-Griffin, et al., 2003 ). Koniak-Giffin and colleagues (2003) were able to find a glimmer of hope when they observed that “participants in the HIV prevention group had a significantly greater increase in behavioral intentions to use condoms at 12 months compared to those receiving the health promotion condition but the effect was small to moderate” (p. 103). Unfortunately, the findings went on to explain that “immediately after the interventions, the participants scored higher on self-efficacy and knowledge than those in the control group, but the groups did not

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differ on prevention beliefs, partner reaction beliefs, subjective norms, or behavioral control” (Koniak-Griffin, et al., 2003, p.103). Probably the most significant finding of the study, as noted by the researchers was “although sexual risk-taking behaviors significantly decreased in the intervention group, many participants, continued to have sex without the use of condoms despite their increased knowledge and behavioral intentions to use condoms" (Koniak-Griffin, et al., 2003, p.104). Overall, the study was able to demonstrate improvement in AIDS knowledge and stated intentions to use condoms at the six month point, but at the twelve month point, the effects of the intervention were no longer significant; the control group and the intervention group were both practicing risky sexual behaviors (Koniak-Griffin, et al., 2003). Some scholarship has been atheorietical in approach, but yet the findings continue to support the conclusion that knowledge is not related to behavior within the African American community. Several studies have reported high rates of HIV related knowledge, yet all have be unable to link knowledge with safer sex behavior (Bachanas, et. al., 2002; DiIorio, Van Marter & Dudley, 2002; Liverpool, McGhee, Lollis, Beckford, & Levine, 2002; Whyte, Standing, & Madigan, 2004). Scholars have even suggested that the literature places too much emphasis on providing information without attempting to understand how the information fits within the individual’s knowledge and beliefs (Donavan, & Ward; 2001; Whyte, et al., 2004). While reporting on African American Sexually Transmitted Disease (STD) patients, one study found that “2/3 (65%) perceived themselves as having no or low risk of HIV infection; this did not vary according to gender or age. Perceived risk was associated with HIV knowledge; however, HIV knowledge was not associated with testing" (Ford, Daniel, & Miller, 2006, p. 843). When summarizing the HIV/AIDS epidemic among African Americans, and expressing the lessons that can be learned from African interventions, scholars stated that "even when they [African Americans] have a high level of knowledge about HIV/AIDS, many still engage in casual and unprotected sex, often with multiple partners" (Okigbo, Okigbo, Hall, & Ziegler, 2002, p. 648). Even among African American college students, the findings were staggering in that "perceived risk was relatively low, with 84% reporting a low risk of acquiring HIV. However 64% of participants reported having unprotected vaginal sex and 16% reported having unprotected anal sex in the past 90 days” (Payne, et al., 2006, p.1914). Even when using a sexological approach to HIV prevention, or a strategy which combines STD prevention strategies with sex education, called the Women's Initiative for sexual health (WISH) scholars reported that “with respect to sexual risk behaviors, condom attitudes, and safer sex self-efficacy, no significant differences were found between the intervention and control groups at either follow-up period. At 3 months, there were trends in the predicted direction with regard to improved attitudes toward condoms and improved sexual communication with one's support system, but these effects dissipated by 9 months” (Robinson, et al., 2002, p. 87). All in all, many models would imply that increases in knowledge will lead to increases in safer sex behaviors, but repeatedly scholars are not able to support this expectation within the African American community. As demonstrated by examining a few of the theoretical and a-theoretical models applied to the African American community, theories are not failing due to inadequate models, poor application, small sample sizes, or other signs of researcher error. The theories are failing due to the cultural norms, and expectancies of this community, some of which are born out of this community’s unique history within the United States of America. A summary of research findings regarding distrust of the government, conspiracy theories, sources of healthcare

Why Theory is Failing in the African American Community

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treatment, reasons for delayed health seeking and testing behaviors, and other barriers to condom use should begin to demonstrate the differences between African Americans and other ethnic/cultural groups.

DISTRUST OF THE GOVERNMENT One cultural consideration which is true of African Americans, although less so of other groups, is a deep seated distrust of the government, and by extension, government sponsored programs. The mistrust of government by African Americans has been labeled as "cultural mistrust" by scholars (Moseley, Freed, Bullard, & Goold, 2007). Cultural mistrust affects the African American community in many less than positive ways. The effect has been documented as causing a reduction in African American’s willingness to enroll in clinical trials and it also reduces the likelihood that patients will be able to receive the most effective medications for the treatment of AIDS (Moseley, et al., 2007). Cultural mistrust also encourages African Americans to receive government health messages with skepticism, denial, or other manifestations of distrust. As an example, in one study of incarcerated African Americans, scholars demonstrated high levels of cultural mistrust when they reported that “more than 2/3(69%) of African American offenders mistrusted government information about HIV/AIDS, agreeing with the statement: ‘You can’t believe information told to you by the government about HIV/AIDS’” (Belenko, Sheldin & Chapele, 2005, p.117). Unfortunately, it is not difficult to determine reasons for the high levels of cultural mistrust among African Americans. Racial discrimination and exploitation of African Americans, both past and present, serve to highlight the differences in treatment between White patients and Black patients, while increasing concerns about all government programs (Corbie-Smith, Thomas, & St. George, 2002). One of the most cited examples of the discrimination and exploitation of African Americans is the Public Health Service Study at Tuskegee. The Tuskegee Experiment has come to symbolize ethical misconduct in clinical research (Bogart & Thorburn, 2006; Corbie-Smith, et al., 2002; Fitzpatrick, Sutton, & Greenberg, 2006; Moseley, et al., 2007; Prendergast, et al., 2001), but to the shame of Americans, discrimination and exploitation extend beyond this single study and includes incidences such as the practice of segregating African Americans into separate (and often unequal) hospitals, efforts to control the fertility of African American women, and repeated experiences of interpersonal discrimination in healthcare (Bogart & Thorburn, 2006). Negative experiences experienced by African Americans have been so prevalent and well documented that several authors have suggested that “African Americans who have experienced discrimination or who are aware of historical discrimination in healthcare may be suspicious of public health prevention messages and of information supplied by health professionals” (Bogart & Thorburn, 2006, p. 1144). Some of this distrust of health professionals is driven directly by an association with government services, programs or funding, while other aspects of the phenomena of distrust for health professionals is driven by other concerns which will shortly be discussed in greater depth. As one attempts to understand sources of cultural mistrust, one also must also consider the American government’s history of being slow to meet the needs of African Americans. Given that most clinical trails do not include African Americans, and to many, it seems as if

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clinical testing is only embarked upon when a disease directly affects the Caucasian population, mistrust about the purpose and relevance of clinical trials as well as government messages about health and wellness are all received with skepticism. Since many messages about HIV/AIDS have been developed by and sent from government organizations, some African Americans use their distrust of the government to deny that HIV/AIDS truly exists (Belenko, et al., 2005). Others, rather than engaging in outright denial, retain a healthy sense of skepticism, one which often leads to inaction. Following from a history consisting of intense distrust of the government, health related conspiracy theories have developed within the African American community.

CONSPIRACY THEORIES Scholars have repeatedly found that a significant percentage of African Americans hold conspiracy beliefs (Belenko, et al., 2005; Bird & Bogart, 2005; Herek & Glunt, 1991; Parsons, et al., 1998; Turner, 1993) and that such beliefs are more prevalent among Blacks than among Whites (Crocker, Luhtanen, Broadnax & Blaine, 1999). Some scholars have suggested that "ignorance perpetuates the development of myths, or traditional stories originating in a preliterate society. Myths appeal to the conscience of a people by expressing their cultural ideals or giving expression to their deeply felt emotions. Myths are stories that transform the unknown to the known without the presence of facts" (Davis, Brown, Allen, Davis, & Waldron, 1995, p.791). Ignoring the disparaging suggestion that myths are tools of the ignorant, it is clear that myths and conspiracy theories have definitely developed and flourished within the African American community (Bogart, & Thorburn, 2006; Crocker, et al., 1999). One could argue that myths and conspiracy theories are not necessarily generated out of an absence of facts or information. Sometimes, these beliefs develop because of previous experiences, or shared information about other’s experiences. As we consider the myths that abound within this population, perhaps a better way to think about these myths and conspiracy theories is to acknowledge that they are largely anecdotal, and primarily transmitted orally (Knopf, 1975). Conspiracy theories also effect health care, health seeking and the interpretation of health messages. More importantly, “these theories take many shapes and vary widely in terms of their believability, with little known about their prevalence or what influences these beliefs" (Parsons, et al., 1998, p.202). Some scholars have suggested that conspiracy theories related to government involvement tend to have two levels, malicious intent, which implies that the government knowingly causes and exacerbates social problems in the African American community, and benign neglect, which implies that the government does not address specific social problems which can cause harm to the African American community (Parsons, et al., 1998; Turner, 1993). Examples of malicious intent conspiracy theories are as follows: belief in reports that HIV is a manmade virus (Belenko, et al., 2005), that Whites want to keep the numbers of Black people down (Bogart, & Thorburn, 2006), so that HIV/AIDS becomes a tool of the government or White America to eradicate various minority groups, particularly Blacks (Belenko, et al., 2005; Herek and Capitanio, 1994; Parsons, et al., 1998). The government's family planning policies are also suspect because they are truly intended to control the number of Black people (Bogart, & Thorburn, 2006). As an example of benign neglect, we

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see evidence of beliefs such as: the government is not telling the whole story about AIDS (Herek and Glunt, 1991), information about AIDS is being held back from the general public (Herek and Capitanio, 1994), or the idea that there is a cure for HIV/AIDS which is being withheld from the African American community (Essien, Meshack, & Ross, 2002). Conspiracy theories are often espoused by trusted sources and carried by various communication modes. African Americans often access these theories through their usual sources of health information which often includes television, interpersonal stories, publication in African American focused reading materials (i.e. newspapers, magazines), radio, and church (Brodie, Kjelison, Hicks &Allen, 2005; Stroman, 2005). In a study of the coverage of HIV/AIDS within the African American newspapers, scholars found several articles which “specifically made reference to the theory that AIDS was a man-made tool for genocide" (Pickle, Quinn, & Brown, 2002, p. 438). Even some of the leaders within the African American community have espoused moral and/or genocide theory arguments to deter Blacks from participating in needle exchange and other prevention programs (Burkett, 1995; Pickle, et al., 2002; Thomas and Quinn, 1993). Regardless of the mode of communication, or the nature of the source of the information, conspiracy theories are often supported by evidence, or perceived evidence. For example, as evidence to support the theory that the government is using AIDS to eradicate the Black community, African Americans “often point to the disease's rapid spread in their community and the history of government non-responsiveness to African American health issues" (Parsons, et al., 1998, p. 207). To support the idea that government driven family planning programs are tools to reduce or limit the size to the Black population, African Americans may state that “medical and public health institutions use poor and minority women as guinea pigs to try out new birth control methods” (Bogart, & Thorburn, 2006, p.1145), and cite examples such as the Tuskegee Airmen Experiment as an exemplar (Cargill, et al., 2004; Corbie-Smith, et al., 2002). There have even been incidences of support from “Nation of Islam doctors or speakers and linking [of] the genocide theory to issues like Kemron and funding equity" (Pickle, et al., 2002, p. 438). Although various scholars have acknowledged that conspiracy theories exist and that they affect health care and health seeking behaviors, there is an appalling dearth of material about the prevalence of conspiracy theories, the underlying sources of conspiracy theories, and the true impact of conspiracy beliefs on message processing (Bird & Bogart, 2005). Scholars have called for more research about conspiracy theories to help determine “the prevalence of conspiracy beliefs regarding HIV/AIDS” (Bird & Bogart, 2005, p.118). Scholars have also suggested that “further research is needed, also, in order to understand how conspiracy beliefs affect high-risk sexual behavior. In particular, prospective studies that examine the relationship between conspiracy beliefs and later sexual behavior are essential. Studies that identify the sources of conspiracy beliefs and examine their diffusion in African American communities could help inform efforts to prevent the emergence and spread of new conspiracy beliefs in the future” (Bird & Bogart, 2005, p. 119). Despite an incomplete understanding of the prevalence and origin of conspiracy theories, scholars have learned some valuable lessons about the role of conspiracy theories within the African American community. Some scholars have observed an association between conspiracy beliefs and less consistent condom use (Belenko, et al., 2005). Others have found that “strong Black identification has also been associated with greater belief in conspiracies about HIV, possibly because stronger identification may be related to a greater knowledge of

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Black culture and history with respect to racism in the US" (Bogart, & Thorburn, 2006, p. 1145). Scholars have also discovered that men are more likely to hold conspiracy beliefs than women (Bird & Bogart, 2005; Bogart, & Thorburn, 2006). Not only are men more likely to hold conspiracy beliefs than women, the two sexes use the conspiracy beliefs in different ways. One study of African American men found that “reports of more frequent perceived lifetime discrimination and less frequent perceived recent discrimination were associated with agreeing with the conspiracy belief”(Bird & Bogart, 2005, p. 111). Another study found that men who had strongly held HIV/AIDS conspiracy beliefs were less likely to use condoms consistently (Bogart, & Thorburn, 2006). The study continued by suggesting that men with strongly conspiracy beliefs about the safety of contraceptives were less likely to be using birth control of any form (Bogart, & Thorburn, 2006). As for women, scholars have found that “being culturally traditional was associated with the enduring conspiracy belief” (Bird & Bogart, 2005, p. 111). Another study suggested that “among women currently using birth control, those with stronger contraceptive safety conspiracy beliefs were less likely to be using methods that must be obtained from a healthcare provider, which are the most effective methods for preventing pregnancy” (Bogart, & Thorburn, 2006, p. 1145). So, it seems that one of the reasons that theory struggles while being applied to the African American community is that few theories account for the impact of conspiracy theories. Many theories which have been applied to the community are behavior change theories and attempt to influence condom wearing behaviors, but none of the theories previously discussed considers the potential effect of cultural mistrust or the role of conspiracy theories in moderating message processing. Perhaps as theories continue to be applied in hopes of changing behavior, the effects of conspiracy theories can be measured, and eventually controlled, resulting in more effective public health programs. Despite the potential impact of conspiracy theories, there remain several other reasons which help further explain the failure of theory within the African American community. An important consideration is the source of health care treatment for many African Americans.

SOURCES OF HEALTHCARE TREATMENT The source that one uses to receive heath care can greatly affect perceptions of the medical system, health outcomes, and adherence to medical advice. Scholars have noted that “African Americans receive less preventative health care than the total population" (Davis, et al., 1995, p.793). Unfortunately, not only does this population receive less preventative health care, many African Americans use some of the worst health care alternatives as their primary sources of care. “A major opportunity to prevent diseases and to promote health lies in patient-provider interaction” (Davis, et al., 1995, p.793). Unfortunately, it has been frequently noted that African Americans are less likely to use a more ideal setting, such as a doctor’s office, as their primary and usual source of care (Gaskin, Arbelaez, Brown, Petras, Wagner, & Cooper, 2007; Payne, et al., 2006). Instead, they are more likely to depend upon community health centers, emergency rooms, health clinics, and hospital outpatient departments (Gaskin, et al,

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2007; Payne, et al, 2006). Some scholars reported that even after “controlling for type of insurance coverage, family income, and geographic region, African Americans were still more likely than Whites to reply on hospital outpatient departments, clinics and Emergency Rooms for their usual source of care” (Gaskin, et al, 2007, p. 22). Although it may be possible that some of the disparities in health care can be traced to the disparities in location used to seek health services, there are several other concerns which could also be relevant to the consideration of health disparities. One such concern is the number of barriers to receiving health services and treatments; barriers which are faced at a greater level by African Americans than Whites (Brodie, et al., 1999; Jain, Schwarcz, Katz, Gulati, & McFarland, 2006). These barriers may increases the likelihood that African Americans will trust physicians than less than Whites who are not facing similar barriers (Moseley, et al., 2007). As is the usual case with a lack of trust, impaired levels of trust reduce the probability of receiving preventative care, decreases adherence to medical advice regarding treatment plans, decreases physician continuity, and decreases patient satisfaction with their medical care (Moseley, et al., 2007). “The patient is therefore hesitant to comply with recommended treatment and subsequently does not alter their behavior” (Davis, et al., 1995, p.793). Also, there have been numerous studies that document disparities in health outcomes and access to health care between White and minority populations (Brodie, et al., 1999; Bullough & Bullough, 1992; Collins & Hawkes, 1997; Keil, Sutherland, Knapp, Tyroler, & Pollitzer, 1992; Mayberry et al, 1995; Mayberry & Stodard-Wright, 1992; Sorlie, Rogot, Anderson, Johnson, & Backlund, 1992). African Americans often face health disparities which range from heightened risk for various medical conditions to worse health outcomes from subsequent diagnoses (Brodie, et al., 1999). As researchers seek to explain disparities in treatment, some have suggested that African Americans may use low quality and underfunded providers (Gaskin, et al, 2007). There is also some evidence that suggests that “physicians serving minority patients have smaller referral networks and experience more difficulty getting their patients access to specialty and hospital inpatient services” (Gaskin, et al, 2007, p. 29). It has been suggested that African Americans may not have the “option to choose a private physician's office as a usual source of care because they live in communities where fewer private physicians practice and therefore must rely on hospital-based ambulatory care” (Gaskin, et al, 2007, p. 29). Although all of these considerations are relevant, given that African Americans are likely to strongly believe their health depends upon themselves (Gaskin, et al, 2007), the need may be more urgent to determine which changeable attitudes or behaviors are likely to explain health seeking behavior rather than focusing on the societal issues which will be more difficult to effect in the immediate future. While trying to determine factors influence which health outlet is selected to meet health needs by African Americans, scholars have suggested that the factors with strongest predictive power are income, education level, and insurance status (Brodie, et al., 1999; Gaskin, et al, 2007; Jain, et al., 2006). Relevant to AIDS specifically, scholars have found that “African Americans were significantly more likely than Whites, Latinos, or Asian/Pacific Islanders to have public insurance, or to be uninsured at the time of their AIDS diagnosis, to be older in age (40 years or older) and be homeless, and less likely to be diagnosed with AIDS be an HIV expert” Jain, et al., 2006, p. 498). Another factor that is important when considering which health outlet to utilize is “health need” (Gaskin, et al, 2007). Despite the fact that health need has not been listed by many scholars, one may suggest that this is the

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factor of greatest import, as it is a frequent occurrence for African Americans to delay health seeking until well beyond initial determination of illness. Delays in health seeking frequently increase the severity of the condition. Also, individuals do not simply wait to see if the illness may leave, but some also seek advice from family, friends, prayer/church, or local healers. These forms of advice may in fact make the condition of concern worse than had the condition remained untreated. These delays, in whatever form they take, often lead the individual to the emergency room or urgent treatment facility due to the nature of the condition. “When the patient is finally seen by a physician (usually in an emergency room or urgent care setting) the quality of interaction with the provider is poor. Health promotion and disease prevention strategies are not reviewed with the patient during this visit, and the patient leaves without any measurable increase of health knowledge”(Davis, et al., 1995, p.793). Also, individuals are usually past the point of early detection, so health outcomes are often worse than they could have been if treatment had been sought at the onset of the illness. When one considers the nature of health care in an emergency room, urgent care, or free clinic, it may not be difficult to understand why African Americans may delay health seeking, and fear the experience. When a patient is in pain and forced to sit in a usually loud, crowded, busy, and impersonal waiting room, and upon finally reaching the point of care, they are addressed by harried, hurried, and again impersonal medical practioners, it does not make for a positive experience that one would desire to undertake on a regular basis. There is also the possible increased fear that health outcomes will be negative “every time one goes to the hospital” given the delays in health seeking which then lead to more severe health outcomes. As theories continue to be applied to the African American community, more attention should be paid to concerns about health care providers and health seeking tendencies. As scholars further understand the health seeking attitudes and behaviors or the community, it will be easier to find ways to apply theory to this population. Despite considering several issues which cause the application of theory to fail in the African American community, there are still other barriers which would need to be defeated. The barriers we will consider next are those which are relevant to condom use in the African American community.

OTHER BARRIERS TO CONDOM USE The final set of barriers which are unique to the African American community as a whole, relate to inaccurate prevention heuristics among intimate relational partners. There are four heuristics that have been identified by scholars. They are as follows: “known partners are safe partners,” “monogamous relationships are safe relationships,” “trusted partners are safe partners,” and “it's too late” (Thorburn, Harvey, & Ryan, 2005, p.336). Each of these will be discussed in greater detail. When considering the “known partners are safe partners” heuristic, there are several common and problematic themes to address. Scholars have found that African Americans hold beliefs such as: People who were healthy looking did not have HIV (Brown, & Hill, 2005; Essien, et al., 2002), committed relational partners do not to sleep around (Brown, & Hill, 2005), some men felt that they could determine if a woman was infected based upon her

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smell (Essien, et al., 2002), the number of partners that a person has is a predictor of their risk of HIV infection (Essien, et al., 2002) and the perception that HIV happened to “outsiders” and “others” (Essien, et al., 2002). The “known partner are safe partners” heuristic is similar to the belief that “monogamous relationships are safe relationships,” in that often at least one partner assumes that the couple is in a monogamous relationship, despite the fact that this has not be explicitly stated. Also, because the background of the sexual partner is presumed to be “known,” the partner is then considered free from infection, and therefore safe, which ultimately reduces condom use. The assumption that the “known” partner is safe also reduces HIV/AIDS testing due to the concern that " receiving an HIV test could affect their relationship with their partner” (Payne, et al., 2006, p.1914). The fear that HIV testing can affect the relationship with their partner is not only held by the “known” partner group, but it is shared by the “monogamous relationships” group. The belief that “monogamous relationships are safe relationships” brings another set of problems to the community. Scholars have found that couples which do not use condoms, are four times more likely to believe that asking the male to use a condom would imply that he was unfaithful (Cornelius, Okundaye, & Manning, 2000; Wingood, & DiClemente, 2006). Others have noted that African American women in exclusive relationships were more likely to be of higher education and income, while simultaneously being less likely to use condoms (Cornelius, et al., 2000; St. Lawrence, et al., 1998). Given that not all relationship are monogamous, even when one partner believes that it is, scholars have noted that consideration of relationships should move beyond the consideration of individual-level sexual behaviors and also consider how members fit within a sexual network pattern (Adimora, Schoenbach, & Doherty, 2006). Through the study of a sexual network, scholars can understand how disease spreads through a community, as well as create better plans to reduce the continued spread. Even if partners are in fact monogamous, usually at least one partner has had prior sexual experiences that would still make them a member of the larger sexual network pattern. When analyzing network patterns, some of the most important features to discuss are “the extent of concurrent partnerships, absolute and relative size of the core group (persons with larger numbers of sexual contacts), average level of risk engaged in by the core, and the extent of sexual interaction or "bridging" between members of the core group and the general population and between the core group and other high-risk subpopulations (Adimora, et al., 2006). Concurrent partnerships have been defined as “multiple simultaneous sexual relationships or sexual relationships that overlap in time” (Adimora, et al., 2006, p.S39). It is important to consider the nature of concurrent partnerships because the relationships allow HIV to spread more rapidly than sequential relationships and they increase the virus’ spread within the population due to its long period of infectiousness (Adimora, et al., 2006). Concurrency has also been found more among African Americans than among other groups, but the data that was reported pertains only to the responses of African American women (Adimora, et al., 2006). Although the concurrency reports that have been published reflect the views of women more than men, scholars in one study found that “more than 1/4 of women (and 42% of men) had multiple partnerships during the preceding year. These partnerships were often concurrent: 26% and 38% of respondents had concurrent partnerships during the preceding 1 and 5 years respectively” (Adimora, et al., 2006, p.S41), so this problem is definitely more than a phenomenon found within African American women. Other startling findings regarding concurrency within the community are: “networks appeared

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dense; most respondents believed that at least one of their last 3 partners had sex with others while in a sexual relationship with the respondent, and women were more likely to report this than men. Almost all respondents had unprotected sex with at least 1 of their last 3 partners on numerous occasions, and a substantial proportion had been diagnosed with a STD during their lifetime” (Adimora, et al., 2006, p.S41). Those members of the community who have had at least four sexual partners in the past year are called the core group (Adimora, et al., 2006). It is within the core that network analysis should begin. Scholars are aware, even when members of the core plead ignorance, that having multiple sex partners ultimately increases the risk of HIV transmission (Brown, & Hill, 2005). It is this increased risk that makes study of the core of special import. Understanding individuals in the core is of primary import because "individuals who either had high-risk characteristics themselves or had potentially high-risk sex partners were more likely to have concurrent partnerships" (Adimora, et al., 2006, p. S42). This finding is somewhat disturbing in that community members who are having sex with core members may believe themselves to be in a monogamous relationship, thus not fully protecting themselves from the spread of disease. Scholars have also noted that African Americans with only one partner in the past year are five times as likely as Whites to choose sexual partners from the core (Adimora, et al., 2006). Finally, we need to be concerned about the core because African Americans, more often than other ethnic/racial groups, tend to choose African Americans as partners which encourages disease to remain within the African American community. Despite the fact that core individuals are characterized by multiple sexual partners, study of the core group will not fully explain the spread of HIV throughout the community. In order for HIV to spread rapidly, particularly through a monogamous community, the core group must be linked to other population subgroups. The group that links the core to other groups is called the bridge population. Adimora and colleagues (2006) stated that “the extent of sexual bridging between these high-risk subpopulations and the general population and the size of this bridge group affect the potential rate of spread of STIs beyond the core and into the general population, as do disease prevalence and the types of mixing patterns within the bridged populations” (p. S39). Given that people are often linked sexually through bridges, it is important to use condoms both the “main” partner and with any other concurrent partners for the protection of all involved. The belief that “trusted partners are safe partners,” is one that is most directly related to condom use within the community. Scholars have found that African Americans hold beliefs such as: Nice-looking people are not likely to be HIV positive, a potential partner's HIV risk can be determined by alcohol consumption/behavior at social gatherings, a reduction in the number of sexual partners will protect against HIV, a potential partner's HIV risk status is determined by duration of acquaintance, a potential partner's HIV risk status can be determined by a self-reported history of injection drug use, a potential partner's HIV risk status can be determined from questions about past sexual activities (Essien, et al., 2002). Much like the issues raised by the “monogamous” group and the “known partner” group, the trusted partner group believes that they know and understand the current and previous sexual and/or injection drug use habits of their partners. This illusion of understanding reduces the ability to navigate conversations about condom use and diminishes the desire to engage in HIV/AIDS testing. Also, it could be possible that members of the community are prone to forget the long gestation period for HIV/AIDS, and therefore assume that once an individual

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has been tested and found negative, they are in fact free from disease, when in fact, that assumption may not be correct. This leads us to the final heuristic group, which is the group that believes that “it is too late” for them to engage in preventative behaviors. The belief that “it's too late” tends to affect members of the community who already have HIV/AIDS. As such, it is a topic that will not be explored in great detail within this work. Suffice it to say that, some members of the community experience a sense of fatalism that immobilizes them, and reduces condom use. Scholars have stated that “fatalism is believed to be associated with a complex psychological cycle characterized by perceptions of hopelessness, worthlessness, powerlessness, and social despair. Specifically, the development of fatalism is associated with poverty, lack of knowledge of disease process, fear of hospitals, and distrust of health care providers” (Okwumabua, Glover, Bolder, & Edwards, 2001, p. 482). When individual experience fatalism, they may choose not to be tested for HIV because they do not want to know their status. They may also choose not to seek health services due to the harm that behavior may cause on existing relationships. Ultimately, fatalism reduces the drive to protect oneself from HIV/AIDS, thus reducing the likelihood that one would use a condom.

INCORRECT BELIEFS Along with the inaccurate prevention heuristics that were just discussed, the community is also plagued by various incorrect beliefs about effective prevention, methods that are effective in determining the health status of a potential partner, and the “reality” of the disease. Theses incorrect beliefs work as barriers to protection, since the individual may believe that they are protecting themselves, or may not see the need to protect themselves due to the inaccurate information that they have accepted. Examples of these incorrect believes are: spermicidal jelly, foam, or cream lowers HIV risk (Belenko, et al., 2005), using a diaphragm or having sex with a man who has had a vasectomy were successful ways of avoiding HIV infection (Belenko, et al., 2005; Essien, et al., 2002; Hobfoll, Jackson, Lavin, Britton, & Shephard, 1994), taking a blood test one week after exposure to HIV will tell you that you are infected (Belenko, et al., 2005), you can get AIDS by being around an HIV infected person, HIV can be contacted through toilet seats, women are immune to the AIDS virus, someone has AIDS whenever he/she is HIV positive, HIV resulted from transplanting a monkey’s liver into a human, there is a cure for HIV whereas AIDS does not have a cure, AIDS is not widespread in my ethnic group because cases shown on TV are from to other ethnic groups, and “it can't happen to me” (Essien, et al., 2002). There also may be some confusion within African Americans as to the reality of the disease. In the early 1990’s there were two African Americans that were highlighted in the media as having HIV/AIDS, Arthur Ashe, and Magic Johnson. In a sample of 201 articles from newspapers which cater to an African American population, and are also published in major cities, scholars found 28 articles on celebrities and HIV/AIDS (Pickle, et al., 2002). Of those 28 articles, 46% featured Magic Johnson and 18% covered Arthur Ashe," (Pickle, et al., 2002, p. 433). Unfortunately, Arthur Ashe did have AIDS, and subsequently died of complications of the disease, whereas Magic Johnson stated that he had HIV and has since continued with a healthy appearing life. Although scholars have not tested the prevalence of

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the belief, there are some within the African American community who believe that Magic Johnson did not have HIV, that he had the disease and has since been cured, while still others do not believe that the disease exists at all and point to Magic Johnson as an exemplar. Any of the previously listed beliefs are dangerous, in that they reduce the community’s willingness to perceive HIV/AIDS as a threat, to be tested, or to use condoms as a preventative agent. To this point, this chapter has reflected upon the attitudes, beliefs, and limitations of the African American community as a whole, and suggested reasons why the application of theory may be failing within this group. There are also four subgroups within the community that sustain the greatest risk of contracting HIV/AIDS. These subgroups each have unique attitudes, beliefs, and at times, behaviors that require special handling. Through reflection on the special needs of these most “at risk” groups, more reasons will be exposed to explain the failure of theory within the African American community.

UNIQUE NEEDS OF AT-RISK GROUPS There are four groups within the adult African American community that have the greatest risk levels for contracting HIV. The groups which should be most concerned with HIV/AIDS are: Men who have sex with men (MSM), currently or previously incarcerated men, Injection Drug Users (IDU), and heterosexual women. Scholars have acknowledged that “we still have too few of social intervention studies to enable us to determine the relative effectiveness of behavioral and social interventions among studies in the different risk areas. Also, the dearth of evaluated social interventions makes it difficult for prevention programs to offer a strong combination of behavioral and social interventions” (Semaan, et al., 2002, p.S41). One study which performed a meta-analysis of research on African American high risk groups, which they labeled as MSM, injection drug users (IDU), heterosexuals, and youth/adolescent, found only 129 studies on these subpopulations (Darbes, Kennedy, Peersman, Zohrabyan & Rutherford, 2002), and later acknowledged that only “52 of the studies merited inclusion in the review because of their high methodological quality”(Beatty, Wheeler, & Gaither, 2004, p. 44). Despite the lack of strong research support, scholars have learned some valuable lessons that are relevant to each of these subgroups. Understanding that each subgroup has different needs and reasons for concern, they will each be discussed independently.

MEN WHO HAVE SEX WITH MEN (MSM) In the not so distant past, there was not much scholarship regarding African American Men who have Sex with Men (MSM). In 2004, one article that reviewed the literature on MSM found only one study that focused on the concerns of African American MSM (Beatty, et al., 2004). Since the frequently discussed book, “Men on the Down Low,” by J. L. King (2004), a wildfire of discussion has spread throughout the African American community. Scholarly work has exploded from one piece in 2004, to 59 articles and 4 conference abstracts in 2005 (Millett, Peterson, Wolitski, & Stall, 2006). Despite the explosion of work, the conversation is only in its earliest stages, as evidenced by the fact that “the majority of HIV

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prevention research targeting MSM populations has occurred in major cities in the northeast and the west and, as a result, we know very little about the attitudes, beliefs, and risks among MSM living in the southeast” (Fitzpatrick, Sutton, & Greenberg, 2006, p. 1908). The southeast does not represent the sum total of the holes in knowledge. Scholars do know that bisexuality, and uncut sex (sex without a condom), especially when high, does increase the risk of HIV transmission (Brown, & Hill, 2005). They are also very aware that there is a higher HIV prevalence and incidence rate for Black MSM than for White MSM despite comparable self-reported risk behaviors (Millett, et al., 2006). African American MSM also have high rates of undetected or late diagnosis of HIV infection (Millett, et al., 2006). In a CDC sponsored study of MSM in 5 cities found that “46% of the African American MSM were HIV-positive, compared with 21% of the White MSM” (CDC, 2005). The study also found that of the participating African American MSM who tested positive for HIV, 67% were unaware of their infection, which was substantially more than the 18% of the participating White MSM who tested positive for HIV(CDC, 2005). To explain the variance in HIV infection rates between African American MSM and White MSM, scholars conducted a study with a sample of over 1,000 MSM. Through this study scholars sought to explore and later diminish the effect of various stereotypes through an examination of common assumptions about MSM and African American MSM. Hypotheses which were not supported by evidence included “Black MSM are more likely than other MSM to engage in high-risk sexual behavior,” “Black MSM are less likely than other MSM to identify as gay or to disclose their sexual identity, which may lead to increased HIV risk behavior,” and “Black MSM are more likely than other MSM to abuse substances, especially injection drugs, that increase their risk for HIV infection”(Millett, et al., p.1008). The hypotheses which found support based upon the evidence included: “Black MSM are more likely than other MSM to contract STDs that facilitate the acquisition and transmission of HIV,” and “Black MSM are less likely than other MSM to be tested for HIV or to know their HIV status, and they may unknowingly expose their sexual partners to HIV” (Millett, et al., 2006, p. 1010). Thus, the importance of reaching Men who have Sex with Men and Men on the Down Low with effective prevention messages. African American MSM are a difficult group to reach due to issues of stigmatization, prejudice, and self-identification (Clarke-Tasker, Wutoh, & Mohammed, 2005). Not only is the MSM population difficult to reach, the population of Men on the Down Low (DL) is an extreme challenge to engage. Despite the fact that scholars found that African American MSM were “not less likely than other MSM to identify as gay or to disclose their sexual identity,” (Millett, et al., 2006, p.1008), DL men, by definition, do not express their homosexual sexual practices, choosing to only acknowledge themselves as heterosexual. DL men often have wives or girlfriends so that they can more easily camouflage their bisexual lifestyle. Since the DL and MSM populations can consist of different men, (i.e. those who have “come out” or are likely to come out at some point versus those who have no intention of identifying themselves as gay) the groups may need to be addressed separately. Addressing the concerns of the African American gay and bisexual community is a somewhat more straightforward task, in that these men have come out and openly acknowledge their sexual practices. Individuals who outwardly acknowledge that they are gay may indeed face issues of stigmatism, prejudice, and homophobia, but they also may be able to find support with friends and allies of the gay community. The support mechanisms that exist within the gay community help to give scholars the freedom to focus on prevention

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of disease rather than on defining sexual behaviors or promoting uncomfortable and undesired conversations. For DL men, it may be more difficult to find acceptance or support, when they refuse to affiliate with the gay community, and because their activities often bring harm to their partners who are unaware of their DL status. Scholars then need to spend time discussing how DL behaviors are harmful to all involved sexual partners, and scholars can get trapped in the ethical issues surrounded the “fairness” of hiding one’s sexual behaviors from concurrent sexual partners. If one can isolate and remove the covert nature of the activities of the DL men, it then becomes more difficult to separate their concerns from the concerns of MSM since both groups are ultimately concerned about the same stigmatizing outcomes. Given this blurring of concerns, some individuals have questioned attempts to separate these two groups, and encourage DL men “come out” and acknowledge, at least to their sexual partners, their homosexual behavior. This entire debate typifies a concern that has been long lived within the African American community, so called homophobia, or at least, a severe stigma against homosexual behaviors and persons. The social bias expressed within the African American community often causes African American gay, bisexual, or DL men to “deny their sexual orientation, continue to engage in risky behaviors, and avoid utilizing HIV prevention services” (Brooks, Etzel, Hinojos, Henry, & Perez, 2005, p. 739). In order to address both the African American gay community and the DL men, scholars have suggested that prevention efforts need to address the social biases “in order to create an environment in which HIV prevention programs will work”(Brooks, et al., 2005, p. 739). Since the fear of stigma or homophobia causes many men to remain silent, scholars have suggested that increased public contact and exposure with stigmatized groups may be an effective way to reducing negative perceptions of these groups (Brooks et al., 2005). They continued by stating that “HIV preventions programs should be implemented with consideration of the social and cultural norms surrounding issues of sexuality, sexual identity, gender role expectations, and masculinity that exist in the communities in which they are located” (Brooks, et al., 2005, p. 739). Finally, scholars have suggested that prevention researchers could combine HIV prevention with other issues, “such as integrating prevention with job training programs, housing programs, criminal justice program, and empowerment programs. New programs should consider a much broader approach to HIV prevention that goes beyond sexual and substance abuse risk behaviors and integrates the larger social, health, and mental health issues affecting members of the target population” (Brooks, et al., 2005, p. 740). Although it is true that HIV prevention programs should consider social and cultural norms of the community, another set of norms that cannot be excluded from focus are religious norms. Many organized religions such as Christianity and Islam, take a dim view on homosexual behaviors. African Americans have long been drawn to the church as a source of health, healing, information, and support. With the church as a backdrop and issues of homosexuality still being considered a “sin,” HIV prevention programs are going to have to find ways to program around the possible negative messages which people still receive from their religious institutions and encourage prevention, perhaps in the face of “sinful behavior.” This theme in HIV prevention programming has not come from scholars alone. When scholars asked African American MSM to make suggestions for additions that may make HIV prevention programs more successful, the “participants recommended in-service trainings of service providers on issues of culture, stigma, and sexuality as they relate to the

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provision of HIV prevention services” (Brooks, et al., 2005, p.741). Although the religious implications of behavior is not a focal point for scholars, it still must be a point that is acknowledged and addressed if prevention programs are going to be successful within this subpopulation.

CURRENTLY OR PREVIOUSLY INCARCERATED MEN There is an extreme dearth in studies about incarcerated men. Considering that African American men are imprisoned at alarming rates, with HIV infections rates also being high, it would seem that there is an urgent need to understand the concerns of this subpopulation. Several studies have found that men who are incarcerated are also at much greater risk for infection and are at risk for continued transmission into other populations (Clarke-Tasker, et al., 2005; Peterson, et al., 1996). For this reason, not only should scholars be extremely concerned about the needs of this group for their own, sake, but they should also be concerned about the effect of ex-convicts bringing disease “home” to their sexual partners. In one study, scholars found that “more than half of the women from this sample of the general population reported that at least one of their last 3 sex partners had been in jail or prison for more than 24 hours”(Adimora, et al., 2006, p. S41). Although many African American women are engaging in sexual relationships, one can presume that those relationships are often free from condom use, by the determination of the male partner. Scholars found that when asked African American ex-convicts about their intended condom use, they reported that “they intended to use condoms often or always in the next 6 months (68%), but 19% reported that they never intend to use condoms” (Belenko, et al., 2005, p.155). Behavioral intentions and behaviors tend to be tenuously correlated at best, but as previously demonstrated, within the African American community, the correlation seems to be smaller than in most other populations. The link between behavioral intentions and behavior is not attributable to a lack of knowledge. Incarcerated African American men have demonstrated high total knowledge scores when asked about the methods of transmission and protection for HIV. One study reports they were able to correctly respond to 84 percent of the questions asked (Belenko, et al., 2005). It could be somewhat explained by considering conspiracy beliefs, given that scholars have cited “previous findings of an association between conspiracy beliefs and less consistent condom use” (Belenko, et al., 2005, p.120). Conspiracy beliefs are more strongly held by the incarcerated population than the general population, perhaps due to the perception that society has failed them. In essence, there is still much to learn about the attitudes and beliefs of incarcerated men. This subpopulation is critical because of the ability they have to increase the spread of HIV/AIDS through the general population. One can only hope that researchers will devote more time and attention to this critical subgroup.

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INJECTION DRUG USE (IDU) Injection drug use is the second leading cause of HIV infection both for African American men and women (CDC, 2006a). African Americans who have the greatest risk of contracting HIV while engaged in high risk behaviors include those who consume alcohol, use drugs intravenously, and those who have mental, emotional and/or psychological disturbances (Somlai, Kelly, McAuliffe, Ksobiech, & Hackl, 2003). Injection drug users are at risk for HIV on at least two fronts. If they share needles, the contact of blood between users can spread the virus. Also, many injection drug users exchange sex for access to drugs, or have sex while high. Either case decreases the likelihood that they will have access, or use, condoms to protect themselves. Despite engaging in multiple risky behaviors, many injection drug users fail to understand their risk. One study found that, “among the 10 women who reported selling sex for drugs, 2 (20%) perceived that they had no chance of acquiring HIV, 6 (60%) perceived that they had a 25% chance and 1 (10%) perceived that she had at least 50% chance of acquiring HIV” (Brown, & Van Hook, 2006, p. 46). The importance of this study does not lie in the large or representative sample size, but rather in the beliefs that this study makes evident. All too frequently, particularly when high, drug users are unable to accurately assess their risk, take preventative measures, or control their behaviors. There have been several successful interventions which have reduced the risk of HIV among the drug using population (Jones, 2004; Needle, et all., 1998; Patten, et al, 2000; Semaan, et al., 2003; Wechsberg, et al., 2003). Despite the success of general interventions, most of these programs were not tailored to or focused on African American or other minority populations. Actually, some scholars have observed that “HIV/AIDS interventions had a larger impact in those studies in which the participants were predominately White than those in which they were predominantly made up of ethnic minorities” (Prendergast, et al., 2001, p. 402). This finding was somewhat explained by the suggestion that “the interventions offered in programs with predominantly minority samples tended to be less comprehensive in terms of the number of intervention techniques that were applied” (Prendergast, et al., 2001, p. 402). Although African Americans have not frequently been the intervention target group, scholars have learned from their success with other groups, and suggest that in order to break the self-destructive cycle of drug use “interventions must use theory and be delivered in culturally sensitive/appropriate ways. A holistic approach is needed with a multilevel effort from consumers, providers, researchers and policy makers. Interventions must be tailored to the targeted group and go beyond a single problem-behavior focus” (Jones, 2004, p.74). Beyond the use of theory, scholars have also noted that “education is so strongly predictive of better knowledge, safer behavior and reduced infection rates that it has been described as the “social vaccine” and “the single most effective preventative weapon against HIV/AIDS” (Hasnain, Levy, Mensah, & Sinacore, 2007, p. 87). The study continues by explaining that among African American injection drug users, there is an inverse association between educational attainment and HIV risk such that “those with an education level less than high school are more likely than their better-educated counterparts to engage in certain risk behaviors that lead to acquiring HIV. They also are more likely to test positive for the virus” (Hasnain, et al., 2007, p. 89). When explaining this observation, scholars stated that “perhaps formal education equips people, including IDUs with increased knowledge that translates into safer behavior, an enhanced ability to understand and act on the health

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information received, as well as access to health services and health education programs, such as those provided in schools and colleges” (Hasnain, et al., 2007, p. 90). Since education seems to be such an important component for injection drug users, and is also necessary for behavior change as predicted by several theories, some have suggested that “HIV education material should be incorporated in a variety of prevention programs such as in schools, self-esteem building, empowerment training, sports programs, and family centered programs” (Jones, 2004, p.74). The African American IDU population is a great risk for HIV infection, but yet, there needs to be much more scholarship that focuses on the needs of this specific subgroup. Scholars can approach this subgroup with hope, since indicators point toward interventions which have proven successful among other IDU populations, but scholars need to invest more time understanding and addressing the ways in which theory can be applied to the unique needs to this subgroup.

HETEROSEXUAL WOMEN Of the groups that sustain the most risk, the group with the greatest cause for concern is heterosexual women. The rate of HIV diagnoses for African American heterosexual women is 24 times the rate for White women (CDC, 2007). African American heterosexual women also face the multi-risk factor, in that the number one method of transmitting the virus is through high-risk heterosexual contact. The problem with ‘high risk’ sexual contact is the fact that most heterosexual sex can be construed as high risk since, unbeknownst to them, their partner may also IDU, MSM, or have the virus without being aware of his own status (CDC, 2007). The number two method of transmission to African American heterosexual women is via injection drug use (CDC, 2007). Women who are IDUs face all of the risks discussed in the previous section, but also add risk due to their sexual practices while high or practices that enable them to become high. In essence, heterosexual women have the most to be concerned about, where HIV is concerned, and yet, for various reasons, many feel as if control of the sexual environment is out of their reach. There are several factors which effect African American women’s decisions to use a condom, or not to use one, as is most often the case. Some of these factors include: fear of condoms busting, being concerned about being checked for HIV, wanting to be popular, older men taking advantage of younger or naive younger women, (Brown, & Hill, 2005), reluctance by men to use condoms, feeling unable to negotiate condom use with their partners, their own negative attitude towards condoms, feeling that spermicide causes irritation, feeling that condoms decrease sexual enjoyment (McKoy, & Peterson, 2006; Winningham, et al., 2004), feeling that asking their partners to use condoms means they do not trust them, or feeling that their partner would assume they do not trust them if they ask him to use a condom, feeling that asking their partner to use a condom implied that they [the women] were having sex with other people, and feeling that discussing condoms damages relationships (Brown, & Van Hook, 2006). Given the myriad of concerns held by women in relationship to condom use, it is of small surprise that more women do not report using condoms regularly. Scholars have found in one study that “nearly 1 and 4 women between 14-44 had at least seven lifetime sexual partners” (Cornelius, et al., 2000, p. 189). Despite the high level of sexual activity, scholars have also

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found that "only 1/3 of the respondents reported consistent condom use" (Cornelius, et al., 2000, p. 186), “only 35% of young African American women reported they always used condoms with a nonsteady partner and 24% always used condoms with their steady partner” (McKoy, & Peterson, 2006, p.1151). Among women who answered questions regarding whether they had used a condom in the last 6 months, “12 (43%) indicated that they had not done so, 4 (14%) reported using one less than half of the time, 4(14%) indicated using one more than half the time, and 7 (25%) indicated the used condoms all the time” (Brown, & Van Hook, 2006, p. 46). In essence, regardless the sexual behaviors practiced, African American women do not feel that they are at risk (Forna, et al., 2006), as noted by “eighty five percent [stating they] did not believe they were at risk of STD or HIV” (McKoy, & Peterson, 2006, p.1157), therefore are unwilling to wear condoms to protect themselves. Perhaps the reason that so many women choose not to wear condoms is the perception, or even reality that they are in a monogamous relationship. It seems a logical decision that women “use condoms less frequently with partners with whom they are in relationships than they do with casual partners” (Thorburn, Harvey, & Ryan, 2005, p.335). Yet, in an interesting twist of logic, women also state that it is unlikely that their partners were able to maintain a sexually monogamous relationship (McKoy, & Peterson, 2006). Despite believing that their partners can not remain faithful, scholars found that “five percent of women had used condoms every time they had sex in the previous 12 months before the survey. Eighty one percent of women did not use condoms consistently stating that they used condoms "more than 1/2 the time", "half of the time" "less than half of the time" or "almost never." There were 13% of women who responded that they "never" used condoms in the last 12 months” (McKoy, & Peterson, 2006, p. 1156). Since it seems that heterosexual women are enjoying an active sex life, one would also speculate that it is because of the joy, companionship and intimacy that they find in the activity. Unfortunately, this does not seem to be the case for many women. Scholars have found that African American women “report having had more negative sexual experiences during the past year than White women, Black men, or White men. Black women are more likely to report a lack of interest in sex, having unpleasurable sex, as well as inability to orgasm in the past year” (Gonzales, & Rolison, 2005, p. 725). Scholars have also found that "the majority of women [in this study] reported engaging in unwanted sex” (Whyte, 2006, p.241). It has also been documented that “individuals who felt less cared for (as identified by nonacceptance) were more likely to participate in high-risk sexual and drug behaviors, which increased their risk for acquiring HIV” (Plowden, et al., 2005, p.26). So if African American women do not want to have sex, why would they not ‘just say no’? Scholars report that “greater than 1/3 of women reported having had sex in order to maintain their relationships. This indicates that these women frequently engaged in sex out of fear of being left, rather than out of desire” (Whyte, 2006, p.241). They also found that women have sex “to avoid being hurt [which is] correlated with both sex to avoid relationship loss and to avoid loss of shelter” (Whyte, 2006, p. 242). Obviously, women are driven by more than a desire to have sex, and some of those drives conflict with messages encouraging condom use. When scholars asked women, through open ended questions, to explain what drives them to engage in high risk sexual behaviors, women reported that the issues were “low self-esteem, alcohol and drug use, a feeling of invincibility, and financial dependence on male sexual partners” (Forna, et al., 2006, p. 1801). When asked in focus group settings to report the most common factors that lead women to ignore or compromise safe sex practices,

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the women suggested that the issues were “having low self-esteem, seeking validation, love and confirmation about their desirability, and wanting to please a man” (Forna, et al., 2006, p. 1801). Since it seems that the concern for African American heterosexual women is one of relational maintenance rather than lack of knowledge about safe sex practices, one could conclude, along with Whyte and colleagues (2004), that simply to provide an individual with information will not improve behavior. Despite the grim outlook for African American heterosexual women, scholars do have a few suggestions that may help program developers. Forna and colleagues (2006) suggest that a multidimensional approach is needed to reduce HIV infection. This multidimensional approach may include training to “improve communication between sexual partners about HIV and STD risk, encourage mutual monogamy, facilitate access to HIV and STD testing, treatment and preventive services, and reach younger at risk women with comprehensive risk-reduction messages, and strategies that include abstinence, condom use, age-appropriate sexual education and promotion of delayed sexual debut” (Forna et al., 2006, p. 1803). Scholars also suggested that “African American women who received AIDS information that featured facets of African American culture were more likely to identify AIDS as a personal threat, compared with women who viewed a standard public health message” (Stroman, 2005, p.27). Finally, if women are encouraged to consider what they will gain, rather than what they will lose by protecting themselves from HIV/AIDS and other STDs, programmers will be more likely to find success (Stroman, 2005).

CONCLUSIONS/CALL TO ACTION The majority of this work has explored the idea that theory has failed when applied to the African American community. There are various reasons for theory’s lack of success, which suggest that with further study, theory can be revised and applied more effectively to this community. It should be apparent that African Americans, in all risk groups, are going to need more that increased information, or culturally presented ‘just say no’ messages for the message to truly hit home. Scholars should spend some time investigating credible spokespersons as determined by the community. Given the often negative history among African Americans, government agencies, and physicians, it seems that messages from doctors, or government sponsors will not receive the greatest consideration. Even the athletes that are selected as spokespersons should be screened so that the community is not lost in conspiracy theories such as “there is a cure for HIV/AIDS but only the rich can afford it.” Scholars should also investigate the forms, prevalence, and breadth of spread among conspiracy theories. It has been long noted that conspiracy theories exist, but it remains unclear how the theories develop, how they spread, and what impact they have on message processing. Some persuasion theories would suggest that if a message receiver is inoculated to a message prior to receiving it, the full message will be received in lesser measure. Perhaps if the community can be ‘warned’ that they will hear conspiracy theories, and then the theories are debunked, safer sex messages will find their way to more fertile cognitive processes.

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Recognizing that there are four groups that sustain the greatest risk among African American adults, the needs of heterosexual women should be considered the most urgent. African American heterosexual women are being infected at the highest rates, and are also dying at the highest rates. It seems that the concerns that women have relating to condom use are often related to issues of self esteem, relationship maintenance, and dependence. Perhaps scholars can pursue avenues of research that will pair empowerment messages with ‘gain framed’ messages, so that women will understand what they have to gain by protecting themselves from risk. Scholars that focus on health disparities research may be interested in pursing questions related to health seeking behaviors. It has been clearly documented that African Americans frequently delay health seeking, often until it is too late to correct the concern. Some of that delay may be due to lack of resources or lack of access to resources, whereas other reasons for delay may include fear, previous experiences with discrimination or fear of discrimination, belief in conspiracy theories (i.e. doctors will use me as a guinea pig), or other currently undetermined reasons. A strong programmatic push that encourages African Americans to visit the physician’s office more regularly will not only help to detect HIV/AIDS within the community, but may also enhance the treatment of other diseases that are disproportionately prevalent within the African American community (i.e. Diabetes). Although theory has failed us in the past, scholars know that the foundation of a sound intervention should be based on a theoretical and practical framework. It is with hope that scholarship continues to advance, and attempts to address the crisis of HIV/AIDS within the African American community. The CDC is currently disseminating several scientifically based interventions such as: “SISTA (Sisters Informing Sisters About Topics on AIDS), a social-skills training intervention in which peer facilitators help African American women at highest risk reduce their risky sexual behaviors,” “Many Men, Many Voices (3MV), an STD/HIV prevention intervention for gay men of color that addresses cultural and social norms, sexual relationship dynamics, and the social influences of racism and homophobia,” “POL (Popular Opinion Leader), which identifies, enlists, and trains key opinion leaders to encourage safer sexual norms and behaviors within their social networks,” “Healthy Relationships, a small-group intervention for men and women living with HIV/AIDS,” and “WILLOW (Women Involved in Life Learning from Other Women), is a small-group, skillstraining intervention for women living with HIV. WILLOW enhances awareness of the risky behaviors associated with HIV transmission, discredits myths regarding HIV prevention for people living with HIV, teaches communication skills in negotiating safer sex, and reinforces the benefits of consistent condom use” (CDC, 2007). Through continued research and application, theory can be corrected to create a brighter future for us all.

REFERENCES Adimora, A. A., Schoenbach, V. J., & Doherty, I. A. (2006). HIV and African Americans in the southern united states: Sexual networks and social context. Sexually transmitted diseases, 33(7 Suppl), S39-45. Adimora, A. A., Schoenbach, V. J., Martinson, F. E. A., Coyne-Beasley, T., Doherty, I., & Stancil, T. R. et al. (2006). Heterosexually transmitted HIV infection among African

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Collins, J. W., & Hawkes, E. S. (1997). Racial differences in post-neonatal mortality in Chicago: What risk factors explain the Black infant’s disadvantage? Ethnic Health, 2(1-2), 117-125. Collins, C., Kohler, C., DiClemente, R., & Wang, M. Q. (1999). Evaluation of the exposure effect of a theory-based street outreach HIV intervention on African-American drug users. Evaluation and Program Planning, 22, 279-293. Corbie-Smith, G., Thomas, S. B., & St. George, D. M. (2002). Distrust, race, and research. Archives of Internal Medicine, 162, 2458-2463. Cornelius, L. J., Okundaye, J.N. & Manning, M. C. (2000). Human Immunodeficiency Virusrelated risk behavior among African American females. Journal of the National Medical Association, 92(4), 183-195. Crocker, J., Luhtanen, R., Broadnax, S., et al. (1999). Belief in U.S. government conspiracies against Blacks among Black and White college students: Powerlessness or system blame? Perspectives in Social Psychology Bulletin, 25, 941-953. Darbes, L. A., Kennedy, G. E., Peersman, G., Zohrabyan, L., & Rutherford, G. W. (2002). Systematic review of HIV behavioral prevention research in African Americans. http://hivinsite.ucsf.edu/insite.jsp?page=kb-07-04-09. Davis, I. J., Brown, P., Allen, F., Davis, T., & Waldron, D. (1995). African-American myths and health care: The sociocultural theory. Journal of the National Medical Association, 87 (11), 791-794. DiIorio, C., Van Marter, D., & Dudley, W. (2002). An assessment of the HIV/AIDS knowledge, attitudes, and behaviors of adolescents living in a large metropolitan area. Ethnicity and Disease, 12(2), 178-185. Donavan, H. S., & Ward, S. (2001). A representational approach to patient education. Journal of Nursing Scholarship, 33(3), 211-216. El-Bassel, N., Witte, S. S., Gilbert, L., Sormanti, M., Moreno, C., Pereira., L., Elam, E., & Steinglass, P. (2001). HIV prevention for intimate couples: a relationship-based model. Families, Systems & Health, 19(4), 379-395. Essien, E. J., Meshack, A. F., & Ross, M. W. (2002). Misperceptions about HIV transmission among heterosexual African-American and Latino men and women. Journal of the National Medical Association, 94(5), 304-312. Fitzpatrick, L. K., Sutton, M., & Greenberg, A. E. (2006). Toward eliminating health disparities in HIV/AIDS: The importance of the minority investigator in addressing scientific gaps in Black and Latino communities. Journal of the National Medical Association, 98(12), 1906-1911. Fleming, D. T., & Wasserheit, J. N. (1999). From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sexually Transmitted Infections. 75, 3–17. Ford, C. L., Daniel, M., & Miller, W. C. (2006). High rates of HIV testing despite low perceived HIV risk among African-American sexually transmitted disease patients. Journal of the National Medical Association, 98(6), 841-844. Forna, F. M., Fitzpatrick, L., Adimora, A. A., McLellan-Lemal, E., Leone, P., & Brooks, J. T. et al. (2006). A case-control study of factors associated with HIV infection among Black women. Journal of the National Medical Association, 98(11), 1798-1804. Gaskin, D. J., Arbelaez, J. J., Brown, J. R., Petras, H., Wagner, F. A., & Cooper, L. A. (2007). Examining racial and ethnic disparities in site of usual source of care. Journal of the National Medical Association, 99(1), 22-30. Gilbert, D. J., & Goddard, L. (2007). HIV prevention targeting African American women: Theory, objectives, and outcomes from an African-centered behavior change perspective. Family & Community Health, 30(1 Suppl), S109-11.

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Hasnain, M., Levy, J. A., Mensah, E. K., & Sinacore, J. M. (2007). Association of educational attainment with HIV risk in African American active injection drug users. AIDS Care, 19(1), 87-91. Herek, G., & Glunt, E. (1991). AIDS-related attitudes in the United States: A preliminary conceptualization. Journal of Sex Research, 28, 99-123. Herek, G., & Capitanio, J. (1994). Conspiracies, contagion, and compassion: Trust and public reactions to AIDS. AIDS Education and Prevention, 6, 365-375. Hobfoll, Jackson, Lavin, Britton, & Shephard (1994), Reducing inner-city women's AIDS risk activities: a study of single pregnant women, Health Psychology, 1994, 13:397403. Jain, S., Schwarcz, S., Katz, M., Gulati, R., & McFarland, W. (2006). Elevated risk of death for African Americans with AIDS, San Francisco, 1996-2002. Journal of health care for the poor and underserved, 17(3), 493-503. Janz, N. K., Champion, V. L., & Strecher, V. J. (2002). The health belief model. In K. Glanz, B. K. Rimer, & F. M. Lewis (Eds.), Health behavior and health education: Theory, research, and practice (3rd ed.), (pp. 45-66). San Francisco, CA: Jossey-Bass. Jones, D. J. (2004). HIV risk-reduction strategies for substance abusers: Effecting behavior change. Journal of Black Psychology, 30(1), 59-77. Keil, J. E., Sutherland, S. E., Knapp, R. G., Tyroler, H. A., & Pollitzer, W. S. (1992). Skin color and mortality. American Journal of Epidemiology, 136(11), 1295-1302. King, J. L. (2004). On the down low: A journey into the lives of 'straight' black men who sleep with men. New York, NY: Random House. Knopf, T. A. (1975). Rumors, race, and riots. New Brunswick, NJ: Transaction Press. Koniak-Griffin, D., Lesser, J., Nyamathi, A., Uman, G., Stein, J. A., & Cumberland, W. G. (2003). Project Charm: An HIV prevention program for adolescent mothers. Family & Community Health, 26(2), 94-107. Liverpool, J., McGhee, M., Lollis, C., Beckford, M., & Levine, D. (2002). Knowledge, attitudes, and behavior of homeless African American adolescents: Implications for HIV/AIDS prevention. Journal of the National Medical Association, 94(2), 257-263. Mayberry, R. M., Coates, R. J., Hill, H. A., Click, L. A., Chen, V. W., Austin, D. F., Redmond, C. K., Fenoglio-Preiser, C. M., Hunter, C. P., Haynes, M. A., Muss, H. B., Wesley, M. N., Greenberg, R. S., & Edwards, B. K. (1995). Determinants of Black/White differences in colon cancer survival. Journal of the National Cancer Institute, 87, 1686-1693. Mayberry, R. M., & Stoddard-Wright, C. (1992). Breast cancer risk factors among Black women and White women: Similarities and differences. American Journal of Epidemiology, 136(12), 1445-1456. McKoy, J. N., & Peterson, R. (2006). Reducing African-American women's sexual risk: Can churches play a role? Journal of the National Medical Association, 98(7), 1151-1159. Millett, G. A., Peterson, J. L., Wolitski, R. J. & Stall, R. (2006). Greater risk for HIV infection of Black men who have sex with men: A critical literature review. American Journal of Public Health, 98(6), 1007-1019. Montano, D. E. & Kaspryzyk, D. (2002). The theory of reasoned action and the theory of planned behavior. In K. Glanz, B. K. Rimer, & F. M. Lewis (Eds.), Health behavior and health education: Theory, research, and practice (3rd ed.), (pp. 67-98). San Francisco, CA: Jossey-Bass. Moseley, K. L., Freed, G. L., Bullard, C. M., & Goold, S. D. (2007). Measuring AfricanAmerican Parents’ cultural mistrust while in a healthcare setting: A pilot study. Journal of the National Medical Association, 99(1), 15-21.

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Neff, J. A., & Crawford, S. L. (1998). The health belief model and HIV risk behaviors: A causal model analysis among Anglos, African-American and Mexican-Americans. Ethnicity & Health, 3 (4), 283-299. Okigbo, C., Okigbo, C. A., Hall, W. B., & Ziegler, D. (2002). The HIV/AIDS epidemic in African American Communities: Lessons from UNAIDS and Africa. Ret(6), 615-653. Okwumabua, J. O., Glover, V., Bolder, D., & Edwards, S. (2001). Perspectives of lowincome African Americans on Syphilis and HIV: Implications for prevention. Journal of Health Care for the Poor and Underserved, 12(4), 474-489. Oliva, G., Rienks, J., Udoh, I., & Smith, C. D. (2005). A university and community-based organization collaboration to build capacity to develop, implement and evaluate an innovative HIV prevention intervention for an urban African American population. AIDS Education and Prevention, 17(4), 300-316. Parsons, S., Simmons, W., Shinhoster, F., & Kilburn, J. (1998). A test of the grapevine: An empirical examination of conspiracy theories among African Americans, Sociological Spectrum, 19, 201-222. Payne, N. S., Beckwith, C. G., Davis, M., Flanigan, T., Simmons, E. M., & Crockett, K. et al. (2006). Acceptance of HIV testing among African-American college students at a historically Black university in the south. Journal of the National Medical Association, 98(12), 1912-1916. Peterson, L., Coates, T., Catania, J., et al. (1996). Evaluation of an HIV risk reduction intervention among African American homosexual and bisexual men. AIDS, 10, 319325. Pickle, K., Quinn, S. C., & Brown, J. D. (2002). HIV/AIDS coverage in Black newspapers, 1991-1996: Implications for health communication and health education. Journal of Health Communication, 7, 427-444. Plowden, K. O., Flectcher, A., & Miller, J. L. (2005). Factors influencing HIV-risk behaviors among HIV positive urban African Americans. Journal of the Association of Nurses in AIDS Care, 16(1), 21-28. Prado, G., Szapocznik, J., Mitrani, V. B., Mauer, M. H., Smith, L., & Feaster, D. J. (2002). Factors influencing engagement into interventions for adaptation to HIV in African American Women. AIDS and Behavior, 6(2), 141-151. Prather, C., Fuller, T. R., King, W., Brown, M., Moering, M., & Little, S. et al. (2006). Diffusing an HIV prevention intervention for African American women: Integrating afrocentric components into the SISTA diffusion strategy. AIDS Education and Prevention : Official Publication of the International Society for AIDS Education, 18(4 Suppl A), 149-160. Prendergast, M. L., Urada, D., & Podus, D. (2001). Meta-Analysis of HIV risk-reduction interventions within drug abuse treatment programs. Journal of Counseling and Clinical Psychology, 69(3), 389-405. Prochaska, J. O., Redding, C. A., & Evers, K. E. (2002). The transtheoretical model and stages of change. In K. Glanz, B. K. Rimer, & F. M. Lewis (Eds.), Health behavior and health education: Theory, research, and practice (3rd ed.), (pp. 99-120). San Francisco, CA: Jossey-Bass. Robinson, B. E., Uhl, G., Miner, M., Bockting, W. O., Scheltema, K. E., Rosser B. R. S., & Westover, B. (2002). Evaluation or a sexual health approach to prevent HIV among low income, urban, primarily African American women: Results of a randomized controlled trial. AIDS Education and Prevention, 14 Supplement A, 81-96. Semaan, S., Kay, L., Strouse, D., Sogolow, E., Mullen, P. D., Neumann, M. S., Flores, S. A., Peersman, G., Johnson, W. D., Lipman, P. D., Eke, A., & Des Jarlais, D. C. (2002). A

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profile of U.S.-based trials of behavior and social interventions for HIV risk reduction. Journal of Acquired Immune Deficiency Syndromes, 30, s30-s50. Somlai, A. M., Kelly, J. A., McAuliffe, T. L., Ksobiech, K., & Hackl, K. L. (2003) Predictors of HIV sexual risk behaviors in a community sample of injection drug-using men and women. AIDS Behavior, 7(4), 383-393. Sorlei, P., Rogot, E., Anderson, R., Johnson, N. J., & Backlund, E. (1992). Black-White mortality differences by family income. Lancet, 340(8815), 346-350. Stroman, C. A. (2005). Disseminating HIV/AIDS information to African Americans. Journal of Health Care for the Poor and Underserved, 16, 24-37. Thomas, S., & Quinn, S. (1991). The Tuskegee Syphilis Study, 1932-1972: Implications for HIV education and AIDS risk education programs in the Black community. American Journal of Public Health, 81, 1498-1505. Thorburn, S, Harvey, S. M. & Ryan, E. A. (2005). HIV prevention heuristics and condom use among African-Americans at risk for HIV. AIDS Care, 17(3), 335-344. Turner, P. A. (1993). I heard it through the grapevine: Rumor in African-American Culture. Berkeley: University of California Press. Wechsberg, W. M., Lam, W. K.K., Zule, W. A., & Bobashev, G. (2004). Efficacy of a woman-focused intervention to reduce HIV risk and increase self-sufficiency among African American crack abusers. American Journal of Public Health, 94(7), 1165-1173. Whyte Iv, J. (2006). Sexual assertiveness in low-income African American women: Unwanted sex, survival, and HIV risk. Journal of community health nursing, 23(4), 235-244. Whyte, J., Standing, T., & Madigan, E. (2004). The relationship between HIV-related knowledge and safe sexual behavior in African American women dwelling in the rural southeast. Journal of the Association of Nurses in AIDS Care, 15 (2), 51-58.h Williams, P.B., Ekundayo, O., Udezulu, I. E., & Omishakin, A. M. (2003). An ethnically sensitive and gender-specific HIV/AIDS assessment of African American women: A comparative study of urban and rural American communities, Family Community Health, 26 (2), 108-123. Winfield, E. B., & Whaley, A. L. (2002). A comprehensive test of the health belief model in the prediction of condom use among African American college students. Journal of Black Psychology, 28 (4), 330-346. Wingood, G. M., & DiClemente, R. J. (2006). Enhancing adoption of evidence-based HIV interventions: Promotion of a suite of HIV prevention interventions for African American women. AIDS Education and Prevention : Official Publication of the International Society for AIDS Education, 18(4 Suppl A), 161-170. Wingood, G. M.., DiClemente, R. J., Mikhail, I., Lang, D., Hubbard-McCree, D., Davies, S. L., et al. (2004). A randomized controlled trial to reduce HIV transmission risk behaviors and STDs among women living with HIV: The Willow Program. Journal of Acquired Immune Deficiency Syndromes, 37, S58-S67. Winningham, A., Corwin, S., Moore, C., Richter, D., Sargent, R., & Gore-Felton, C. (2004). The changing age of HIV: sexual risk among older African American women living in rural communities. Preventative Medicine, 39, 809-814.

In: Progress in Education, Volume 17 Editor: Robert V. Nata

ISBN 978-1-60692-505-8 © 2009 Nova Science Publishers, Inc.

Chapter 2

AGAINST SCIENCE EDUCATION: THE AIMS OF SCIENCE EDUCATION AND THEIR CONNECTION TO SCHOOL SCIENCE CURRICULA Peter Davson-Galle Faculty of Education, University of Tasmania

ABSTRACT To clarify: in this chapter I will speak only of compulsory science education in schools; much of what I say will not transfer across to either science electives in schools or to undergraduate science. Such science education, like all compulsory education, is an exercise in force against students. Overriding individual autonomy in this way is not to be lightly done and should involve appeal to aims that are of sufficient importance for the individual, or the group/society, to outweigh such loss of freedom over one's own mind's contents. Moreover, the loss of freedom is guaranteed; in order to outweigh it, the benefits aimed at should not just be of sufficient moral importance but be attainable with sufficient probability for a suffient proportion of students. Finally, to justify the imposition of science education requires not just the probable achievement of ends that are of sufficient importance to outweigh the loss of freedom that is their cost but the absence of better candidates that might occupy the same "time-slot" of lost freedom. All very vague, admittedly, and it is the burden of this chapter to examine this issue in further detail as an exercise in sustained argumentation. My contention will be that such argumentation in justification of compulsory science education cannot be satisfactorily advanced at the moment and, in any event, does not seem to have been yet advanced in the extant literature. Accordingly, as compulsory school science education is without a satisfactory available warrant, it should be excised pending the provision of one.

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INTRODUCTION From at least the time of the Sputnik scare, the state of science education has been a topic of concern and controversy in Western nations. Familiar to readers will be the flurry of reports and reforms concerning such education. I have no intention of rehearsing the detail of this here1. I will make one observation, however. Much, not all, of the discussion takes for granted that it is a good thing for school students to have a substantial introduction to the ideas and processes of science and then proceeds to fuss about how that might most effectively occur. In effect, in the terms of this chapter, this is to assume as satisfactory some set of aims for science education and devote one's intellectual energies to the task of judging how to achieve those aims. Less attention seems to have been focused upon what those aims should be and even less upon a thoroughgoing exercise in justification of those aims. And, even assuming those aims, the literature seems in adequate in thoroughly justifying curricular proposals as means to their achievement. The focus of this chapter is upon those latter tasks as aspects of addressing the question: 'what would justify compulsory school science education?'. My judgement is pessimistic as to the chances of such a justification being available or, at least, being available for anything that very much resembles the sorts of curricula common in schools.

INDIVIDUAL AUTONOMY AND THE ONUS ARGUMENT In a recent paper (Davson-Galle, 2006) I recanted from earlier works (Davson-Galle, 1994, 2002, 2004a) of mine in which I had advocated greater presence of philosophy of science in school science education. In that recantation, I persuaded myself that no good case could be made out for having philosophy of science (in any of a range of versions that I examined) as part of a compulsory curriculum in schools. At the end of that paper, I observed that the broad architecture of the paper's argumentation 'would seem to apply to other parts of the compulsory curriculum, including much of science' (p.32 of online listing) but that exploring such matters was not my concern in that paper. This chapter does have such exploration as its concern. The broad argumentative strategy of the chapter is identical to that earlier paper. The only difference is that it is directed at the proposal that science be compulsory, not that philosophy of science be compulsory. As before, the chapter rests its case on an onus argument. The portrayal of such a general onus argumentative strategy was more elaborate in that paper than I will reproduce here and for further details I simply refer readers to that paper2. The key assumption of the onus argument which I will follow is that it is a good thing, in and of itself, for people to be able to think what they wish to and to act as they please. This is not to champion personal autonomy no matter what. Rather, it is to say that if one is to advocate stopping someone from acting or thinking as they please, then the onus is on such a would-be autonomy suppressor to come up with some good enough reason for that. Such an

1

Michael Matthews gives good overviews in his introduction to William McComas's edited anthology and in a monograph of his own (see Matthews, 2000 and Chapter 3 of his 1994, respectively). 2 See the section entitled: 'Individual Autonomy and General Grounds for Its Denial'.

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argument would generally3 involve establishing that some sort of benefit would ensue as a result of the type and extent of autonomy reduction involved and, moreover, enough such benefit to outweigh the autonomy loss that is its cost. Unless such a case can be made out, the "default" position of allowing someone to exercise autonomy is operative. Note the "logical geography" of such an onus argument. It is not for me to argue that autonomy is a good thing. I take it as an assumption that, other things being equal, it is. (I also take it that granting this assumed moral status to autonomy is not wildly morally idiosyncratic of me.) It is for the other party to argue that sometimes other things are not equal and outweigh autonomy; that is, to argue that, on these matters, for these reasons, autonomy should be suppressed. I am taking the exercise of autonomy to be some sort of prima facie right of a fundamental sort, a "good" in itself that doesn't need warranting by appeal to some further moral principle. It might be outweighed in importance by some higher good and such a higher good's attainment might demand autonomy-suppression but that has to be established in order to discharge the onus. I am willing to allow that there are all sorts of good reasons for restricting a person's autonomy and sometimes reasons for restricting it in a temporally sustained way (prison, for example). My point is simply that those reasons have to be advanced and be satisfactory. Turning to education, I take the institution of schooling to indeed be a sustained exercise in autonomy suppression. I take it as obvious and general knowledge that most students would not voluntarily choose to be at school studying the subjects impose and for the length of time that they have them imposed upon them. Generally, then, schooling is an exercise in force. Can such compulsion be warranted? If not, then the onus is not discharged and student autonomy should be restored. Schooling is, of course, made up of various subjects and activities and it might well be that some of these are more able to be warranted than others. In this chapter, my focus is limited to science and, broadly put, the issue is if such an onus can be discharged - can forcing scientific knowledge, skills etc upon students who wouldn't choose to have them be justified? Of course it is but autonomy reduction. It is not as if compulsory science education constitutes total enslavement of mind and action. However, nor is such force to be treated as a trifling concern. The point of the onus argument is that any interference with an individual's autonomy requires warranting. An appreciation of this point is reasonably easily gained. I surmise that few adults would countenance being told that they had to lose control over however many hours school science curricula involve to learn things that they do not wish to learn. Saying that it was only a partial loss of autonomy so what was the fuss all about would be, I surmise, inadequate mollification of their outrage. At the very least, such an adult would rightfully demand to know why, to know what was supposed to justify her loss of control over a part of her life - ditto for students. Indeed, it is instructive to keep in the back of one's mind, when considering the putative warrants considered below, if they would be satisfactory warrants for forcing adults in relevantly similar circumstances to think and act as they would not choose to. How, then, might such an onus be discharged in the case of compulsory school science education?

3

I say 'generally' because there is one other possibility, as will be elaborated upon below - that of an agent retrospectively approving of what had earlier been forced upon her.

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POSSIBLE JUSTIFICATORY STRATEGIES IN DISCHARGE OF THE ONUS There seem to be four broad sorts of putative warranting strategies that one might advance for such autonomy reduction: 1. the future adult that the student will become would retrospectively endorse such loss of freedom in order to satisfy some curricular aim or other; 2. such autonomy reduction is for the benefit of the individual; 3. such autonomy reduction is for the benefit of the group; or 4. some combination of the above. In what follows, I methodically work through a number of possible candidate aims as warrants for compulsory school science education (hereinafter mostly just 'science education' for short). Some will be standard fare, some not so much. For each, the issue will be if such an aim, to the extent to which it seems plausible to believe that it can be achieved by some curriculum, is of sufficient importance to outweigh the loss of individual freedom involved. Of course, in doing this, I will be making moral judgements as to the relative importance of some aim's level of achievement versus the loss of autonomy that is its cost and others might order their priorities differently. My supposition is that my deliberations won't be wildly morally idiosyncratic and will at least count as "food for thought" for other moral agents interested in addressing these issues. Note the italicised words above. Crucial to my case will be the suggestion that it is not so much the worthiness of an aim, in and of itself, that is to be put against student loss of freedom, it is the plausible extent to which it would be achieved in students. That, say, peace on Earth for all time would be sufficiently meritorious to outweigh school students' loss of freedom hardly counts as an aim that warrants science education if students' participation in the science education curriculum in question simply doesn't have the desired consequence to any significant extent. (I don't, obviously, suggest that anyone has tried to warrant compulsory school science education in this particular way; it is simply an illustration of the point that, however noble the end is, it doesn't warrant a means unless the means actually achieves the end - and achieves it to what is deemed to be a satisfactory extent). Note also that not all of the possible content that might constitute a science education curriculum will necessarily fare equally well as means to the achievement of various candidate ends, or aimed at results. The above point about the achievability of aims being an important element in their chances of warranting a compulsory curriculum will likely be nuanced by such curricular detail. Note that this fine structure is not just a matter of biology versus physics versus geology, or integrated science studies versus discipline-based subjects, or science content versus science process, or even, with a gesture at recent enthusiasm for various constructivist theories, passive transmission of received knowledge versus active construction of one's own "knowledge" (a misnomer in my view). Within any of these there are variations as to the quantity of material covered (the size of the curriculum, if you like) and the level of generality/specificity that one might go into.

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Finally, students vary and it is possible that what one might be able to warrant forcing on some students, one cannot warrant forcing on others. One issue here would again be the extent to which a particular aim was able to be achieved. Johnny might gain much from his school science education in terms of fulfilling some aimed-at end, whilst Janie might not. As will be readily appreciated, the above spread of intersecting variables forms a multidimensional matrix with quite a lot of cells. As this is a book chapter and not a book in its own right, I will clearly not be able to address each possibility in fine detail. Fortunately, groupings of possibilities seem to share enough features to be able to be profitably considered together. Despite this, my treatment is, perforce, embryonic, although, in my view, a useful starting framework for further work. A recurring theme in what follows is that, generally speaking, there seems to be a problem in finding realistic aims, ones plausibly achievable to an extent that would warrant freedom loss on the part of all students. I allow that that sort of judgement rests upon empirical propositions (that this means doesn't achieve that end to such and such an extent). Although not my field (I am a philosopher, not a social scientist of any sort) what I have accessed of the science education literature seems rather thin to the point of transparency when it comes to longitudinal studies linking science curricula of various sorts with the achievement of various candidate aims - especially if those aims refer to situations later down the track concerning the adult citizens that the students become. Of necessity, my conclusions rest more upon assumptions than I would like, although I do take the assumptions to be plausible ones. If I am correct about the paucity of empirical research on these matters, then I do not see this as a problem with my argumentation. The whole point of the (above outlined) onus argumentative strategy of the chapter is that the burden of proof is not upon me but upon those who would impose science curricula. It is for them to establish that those curricula perform as advertised by reference to aims which (were they to be achieved to a satisfactory extent) would warrant the freedom loss that is their cost. No news is bad news for such theorists, not for me. That said, there may well be studies that have escaped my attention and that possibility is a potential weakness in the empirical premises that my arguments (to the effect that the onus obligation has not been satisfactorily discharged) rest upon. As things stand, I will, to an uncomfortable extent, rely on common sense plausibility appraisals of the truth of most of my empirical claims. Despite this potential weakness, what I assert does seem to me to be plausible and, if I am wrong, then I would be delighted to have that shown by reference to competent empirical research. So, even if making a series of what I will suggest to be unsubstantiated and dubious empirical claims, what might an argument attempting to discharge the onus and warrant science education look like? I suggest that all such arguments would be variations on the following schema: MP1 having aim X satisfied in an individual to extent Y would be of sufficient benefit to the individual and/or the group to outweigh the loss of autonomy involved for that individual in achieving that aim to that extent DP1 having compulsory science education of sort A would achieve aim X to extent Y DP2 no other expenditure of the same resources would achieve aim X to an equal or greater extent than Y

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M/DP1 no other aim beneficial to the individual and/or the group that is in rivalry to having aim X satisfied to extent Y is able to be satisfied to an extent that brings equal or greater benefit to the individual and/or the group than aim X being satisfied to extent Y So, MC1 there should be a compulsory science curriculum of sort A A few words of clarification are probably in order as, although familiar to analytic philosophers, laying cases out like this as formal arguments seems, from the literature that I have read, to be an unfamiliar business within science education circles. Note that the idea is that every proposition before the word 'so', when conjoined, form a set of premises whose role is to entail the argument's conclusion. For this to occur, things commonly left as "hidden assumptions" in less rigorously portrayed arguments become explicitly listed. The merit of this is that all of the elements constitutive of the case in question for the conclusion are explicitly laid out for critical scrutiny. My contention will be that all of the usual attempted justifications for forced science education have a weak spot somewhere (commonly the version in question's DP 1). That any particular argument for a given conclusion has a flawed premise (or premises), and thus fails in establishing its conclusion, does not automatically count against the conclusion being satisfactory. It just means that such a conclusion can't be warranted in the proposed manner. That this is so doesn't at all count against the chances of some other, independent, argument for the same conclusion faring better. (Thus I will be examining independently on their merits a number of putative warrants for forced science education.) Mind you, if the standardly advanced warrants for some course of action fail and nothing more promising looms on the horizon, one would be beginning to view the course of action in question (in our case, forced school science education) as literally indefensible. Looking at this schema, note that the supporting premises are of two distinct sorts. Some are labelled as MPs and some as DPs. The 'M' stands for 'moral' - these premises express some sort of moral or ethical stance that the author endorses. The 'D' stands for 'descriptive' these premises express the author's claims about what is some sort of factual truth (commonly causal connection claims, as is the case here). I also have M/DP1 which has aspects of both propositional types. Ideally, this would be dis-aggregated into those aspects as separate premises but I have judged it to be clearer in this context to leave things as they are. So, one form of challenge to any argument putatively warranting its conclusion is to dispute some premise upon which the case rests. This might involve disagreeing with the author about what is right or wrong, good or bad - in short, entering into a moral dispute with the author about the merits of some MP. Then again, it might involve challenging some descriptive premise by suggesting that the author has not got his facts straight or, perhaps, that there is no reason to believe that he has. Or one might find fault with instances of each type of premise. In what follows in considering various putative justifications, I will be advancing each sort of complaint.

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SOME POSSIBLE AIMS OF SCIENCE EDUCATION OFFERED IN DISCHARGE OF THE ONUS The key moral motivation is provided by MP1. Although, as we will see below, each of the other premises can be vulnerable, I will initially focus on that premise. So, what might be advanced as benefits that outweigh the loss of autonomy that is their cost? In effect, what is to be filled in as X, an aim that is sufficiently worth achieving that it seems worth autonomy loss (if achieved to a certain extent)? I suggest the following as a fairly comprehensive list of what emerges in discussions of the aims of science education. Some of the following have official imprimaturs, some do not. All seem worth consideration regardless of their status as currently fashionable or not, especially given the difficulty that will emerge below in having any warrant succeed. Note that it is not as if each is necessarily a "stand-alone" candidate aim; it might well be that combinations of aims form a package of benefits that is more successful in warranting autonomy loss than its component parts considered severally. Finally, note that, in the discussion of the following, reference will be made back to the four broad strategies for warranting any overriding of someone's exercise of autonomy that were outlined earlier. So, one might attempt to support compulsory science education by appeal to a schooling aim that as many students as possible should: 1) be prepared for the workforce; 2) contribute to the nation's economic wealth; 3) be able to cope in an increasingly technologically and scientifically sophisticated world; 4) understand the workings of the world around them as part of a "liberal education"; 5) be prepared to successfully pursue their own life goals; and/or 6) be prepared to be able to fulfil the role of citizen. In each case, apart from any general agreement that it is "a good thing" for people to have these qualities, the key thing that makes these candidate aims for compulsory school science is presumably the view that (severally, or in combination) they could act as warrants for some variation on the spread of science curricula currently enacted or proposed. But, for such warrants to work as warrants, as ends justifying some science curricular type as means, the latter would have to work in achieving the end and, moreover, work to an extent sufficient to warrant the loss of student autonomy that it entails. Moreover, any such warrant is always one that can only be adequate if there is no other course of conduct which is a rival for the same (or a lesser) amount of autonomy suppression yet is more beneficial in some way than the current proposals. Such benefit might not necessarily be by reference to the same putatively good ends that are appealed to by science curricula. Curricular warrants are always relative. It is not just that something is to be good enough to be worth autonomy reduction, it has to be more worth it than rival possibilities or else that particular substitute for autonomy won't be warranted. I rehearse such familiar points from the theory of practical reason just to remind us that it is not as if discussions of aims of particular disciplinary curricula are events insulated from consideration of other curricular possibilities. (My impression is that, for rather too much of the time, issues to do with possible science curricula are indeed considered in an overly insular way.)

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However, in most of what follows, I will put such complications to one side as the broad thrust of what I will suggest is that, regardless of any claims of its rivals to warrant autonomy reduction and to warrant it more robustly than any variation of science education, the latter simply fails anyway. The concern is not so much that other things are better, it is that, regardless of their merits, science education might not be good enough to even get on a "shortlist" for prioritisation as it seems to achieve nothing worthy enough to warrant the loss of autonomy involved. I will first consider the candidate warranting aims individually and then talk about their possible combination. As touched on earlier, in each case, the general nature of the putative benefit that is to outweigh autonomy reduction will involve appeal to one, or a combination, of the three sorts of strategy generally available for those who would seek to justify stopping anyone doing what they would choose to do. We met these earlier when discussing the onus argument strategy of this chapter. To use as an illustrative example the "preparation for employment" aim listed above (one which I will discuss in the moment), one would be asserting the following in fleshing out MP1 in our argument schema. Either the adult (John) that Johnny will grow into will have to be of the view that he is grateful that he was made to study science because look how useful it has been for his career or, regardless of what John comes to think, it will indeed be of sufficient use in his employment to yield enough benefit to him, or to the rest of us, to warrant imposing it on him against his will. (The above disjunction is inclusive and thus these warrants might combine to outweigh his autonomy loss even if they fail to do that when considered severally.)

WORKFORCE PREPARATION? Turning to those candidate aims, the most easily dismissed is any suggestion that science education is able to be justified by appeal to the end of having students prepared for the workforce. I have several observations concerning this suggestion. First, in clarification of the putative warrant, it is not to be taken as being limited to preparing students for whatever jobs they might be able to enter immediately upon leaving school. Especially in modern Western societies, students would likely proceed to post-school education before entering whatever employment path they have in mind. So the school level preparation might be more like stage one of a multi-stage process of preparation for employment. Further, it is no part of the suggestion that science education alone would constitute employment preparation. Rather, the suggestion would be something like that it was a necessary component of a suite of measures that constituted the best such preparation. What would have to established would be it actually having that status. Even so, the claimed warrant looks silly. Even in today's world there are simply not enough jobs that deploy the knowledge and skills of science to warrant students being forced to engage in science education. That some will go on to become scientists or to enter some other profession or trade that directly utilises some science in the performance of the job is not a warrant for science education being compulsory across-the-board. Not enough school leavers will have such futures to warrant imposition of science upon all. Moreover, closer thought about the jobs that do utilise science makes it quickly obvious that they do not utilise the full breadth of science that would be standardly considered constitutive of school science

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curricula. For instance, an auto-electrician might find some areas of physics useful background and contextual knowledge for specialised trade study but not even all areas of physics are relevant to such an occupation - consider astronomy - and certainly many standard areas of science curricula, like biology, are totally irrelevant to such a job. I take the above to be blatantly obvious and put it that if there is an aim of science curricula that provides warrant for the autonomy-reducing compulsoriness of such a curriculum, then it will lie elsewhere. As it stands, one would be replying to a student challenge: 'why do I have to do this when I don't want to?' with 'you all have to do all of this because some of you will find bits of it it useful in your later employment'. I judge this to be a very unsatisfactory reply indeed and to not constitute a satisfactory warranting of autonomy reduction by reference to any, or all, of our three broad ways of discharging the onus argument. None of this, of course, counts against various parts of science being voluntary options in school nor against various tertiary educational institutions and employers stipulating various particular areas of science as pre-requisites for entry to a course or for employment but all of that is beside the point of my focus in this chapter upon all students being made to study science at school.

CONTRIBUTION TO SOCIETY'S WEALTH? What, then, of the second of our putative warrants for science education - that of contributing to the nation's wealth? Presumably two of our onus-discharging categories of justification, that John will postfactum approve of the autonomy lost by Johnny, his earlier stage, and that science education is for John's individual benefit, are not so much the point here. The focus of this putative warrant seems clearly to be "the good of the group". No doubt if one trawled through the economics literature, one would find ample evidence of correlations between a population's level of educational achievement and its collective material wealth. There might even be a correlation between its level of education in science and its wealth. That correlation might even be causally based such that, to some extent, the collective societal wealth level is caused by the level of science education (though no one would presumably claim the latter to be the proximate cause, even in part, of the former; the causal chain is going to have more connecting links, ones to do with the thoughts and activities of those scientifically educated). Let me allow all of this. Although I am unaware of data analyses connected to anything finer grained than the first claim of the last paragraph, my possible ignorance of other levels of analysis is beside my point. Even if all of the above claims were to be true, they do not constitute adequate enough descriptive premises to act in arguments discharging the onus facing the autonomy restrainer. It is hard to see how Johnny's school science education is going to help society's collective wealth except via John's job-related activity. As such, much of the previous discussion applies again. By all means one might target some areas of science, or some areas of science for some individuals, as ones conducive to wealth creation. Whatever the detail of all of this turns out to be, it is not even faintly plausible that much, if any, greater economic

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benefit will ensue if the net is spread more widely to include all students and the curriculum to cover the fairly comprehensive spread of disciplines and areas typical of school science curricula. My suspicion is that, when one looks for causal connections, the story will be more particularised and such detail is masked by simply noting blanket relationships. Or so I assert. The assertion seems obviously true to me but the history of science is larded with views that seemed obviously true at the time but came later to be held not to be. So, as usual, I might have my facts wrong. However, again as usual, it is not my task to fuss over much about this. It is for those who would deploy appeal to such improvement in societal wealth (or economic benefit) as an aim of science education aim to discharge the onus. It is for them to provide the data analyses supporting their claims that such consequences would, indeed, ensue and ensue better than with more targeted science education. Finally on this aim's use as a putative warrant, it is worth reiterating a point made in an earlier paper (Davson-Galle, 2006). Even if it is established that, in virtue of what John ends up doing, it is true that Johnny having science education forced upon him will lead to an increase in society's wealth and, moreover, that it would be a large enough increase to outweigh the loss of Johnny's autonomy whilst at school, would the argument work too well for comfort? If we are willing to metaphorically chain Johnny to his desk for the sake of the group's wealth, then why wouldn't such a warrant transfer, mutatis mutandis, to the case of John? My surmise is that those who might think in terms of this sort of economic argument for science education would baulk at such an extension from Johnny's to John's autonomy being forcibly removed - but why? Why wouldn't this be some sort of "ageist" double standard of an insupportable sort? And, if the cases are morally relevantly similar, and the proscription on constraining John's autonomy for the sake of our wealth is upheld, then that case for constraining Johnny's autonomy would similarly collapse on pain of inconsistency. Of course, we sometimes do constrain adults' autonomy for the collective good in all sorts of ways. But none of those seem to provide a precedent of any useful application here. An obvious case is that of criminals and some criminals' actions (like large scale fraud, perhaps) have consequences for the group's wealth but presumably no one would suggest a parallel with school students. They are not having their autonomy restriction proposed as a punishment. A closer parallel, and one that operates in some countries, is that of forcing the unskilled unemployed (but not the unemployable) to engage in some sort of vocational training as a pre-condition of continuing to receive unemployment benefits from the group. Assume that this is warranted, would it provide a way of discharging an onus that would transfer to our purported economic case for compulsory school science education? I think not. Look at the adult case more closely. Basically, what is being relied upon is some sort of principle to the effect that no one has the right to be an economic burden upon the group if they have the potential not to be. And, if that potential is not yet realised but could be with appropriately targeted retraining, then that retraining should occur, by force if need be. But it is one thing to warrant autonomy restriction in order to achieve the benefit for the group of avoiding financially burdensome individuals and quite another to impose such a restriction in order to increase societal wealth. I am an academic. Were the job market for academic philosophers to collapse and I were to become unemployed and reliant upon the benevolence of the group, then it might be proper to insist that I retrain in some way so that my negative contribution ceases. Then again, pleasant way of life though it is for me and no negative financial drain on society (in that I have a salary, pay taxes and so on) there is little doubt that

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I could contribute better to increasing societal wealth by doing something other than philosophising. Should I then be forced to retrain as a widget entrepreneur just because that would be of greater economic benefit for the group? I trust that the answer to the last question would be 'no'. Given this, and assuming that young people should not be forced to do things for the group's benefit to any greater extent than old people have to, there are entailments here for the societal economic benefit rationale for compulsory school science education. The most that seems warranted as an imposition on students' autonomy is that they are forced to do something or other that will (directly, or indirectly via being the foundation for later study) enable them not to be a financial burden upon the rest of us (assuming that they have that potential). The focus is negative, not positive. Their duty to the group is simply not to be a burden on it as opposed to positively contributing to it. But such burden-avoidance might be achieved with no science education at all and via schooling totally devoted to preparing them for success as a widget entrepreneur, a subsistence-level, garret-living, artist, a clerk in a bank or even a society-rejecting survivalist hermit. To reiterate, we don't push adults around unless they impact negatively upon us. Maybe we should but I am operating on the moral assumption that we shouldn't. We don't insist that adults contribute positively to the economy and forcibly retrain them if they do not do so and, unless a morally significant difference can be pointed to, we should not do so to students either. At least, that is what consistency seems to demand and the onus is on anyone wishing to draw an age-based distinction to present arguments for its legitimacy. Keep in mind that I am not presenting arguments for student autonomy (there is a literature within philosophy of education on that). I am assuming that it is a good thing and it is for others to present arguments for its negation via forced science education. In any event, as touched upon above, the societal wealth argument hardly seems to hold promise as a warrant for science education being inflicted upon all students as opposed to it being inflicted upon some students as not all students would be able to contribute positively to the economy via what they learnt from their science education anyway. I take this to be a failed warrant attempt.

"COPING"? What, then, of our third putative way of discharging the onus - that compulsory science education is justified in virtue of it preparing students to "cope" in an increasingly technologically and scientifically sophisticated world? This seems mostly to be in the camp of "benefit to the individual" as a type of warrant. But does it succeed? One of the refrains of the previous discussion has been that the aims under scrutiny seemed, at best, to provide warrants for some, but not all, students undergoing forced science education in virtue of the fact that the future circumstances appealed to did not seem to apply across the board. On the face of it, this aim looks more promising in that respect at least in that, except for folk like the Amish, all students will go on to live in such an increasingly technologically and scientifically sophisticated world. So, the scope of the applicability of the warrant seems on safer ground than before. Despite this merit, the case also seems to be

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hopeless as a warrant for anything like a standard science curriculum being forced upon students. This is for a number of reasons. The first of these rotates around the idea of "coping" - what counts as coping in a technologically and scientifically sophisticated society? Consider the case of an excolleague's father, a renowned symphony orchestra conductor. Reportedly, if a light bulb in his house needed changing, he would call an electrician. If the external rear-vision mirrors on his car were out of adjustment, then he'd drive to the garage and get a service attendant to carry out the adjustment. And so on. Perhaps the story has been embellished in the telling but its truth or otherwise is irrelevant to its illustrative power. Is such a person coping with the technology of light bulbs and cars? I fail to see why one would bother to withhold judging that he is, albeit indirectly. And, in any event, if not, then I fail to see that learning theories of electricity or optics or mechanics would assist. Even in a very technologically and scientifically sophisticated environment (indeed, perhaps especially in such an environment) most people are but users of science and technology and can satisfactorily perform that role with minimal understanding of what they are using and with reliance upon the expertise of others and certainly without much of a glimmer of the science involved. That I now use a computer instead of a pen and paper to write this, does not require me to understand the boolean algebra employed in the software used in the computer (although, as it happens, I do). My second reason for dismissing this aim as a way of legitimately discharging the onus is to look at the mismatch of the areas of science covered in a standard school science curriculum and those manifested in those aspects of the world impinging upon citizens' lives. For this warrant to work, one would have to show a fairly tight alignment. I suggest that more is contained in usual science curricula than is so manifested. Given this, the best that this sort of aim could justify would be a curriculum of less breadth than those for which warrants are sought. Finally, it is not as if one copes or does not in an on/off way. Rather, one copes to a greater or lesser extent and what would have to be established by anyone attempting to discharge the onus by appealing to this "coping with science and technology" aim is that the individual would benefit sufficiently much more from the increased coping gained from science education to outweigh the loss of autonomy that is its cost. I don't find the prospects of this demand being met to be great enough to provide any comfort for the advocate of compulsory science education. I take this, then, to be another failed warrant. Clearly, my view is that the foregoing attempts at discharging the onus fail in fairly clearcut and obvious ways. I am, of course, open to challenge concerning my discussion of them but, pending such counter-argument, I think that serious defenders of forcing standard school science curricula on un-unwilling students should look elsewhere for a viable warrant. Others of our possible ways of discharging the onus look more promising.

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(INTRINSIC) WORTHWHILENESS OF SCIENTIFIC UNDERSTANDING AS PART OF A LIBERAL EDUCATION? Another possible rationale for forced science education is, to my mind, the most promising. This is the "liberal education" aim. What is at stake here is a conception of how we (or, in this chapter's case, I or you) want people to be. This is not so much so that they can do things that I judge to be good (like become research scientists, or good citizens, or productive workers) either for their own sake, or that of the group. Our previous discussion was of a broadly consequentialist sort in that I was discussing the merits of science education in terms of outcomes that would benefit them, or us, in the future. The general pattern of discussion was to ask if, as a result of their science education and the knowledge and skills that are residual from it into their adult lives, there was (sufficiently) increased benefit across-the-board (for the individual and/or for the group) to warrant the blanket autonomy suppression involved. Generally speaking, my judgement was that it was hard to see enough of an effect for enough people to warrant blanket prescription and forced acquisition. Given the swiftly dismissive nature of my analysis, it didn't much matter that we were operating with a fairly rough and ready conception of the benefits involved. I just "took it as read" that a nation being economically wealthy, or an individual being employed, or an individual being able to "cope" in a scientifically/technologically sophisticated society was a good thing without much bothering with the "why?" of things. Even on a rough understanding of these, the problem was that there was a disconnection of an obvious sort between science education and these supposedly consequential goods and what the detail of any deeper story was as to what counted as a benefit was beside the argumentative point. At this stage of my discussion, however, I want to clarify things a little further (though still only as much as my argumentation demands as opposed to refining ideas in fine detail as an exercise in its own right). In the foregoing, if we were to ask questions like: 'what is employment, societal wealth or "coping" good for?', and then, whatever the answers, further ask what they were good for and kept asking, then, on pain of a vicious infinite regress, such a chain of justification would have to run out in one or more valued states of affairs where, if asked why that is such a good thing, the answer would be that it just is. In short, that someone is, say, employed is extrinsically valuable and, in cashing out that extrinsic (or, as it is sometimes called, instrumental) value, we would, sooner or later, be appealing to something else that is intrinsically valued (in and of itself) as its deep motivating warrant. Without wishing to rehearse the byzantine details of utilitarian or consequentialist theories of ethics, I suggest that the likeliest candidate intrinsic value appealed to in cashing out answers to such questions would, in some sense, be human happiness. Why do we want someone prepared for the workforce? - because (with some intervening causal links) he would most likely have a happier life were he to be so prepared than if not. Why do we want society to be economically wealthy? - because its citizens would have their happiness improved as a result. Why do we want John to be able to "cope"? - because he would most likely have a happier life if he were to be able to than if not.

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As alluded to above, there are all sorts of complicating issues that are familiar within the moral philosophy literature but are unexplored here. One is the tension between group happiness and individual happiness. Depending on quite how the scarcely pellucid former gets cashed out, it might be best achieved by having John unhappy, a sacrificial lamb for the sake of the higher happiness of the group, collectively. But such complexities are indicated only to be ignored. My point is simply that, in some form or other, happiness is likely to be the intrinsic value at the bottom of the idea of individual or group benefit. I wished to expose and stress this because the rationale that I wish now to explore, and with which I have some sympathy, has a different intrinsic value in mind in its putative warranting of forced science education. Moreover, it is one that is arrived at directly rather than via a chain of arguments connecting some extrinsic good with its ultimately warranting intrinsic one (happiness in the above discussion). The warrant appeals to some sort of conception of how all citizens should ideally be. It might well be a complicated picture with many elements and some of those elements might be in tension with others in that one couldn't maximise all of them in all citizens because more of one might involve less of the other. We have seen this sort of tension illustrated above in that more happiness (via, say, more wealth) might be the cost of less autonomy. As is almost always the case in ethical decisions on complex matters, it is difficult to sort out where one's sympathies lie in a neat rank order way and such decisions are complicated by issues of degree concerning how much loss of one thing is the cost of how much gain in the other. My above judgements that the already considered putative warrants did not plausibly give enough benefit to outweigh the amount of autonomy loss that is their cost have already been nuanced by considerations of this sort as to the extent of benefit involved. This putative warrant is different though. The claim is not that we, or John, will be happy as a result of some regimen of forced science education; rather, the appeal is to another intrinsically valued state of affairs, one that is part, at least, of my conception of how all citizens should ideally be. How so? I will assume that the style of science education involved is meant to give students some knowledge of how the world works (or, at least, of our best warranted hypotheses concerning that). I am not, that is, concerned to consider any case for some of the more radical constructivist construals of science education4. I also assume that such science education is meant to give some grasp of how it is that such knowledge is arrived at and of why it is that such views receive that imprimatur as knowledge. Call these: 'knowledge about the world', 'knowledge of scientific method' and 'knowledge of the epistemic status of scientific claims'. What might thus be claimed is that science education is worth losing some autonomy for because it is an intrinsically good thing for individual citizens to have those three types of knowledge as part of their intellectual suite. I mean this primarily as a good thing for the individual. There is no suggestion that it is good for the group in any way that is not merely additive of those individual intrinsic goods5. Nor, to repeat, am I claiming that any happiness benefit will flow to the individual by having such knowledge - it might, it might not; but that is not the motivation here. The suggestion is simply that, other things being equal, an 4

For discussions of Constructivism in science education, see my 1999 paper, the papers in the 1998 anthology edited by Michael Matthews (and Harvey Siegel's 2004 essay review of it) and Andreas Quayle's 2007 paper; apart from these, the journal Science and Education is generally a rich lode of ore to mine on this topic. 5 See my 2006, pages 28-29 (of this online version) for a fuller discussion of this "merely additive" point.

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individual having such knowledge is an intrinsically better individual than one relevantly ignorant. In some sense, a better life is lived just in virtue of knowing something of the workings of the world, of how that knowledge has been arrived at and of why such knowledge claims should be deemed justified. Others' moral priorities might differ but all of this strikes me as having more chance of successfully discharging our onus as would-be autonomy reducers than our previously considered candidates. In answer to the old question: 'what is the good life?', I, at least, am inclined to reply that, in part anyway, it is a life lived in knowledge of the matters listed. And the suggestion that such knowledge is so intrinsically valuable than it is worth forcing people (or is it just students?6) to acquire it, is a suggestion that has justificatory promise - at least by reference to my priorities. After all, I have not said that nothing could ever be warranted that involved forced acquisition; all that I have suggested is that forced science education doesn't seem warranted by our earlier considered possibilities. One fault with some earlier putative warrants was that the many suffered autonomy loss for the individual good of the few or, at best for the good of the group via what that few might do. This concern seems, on the face of it anyway, not to apply here. Each person would be a better person (other things being equal) with such a suite of knowledge than without it. But there is another worry with this putative rationale, one that has concerned me in the past when considering the inclusion of compulsory philosophy of science in school curricula (Davson-Galle, 2006). How much of an intellectual transformation is it reasonable to expect science education to achieve across-the-board and how much decay of that intellectual state would occur over time? Answers to these questions will, I suggest, depend on just what one has in mind here. Two things are, however, blatantly obvious. First, the more abstract and complex the ideas involved, the more difficult it will be for them to be established in students' minds by science education. Second, the more the curriculum is a mass of detail, the more that detail will, generally, be forgotten. The former is a concern but the latter is not. Considering the latter point about detail, I am not advocating anything like a detailed content-rich traditional science curriculum working through the detail of laws of physics, chemical formulae and reactions, biological taxonomies and so forth. That such detailed clutter is lost quickly upon leaving school doesn't particularly upset me because that is not the level of understanding which I am considering as possibly being worth forcing upon students. What I have in mind here is a "broad sweep" introduction to our scientific understanding of ourselves and the universe of which we are part7. If we are talking of across-the-board science education, then what I would value is a skeletal treatment of the major ideas and themes of our current scientific picture of things with the flesh to be left to later specialist training or to those voluntarily pursuing such further knowledge. Of course all of this is rather vague and the chapter and verse of such a curriculum's content would be a largish task to articulate and would, no doubt, involve considerable debate even among those inclined to agree with such a shift from detailed science content to a focus merely upon "big ideas". That chapter and verse will not be pursued in this chapter. 6

There is a concern here: were adults not to value being as we value them being, should we force them to comply with our template, not just as to how they must behave but, as to the contents of their minds? 7 See Matthews, 1994, Chapter 3 on trends of this sort of a decade or so ago.

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Of course we could, with enough time, do both the big ideas and the detail. My point is simply that, so far, I can't warrant to myself such further loss of student autonomy especially when so little of the detail would be retained over time. Mind you, even a "big picture" science curriculum has concerns to be raised. It seems plausible that discussion-style pedagogy might be best suited to moving students' frameworks of belief from whatever they start with to the preferred framework. If the latter is not to be merely dogmatically held (and I find a dogmatically held set of beliefs to dubiously count as an intrinsic good) then students will have to not just hold the beliefs but understand something of how they came to be held and why that process is epistemically meritorious (if it is8). (These constitute the second and third areas of knowledge articulated above. Here things become awkward fast. These points, about the methods of scientific enquiry and about the epistemic justification of scientific frameworks of belief, become complex and sophisticated as soon as one enquires seriously into them. The latter one, concerning epistemology, is one that I have addressed previously (Davson-Galle, 2006) and the results of my analysis then were not sanguine. As observed above, the more abstract the material that is taught the less likely it is to be understood across a school cohort. Yet, if even the "broad brush" ideas of science are to be understood in a non-dogmatic way, then some grasp of epistemology is enjoined. I won't rehearse the detail of the earlier paper but the upshot of my analysis was that, beyond the most basic level of (partly misleading) "Nature of Science"-style dogma, epistemological understanding is not plausibly achievable to any great extent. There is some dispute as to what would be on the list9 of uncontroversial claims about the nature of science but say that, with respect to epistemic elements, some sorts of propositions like the following were among those that were the target for Johnny (and, later, John) to have as items of knowledge: 'one should generally believe what scientists are confident is true, because those beliefs are based upon observation and experiment (although belief should always be tentative because new data may be difficult for current theories to explain or new theories might be invented that to an even better job of explaining existing data)'. This is fine, the philosophically naive might think. But it leaves all the hard epistemic questions un-addressed and un-answered. Yet to pursue that complexity is, as I have noted in that earlier paper, unfeasible. Perhaps I am overly pessimistic but I will simply rest this chapter's case upon the assumption of that earlier paper's argumentation's soundness. In short, across the spread of school students, anything but achieving mere assertion of epistemic stances that are, perforce, overly simplistic, is not an available option. But is what is perhaps available, mere "learning off" of epistemic propositions, worth its cost in autonomy? In particular, is having such a collection of epistemic beliefs about the status of science of any intrinsic merit? In that previous paper, when I considered this question as part of a more general question about the role of philosophy of science in school science, I was in two minds concerning this but I was inclined to think that it might well be. However, the more I consider the merit of possessing such simplistic beliefs the more I consider it to be dubious that they are of any intrinsic benefit as part of the framework of belief of an intellectual agent. 8 9

See the references on Constructivism mentioned in Note 4, above. See Matthews, 1994, pp. 37-40 for a candidate list and McComas et al., 1998, p. 513 for another one (a version of the latter paper occurs as Chapter 1 of McComas, 2000).

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Consider the way that I spoke earlier. I listed three items of knowledge that might be judged intrinsically worthwhile for citizens to have. If the most that most students can have as a curriculum outcome is mere belief that such and such warrants a scientific hypothesis, then they don't seem to have epistemic knowledge concerning the status of such (putative) warrants. Certainly they don't have their epistemic views "first-person" warranted by having worked through the epistemological debates in the manner that academic philosophers might. Of course, in and of itself, that might not matter for the status of the belief as knowledge. It is familiar for epistemic agents to distribute such justificatory tasks so that much of what we would ordinarily claim that we know is justified on the basis of testimony. I hold a belief on the basis that a body of experts in that area hold that belief and that they have done their epistemic homework and are able to justify their views. In short, I am an epistemic parasite upon their expertise and judgement. Generally speaking, this is quite sound practice and, indeed, unavoidable unless one is to have an enormously restricted subset of one's beliefs that one can claim to know. Of course there is one glitch with this. In effect, what is being said is that I know because the experts know and I know that they know. It is the last bit that is problematic. One of the difficulties in sub-contracting epistemic tasks to others is knowing to whom that task can be safely passed. It is notorious that some humans are gullible in their endorsement of various "new-age" religious and alternative medical beliefs and practices on the basis of "expert" advice. I will assume that some such "experts" are deluded and their positive answers to a request for epistemic assurance: 'do you know this stuff to be true?' would be very unwisely relied upon10. The problem is by no means a trivial one. The United States would count as a fairly intellectually sophisticated country by world standards yet it is also well known as as having a surprisingly high proportion of Christians of a fairly unsophisticated sort with anti-scientific frameworks of belief11. Such people have undergone some sort of science education and, presumably, adjudicating between conflicting "experts" endorsing and advocating conflicting propositions on the same issue is part of the problem they face, and have failed to cope with, as intellectual agents. But upon what basis can they sensibly choose? One way to assist such agents is to walk them through a detailed exercise in philosophising about semantic and epistemic issues at hand. But, as noted above, this is simply beyond most students (and, I would suggest, teachers, for that matter) if what is in mind is a sophisticated enough engagement with the epistemic issues involved to be able to sort "sheep from goats" in choosing whose testimony to trust as a suitable authority on the matters at hand. One can assert authority and offer "Nature of Science" nostra for simple acceptance but the issue remains that others might offer contrary advice. This sounds to be quite a bind for students' chances of scientific knowledge. They can't justify their first-order scientific beliefs in any direct way by their own epistemic thought. Nor do they have the capacity to sensibly choose which of a range of competing claimants to authority to trust as legitimate sources of testimony to warrant their views indirectly. 10

Nor is the problem automatically just a problem to be found in some sort of intellectual fringe; controversies occur within the mainstream as well - the philosophical naivety of a good number of mainstream scientists is notorious within philosophy of science. 11 See Mahner and Bunge, 1996, on religious and scientific views' incompatibility and Matthews, 1994, p. 34 (and the "conceptual change" literature generally) on the persistence in students of what would be deemed to be false views despite them having undergone science education.

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As far as I can see, this rules them out as having scientific knowledge in the sense of knowing that their scientific beliefs are justified. Admittedly, that doesn't stop those views been indeed justified12. The epistemic status of an agent's beliefs is not automatically as that agent is in a position to judge. Thus Johnny's belief in various propositions of science might be without him being able to give any satisfactory warrant (of either a direct or an indirect sort) for such beliefs yet they might be warranted in the sense that epistemically competent judges judge them to be so. So, were we to be optimistic13 about the epistemic status of the broad architecture of some scientific framework of beliefs, could we legitimately force belief in such a framework upon Johnny in virtue of it being, indeed, knowledge, despite us being unable to have Johnny capable of judging that it is so? In effect, that is for us to ask him to take the offered propositions on trust without him being in a position to properly judge us as a trustworthy source of testimony. Why should he take our view rather than that of Pastor Pangloss of the Blessed Brethren of the Shoe? I don't see how we can answer this question in a way that is both generally comprehensible to students and philosophically legitimate. I deal with this issue of epistemic warrant at some length because it strikes me as a very serious issue for this "intrinsic worthwhileness" attempt to warrant a forced acquisition of at least the broad framework of a scientific picture of the world. Assuming the above pessimism about being able to rationally justify a scientific belief system to Johnny, science education (or, perhaps, "education") is tantamount to a form of indoctrination. As observed above, it is by no means clear to me that students' possession of a framework of belief that is held without conscious warrant is a state of affairs that I would favour in and of itself. (This is not, of course, to say that such a state of affairs is not extrinsically worthwhile; it might well be. But if such a framework of belief is good for something else to an extent that warrants imposing it by force, then there had better be some justification available that is more satisfactory than the ones considered in earlier sections of this chapter.) But what perhaps could be known by students is not that, say, species evolved by natural selection of some genetic variations over others but that most biologists believe that. Presumably this would require something like survey data concerning biologists' views being available. Yet, if so, then the same issues arise again. Do students have to follow enough statistics to see why some survey data warrants a particular interpretation? This is obviously too big an ask. Should they, then, just take things on trust and judge the survey claims as trustworthy testimony given that the work was done by reputable authorities? There is certainly enough dodgy social science around to cause some misgivings here14 thus the issue of judging claims to authority arises again. However, independently of the issue of surveys, one might assume that if a set of views is presented in textbooks, then that shows that such views constitute accepted conventional scientific wisdom. There is, of course, some danger that texts are over-simplified or just out of date but we are, after all, only talking of broad frameworks so perhaps they could be allowed to be a close enough approximation to "conventional wisdom". So, despite some misgivings, let me allow that there would be no great epistemic impediment to students being able to know that most scientists (in a field) believe such and such a suite of views. They could know that a thesis was conventional 12

Dancy, 1985 is a readable introduction to these matters; see Chapter 9 in particular. Again, see Dancy, 1985; this time, Chapter 1. 14 See Huck and Sandler's (1979) delightful analyses of dubiously interpreted data in published research reports. 13

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wisdom in science without knowing the thesis itself (that is, without themselves having any justified belief in it). Would such knowledge about scientists and their beliefs be worth having (in and of itself)? Maybe not. In effect, this would amount to Johnny knowing that one particular intellectual institution's members believe the world to be thus and so. Johnny might also know that those scientists believe their views to be justified. He might even believe those views himself15. What he doesn't know is whether these views are to be trusted or not. But what is so great about this situation? Is this an intrinsically worthwhile way for an intellectual agent to be? Not in my view. So, my present inclination is to think that this epistemic roadblock undermines the claim that student belief in the broad framework ideas of science is worth having in and of itself. So much, then, for the third and first of the three knowledge elements that I had in mind as constituting a possibly intrinsically valuable version of science education; what of the second: scientific method? Others may differ in their value-judgements but I had this in mind as part of a package with that package being intrinsically valuable. Concerning science, what would be intrinsically good would be for those three items of knowledge to be possible but if the only one that is possible is knowledge of the methods of scientific enquiry, would that be intrinsically worthwhile just by itself? Not to me. In any event, it is not at all clear that such knowledge is any more available than its fellows anyway. My previous concern, the general inability of students/citizens to comprehend complex and abstract ideas, arises again. There are at least two construals of this "knowing scientific method/s" potential aspect of science education. One is a normative, a priori, conception of how scientists should go about their enquiries. The other is a social science style description of how scientists happen to go about their business. I said that the former was normative. This is now a somewhat un-popular meta-philosophical conception of the intellectual status of philosophy of science. In effect, it suggests that philosophy of science might legitimately say something like: 'scientists should pursue their enquiries in such and such a manner, not in the manner that they are'. On the latter, one simply reports that scientists do, as it happens, pursue their enquiries in so and so a manner. Whether philosophy of science has this intellectual authority over science is controversial and it is no task of this chapter to engage in such meta-philosophy16. My purposes in mentioning this distinction are two. First, if one takes the normative construal of knowing the methods of science, then the issues are basically epistemic ones about the justifiability of the candidate method of operating in seeking to know what the world is like and my above discussion of this with its attendant pessimism applies again. In short, even if such knowledge is intrinsically worthwhile, the justification of such epistemic claims is a very complex business and having adequately considered views on such matters is beyond most students17.

15

But see Note 11, above See my 1990 for my engagement with that issue. 17 And, as touched on already, I suggest that teachers and scientists would find the same issues out of their field of expertise - my point does not, however, depend on the truth of that suggestion. 16

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Second, if one instead construes the knowledge as merely descriptive of the practice of scientists, then I will allow that such knowledge might be as readily available as our earlier discussed knowledge of what theses scientists in the field would subscribe to as true. Again there methodological concerns about the sorts of social scientific enquiry that yield such generalisations but, again, I will pass over any such hesitations and allow that such knowledge is available and that students could, at least, know that scientists pursue their enquiries in such and such a way (or ways). Here the issue is the worthwhileness of such mere knowledge that scientists act in certain ways without the capacity to appraise those actions. (Compare knowing that witchdoctors act in certain ways.) And note that it will have to be sufficiently worthwhile to warrant forcing such knowledge upon students. Again, I can't see enough value in such knowledge to warrant its forced acquisition. Others may differ of course but, if so, they should at least be clear that in attempting to warrant this aspect of possible science education as an element of a broader liberal education, then it is mere knowledge that practices occur without the capacity to appraise the legitimacy of those practices. (Again, compare this with knowing that witch doctors act in certain ways.) The upshot of all of this is that, despite its initial appeal (to me at least but it is certainly a common view), trying to warrant forced acquisition of a broad framework of scientific views in virtue of having such scientific knowledge being an intrinsically valuable thing seems to fail because the views in question would not be held by students as things that they know but would, at most, have the status of mere belief or, at best, knowledge that others have certain beliefs. And, I suggest, that is not status enough to be intrinsically valuable enough to override agents' own wishes about the contents of their own mind. In any event, if some version of this warrant is accepted, it would have to be by valuing mere belief as the desired state. The merit of such mere belief in central tenets of science as opposed to, say, superstition, would be their truth. This may be enough for some but not for me. This is, though, the closest of those that I consider to constituting a satisfactory aim upon which to rest discharge of the onus. So, another failed attempt. So far, so bad for justifying forced science education but what of our remaining putative rationales? As said before, however, even if what is learnt from compulsory science education is not intrinsically valuable, that does not stop it being extrinsically valuable.

PURSUING LIFE GOALS One thing that is sometimes advanced as a rationale for compulsory schooling is that students should be made to acquire various skills, items of knowledge and affective qualities because such things are "enabling"; in particular, they are things that assist students to successfully pursue their own life goals. As an illustration, being able to read and write and to communicate in a comprehensible way with substantial conformity to linguistic conventions is a precondition for pursuing most life goals especially if those goals require funding and the usual available source of sufficient money is via paid employment. Of course, there would be exceptions to this but, except when it is clear who these exceptions are (those severely intellectually disabled, or those with a substantial inheritance, for instance) it would seem that the probabilities favour forced literacy (to at least some set level) for all. Generally, this

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would seem to be a rationale that would discharge the onus in two ways. The first is that whatever Johnny might think of forced literacy, John is likely to retrospectively approve of it in that he appreciates being able to better pursue his life goals. Second, for most life goals at least, having such goals achieved is likely to be for John's individual benefit. I mean this literacy case only as an illustration and it doesn't matter if the above sketch is overly optimistic about its chances of success in discharging the onus in this "pursuit of one's own life goals" way. My point is: can compulsory science education (in some usually discussed variation or other) manage such a route to discharging the onus? In a word, no. For this putative rationale for forced science education to succeed, enough of the skills, content and so forth acquired by school science students would have to be present to a sufficient extent to contribute sufficiently to enough life goals of enough students (and without superior substitute causal elements being readily enough available) to outweigh the degree of across-the-board loss of autonomy that is entailed by the forced acquisition. I have left this as one rather convoluted sentence to emphasise just how many "boxes have to be ticked" here. The rationale won't work if enough individuals' life goals don't involve the deployment of whatever they would gain from science education. Nor would it work if, although relevant, things would not be in place to enough of an extent to have the effect desired. And so on down the various qualifications just listed. Note in particular the presence again of those qualifiers to do with the degree or extent of the success of the relevant causal connection. This focus upon the extent of the achievement of ends is a recurring theme of the chapter. Looking down my list, my judgement is that someone appealing to this sort of warrant in discharge of the onus is near doomed to failure. As is also a recurring theme of the chapter, I know of no empirical research that tracks such connections and, while I would be delighted to be pointed to such work, I simply don't think that it exists; and, if I am correct in this, then the appeal to the usefulness of science in the pursuit of one's life goals constitutes rhetoric without proper empirical support. Education is too expensive of society's resources and individuals' freedom to rest on mere rhetoric. One intermediary link in the causal chain from science education (as means) to goal satisfaction (as end) is if the goal is not directly science-connected but involves money. As was touched upon in the literacy illustration, the most common route to having money is employment and if the skills and knowledge etc acquired from science education were sufficiently connected to the performance of a sufficient number of jobs then our justificatory task would be more clearly satisfied. But, as discussed in an earlier section, it is simply blatantly obviously false that enough jobs require the spread of knowledge and skills under discussion for that to constitute a warrant for their acquisition. So, if this warrant is to work, one would have to be suggesting some other causal connection of either an indirect sort (as with the employment case but involving some different intermediary link) or a direct sort (where pursuing one's goal directly utilises scientific knowledge or skill). I can come up with various instances of particular connections (as I can with all of our putative warrants) but the difficulty facing the advocate of forced science education is that, to discharge the onus, there has to be something (or a summation of individual somethings) that applies fairly much across-the-board. Unless this is so, we are again replying to a student challenge with the unsatisfactory response: 'you all have to do all of this because some bits of

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it will prove to be useful, and in some cases necessary, for some of you achieving some of your life goals'. The trouble is that it is obviously not so. I take this to be an obviously failed warrant.

BECOMING A"GOOD CITIZEN"? The last candidate sets out to warrant science education by suggesting that it has a role to play in preparing students to fulfil the role of citizen. Of our three broad warrant strategies, this seems to most firmly fall into the camp of force being justified by appeal to the good of the group. Allow that we have some sort of broad aim of schooling generally being that it should help turn students into good citizens (or, perhaps, less directively, provide them with skills and knowledge that will assist them in being able to act as good citizens18). Even so, can we warrant the forcing of science education as being a sufficiently important part of the means for the achievement of the end: "good citizens"? I take the science education literature to consider this to be a major justification for school science19. I have considered this type of warrant in a past paper (Davson-Galle, 2006) but as a warrant that might be held to justify compulsory philosophy of science education (especially the ethics of science) and ended up thinking that it failed in that task. This is, however, a different kettle of fish and perhaps forced science education can be warranted in this way even if forced education in philosophy of science can't be. Despite that different focus, there are some similarities in my argumentative strategy to that earlier treatment. As will be a familiar refrain by now, the tasks facing the would-be onus discharger are many. First, "good citizen" has to be unpacked. Second, the knowledge, skills and attitudes that would be gained from science education that, prima facie, would seem to play some role as means to the achievement of the end of having good citizens will need to be identified. Third, these plausible "means-end" connection claims' soundness would have to be investigated and, in particular, two things would have to be clear: for what percentage of students we would get what degree of achievement of those aimed that ends and, for how long such achievement would last. Fourth, the pervasiveness, extent and persistence of the effects of the science education curriculum would have to morally add up to enough of a benefit to outweigh the loss of autonomy that is their cost. As will be predicted, I find each of these tasks to be problematic. First, the idea of the "good citizen" here seems to be one that has as one of its elements, the citizen making, or being able to make, decisions of a certain sort. (Note again the disjunction here. It is one thing to have a capacity and another to exercise it.) So, what decisions are in mind here? 18

Note that one should distinguish being able to do something from doing it; one obvious way in which the former, but not the latter might obtain is if one is without relevant motivation. 19 See Driver et al., 1996, p. 18 and Bell and Lederman, 2003, p. 353 for some discussion of what Driver called 'the democratic argument'; see also Matthews, 1994, Chapter 3 (especially p.36).

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In this context, presumably the focus would be on decisions that involve the application of scientific knowledge and/or the exercise of the skills of scientific enquiry and/or the influence of the affective attitudes typically driving scientific enquiry. Given that the driving idea is that of the "good citizen", I take it that it would be only those decisions that impact upon the group that we are talking about. As earlier, I will consider this impact to eventually appeal to the happiness levels of the group. So, we have citizens making decisions and some of those decisions affect the happiness of the group. Good decisions of this sort by citizens are those that increase the happiness of the group (or, at least, avoid decreasing it). In order to make some such good decisions, a citizen would have to have the sorts of knowledge, skills or attitudes fostered in school science curricula. Other things being equal, the extent to which someone is a good citizen is a function of the extent to which, when faced with such decisions, they make good ones. Even at this stage, I have two concerns. One is that it is by no means clear to me just how many science-using civic decisions are actually faced by citizens. Nor, of those, how many are of very much importance to the happiness of the group. No doubt some citizens are in the thick of things but for this to be a warrant for science education for all students, one would want one of two things to obtain. Either a fair majority of citizens will be in such decision circumstances often enough for their employment of the science forced upon them in school to generate enough group happiness to outweigh the across-the-board loss of autonomy involved or, alternatively, it may be that only a minority will be in such decisions situations but we can't, with enough probability, predict who and the decisions those few will make will be of such importance that it is worth society inflicting the knowledge (etc) on all students for the sake of the increased group happiness generated by the few who actually get to use their school science. Of course, to pick up on the earlier disjunction, we are also going to be making assumptions about citizens bothering to engage in such decision-making and, if they do, using their scientific knowledge (etc) to inform, and partly guide, their decisions. In short, with respect to the civic decisions made by good citizens, it is not at all clear what the likelihood is of enough citizens being faced by, and willing to engage in, enough science-informed decisions of enough importance that the resultant boost in group happiness outweighs the autonomy loss. Perhaps there is some empirical research on this issue but, as usual, my impression is that there is not (I know of none). Unless there is, the chances of this putative way of discharging the onus being anything beyond empty rhetoric are slim. Moreover, to return to the idea of the "good citizen", the role played by science in being such a citizen is, at best, partial. First, all that such science can supply to the arguments constituting rational deliberation about the issue at hand is what I earlier called 'descriptive premises'. What it won't do is supply moral premises20 articulating the ethical stances driving the decision. One can be scientifically informed concerning the options facing one in a decision situation yet be evil and choose an option that is anything but for the benefit of the group. It might be objected that no one is suggesting that science would be the whole story of such civic decision-making, just an important part21. Such a response is, however, unsatisfactory. 20 21

See my 2002 and, more elaborately, my (forthcoming) 2008. Focusing on this aspect is what people usually have in mind when talking of someone making an informed decision.

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If one is to warrant science education by appeal to its role in producing good citizens and unpack the relevant part of that as making good decisions then the warrant will not work if what one gets is scientifically informed but bad decisions. The moral and descriptive premises conjoin to generate the decision and, unless the former properly in place, then it is hard to see how just the latter would be of much use in the attainment of the desired outcome. A further problem here is that the most effective way of producing citizens with good values is by indoctrinating those values into them. There is possibly something to be said for this22 but note that there are all sorts of concerns about the whole notion of what the right values might be, ones that the briefest of forays into any undergraduate text in moral philosophy will make manifest23. I earlier unpacked the idea of a good citizen as one acting for the happiness of the group because that has been my impression of the values driving this putative justification of science education. However, that that is what one should be aiming for is itself controversial24. In any event, it is one thing to be confident that you have a set of values that you are happy to endorse and another thing to be willing to indoctrinate them in other people. Any such indoctrination of "good values" inherently involves further loss of freedom of thought (on those matters) and is, indeed, a somewhat more severe and longlasting negation of autonomy than the limited prison-sentence style loss of autonomously directed time that is entailed by most compulsory curricula (including forced acquisition of scientific knowledge and skill). Finally on this point, even if it were thought that it was good enough that having and deploying scientific knowledge was an aspect of acting in the manner of a good citizen, this putative justification would only work if there were not other aspects that were in rivalry with science education and even better served the end of having good citizens. This is no slight concern. Given the limited amount of time available for schooling and the jostling of competing claimants for time and space, to include science is to exclude something else. Perhaps better analytical skills in making critical sense of complex issues would be time better spent than learning science, or a greater understanding of political history, or... and so on. Anyway, there are rival ends suggested as curricular aims that might be worthier of pursuit. For instance, think back to the earlier quick discussion of being able to pursue one's own life goals. Such an aim would likely involve different curricular foci than a "good citizens" one. All in all, as soon as one begins to think seriously about the idea of students becoming good citizens as a possible motivating end for forced science education, problems emerge that are not manifest if things are left at the rhetorical level of "feel good" slogans. A second task facing those tempted to follow this path to discharge of the onus is to articulate a little more clearly the aspects of the mooted science curriculum that are seen as serving the "good citizen" end. One trouble here is much as before. Is it really possible to see the spread of disciplines of science and topics within them that constitute a usual science curriculum as all being relevant to the sort of science-involving decisions that citizens might face? I think not but the onus is on those using this aim to warrant compulsion to supply more detailed "chapter and verse" 22

I have discussed this in my 1995a and 1995b. See my forthcoming 2008, Chapter 9, for a sketch of some of the issues. 24 The proposal is a version of Utilitarianism and the moral philosophy literature is extensive on the issues. 23

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analyses. My hypothesis is that, at best, what would end up being warranted as a result of any such analysis would only be various fragments of science. No doubt some students will face situations where they are will be wanting to make decisions (as voters, say) and, in order for such decisions to be well-informed, some scientific knowledge would have to be utilised as descriptive premises in the arguments constitutive of their deliberations. But even in such cases, it is simply not at all clear how much use school science education would be. This is not because most of it would be forgotten (though I find that plausible) but because the science involved in such decision-making is usuallytoo complex to have been covered at school level. Two illustrations will suffice. At the time of writing, citizens in my region are in dispute about the desirability of a pulp mill (turning woodchips into pulp for paper manufacture) being built. One issue among many is if the proposed mill will impact upon the environment in various ways to an extent that, for some citizens at least, would be deemed to be a negative that would outweigh plausible economic benefits arising from the mill25. Environmental groups have commissioned scientific advice, as has the company proposing the mill and the State government has an odd history of setting up one appraisal process, aborting it and then hiring external consultants to produce another report in a faster manner. Needless to say, there have been competing claims about the lack of disinterestedness of each of these parties in choosing what scientific claims to put forward and emphasise but there has also been some first-order scientific dispute concerning those claims themselves. Will such and such a level of the mission of this gas, or that liquid effluent, produce this particular effect upon humans or that effect on seals or...? Will such a mill produce so-and-so level of toxic product or only such and such a level? And so on. Even if I remembered all that my science teachers had taught me, I can't see how that would help me in such a decision situation. I am in the hands of the experts. The best that I can manage is trying to decide which experts to believe; in terms used earlier, to whom I should "sub-contract" such premises in virtue of them being appropriate authorities. This is a difficult business and, as noted, school science is scarcely going to help. A second, more general, example is the global warming controversy. Again, competing claims are made and, curiously, it might seem as if the issue is resolved and that I can confidently trust that global warming is indeed a fact and, moreover, significantly caused by humans. In short, whatever debates there have been in the past, isn't the issue now settled? Fine but then there bursts upon the scene an article in the serious press counselling caution on the grounds that the vast majority of scientists have agreed on things before and been shown to be subsequently wrong and that they might be wrong this time as well because they seem to be not properly considering a rival hypothesis emphasising the role of cycles of solar emissions - at least according to some scientists. Again, I have a conflict among competing authorities' testimony and my school science will not be of any use in adjudicating such disputes. Even if it seemed to me that, say, the solar emissions theory is more plausible than the rising CO2 levels theory, some of those better educated in science than I am would disagree. Why should I trust my own semiignorant appraisal? But if not, whom to believe?

25

In pondering upon this example one can perhaps entertain the idea that compulsory economics would be another candidate school curriculum item.

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The issues that I wish to come from these two examples are that, even if I recalled all of my school science and explicitly deployed it in making science-involving decisions facing me as a citizen, it is simply not at all plausible that the right connections exist between what is acquired in school science and the making of "good decisions", even to the limitedextent of making merely scientifically informed decisions. It might be objected here that no one was ever suggesting that school science will cover the sort of chemical, biological and medical issues that arise in the pulp mill case, for instance. The claim would rather be that it would provide a basis for acquiring the relevant scientific knowledge so that an informed decision could then be made. At best, this sort of argument would seem to warrant aspects of school science but not the full spread of topics as not all of those topics would plausibly perform such a "basis providing" function. However, this is not the major difficulty. It is simply not established by research (and is, in any event, implausible) that even if citizens were to retain what was taught to them in their school science curricula, most would have the capacity to build upon that basis to become scientifically informed upon the issues or even to become informed enough to adjudicate among rival candidate authorities. Nor is it even established that a sufficient proportion of citizens will so use their science education to even attempt to become informed and (assuming other decision-making elements are present) make good decisions such that the resultant group benefit gained from this intellectually active subset of students warrants across-the-board compulsion to ensure that the subset is "caught and taught". Moreover, one would have to be confident that this subset could not be predicted in advance (so that one could, instead, selectively force science only upon those who are likely to produce such future group benefit). One would also have to be confident that, without school science, they would not be able to become sufficiently scientifically informed on an ad hoc basis in various decision situations to generate the benefit. That concerned citizens might pursue relevant knowledge regardless of what they learnt in school is not, on the face of it, an implausible suggestion to make. As is a familiar refrain in this chapter, I contend that no one has bothered to do research on the spread of issues at all and that, in the absence of the findings of such research, rhetoric and wishful thinking seems to be the rather unsatisfactory basis for stopping students choosing to learn what they wish to (or not learn as the case may be). The third of the above-listed tasks for the autonomy suppressor concerns the actual presence of the right causal chains between forced science education as means and good decisions as ends. Even were none of the afore-mentioned concerns to be crippling, any such "good citizen making good decisions" attempted warrant would plausibly fail owing to two other concerns. As noted above in another context, there are genuine concerns to be aired about the level of retention of whatever is gained from forced school science education. What are necessary for this line of justification to succeed are longitudinal research studies tracking students years and decades down the track to see if most still retain, to any sufficient extent, whatever aspects of their school science are deemed to be connected conceptually and argumentatively to science-relevant decisions they face and have faced and will face. I conjecture that the results of such research would be dispiriting for the advocates of forced science education (not to mention science teachers). Moreover, even if the elements relevant to some decision were still substantially in place in John's head as a result of Johnny's schooling, would John deploy them? To do so is for John to be willing to pursue the making of an informed decision. I question how much is known of citizens' serious engagement with the big science-relevant issues of their time.

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Quite possibly there is a literature more generally on citizens engagement or apathy and intellectual sloth concerning various civic issues and even if there were to be no such literature specifically connected to science-relevant issues (as I suspect to be the case) then it might well be that those mounting this putative defence of forced science education could find plausibly transferable research findings from other such issues. My conjecture is, though, that the results would be mis-pleasing. I am perhaps overly cynical about the qualities of my fellow citizens but I surmise that engagement would only generally occur if the issue were to be a local one that impacted directly upon individuals or one that bore upon high-level commitments that the citizen had. To illustrate my conjecture, consider my pulp mill example from above. I live in Tasmania and it is mainly one part of the north of Tasmania that would be affected directly one way or another by the mill's construction. The State government will ultimately exercise power on the matter and, in due course, voters will exercise power over the State government come the next election. So, one opportunity for them to make good decisions as good citizens is how they vote. My suspicion is that it will only be those in the north who would have bothered to try to follow the scientific "ins and outs" of the debate and in so far as the government's role in the pulp mill controversy is a factor in the thinking of voters from elsewhere in the State (itself a dubious assumption) the decision will be made in relative ignorance of the scientific issues involved. Why? - because it does not directly affect them. An instance of motivation to connect to an issue because of high-level beliefs and commitments would be the controversy concerning the history of the earth and thus the proper contents of the science curriculum. Some of those engaged with the debate (not necessarily as vocal contributors) are engaged because of religious convictions concerning the interpretation and truth-status of the Bible. Given that, they deem geological theory to be false. Hopefully they would make good decisions as good citizens but, as the history of this particular debate attests, objectivity of appraisal of the science involved (even if John is intellectually capable of it) is not plausibly going to happen if extra-scientific yet powerful motivations exist for one stance in the debate being adopted. It is by no means clear how efficacious any science education could26 be in the face of such a prior conviction. In summary of this point, will John retain enough of his forced school science to contribute usefully to decisions of a science-relevant sort that face him as a citizen? And, even if he did, would he bother to deploy such skill and knowledge rigorously enough, enough of the time, to make forcing such skill and knowledge on Johnny justified? As is patently obvious, I am pessimistic here. However it is not my intellectual duty to support my pessimism so much as that of the user of this "good citizen" putative warrant to support their optimism so that the onus can be discharged. Fourth, I reiterate that whenever empirical evidence is available, it would have to demonstrate, or at the least very plausibly suggest, that forced science education for all gives a benefit to an extent judged sufficient to outweigh attendant autonomy loss. So, it would have to establish that what occurs in such science education would be relevant to some particular range of civic decisions for some number of citizens, that the results of such science education would be generally retained to some identified extent and that such residual skills and knowledge would actually be generally deployed with some degree of rigour in some specified subset of civic decisions to which they are relevant. 26

See note 11, above, Siegel, 2004 and my 2004b.

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This is a complex "ask" of empirical researchers but something like this would have to be available for the onus to be discharged for we have to have a feeling for how much of a benefit we are likely to get as a group from forced science education before we can judge if it is enough of a benefit to an outweigh its cost - diminution of student autonomy. In summary, the upshot of all of this is that it is not at all clear that those advancing such a "good citizen" rationale can provide the requisite evidence that forced science education actually produces benefits for the group of the sort envisaged and/or to an extent that outweighs the loss of autonomy involved in the achievement of that benefit. It should also be remembered that if the goal is group benefit, then there may well be ways of negating student freedom that would more plausibly produce enough benefit to outweigh such autonomy loss. So, even if I am wrong and forced science education comes out ahead on a (group benefit/loss of freedom) benefit/cost "equation", rival courses of action might do even better. For instance, if what one wants is good citizens and if that is clarified as those that act for the increased happiness of the group, then we might be better off spending the time freed up by dropping the compulsory science curriculum for moral indoctrination of the virtue of benevolence. I judge this to be another failed warrant, one that fails to make its case beyond rhetorical flourishes.

COMBINATIONS? Sometimes warrants that fail individually can succeed collectively. Although I have judged that none of what are sometimes aired as justifying forcing science on Johnny have made out a case either in terms of John's retrospective endorsement, benefit accruing to John and/or benefit accruing to society, perhaps a plus point here from such and such a rationale added to another plus point there from another rationale, added to... would all add up to enough of a total benefit to outweigh autonomy loss and thus successfully warrant forced across-the-board science education for all students. Perhaps. It's very hard to sensibly judge this in an empirical vacuum. I have suggested that little has been done to longitudinally track the extent to which putative good consequences actually do obtain. Given this, it is hard to do any such additive calculations where what are being added together are of unknown extent. The best that can be managed is an informal guess based upon one's general knowledge of the world and of one's fellow citizens. In my case, I judge matters pessimistically. For me then, the onus would no more be discharged by our rationales in combination than by them severally.

CONCLUSION The conclusion that I reach from the above is that none of the extant warrants for forcing science education on all students succeeds in discharging the obligations associated with the onus argument. Unless either some error has occurred in my argumentation (perhaps concerning some impressions of mine about the paucity of empirical research on key matters)

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or some other rationale is offered that fares better, the current situation in schools is morally indefensible. Science education in anything like its present form should cease to be compulsory and should be an option. It is without aims of sufficient merit and achievability to be worth forcing on people. I have noted that I finished an earlier paper by observing that its argumentative strategy might have success against more targets than that of that paper. I could make the same observation again (the compulsory mathematics curriculum, for instance, seems to me to in large part be a total waste of time). Does this mean that I am some sort of mad radical enthusiast for total liberty of thought and action on the part of students (and older folk)? No. There are certainly areas of learning that I would force into students' (and, for that matter, deficient adults') heads with a clear conscience and for reasons that I consider to satisfactorily address the challenge of the onus argument. It is just that science is not one of them.

REFERENCES Bell, R., and Lederman, N. (2003). 'Understandings of the Nature of Science and Decision Making on Science and Technology Base Issues'. Science Education, 87, 352-377. Dancy, J. (1985). Introduction to Contemporary Epistemology. New York: Blackwell. Davson-Galle, P. (1990). History and Philosophy of Science: Mixture or Compound?'. In D. Herget, (Ed.), History and Philosophy of Science in Science Teaching (pp.113-127). Tallahassee: Florida State University. Davson-Galle, P. (1994). Philosophy of Science and School Science. Educational Philosophy and Theory, 26 (1), 34-53. Davson-Galle, P. (1995a). 'Advocatus Diabli or Advocatus Dei?'. Critical and Creative Thinking, 3 (1), 28-34. Davson-Galle, P. (1995b). 'Rejoinders to Cam, Cresswell and Hobson'. Critical and Creative Thinking, 3 (1), 41-42. Davson-Galle, P. (1999). Constructivism: a Curate's Egg. Educational Philosophy and Theory, 31 (2), 205-219. Davson-Galle, P. (2002). Science, Values and Objectivity. Science and Education, 11 (2), 191-202. Davson-Galle, P. (2004a). 'Philosophy of Science, Critical Thinking and Science Education', Science and Education, 13 (6), 503-517. Davson-Galle, P. (2004b). Understanding: 'Knowledge', Belief' and 'Understanding'. Science and Education, 13 (6), 591-598. Davson-Galle, P. (2006). Why Compulsory Science Education Should Not Include Philosophy of Science. Science and Education (published online prior to hard copy issue DOI 10.1007/s11191-006-9043-9) http://www.springerlink.com/content/78514161m5753217/?p=a6c17c4ed08347be86cf0c6c0c f43ca6 and pi=59 Davson-Galle, P. (forthcoming 2008). Reason and Professional Ethics. Aldershot: Ashgate. Driver, R., Leach, J., Miller, A., and Scott, P. (1996). Young People's Images of Science. Bristol: Open University Press. Huck, S. and Sandler, H. (1979). Rival Hypotheses. New York: Harper and Row.

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Matthews, M.R. (1994). Science Teaching. New York: Routledge. Matthews, M.R. (2000). Forward and Introduction. In W.F. McComas (Ed.), The Nature of Science in Science Education: Rationales and Strategies (pp. xi-xix). Dordrecht: Kluwer. McComas, W.F. (Ed.) (2000). The Nature of Science in Science Education: Rationales and Strategies. Dordrecht: Kluwer. McComas, W., Clough, M., and Almazroa, H.(1998). The Role and Character of the Nature of Science in Science Education, Science and Education 7(6), 511-532. Quayle, A. (2007). Radical Constructivism and the Sin of Relativism. Science and Education, 16 (3-5), 231-266. Siegel, H. (2004). The Bearing of Philosophy of Science on Science Education, and Viceversa: the case of Constructivism. Studies in History and Philosophy of Science35, 185198. Siegel, H., and Smith, M. (2004). Knowing, Believing and Understanding. Science and Education,13 (6), 553-582.

In: Progress in Education, Volume 17 Editor: Robert V. Nata

ISBN 978-1-60692-505-8 © 2009 Nova Science Publishers, Inc.

Chapter 3

BECOMING DIFFERENT: PERSPECTIVE TRANSFORMATION THROUGH POST-REGISTRATION BACCALAUREATE NURSING STUDIES Melanie Birks, Ysanne Chapman and Karen Francis School of Nursing and Midwifery, Monash University, Gippland Campus, Northways Road, Churchill, Vic., 3842 Australia

ABSTRACT Education has the potential to transform. For nurses employed in complex, constantly changing health care environments, continuing education is essential. Postregistration baccalaureate courses are an important means by which certificate and diploma qualified nurses can upgrade their existing qualifications to degree level. Often nurses who wish to pursue tertiary education are constrained by geography, work and personal commitments. The increasing number of courses offered by international universities provides a mechanism for accessing higher education that would otherwise be unobtainable for nurses. This paper reports on the experience of change that accompanied a post-registration degree course undertaken in off-campus mode by nurses in Malaysian Borneo. As part of a larger study employing grounded theory methodology, these findings are discussed in the context of the development of professional identity through perspective transformation.

Keywords: baccalaureate nursing education; grounded theory; Malaysia; perspective transformation; post-registration degree studies

INTRODUCTION Occupying a position at the front line of health care ensures that the nursing role is diverse and subject to the forces of change that are ever present. Nurses must therefore possess the ability to adapt to the rapidly changing, dynamic nature of the health care setting.

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The economic and social implications of existing within a global environment further compound the situation for nurses who strive to provide a high standard of care in circumstances where client and employer expectations are high and resources poor. Baccalaureate level education continues to offer a solid foundation for registered nurses who wish to increase their knowledge base and improve their skills in order to enhance the care that they provide in practice. The purpose of this paper is to explore the process by which registered nurses in Malaysian Borneo experienced change and ultimately a professional transition through the acquisition of such knowledge and skills from an off-campus, postregistration degree program.

BACKGROUND The complexity of the nursing role has increased exponentially over recent decades in response to scientific, technological and economic advancements. The demands that are placed on nurses will continue to increase and existing knowledge, skills and attitudes will be challenged as the pressures on the health care environment show no sign of abating in the future. This is particularly the case for nurses in developing countries such as Malaysia (Shamsudin, 2006). Here specific health issues and a lack of resources often present barriers to nurses as they strive to provide quality care, a situation that has seen the standard of nursing practice being criticized in recent years (Samy, 2006). Baccalaureate nursing education is an important factor in meeting the demands of a health care system that is becoming more and more complex (Rush, Waldrop, Mitchell, & Dyches, 2005). For nurses to rise to the challenges that changes in the practice environment present, higher educational qualifications are a necessity (Lillibridge & Fox, 2005). In Malaysia, nursing lacks the status of other occupations in this country which is compounded by the fact that most nurses possess the minimum certificate or diploma level qualifications. Many nurses recognize the importance of further education for their personal and professional development and therefore seek entry into the tertiary education sector through postregistration degree programs (Chiu, 2005). Post-registration degree programs provide a mechanism by which registered nurses can upgrade their existing qualifications. Sociocultural and political issues limit the amount of tertiary education options available for nurses in Malaysia (Chiu, 2005). Nurses in more remote locations within Malaysia, including those in the eastern states of Sabah and Sarawak on the island of Borneo, have even fewer study options. Since the 1990s, there has been an increase in the number of international universities seeking to offer courses off-shore (Stockhausen & Kawashima, 2003). Malaysia too has been affected by this trend, with international institutions offering post-registration and post-graduate nursing programs via a variety of educational modalities. The flexibility offered by such delivery methods ensures that nurses who would otherwise be prohibited by shiftwork requirements, personal commitments and geographical isolation, can access tertiary study. Health and nursing are global issues. The globalization of nursing education ensures an appropriate focus on sociocultural issues within the broader context (McKenna & Samarawickrema, 2003). Through baccalaureate nursing studies, registered nurses are able to acquire the knowledge and skills that serve to transform their performance in the workplace to positively

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effect patient outcomes (Delaney & Piscopo, 2004). Whether post-registration degree courses impact directly on patient care has been questioned (Hardwick & Jordan, 2002; Zuzelo, 2001). It is clear, however, that education does result in changes for the nurse both personally and professionally that at the very least indirectly influence nursing practice (Wood, 1998). This research explores the nature of change that was experienced by registered nurses in Malaysian Borneo through undertaking off-campus post-registration degree studies in the context of the process by which it occurred.

STUDY DESIGN Grounded theory methodology, as described by Glaser and Strauss (1967),and later developed by Strauss and Corbin (1990; 1998) and Charmaz (2006), was employed in this research. In using grounded theory, the researcher aims to explain the phenomenon under study through the production of a theory that is generated from and grounded in raw data (Speziale & Carpenter, 2007). The emphasis of grounded theory on process makes it particularly suitable for this study. In recognition of the unique sociocultural environment of the setting in which this research was conducted, we employed grounded theory within an ethnographic framework that incorporated guiding symbolic interactionist and constructivist philosophies (Birks, Chapman, & Francis, in press).

Becoming professional

Becoming different Bringing others along Seeing things different light

in

a

Thinking differently

Seeking knowledge, discovering learning

Figure 1. The process of becoming professional through baccalaureate degree studies.

The setting for this study was the East Malaysian States of Sabah and Sarawak on the island of Borneo. Participants in this study were registered nurses who had completed the Bachelor of Nursing (Post Registration) course through one Australian university that had offered the program via off-campus mode in Malaysia since 1999. All but one participant were female. Approval for this study was obtained from the University’s ethics committee prior to commencement. Data was collected using ten in-depth individual and five focus

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group interviews. These interviews were conducted in five locations across the two states that comprise Malaysian Borneo. A qualitative data analysis software program (NVivo 7) was employed for the purpose of data management. Theoretical sampling, concurrent analysis and the use of memos, characteristic of grounded theory methodology (Strauss & Corbin, 1998), ensured rigour and aided the direction of data collection, analysis and theory generation. This paper describes a significant component of the theory that was generated from our research into the impact that undertaking post-registration degree studies had on nurses in Malaysia Borneo. The theory generated from this larger study explains the process of seeking knowledge, discovering learning through becoming different to the eventual outcome of becoming professional (Figure 1). The following discussion describes the largest phase of becoming different.

FINDINGS – BECOMING DIFFERENT The experience of undertaking post-registration degree studies saw nurses in Malaysian Borneo going through a process of becoming different. The extent of change varied. For some the transformation was quite noticeable and distinct, for others it was gradual and an extension of previous education and experience. A conscious awareness of change was not always realized until the outcomes of study were explored and discussed. The process of becoming different occurred across a number of dimensions: Yeah, I’m different, yes… As a person, as a nurse, as a professional, yes. In seeking knowledge the nurses expected changes and outcomes in regard to that knowledge. The actual nature and extent of change that resulted from the process of becoming different was, however, unexpected: I know that I will change… I tried to learn more of course I expect myself to change but I really feel… a lot of difference... Of course… I expect myself to have more knowledge after spending money, going through all this hardship… of course I… [have] confidence I will have more knowledge… but I really… [am] happy and, and proud… it changed me… The nurses had become different as a result of their studies. This change was reflected in a new way of thinking and a changed attitude. The new perspective that was adopted by the nurses could not be contained within themselves as they sought to bring others along to their new way of thinking, feeling and being.

Thinking Differently Undertaking baccalaureate studies in nursing resulted in a change in thinking processes and skills. Completing the degree changed the approach that the nurses had towards

Becoming Different reasoning, problem solving and decision-making. thinking were developed as a consequence of study:

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Such skills in analytical and critical

It will make you more [of a] critical thinking type of person…doing the degree, yeah… Make[s] you think… not like [you] just go to the ward and then you work [and] after that you just go back, no… But somehow, there’s a difference between those who… take up [the] degree and those who [do] not… in terms of knowledge and… critical thinking… Both the content and process of study provided tools that contributed to the change in thinking. Learning about frameworks for such things as problem solving and change management are examples of content that facilitated thinking differently. The actual process of studying at tertiary level necessitated the development of higher order cognitive skills: It is the reflection that is important. With the reflection… comes a sense of wanting to be more responsible, right, and… want[ing] to improve. When you are reading something you just say oh, why can’t we apply [it]? It can be done elsewhere, can’t we try to apply [it] in our own setting? You tend to think, you tend to have that type of thoughts coming… The change in thinking, while occurring as an internal process, manifested in various ways outwardly. Nurses were less impulsive in thought, speech and action, a consequence of what one nurse in this study referred to as ‘professional thinking’. Thinking differently was most powerfully expressed in the ability to transform and transfer the knowledge acquired through study in the practice area and sometimes beyond. Prior to doing the degree care provision occurred with a more task orientated mentality as this approach was characteristic of basic training. The nurses were responsible and hard working prior to undertaking the degree, yet discovered enhanced abilities to organize and deliver care as a result of their studies. Theory was utilized in a variety of practice contexts with confidence and positive effect: And when [the] accreditation people… came… my unit [got] a very good remark. And, and the surveyor [said]… I’m the only person who clearly document[ed] everything and show[ed] it to the surveyor when they [came]… That made my… hospital director [change his attitude] towards me because after [the] survey my unit got [a] very good [report]… The concept of praxis was embraced during and following completion of degree studies, if at times subconsciously. The experience gained from developing critical, supported arguments in the writing of academic papers during the course reinforced the need to ensure an evidence-based approach to practice and in interactions with patients and others: … in the degree, we are asked to write some paper[s]… everything you have to backup with literature... So from there the way we do the assignment then we will know that… in our daily management, our daily life as a nurse… I will remember okay, you must have… support… only then people will give [things to] you… now before I go and talk, I will do my homework first.

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Certain course content was more applicable by different nurses in different contexts yet all subjects were considered of value. Some topics of study were particularly highly valued, likely reflecting the lack of comprehensive coverage of such subjects in previous education. The value of research and skills in data collection were embraced. A new perspective on the rights of patients and the need to ensure protection of these was adopted as a result of studies in law and ethics. Skills in practical areas such as health assessment and documentation were enhanced as were those in communication. Leadership and management subjects developed such skills in nurses at all levels of practice. Organisation and delivery of patient care on the individual level were improved, as was the ability to lead and manage staff: And every time you are given a project [you thought well], I’m going to do it well… not sort of trial and error you know because… you have the theory already and you would like to apply those theories…Remember we are doing this management one, the Kurt Lewin’s theory, the change management? Well it actually [will] make you think… what action you should do first. It actually has changed… my style of management and if [there are] any changes I want to bring about… I won’t enforce… it to them because I realize that you are working with a group of people and [if] you want to be effective, there are certainly things that must take place. You cannot just… change as you’d like... The value of some subjects, although not initially apparent, became evident when their applicability to practice was revealed: [Nursing theory] was the first topic that we attempt[ed] you know. I sa[id] my goodness, that is how the tertiary study, the degree level is… But after we completed the unit, we finally realize[d] that this is something that… [is] very fundamental to back up our… thinking… [about] why we are a nurse and who we are. That is what… I think that unit gave us…who we are and… what we have to do… after I have done the study then I come to th[at] conclusion. Otherwise we don’t realize. We thought that, never mind… a nurse is a nurse. Not all the knowledge obtained from degree studies was altogether new, often old ideas were given a fresh perspective. Knowledge obtained from previous study and experience was refined and consolidation as new knowledge was accommodated and assimilated. Existing practices and beliefs were supported, reinforced and validated: It is inside me all this while but with the studying, with my studies it sort of, you know, reinforce. And I am glad that what I’ve been practicing is very well supported. You know, when you are reading… this is my belief and you feel pleased that… what you believe is there, on paper, you know, in black and white… A change in the ability to think was a significant outcome of post-registration degree studies. Such changes did not occur in isolation but contributed to and were accompanied by changes in attitudes, values and beliefs.

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Seeing Things in a Different Light Nurses in Malaysian Borneo who undertook degree studies experienced changes beyond the cognitive processes that were described as thinking differently. An affective change occurred in which existing attitudes were altered and a changed perspective was adopted towards many aspects of their personal and professional lives: …you tend to see things in a very different light altogether… The wealth of new knowledge and enhanced thought processes resulted in a challenging of old values and an ability to see the world through a fresh light, a new lens: …after I [had] taken my… degree in nursing it helped… me to see thing[s] in a very wide way… the more you read… the more you [are] exposed it [makes a] lot of difference in looking at things… when there’s a problem here, when there’s a project for you to solve or whatever like [with a patient], you look at thing[s] in a very different way… before I took my degree I only focus [on] thing[s] in one way… Greater insight and less complacency saw a more positive outlook develop both within and outside of the workplace: Even in your own other personal life, the way you look at life, [it’s] different. The enlightenment enabled a new appreciation of nursing. Completing a degree in nursing resulted in a new understanding of what nursing is, should and can be. Most significant was the recognition of what nursing is not. Notions of the nurse as a dependent handmaiden were rejected: I think the greatest change is... how we look at ourselves as nurses. So, are we a nurse, a nurse that is only following doctors’ orders? Or are we a nurse… [with] knowledge and… something to say? So, are we treating the patient correctly? … in the past… we are always… dependent on somebody’s idea, somebody’s view, somebody’s instruction. We always lean on somebody else i.e. the doctors, the other… allied health professionals. We always are leaning on… them, we can not make our own decision[s]. Say [for] example… pressure sore[s], you don’t have to wait for the doctor, we must make our own nursing diagnosis. And so that means to say that we must be independent. The ability to ‘see things in a different light’ following the completion of baccalaureate studies extended beyond the role of the nurse in practice to the status of the profession itself. The status of nursing as a profession was validated and borne out by the experience of study. Nursing was seen as a distinct, respectable profession. Nurses saw themselves as equal with, rather than subordinate to, other health care professionals. The accountability and responsibility associated with being a professional was accepted as nurses acknowledged their own role in securing and maintaining this status:

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For now, number one, we learn to help our own nursing, if nobody want[s] to help nurses, who is going [to]? If we as a nursing profession, we do not want to protect our own nursing, we do not want to help our nurses, who is helping? The doctor will not help us. While the belief that nursing was a profession may have been held to some extent before the degree, for many this was an awakening. Only one participant in this study rejected the issue of professional status as important, favouring maintaining a focus on the foundational principles of nursing: …about the politics in nursing, I think nursing is nursing, what we should do is tak[e] care of patients, that is our main job, main duty… New perspectives on nursing as a profession and in practice resulted in a renewed enthusiasm for work. A new pride in and passion for nursing was discovered. Nursing was no longer just a job. There was more to daily life than simply going to work and coming home at the end of the shift. A new concept of work as interesting and enjoyable was conceived: …the job becomes very, what do you call that? It’s very exciting…there are times I think we’ve probably just taken it as a job, but… it’s not just a job. You know, there is something exciting in it… you know that you can contribute. The contrast of altered conceptions to those held previously was a manifestation of the difference that possession of a nursing degree and the associated knowledge made. Those who completed the degree saw the difference in themselves as a nurse after completing the course. They also recognized a difference between themselves and others who had not undertaken study at this level: Those who have done the degree… they can… perform their work better. They’re more confiden[t], you see… and you can actually interact better with them, than those who have not done their degree. The ‘different light’ was therefore shone upon others. Varying levels of frustration developed with the attitude, behaviour and practice of those who did not share this new conception of the profession and enthusiasm for the role of the nurse. Those who were viewed with this critical eye included junior nurses, colleagues and management. Previously unseen failings such as complacency, lack of initiative, failure to advocate for patients and inadequate communication skills were illuminated from a new perspective. A drift into declining standards of care had become apparent to these nurses. Was this a new trend or had it only become apparent because of the new lens through which the world was filtered? In any event, the frustration and critical sensitivity were tempered where there was an awareness that they themselves were like this before having the opportunity to undertake tertiary study: You see for example I go to the ward… I say why [doesn’t] this patient… have [an] IO chart? [They say] “Doctor didn’t order”. Oh god! Well that made me angry. For [another] example… patients already [are] dying… gasping, it is not visiting hours, all the relative[s]

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[are] outside… I just don’t understand why they didn’t change their mind, why are they so straight, so rigid that you know they cannot come in. So I always tell them [to] let them come in, let the family be with the patient the last journey, last minute. Everybody very straight…Very fixed and I feel that I was like them before… I feel that I don’t blame them…but sometime[s] I still want to scold them… after I scold [them I] pity them… if they have money to go for [the] degree they will make [a] difference, they will be different. The image that was portrayed by nurses was also captured by the now critical focus of the graduates’ eyes. The impact of the negative presentation and conduct of others was a source of further frustration and disappointment for those who had been exposed to the knowledge and experience gleaned from baccalaureate studies. The frustration and disappointment was intensified by awareness that this portrayal further diminished the image of the nurse within the health care team and, more especially, amongst the general public: People only look at you as a carer…but nursing actually is a profession, it’s a very respectable profession but people [think] “oh you [are a] nurse... oh no”, you know?... You know this is how… people see you, not as a profession[al]. People are look[ing] at you [as] equivalent to the clerk, the ward clerk [and] we are not, so this is how you [present] yourself. Although there were improvements in the image of nurses and nursing as displayed through the media, there remained concern about the harmful impact that resulted from the negative perception that was held by others. Nursing was considered a “lowly”, rather than noble occupation, indicating a lack of understanding amongst health care professionals and the public alike as to the role of the nurse in reality. Parents tended to discourage their children from a career in nursing, especially if they were academically strong. The profession in Malaysia was seen to be dependent, remaining under the control of the medical fraternity even at governmental level. The fight to overcome these images was to be a difficult one, particularly in an environment in which one nurse was asked by a doctor “do you need a degree to carry a bedpan?”. Exposure to an international degree course and literature from a broader nursing environment heightened the awareness of constraints faced by the profession locally. For some nurses in Malaysian Borneo this experience was not their first exposure to an international perspective of nursing. Few had worked or studied overseas prior to undertaking the degree and others had been vicariously exposed through the experience of colleagues. Nevertheless the outcome was the same. A point of reference was established against which nursing in Malaysia could be compared. Although there was recognition of cultural variations there was also a measure of concern and dissatisfaction at the lack of progress of the profession locally. All that was illuminated by the new light was not entirely positive, yet there remained an appreciation of the real rewards that accompanied completion of the degree. The nurses in this study graduated from a course that was not recognized by the Malaysian Government at the time, yet chose this program because it enabled them to study off-campus on a part-time basis. Some degree of frustration was felt by those nurses who experienced a lack of reward

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and a limitation in function as a result of not possessing a recognized qualification, particularly for nurses employed in the public sector. Certainly, recognition, promotion and the accompanying remuneration would have been welcome, but these were seen as secondary rewards. True rewards came in the form of other positive outcomes such as the ability to perform better in practice and contribute to the profession. These were seen by most nurses as a bountiful return for the time, effort and expense invested in study. Enlightenment came from degree studies, both in terms of how the graduate saw their world and how their thought processes changed. They were seeing things afresh and ultimately wanted others to experience this new perspective. The advantages were potentially far reaching. Colleagues, family and friends shared in the spoils of tertiary study. Ultimately the patient and the profession would reap the benefits.

Bringing Others Along Completing a degree brought with it a new responsibility towards other nurses and the nursing profession. Possessing new knowledge, a changed way of thinking and valuing was accompanied by a desire to influence others so that they too would become different. This outcome was achieved in a number of ways, but most directly through the sharing of knowledge. More than a desire, there was almost a compulsion, an automatic tendency to share knowledge with colleagues and junior nurses. The knowledge that was shared went beyond simply factual information. The importance of such things as critical thinking, good communication, reading, quality care and accountability was imparted to others. Beyond the overt sharing of knowledge, the ability to influence other nurses was achieved covertly by role modeling: I have been trying to practice what I feel… should be the way, you see. And in a way…I’m able to influence the others nurses… Yeah, the role modelling is very important… in my own ward, my own environment, when I observe how the nurses approach, they are actually following me, you know? Together with the degree came the credibility necessary to be taken seriously as a role model. Application of the knowledge, skills and attitudes gained from degree studies often served as an example that was followed by others resulting in improvement in practice and patient care. Ultimately the aim of influencing others was to build them up as professional nurses. The need to develop subordinate staff through delegation was acknowledged. Degree studies had shown nurses the true significance of the profession and a desire to protect it. Building up junior staff to become future leaders and to continue the cause was seen as a means to this end: We have to build them up to be a leader like what we are… I think this is a very important aspect also, not only to supervise them, to teach them, we also have to delegate the work to them… they should be the future leaders to take over, to take over our place… we want the profession to continue… we are proud of the profession we want the profession to progress further not only to stay put there or…regress…

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The need for more, if not all, nurses to obtain a degree was strongly felt. Tertiary study was seen as a means to many ends, which included career development, self improvement, improved patient care, enhanced status and overcoming the deficiencies inherent in basic training. The nurses who had completed baccalaureate studies recognized positive changes in themselves and wanted others to also experience such benefits. Motivating and encouraging others extended to offers of support and guidance to nurses who had enrolled in a degree course or were contemplating doing so. Advice on dealing with finances, managing time and surviving study generally was freely offered in order to assist others to join the ranks of baccalaureate qualified nurses. Either intentionally or by osmosis, the positive effects of having successfully completed tertiary study spread beyond the workplace to the setting of an example for extended family and friends. Education is highly regarded in Malaysian culture and obtaining the degree cemented the ability to influence others outside of the workplace with both immediate and wide-ranging impact: …we’re all from[a] poor family in a sense. But I said to [my children] that should never become a hurdle because as long as you are willing to work hard you’ll be able to make it in life, but you cannot make it without education either, these two must go together… it is a… motivation tool actually… …in my community we [have]… this motto… ‘one degree for every family’ and this is a motto set up because we are a very small community and we said if we don’t do that then in the near future our community might just vanish. And to be able to be [on] par with other people because we are so small we must be able to, to achieve to the level [of] other communit[ies]…So this is the message we are sending down to all the people… in the village and everywhere.

DISCUSSION The process of becoming different for the nurses in this study was a bridge between their original desire for knowledge and the ultimate outcome of this experience which saw them becoming professional. The transformation that impacts on nurses personally, professionally and in practice through post-registration degree studies is well documented (Brown, 2000; Chiu, 2006; Fraser & Titherington, 1991; Hardwick & Jordan, 2002; Lillibridge & Fox, 2005; Ritchie, Evans, MacNeil, & Micsinszki, 2005; Rush, Waldrop, Mitchell, & Dyches, 2005). The eventual change that occurs has been described as a socialization (Alverson, Brown, & Pepa, 1999) or resocialization (Cragg, Plotnikoff, Hugo, & Casey, 2001) to the profession of nursing. Maltby and Andrusyszyn (1997) argue that neither term is appropriate because as registered nurses, some degree of professional socialization would have occurred prior to returning to study. For this reason these authors prefer the term ‘perspective transformation’ to describe the process that these nurses go through when undertaking baccalaureate degree courses. Perspective transformation as a theory of adult learning has been developed over the last three decades by Jack Mezirow, arising from his research into women returning to study

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following a long break (Taylor, 1997). The use of this term to describe the experience of nurses undertaking post-registration degree studies sees it remain consistent with these origins. The cognitive and affective changes that represented becoming different for the nurses in our study, along with their desire to effect changes in others, described such a transformation of perspective. The perspective transformation that occurs through undertaking post-registration baccalaureate study is empowering (Maltby & Andrusyszyn, 1997). Witt (1992) identifies such courses as a means of developing attitudes and behaviours to counter oppression in nursing. This effect is an important one for nurses and the nursing profession generally, yet is particularly significant for nurses in Malaysia. Nursing in Malaysia struggles against low status and a poor image, being viewed as a menial occupation rather than a profession in its own right (Bryant, 2003). Problems of power and status are of course not confined to nursing in Malaysia, these remain elements of oppression for the profession in the broader context (Fletcher, 2006, 2007). The changes that were evident for the nurses in our study support the assertion that perspective transformation has occurred with liberating effects. Roberts (2000) proposes a model of professional identity development for nursing that provides a framework for examining and explaining this process. Within this framework, nurses move through stages of unexamined acceptance, awareness, connection, synthesis and political action. The first three of these stages are relevant to our discussion of the findings described above. Unexamined acceptance describes a phase during which nurses exist in a state of unawareness. Nurses are accepting of their situation because this is the only environment with which they are familiar and they therefore fail to sense anything amiss (Witt, 1992). MacIntosh (2003) refers to a similar concept of ‘assuming adequacy’ which she attributes to a lack of reflection on the part of the nurse. For nurses in Malaysia the situation is confounded by the role and status of women generally, given that the profession in this location is more than 99% female (International Council of Nurses, 2006). Although women in Malaysia enjoy a stronger social status than those in other Asian or Muslim countries (Kent, 2006), they nonetheless face social and economic inequalities that are culturally driven (Ariffin, 1999; Luke, 2001). We argue that, while nurses in the western world face an oppressed status relative to women in their broader communities, the situation is reversed for nurses in Malaysia. In this country, the status of women in the workplace is higher than in the home (Luke, 2001; Wiedemann, 2003). Nurses experience less oppression in the workplace, relative to their position in society at large, than do their international colleagues. The process of identity development will therefore be somewhat different for these nurses. The yardstick by which their status is measured is calibrated against the broader environment, revealing a relatively better situation in the workplace. The shift from unexamined acceptance to awareness is therefore more significant for nurses in Malaysia. It is through a process such as education that the shift from unexamined acceptance to awareness occurs. Awareness for participants in this study began with them being exposed to a new world of knowledge and learning. The ability to use, transform and transfer this knowledge fed the awareness. Thinking differently as a finding of this study reinforces the outcomes of research into similar courses (Lillibridge & Fox, 2005; Ritchie, Evans, MacNeil, & Micsinszki, 2005; Zuzelo, 2001). Earlier work also found that nurses are able to apply knowledge from post-registration degree studies in practice (Brown, 2000; Fraser &

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Titherington, 1991; Lillibridge & Fox, 2005) and integrate it with existing experience (Rush, Waldrop, Mitchell, & Dyches, 2005). Our finding that nurses were able to bridge the theory practice gap did, however, conflict with findings from some previous research (Hardwick & Jordan, 2002; Zuzelo, 2001). The development of critical thinking abilities specifically, as described by the participants in our study, has been explored in other post-registration nursing degrees, with conflicting outcomes. For the most part, researchers found that critical thinking ability increased with exposure to baccalaureate nursing courses (Brown, Alverson, & Pepa, 2001; Chiu, 2006; Harrington, 1996; Yeh & Chen, 2005). Other studies found no absolute difference as a result of study (White & Gomez, 2002) or no difference relative to pre-registration nursing students (Girot, 2000; Shin, Ha, Shin, & Davis, 2006). The study by Girot (2000) found that academic rather than practical experience was more likely to enhance decision making skills, explaining the enhanced ability in this regard for the participants in our study. A significant outcome for the nurses in our research is the change in perspective described as seeing things in a different light. Tertiary studies situated participants in a position from which they could reexamine their role as nurses, the profession generally and the behaviour of others from a new perspective. Such changes are crucial as nurses move through Roberts’ (2000) initial stages of identity development and consolidate their state of awareness. Changes in the way that post-registration baccalaureate nurses view their role and the profession have been identified in earlier research (for example Alverson, Brown, & Pepa, 1999; Rush, Waldrop, Mitchell, & Dyches, 2005; Stockhausen & Kawashima, 2003; Witt, 1992; Zuzelo, 2001) although, generally speaking, discussion of these issues in the context of post-registration degree studies is limited. While significant to the profession globally, such concerns are less likely to be evident in research into post-registration degree outcomes. Why then were a greater understanding of nursing and a new perspective on the status of the profession significant outcomes for the nurses in our study? An explanation can be found in the emphasis that Mezirow (1997) places on the importance of cultural context when considering perspective transformation that results from education. Despite the standing of nurses in Malaysia being stronger than that of women in society in this location, nurses still experience professional status that is less well developed than their counterparts internationally. Maltby and Andrusyszyn’s (1997) belief that nurses do not undergo resocialization as a result of returning to study, while relevant in western society, may not be true of the participants in our study. The profession is less developed in Malaysia and some degree of professional socialization is clearly occurring as an outcome of the perspective transformation experienced by these nurses. The new understanding and appreciation of their role as a nurse, plus an increased regard for the profession, together with a rejection of negative images and a reduced tolerance for poor behaviour of others, may well reflect the greater disparity between their own earlier experiences of nursing and new insights gained from their studies. The third stage of Roberts’ (2000) model of identity development is connection. Roberts believes that it is during this stage that nurses seek out other nurses who share their developing identity. Such a situation is possible where there exists a critical mass of nurses who hold similar perspectives. Baccalaureate nursing programs in Malaysia are, however, relatively new and the ability to forge such relationships is reduced. Connection for nurses in Malaysia therefore occurs through the strategies discussed above as bringing others along. The professional enhancement of others through strategies such as role modeling, sharing

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knowledge and encouraging others to study, has immediate positive effects for both the nurses and the work environment. The desire to share the benefits of study with others is a recognised offshoot of baccalaureate study, both in the workplace (Leonard, 2003; Rush, Waldrop, Mitchell, & Dyches, 2005) and amongst family (Zuzelo, 2001). In the case of these baccalaureate nursing graduates, such activity goes further in that it produces the support system that is vital for their developing professional identity. The findings discussed in this paper describe the process of becoming different for nurses who completed degree studies in Malaysian Borneo. These nurses experienced a perspective transformation that involved movement from a state of unexamined acceptance, through the lengthy process or awareness, to a point of establishing connection. While the findings discussed here only describe this transformation as occurring as part of the process of study for these nurses, the outcome of this process, that of becoming professional would see the nurses move through the final phases of Roberts’ (2000) model (Figure 2). Political action

Becoming professional Synthesis

Becoming different

Connection

Bringing others along Seeing things different light

in

a

Thinking differently

Seeking knowledge, discovering learning

Awareness

Unexamined acceptance

Figure 2. Becoming different within a framework of professional identity development.

IMPLICATIONS, LIMITATIONS AND RECOMMENDATIONS The findings of this study have a number of implications for nursing research, education and practice. The manifestations of the process of change that result from post-registration degree studies serve to inform areas such as curriculum design, policy development, and workforce planning. Educators can draw from the experiences of individuals who have

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undertaken baccalaureate nursing degree studies in order to enhance the development and delivery of tertiary programs for registered nurses. The liberating effect of the perspective transformation that accompanies completion of a post-registration degree affirms the value of such courses. The findings discussed above provide direction to labour force policy-makers in undertaking necessary structural and procedure workplace changes that capitalize on the broader constructive outcomes indicated by this study. It is clear that the experience of undertaking a post-registration degree course was a positive one for the participants in this study. The perspective transformation expressed by these nurses as cognitive and affective changes had a flow on effect to the workplace and those within it. This outcome reinforces Rambur, McIntosh, Palumbo and Reiner’s (2005) conclusion that baccalaureate education for nurses has implications beyond the individual that extend to others and ultimately impact at the societal level. Nurses who have a positive attitude to their role and their profession are less likely to seek opportunities for employment in other locations where they feel more appreciated, an issue that has been of concern to the health care system in Malaysia (Bryant, 2003). Generalisation of findings is not the intention of qualitative studies such as that reported here. It is possible that the focus on one educational institution providing a specific course in one location may be regarded as a limitation, although the contribution of these findings to existing knowledge is not diminished given the specific aims of this research. Another potential limitation in this study is that those nurses who volunteered to participate may have done so as a result of recognition and appreciation of the extensive positive changes that they had experienced through the process of study. Further research that explores courses offered by various institutions via different modes of delivery may serve to confirm, clarify and enhance the findings reported above. Wildman et al. (1999) suggests that the experiences of others, such as patients, colleagues and managers should also be considered. The perspective of these significant individuals may prove valuable in enhancing that of the nurses themselves in studies such as the one described here.

CONCLUSION This paper has described the process of perspective transformation as experienced by nurses in Malaysian Borneo through undertaking post-registration degree studies. Such a transformation is not an unexpected consequence of education. In the case of the nurses in this study, however, the significance of the process of change is greater when considered in the broader sociocultural environment in which it occurred. The professional identity development that characterized this process, although requiring contextualizing to accommodate the unique nature of the broader environment, was personally and professional empowering. The potential of education to produce outcomes that are far reaching is made clear from the findings of this research and serve to remind educators and policy makers that the impact of further education for nurses should not be underestimated.

REFERENCES Alverson, E., Brown, J. M., & Pepa, C. A. (1999). News, notes & tips. Role conception of RN-BSN students. Nurse Educator, 24(4), 9-10.

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Ariffin, R. (1999). Feminism in Malaysia: A historical and present perspective of women's struggles in Malaysia. Women's Studies International Forum, 22(4), 417-423. Birks, M. J., Chapman, Y. B., & Francis, K. L. (in press). Grounded theory methodology in action: Transforming method in exploring outcomes for baccalaureate nursing graduates in Malaysian Borneo. . In A. Morales (Ed.), Distance education issues and challenges. New York: Nova. Brown, J. M., Alverson, E. M., & Pepa, C. A. (2001). The influence of a baccalaureate program on traditional, RN-BSN, and accelerated students' critical thinking abilities. Holistic Nursing Practice, 15(3), 4-8. Brown, S. E. (2000). Does a multi-disciplinary health degree provide a satisfactory postregistration course for nurses? A follow-up survey of health science studies graduates. Nurse Education Today, 20(8), 613-619. Bryant, N. H. (2003). Women in nursing in Islamic societies. Oxford: Oxford University Press. Charmaz, K. (2006). Constructing grounded theory: A practical guide through qualitative analysis. London: Sage. Chiu, L. H. (2005). Motivation for nurses undertaking a post-registration qualification in Malaysia. International Nursing Review, 52(1), 46-51. Chiu, L. H. (2006). Malaysian registered nurses' professional learning. International Journal of Nursing Education Scholarship, 3(1), 12p. Cragg, C. E., Plotnikoff, R. C., Hugo, K., & Casey, A. (2001). Perspective transformation in RN-to-BSN distance education. Journal of Nursing Education, 40(7), 317-322. Delaney, C., & Piscopo, B. (2004). RN-BSN programs: Associate degree and diploma nurses' perceptions of the benefits and barriers to returning to school. Journal for Nurses in Staff Development, 20(4), 157-163. Fletcher, K. (2006). Beyond dualism: Leading out of oppression. Nursing Forum, 41(2), 5059. Fletcher, K. (2007). Image: Changing how women nurses think about themselves. Journal of Advanced Nursing, 58(3), 207-215. Fraser, M., & Titherington, R. (1991). Where are they now? The career paths of graduates from post-registration degrees in nursing in England. International Journal of Nursing Studies, 28(3), 257-265. Girot, E. A. (2000). Graduate nurses: Critical thinkers or better decision makers? Journal of Advanced Nursing, 31(2), 288-297. Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. New York: Aldine. Hardwick, S., & Jordan, S. (2002). The impact of part-time post-registration degrees on practice. Journal of Advanced Nursing, 38(5), 524-535. Harrington, J. H. (1996). Research abstract. Socialization into the professional role as experienced by the RN/BSN. Pennsylvania Nurse, 51(11), 18. International Council of Nurses. (2006). Asia nursing workforce profile 2006. Retrieved 23 July, 2007, from http://www.icn.ch/Flash/sew_awprofile06.swf Kent, J. (2006, 8 March). Malaysian women 'suffer apartheid'. Retrieved 12 April, 2007, from http://news.bbc.co.uk/2/hi/asia-pacific/4784784.stm Leonard, T. (2003). RN to BSN: Advice on returning to school. AORN Journal, 77(3), 598600.

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Lillibridge, J., & Fox, S. D. (2005). RN to BSN education: What do RNs think? Nurse Educator, 30(1), 12-16. Luke, C. (2001). Globalization and women in academia: North/West-south/east. Mahwah, N.J.: L. Erlbaum Associates. MacIntosh, J. (2003). Reworking professional nursing identity. Western Journal of Nursing Research, 25(6), 725-745. Maltby, H. J., & Andrusyszyn, M. A. (1997). Perspective transformation: Challenging the resocialization concept of degree-seeking registered nurses. Nurse Educator, 22(2), 911. McKenna, L. G., & Samarawickrema, R. G. (2003). Crossing cultural boundaries: Flexible approaches and nurse education: A case study. CIN: Computers, Informatics, Nursing, 21(5), 259-264. Mezirow, J. (1997). Cognitive processes: Contemporary paradigms of learning. In P. Sutherland (Ed.), Adult learning: A reader (pp. 2-13). London: Kogan Page. Rambur, B., McIntosh, B., Palumbo, M. V., & Reinier, K. (2005). Education as a determinant of career retention and job satisfaction among registered nurses. Journal of Nursing Scholarship, 37(2), 185-192. Ritchie, L. A., Evans, M., MacNeil, M., & Micsinszki, S. (2005). "Surviving": Registered nurses' experiences in a baccalaureate nursing program. International Journal of Nursing Education Scholarship, 2(1), 12p. Roberts, S. J. (2000). Development of a positive professional identity: Liberating oneself from the oppressor within. Advances in Nursing Science, 22(4), 71-82. Rush, K. L., Waldrop, S., Mitchell, C., & Dyches, C. (2005). The RN-BSN distance education experience: From educational limbo to more than an elusive degree. Journal of Professional Nursing, 21(5), 283-292. Samy, F. A. (2006). Government nurses not up to par. The Star online. Retrieved 15 May, 2006, from http://thestar.com.my/news/story.asp?file=/2006/5/15/naions/14242984&sec=nation Shamsudin, N. (2006). 30th anniversary editorial. Better late than never. Journal of Advanced Nursing, 53(3), 262-263. Shin, S., Ha, J., Shin, K., & Davis, M. K. (2006). Critical thinking ability of associate, baccalaureate and RN-BSN senior students in korea. Nursing Outlook, 54(6), 328-333. Speziale, H. S., & Carpenter, D. R. (2007). Qualitative research in nursing: Advancing the humanistic imperative (4th ed.). Philadelphia: Lippincott Williams & Wilkins. Stockhausen, L. J., & Kawashima, A. (2003). An evaluation of an Australian bachelor of nursing program for Japanese nurses: Perceptions of Japanese nurses' learning experience. Nurse Education in Practice, 3(4), 212-219. Strauss, A. L., & Corbin, J. M. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, Calif.: Sage Publications. Strauss, A. L., & Corbin, J. M. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory (2nd ed.). Thousand Oaks, Calif.: Sage Publications. Taylor, E. W. (1997). Building upon the theoretical debate: A critical review of the empirical studies of Mezirow's Transformational Learning Theory. Adult Education Quarterly, 48(1), 34-59.

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White, M. J., & Gomez, G. (2002). Critical thinking. Outcomes of critical thinking and professional attitudes in RN/BSN completion programs. Nurse Educator, 27(2), 71-72. Wiedemann, C. (2003). Women working for reform. Retrieved 12 April, 2007, from www.qantara.de/webcom/show_article.pho?wc_c=307&wc_id=20&wc_p=printmode= 1 Wildman, S., Weale, A., Rodney, C., & Pritchard, J. (1999). The impact of higher education for post-registration nurses on their subsequent clinical practice: An exploration of students' views. Journal of Advanced Nursing, 29(1), 246-253. Witt, B. S. (1992). The liberating effects of RN-to-BSN education. Journal of Nursing Education, 31(4), 149-157. Wood, I. (1998). The effects of continuing professional education on the clinical practice of nurses: A review of the literature. International Journal of Nursing Studies, 35(3), 125131. Yeh, M., & Chen, H. (2005). Effects of an educational program with interactive videodisc systems in improving critical thinking dispositions for RN-BSN students in taiwan. International Journal of Nursing Studies, 42(3), 333-340. Zuzelo, P. R. (2001). Describing the RN-BSN learner perspective: Concerns, priorities, and practice influences. Journal of Professional Nursing, 17(1), 55-65.

In: Progress in Education, Volume 17 Editor: Robert V. Nata

ISBN 978-1-60692-505-8 © 2009 Nova Science Publishers, Inc.

Chapter 4

PERSPECTIVES ON HEALTH EDUCATION RESEARCH – VULNERABLE POPULATIONS Lisa M. Jamieson and Gloria C. Mejía University of Adelaide, Australia

ABSTRACT Health education research is a predominantly Western construct. Problems frequently arise in regards to idea communication and project ownership when investigations are implemented among vulnerable populations, particularly when researchers are from non-vulnerable backgrounds. Participatory Action Research (PAR) is a relevant methodology in health education research involving vulnerable populations because of its fundamental tenets that power be equally shared between the researchers and the researched, that data and information not be removed from their contexts, and that the data collection process be directly influenced by history, culture and local environment. Contemporary health behaviour models, such as the PRECEDE-PROCEED planning model and the Diffusion of Innovation model, suggest that health education interventions among vulnerable populations have much to gain from embracing more holistic, PAR approaches, which in turn are more likely to result in a sustained reduction in harmful health behaviours among vulnerable populations.

INTRODUCTION This chapter considers perspectives on health education research in relation to vulnerable populations, as separate from health education research perspectives on general populations. The challenges of applying theories for understanding health behaviour change among such groups are addressed, and key concepts to consider when developing sensitive interventions among vulnerable populations defined. PAR as a useful methodology in health education research among vulnerable groups is described, as is the utility of the PRECEDE-PROCEED planning model and the Diffusion of Innovation model. Two case studies are provided by way of example, one in a developing country context and the other in a developed nation.

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DEFINITION OF “VULNERABLE POPULATION” There is inconsistency in defining “vulnerable” populations (Ruof, 2004). Bio-ethicists such as Kottow (2003) argue that vulnerability is intrinsic to human nature and that at some point all humans are vulnerable. Some argue that labelling certain groups as vulnerable is demeaning (Danis and Patrick, 2002), while others hold that non-vulnerable groups have a special responsibility towards those who are vulnerable (DeBruin, 2001; Goodin, 1985). Vulnerability is a basic principle in European bioethics and biolaw, along with autonomy, dignity and integrity (Partners in the BIOMED-II Project, 1998). It is thought to express the finitude and frailty of life, and considered to be an object of moral principle. Vulnerable populations may thus be defined as those whose autonomy, dignity or integrity are threatened and for whom assistance should be provided to enable them to realise their potential. In the health education research context, vulnerable populations may be considered as those groups whose demographic, geographic or economic characteristics impede their health or access to health care services (Blumenthal et al., 1995). The health, and health-related behaviours, of vulnerable populations is unique to that of non-vulnerable groups within a given country or community, with vulnerable groups tending to be less educated, more often living in poverty and less likely to have adequate health care access than their more privileged counterparts. The proportion of persons below the poverty level is higher among vulnerable populations in most developed countries (Australian Institute of Health and Welfare, 2006; New Zealand Ministry of Health, 2006; US Department of Health and Human Services, 2000; Health Canada, 2006). Many differences in health status and access to health care between vulnerable and nonvulnerable groups can be attributed to socio-economic rather than racial, ethnic or cultural factors. However, as the effects of culture, poverty, racial discrimination and culturallyinsensitive health services are usually inter-related, it is often difficult to disentangle the relative contribution of these factors on observed health differences. Other barriers, including language and long travel distances for rural residents, also disadvantage vulnerable populations in relation to access to health care.

THE SCORE OF HEALTH EDUCATION Health education is an essential component of health promotion – a social and political process aimed at improving socio-economic and environmental conditions and strengthening community action to improve health (Smith et al., 2006). Simonds (1978) defined health education as “bringing about behaviour changes in individuals, groups and larger populations from behaviours that are presumed to be detrimental to health, to behaviours that are conducive to present and future health”. Subsequent definitions of health education emphasised voluntary, informed behaviour changes, for example, in 1980, Green and colleagues defined health education as “any combination of learning experiences designed to facilitate voluntary adaptations of behaviour conducive to health” (Green et al., 1980). The Ottawa Charter for Health Promotion defines health education as “the process by which people are given knowledge, awareness, and the skills needed for them to take greater control of their own health” (WHO, 1986).

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Health education includes not only instructional activities and other strategies to influence health behaviour, but organisational efforts, policy directives, economic supports, environmental activities, mass media and community-level programs. It covers the continuum from disease prevention to the detection of illness for treatment, rehabilitation and long-term care. Health education is delivered in almost every conceivable setting – from the most privileged communities in developed nations to the most impoverished areas of third world countries.

APPLYING HEALTH EDUCATION THEORY TO VULNERABLE POPULATIONS Attention to the unique characteristics of vulnerable populations has been renewed in recent years, as health disparities persist despite advances in modern medicine (US Department of Health and Human Services, 2000; Australian Institute of Health and Welfare, 2006; Morris et al., 2005). The rationale for specific health education research programs among vulnerable populations appears to stem from four observations: (1) the growing diversity among vulnerable groups in many nations; (2) the increase in health disparities between such populations; (3) the differences in behavioural risk factors prevalence across vulnerable groups, and (4) the differences in health behaviour predictors across vulnerable populations. In order for health education projects among vulnerable populations to be effective, they need to be designed with a deep understanding of the target audience, their health and social characteristics, as well as their beliefs, attitudes, values, skills and past behaviours. As described by Resnicow and colleagues (2002), one of the most fundamental principles in contemporary health education research among vulnerable groups is to “start where the people are”. In the same vein, only 200 years earlier, the Danish philosopher Kierkegaard suggested that “in order to truly help someone, I must be able to understand what he/she understands. If I do not do that, then my greater understanding does not help him/her at all. The helper must first humble himself/herself under the person he/she wants to help and thereby understand that to help is not to be the most dominating but the most patient, to have a willingness for the time being to put up with being in the wrong and not understanding what the other understands” (Bloom, 1989). Some academics contend that conceptual health behaviour models derived from a professionally-centric perspective fail to incorporate the social, psychological, cultural and historical characteristics of vulnerable populations (Sullivan et al., 2006). For example, Social Cognitive Theory emphasises individual-based determinants such as self-efficacy, personal goals, self-evaluative expectations, self-management and assertiveness skills (Bandura, 2001), which are rooted in what Jones (2004) considers to be Eurocentric, predominantly male values of competitiveness, materialism, personal achievement, impulse control and selfdeterminism. Such individual-centred models are, some have argued, too mechanistic and fail to adequately account for environmental determinants such as stress, racism, poverty, poor access to health services that for many vulnerable populations may be more influential than individual motivation alone (Crosby, 2006).

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In the contrasting approach, it is assumed that the fundamental determinants of behaviour operate similarly among all populations, and that psychological and behavioural models can be successfully adapted across a range of diverse vulnerable groups (Bandura, 2001). However, it has been suggested that successful adaptation requires an integrative understanding of the unique environment of the target population, and that modification of conventional health behaviour change models need to take the unique characteristics of such populations into account. Health education research among vulnerable populations requires investigators to examine ethno-centric (or professionally-centric) assumptions inherent in their methods and to attempt to incorporate alternative conceptualisations of human experience. This requires a perspective whereby researchers approach a community not from a deficit model, which assumes one way assistance, but with the intention that they will learn and benefit from their experiences as much as the target audience. It means embracing the view that the community has resources, wisdom, solutions and energy that can be mobilised to improve its health status. These are the central tenets underpinning Community-Based Participatory Research (CBPR) and in particular, Participatory Action Research (PAR) approaches, which are increasingly being used in health interventions involving vulnerable populations throughout the world (Baum et al., 2006; Potvin et al., 2003). CBPR and PAR are described in more detail below.

COMMUNITY-BASED PARTICIPATORY RESEARCH (CBPR) AND PARTICIPATORY ACTION RESEARCH (PAR) CBPR is a collaborative approach to research that aims to produce knowledge that will be translated into positive social change (Israel et al., 2001). It engages the community in all phases of research. CBPR is particularly effective in addressing health and health care disparities, developing culturally sensitive instruments and in providing the means for a deeper understanding of communities and their circumstances. It is an exceptionally useful tool in research involving vulnerable groups. Although each community-researcher partnership develops its own values in CBPR, pioneers such as Israel and colleagues (Israel et al., 1998; Israel et al., 2001) identify the following set of key principles: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Recognise the community as a unit of identity Build on strengths and resources within the community Facilitate collaborative partnerships in all phases of research Integrate knowledge and action for mutual benefit for all partners Promote a co-learning and empowering process that attends to social inequalities Involve a cyclical and iterative process Address health from both positive and ecological perspectives Disseminate findings and knowledge gained to all partners Involve long-term commitment by all partners

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CBPR includes several approaches to research that actively involve communities such as PAR, feminist research and community research (Israel et al., 1998; Israel et al., 2001). Among these, PAR is particularly appropriate for research among vulnerable populations; it evolves from critical theories with a focus on oppressed groups and therefore requires an understanding of authority and power relations of all partners (Hagey, 1997). It stems greatly from the work of Freire on critical reflection (action and reflection go together) and his “pedagogy of the oppressed” (Freire, 1970). At the core of PAR methodology is empowerment through community engagement and capacity building. PAR consequently serves two functions: a research function, to show processes, progress and results, and an action function; a tool for reflection, discussion and decision-making (Baum et al., 2006). In both research and practice, PAR is collective, selfreflective inquiry undertaken by researchers and participants so they can improve healthrelated practices and situations in which they find themselves. The reflective process is directly linked to action, influenced by understanding of history, culture and local context, and embedded in social relationships. The researcher is not an external observer in PAR, but is constantly challenged by ideas, events, information and arguments posed by study participants. PAR requires researchers to work in close partnership with the community; requires each player to learn methods of working together to manage potentially conflicting agendas; including differences in priority perceptions, community politics and interpretation of findings. The PAR movement consequently challenges the system of knowledge control established through mainstream research. However, PAR should not necessarily be considered as an alternative to existing scientific processes, but as a way in which theoretical understanding and social progress may be enhanced. PAR expands conventional approaches in three important ways: the focus is on research that aims to enable action; it advocates for power to be equally shared between researchers and the researched; and it does not aim to remove data and information from their contexts. Although in the words of one researcher PAR is “a painful, self-reflective process” (Wallerstein, 1999), it is the ultimate method in health education research among vulnerable populations in regards to ensuring cultural sensitivity.

CULTURAL SENSITIVITY Cultural sensitivity is one of the most widely accepted principles in health education research, and is particularly pertinent in projects involving vulnerable populations. There is little evidence, however, on how to achieve cultural sensitivity, and how to measure its impact on psychosocial and behavioural outcomes, particularly among vulnerable groups (Patrick et al., 2006). According to Resnicow and colleagues (1999), cultural sensitivity can be conceptualised in terms of two primary dimensions: surface structure and deep structure. Surface structure involves matching intervention messages to observable characteristics of a target population. For print and audiovisual materials, surface structure may involve using people, places, language, music, foods, brand names and locations familiar to the target audience. Surface structure includes identifying the most appropriate settings for program delivery. It also entails understanding characteristics of the behaviour in question, and the context in which the health behaviour occurs. Surface structure refers to the extent to which

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interventions fit with the culture, experience and behavioural patterns of the target audience (Resnicow et al., 1999). Deep structure, the second dimension of cultural sensitivity, is less readily visible, especially among vulnerable populations. It reflects how cultural, social, psychological, environmental and historical factors influence health behaviours differently across different populations (Marin et al., 1995). This includes understanding how members of the target population perceive the cause and treatment of illnesses as well as how they perceive specific health behaviour determinants. Deep structure involves appreciation for how religion, family, society, economics and the government, both in perception and influence, target behaviour. For example, many poor farmers in Uganda believe that white workers are covertly encouraging the spread of HIV/AIDS in their communities (Ssali et al., 2005). When implementing health education projects among such groups, including messages that incorporate, though not necessarily condone, such beliefs may enhance program acceptance. Whereas surface structure generally increases message comprehension, deep structure conveys salience. Put another way, surface structure establishes the acceptability of an intervention, whereas deep structure is essential for project impact (Dunn et al., 2006). Although most vulnerable populations share common values regarding issues such as family, there are differences in some core values that may influence how health behaviour interventions are tailored. For example, core cultural values for vulnerable people of African origin in the United States are often described as including communalism or spiritualism, respect for verbal communication skills, connection to ancestors and history, commitment to family, and intuition and experience versus empiricism (Delva, 2001; Neuliep, 2006). Core cultural values among Australia’s Indigenous population include a strong emphasis on oral traditions, with “stories” being an important and time-honoured method in which information has passed between generations (Cass et al., 2002). Indigenous Australians also have a profound connection with their “country”, the geographic area in which their ancestors lived and within which strong spiritual connections exist (Burgess and Morrison, 2007). The use of oral communication and stories, religious or spiritual themes, and historical references to convey messages may thus be invaluable when developing health education research programs among vulnerable groups such as these.

DEVELOPING CULTURALLY SENSITIVE INTERVENTIONS Focus groups are a potentially valuable means for obtaining information to develop culturally sensitive interventions. During the formative phase of intervention planning, members of the target audience can be convened to explore thoughts, feelings, experiences, associations, language, assumptions, and environmentally enabling and constraining factors in regard to the health behaviour of interest (Pope and Mays, 2000). Exploratory focus groups also provide an opportunity in which the role of culturally-based messages, and the unique language that may be used around a particular topic, may be examined. For example, in the ebino-education project described in Case Study I below, rural-dwelling Ugandans revealed the term “slim” to mean AIDS, a term previously unknown to the non-Ugandan researcher, and in the oral health promotion initiative among regional-dwelling Indigenous Australians (Case Study II), the term “sugar” was frequently used to describe diabetes. Incorporating such

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terminology can increase the surface structure sensitivity of an intervention. It can also be useful to explore how the target population perceives how the determinants of the target health behaviour may differ in their community relative to the population as a whole.

APPLYING HEALTH EDUCATION THEORY AMONG VULNERABLE POPULATIONS Some models of health behaviour are culturally sensitive by their very foundation. For example, the PRECEDE-PROCEED planning model (Figure 1) relies on the fundamental principle of community participation in defining problems, solutions and programs (Green and Kreuter, 1999). Accordingly, at each step in the PRECEDE-PROCEED assessment, it is essential that input from the program’s intended audience is included. PRECEDE Step 5 Administrative and policy assessment

Health promotion Health education Policy regulation organisation

Step 6 Implementation

Step 4 Educational and ecological assessment

Step 3 Behavioural and environmental assessment

Step 2 Epidemiological assessment

Step 1 Social assessment

Predisposing factors Reinforcing factors

Behaviour and lifestyle Quality of life

Health Enabling factors

Step 7 Process evaluation

Environment

Step 8 Impact evaluation

Step 9 Outcome evaluation

PROCEED

Figure 1. The PRECEDE-PROCEED Planning Model [Green and Kreuter, 1999].

The acronym stands for Predisposing, Reinforcing and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation (Green et al., 1980). PROCEED (Policy, Regulatory and Organisation Constructs in Educational and Environmental Development) was added in 1991, in recognition of the importance of environmental factors as determinants of health and health behaviours. PRECEDE-PROCEED is a nine-step planning process that begins at the end, focusing on the health-related outcomes of interest and working backward to determine which combination of intervention strategies will best achieve the objectives. The planning process begins with the proposition that health

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behaviours are complex, multidimensional and influenced by a range of factors (Green and Kreuter, 1999).

Step 1: Social Assessment The purpose of Stage I is to determine a community’s perception of their own needs and quality of life (Green and Kreuter, 1999). A social assessment also considers the community’s problem-solving capacity, its strengths and resources, and its readiness to change. It is important to establish trusting relationships between researchers and the target audience at this stage, recognising that the building of such trust requires time and consistency (Patrick et al., 2006).

Step 2: Epidemiological Assessment An epidemiological assessment helps determine what health problems are most important for which groups in the community (Green and Kreuter, 1999). With data on the community’s health problems, a researcher is ready to set priorities and write program objectives. Programs that have implemented the PRECEDE-PROCEED model have been successful when decisions were guided by the desires of community members, and when consideration was given to health problems with the greatest impact, those that were previously not a priority, and those for which solutions were realistically available (Patrick et al., 2006).

Step 3: Behavioural and Environmental Assessment This stage involves examining factors that contribute to the health problem under consideration (Green and Kreuter, 1999). Behavioural factors are individual behaviours or lifestyles that contribute to risk of the health problem, while environmental factors are social or physical factors external to the individual, often beyond an individual’s control, but that can be modified to influence the health outcome in question.

Step 4: Educational and Ecological Assessment This phase involves identifying the antecedent and reinforcing factors necessary for the change process to be initiated and sustained. These factors are classified as predisposing, reinforcing and enabling. Predisposing factors are antecedents that provide the rationale for the behaviour and include individuals’ knowledge, attitudes, beliefs, personal preferences, existing skills and self-efficacy beliefs (Green and Kreuter, 1999). Reinforcing factors are elements associated with a behaviour that provide continued incentive for behaviour persistence (Green and Kreuter, 1999). Examples include social support, peer influence, significant others and vicarious reinforcement. Enabling factors are antecedents to behaviour that allow a motivation to be realised (Green and Kreuter, 1999), and can affect behaviour

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directly or through environmental factors. They include programs, services and resources and, in some cases, new skills that are required to enable health behaviour change.

Step 5: Administrative and Policy Assessment Defining the intervention strategies and final planning for their implementation occurs during the administrative and policy assessment stage. Its purpose is to identify the circumstances in a program’s organisational context that could facilitate or hinder program implementation. The PRO in PROCEED is defined by Green and Kreuter (1999) as: Policy; the set of objectives guiding the organisation’s activities, Regulation; the act of implementing policies and enforcing rules, and Organisation; the bringing together of resources necessary to implement a program.

Steps 6 to 9: Implementation and Evaluation The program is ready for implementation in this phase (step 6). Data collection plans should be in place for evaluating the process, impact and outcome of the program (steps 7–9). Typically, process evaluation determines the extent to which the program was implemented according to protocol. Impact evaluation assesses change in predisposing, reinforcing and enabling factors, as well as in the behavioural and environmental factors. Finally, outcome evaluation determines the effect of the program on health and quality-of-life indicators. The following is a case study in which the PRECEDE-PROCEED planning model was used as a framework for a health behaviour change program implemented in a rural district in Uganda. Background of the project is provided, followed by a synopsis on how the specific PRECEDE-PROCEED criteria were met.

CASE STUDY I; THE EBINO EDUCATION PROJECT Uganda is a landlocked country over 240,000 square kilometres in area in central East Africa. In 2001, the population was estimated to be over 22,780,000, with a density of 94.5 people per square kilometre (Fitzpatrick et al., 2003). Agriculture dominates the economy, contributing 44 percent of the gross domestic product and employing an estimated 80 percent of the working population. The literacy rate is 55 percent for men and 20 percent for women, while current life expectancy is 45.0 years for males and 50.5 years for females (WHO, 2005). Traditional healers in Uganda are ubiquitous. Because they share the same culture, beliefs and values as their patients, they are often the first point of contact for those seeking health care provision (Accorsi et al., 2003). Traditional healers thus play an important role in the delivery of primary health care, particularly in remote communities (Kubukeli et al., 1999). A common practice undertaken by traditional healers in Uganda is that of ebino (“false teeth” or “maggots”) extractions (Accorsi et al., 2003). The custom arose from the belief that unerupted deciduous canine teeth (“maggots”) cause fever, diarrhoea, vomiting and other infant

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illnesses, necessitating their removal. Ebino extractions are usually undertaken with unsterile instruments including bicycle spokes, knitting needles, razor blades, scissors, broken glass or finger nails. The operator uses a tool to make an incision along the top edge of the gum and extracts the suspected cause of child ill health (Stefanini, 1987). In some areas of Uganda, the frequency of ebino extractions is one in every three children (Accorsi et al., 2003; Pindborg, 1969). Complications often arise from ebino extractions, including septicaemia, anaemia, osteomyletis of the maxilla and mandible, tetanus and haemorrhage (Accorsi et al., 2003). Damage to the developing permanent canines may also occur and cause such teeth to be malpositioned, hypoplastic or missing in adulthood (Holan and Mamber, 1994). Repetition of ebino extractions in multiple infants at the same sitting using the same unsterile instruments may additionally promote transmission of infectious diseases such as HIV/AIDS (Jolles and Jolles, 1998). In some rural areas of Uganda, the frequency of HIV/AIDS is one in three people (Stoneburger and Low-beer, 2004). Previous initiatives designed to reduce the prevalence of ebino extractions have included health promotion (Kirunda, 1999), cooperation with traditional healers and encouragement to use other traditional customs for ebino symptoms (Accorsi et al., 2003). The Ebino Education Project aimed to explore traditional concepts of ebino through focus group discussion methodology and to develop a context-specific, tailored and targeted community-based ebino education tool that sought to increase knowledge and awareness of ebino extraction alternatives so that the prevalence of such practices, and consequent burden on child illhealth, might lessen. The study framework was based on the PRECEDE-PROCEED planning model. The project took place at a private-not-for-profit health service in the Rukungiri district, south west Uganda. The hospital services an area of around 200 square kilometres (approximately 10,000 people). The study comprised two components: (1) focus group discussions to identify local perceptions of ebino and (2) development of a culturallysensitive ebino-education tool based on findings from (1) delivered primarily to women’s groups in the community. The focus group discussions covered five separate themes (what is ebino, what are the causes of ebino, what happens after ebino extractions, what are alternatives to ebino, and what does the group suggest as ways to remove the ebino problem) and were tape-recorded, translated and transcribed. Upon analysis of the focus group discussion findings, and with further dialogue with the hospital and community councils, it was decided to employ three strategies in the ebino education workshops; a role-play, a didactic lecture and a debate/discussion forum. The workshops were conducted by an ebino education team, which consisted of the first author, a local dental assistant and two members of the hospital community outreach team. The role-play component was aimed at less-literate participants and was designed to be fun, entertaining, informal and visual. Lasting for five minutes, it generally followed the lines of the first author dressing as a local woman with a baby on her back, and consulting with another local woman (dental assistant) about ebino. The dialogue followed several themes: concern that the child was ill and the mother’s desire for the child to have ebino extractions; explanation that it was not because of ebino that the child was sick but other factors; distrust of Western medicine and conviction that other children’s health had improved following extractions; challenge that some children don’t recover after ebino extractions and if they do

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the children do not develop deciduous canine teeth, suggestion that what was removed was not a “maggot” but a young tooth, that ebino extractions were conducted with unclean instruments that increased the infant’s chances of contracting HIV/AIDS; questions as to ways the child’s health could be returned without the ebino extractions; information on hygiene, diet and hospital attention; and scientific reasons behind fever, malaise, vomiting and diarrhoea. The second part of the initiative embraced a didactic approach whereby diagrams, models and posters were used by members of the ebino education team to explain the position of unerupted deciduous canine teeth in the gum, the consequences of their removal with unsterile instruments, the risk of HIV/AIDS transmission when multiple children were treated in one sitting, the importance of deciduous canine teeth in the eruption pattern of permanent canine teeth and scientific explanations for infant symptoms traditionally associated with ebino. The third component involved a discussion/debate among workshop participants with ebino education team members acting as facilitators. In the debate, those who maintained that ebino extractions were a necessary remedy for infant ailment relief were asked to challenge those who supported the scientific model of ebino symptom aetiology. At the workshops’ cessation, attendees were awarded with ebino education certificates and encouraged to discourse with other community members about the program’s content. The program’s effectiveness was assessed by follow-up focus group discussions being held with the original focus group participants one and a half years after the program’s inception, and by monitoring the prevalence of hospital admissions for ebino extraction complications and other infant illnesses in this period. The initial focus group discussion findings were grouped into themes that related to the key questions. There were a variety of opinions expressed. The “what is ebino” theme included a range of theories and beliefs that generally involved maggots and poor health. The second theme “what are the causes of ebino” contained a number of responses that illustrated a general lack of awareness of ebino aetiology from a scientific perspective, with some answers revealing a superstitious element. For the “what happens after ebino extractions” theme, responses varied depending on the extent that participants had witnessed children recovering from, or having been traumatised by, ebino extractions. An apparent belief that there were no options to ebino extractions was evident when the question “what are alternatives to ebino” was presented to the groups; an inherent conviction that if the “maggots” were left in situ, the infant would become unwell again. For the final theme “what does the group suggest as ways to remove the problem of ebino” a range of solutions were provided, none of which had a scientific basis. All participants of the pre-intervention focus group discussions took part in an ebino education workshop. There were twenty three workshops held; one in each of the communities serviced by the hospital outreach program and eight to mothers’ groups attending the hospital for post-natal care. The number of attendees at each presentation varied from 42 to 112, with a total of 1874 women exposed to the program (mean of 58 women per gathering). There were between 15–20 men who stood around the periphery of each education session but their numbers were not counted as many men were not present for the duration of the intervention. Each session took approximately three hours. Four follow-up focus-group discussions were held one and a half years after the ebino education program’s inception, with the same participants as those in the initial groups. The

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methodology was the same as that used for the initial focus group discussions, with the same questions being asked by the facilitator. In comparison to the initial answers provided for the “what is ebino” question, the follow-up findings differed markedly, for example, a greater acknowledgement of the scientific reasons behind ebino symptoms was disclosed. Similarly, responses elucidated from the “what are the causes of ebino” question varied considerably from the initial focus group discussion findings, with more scientific causes being understood and discussed. For the “what happens after ebino extractions” item, participants provided a range of responses that differed markedly to those provided in the first instance; again conveying a greater understanding of Western health concepts. In the initial focus group discussions there appeared to be limited knowledge of alternatives to ebino extractions. However, when this question was repeated in the follow-up discussions, a range of health–promoting options were provided. A number of healthpromoting suggestions were similarly offered when the “what does the group suggest as ways to remove the ebino problem” item was asked, which was in direct contrast to responses provided in the initial discussions (direct quotes are available from Jamieson, 2006). One and a half years following the ebino education program’s inception, post-ebino extraction complications fell from being the 5th most common reason for infant admissions in the hospital to the 11th, with the number of admissions for ebino extraction complications falling from 22 to 9 (a decrease of 59.1 percent). Of the nine who were admitted with postebino extraction symptoms, seven received the extractions in the previous four hours and presented before gingival swelling commencement, meaning the child’s survival prognosis was relatively high. The number of hospital deaths resulting from ebino extraction complications in the same period fell from eight to zero, while the number of in- and outpatient services for infant complaints (predominantly gastro-intestinal) rose from 279 to 498. Four community members were trained as ebino education health workers and employed by the hospital to continue the ebino education series. After one and a half years of the program’s implementation, there appeared to be increased community awareness of the scientific reasons behind infant fever, malaise, diarrhoea and vomiting; and greater acceptance of hospital services for child illnesses historically treated by traditional healers. The program appeared to create a ripple effect whereby the ebino education theme was picked up and incorporated into other areas of hospital services, for example, in AIDS education clinics, ante-natal classes, the rehabilitation clinic, theatre and prayer groups. General hospital staff began discussing the scientific basis of ebino symptoms to patients in many areas of the hospital and it was the topic of discussion in several church services (the ebino education team presented the role play component of the education tool to four church congregations). There was increased dialogue about the ebino tradition and rising acceptance of alternatives to ebino extractions among communities where the ebino education program had occurred. Many people presented at the hospital dental clinic to further discuss the ebino tradition. The following illustrates more specifically how the PRECEDE-PROCEED framework was helpful in development of the Ebino Education Project.

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Step 1: Social Assessment • • •

Discussions with local councils, church leaders, hospital management, baseline data collection of hospital ebino admissions. Ability of community to change with support of key community leaders. Local leaders believed it was easier for a person of non-African descent to implement the project in the first instance.

Step 2: Epidemiological Assessment • •

•

Focus group discussions held with a convenience sample of local community members. Ebino considered a problem by all. Focus group findings taken back to hospital and community councils. It was decided by these groups that three strategies should be employed in the ebino education workshops; a role-play, a didactic lecture and a debate/discussion forum. It was the view of the hospital and community councils that a specific intervention that targeted women was required in order for women to take part; that men in the community would join in as a matter of course.

Step 3: Behavioural and Environmental Assessment •

• •

Individual/lifestyle behaviours considered detrimental in regards to ebino extraction practises included limited education and traditional healers holding substantial power at a community level. Social factors included local customs being deeply entrenched, minimal exposure to Western medical/scientific concepts. Physical factors included being remotely located (closest town 2 hours drive on a dirt road, minimal car ownership, public transport erratic/non-existent).

Step 4: Educational and Ecological Assessment • • •

•

Pre-disposing factors included strong community values, traditional healers, limited education. Reinforcing factors were social support, peer influence, scarce knowledge of alternative approaches, limited exposure to Western ideology. Enabling factors included increased awareness and education about ebino through the Ebino Education Project – participants in workshops exposed to new ideas, program installed in hospital, women’s groups, sustained (1.5 years). Debating skills were enhanced through workshops = empowerment. Hospital policy change; at a government level ebino extractions made illegal; hospital role more enforcing.

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Strong role of hospital and church to outrule traditional healers’ ebino extraction practises.

Step 5: Administrative and Policy Assessment • • • •

Policy; hospital community outreach, hospital, churches and councils supportive of initiative. Regulation; employment of personnel in ebino education capacity (later merged with AIDS awareness). Organisation; communication between different sectors; community councils, church councils, hospital councils – often the same people on many committees. Barriers to implementation; distance to major centres/large numbers of traditional healers.

Steps 6 to 9: Implementation and Evaluation • • •

•

Program successfully implemented. Process evaluation; program was implemented according to protocol, but required marked flexibility and last minute changes. Needed to be innovative with ideas. Impact evaluation; changes in predisposing (increased education), reinforcing (education at a community level, key community leaders on side), enabling (increased dialogue) factors. Outcome by reduction in ebino hospital admissions – marked quality of life changes – no death in period observed.

THEORY OF DIFFUSION OF INNOVATION Another suitable health behaviour theory useful for health education projects among vulnerable groups is the Theory of Diffusion of Innovation. This theory derives from a body of research that attempts to identify patterns of program diffusion by using a broad range of innovations (Green and Johnson, 1996). It is particularly valuable among vulnerable populations because of its emphasis on creative, novel and innovative approaches. Innovation is defined as “an idea, practice or object perceived as new by an individual or other unit of adoption”, while diffusion is defined as “the process by which an innovation is communicated through certain channels over time among members of a social system” (Rogers, 1995). Rogers (1995) identified characteristics of an innovation that were most likely to affect the diffusion process as: 1. Relative advantage 2. Compatibility 3. Trialability 4. Observability

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5. Impact on social relations 6. Reversibility 7. Communicability 8. Time 9. Risk 10. Uncertainty level 11. Commitment 12. Modifiability (Table 1). Table 1. Characteristics of an innovation most likely to affect the diffusion process [adapted from Oldenburg and Parcel, 2002] Attribute Relative Advantage Compatibility Complexibility Trialability Observability Impact on social relations Reversibility Communicability Time Risk and uncertainty level Commitment Modifiability

Key question Is the innovation better than what it will replace? Does the innovation fit with the intended audience? Is the innovation easy to use? Can the innovation be tried before making a decision to adopt? Are the results of the innovation observable and easily measured? Does the innovation have a disruptive effect on the social environment? Can the innovation be reversed or discontinued easily? Can the innovation be understood clearly and easily? Can the innovation be adopted with minimal investment in time? Can the innovation be adopted with minimal risk and uncertainty? Can the innovation be used effectively with only modest commitment? Can the innovation be updated and modified over time?

The process of diffusion also typically involves five stages: innovation development, dissemination, adoption, implementation and maintenance. This innovation-development process links together the resource system (professionals, experts, scientists), the diffusion process (activities required to spread the innovation), the linkage system (strategic planning to link the resource and user systems), the implementation process (collaboration to assure diffusion) and the user system (the target audience for adoption) to provide the best opportunities for an innovation to be accepted, adopted and used.

PLANNING FOR DIFFUSION: INNOVATION AND ADOPTER CHARACTERISTICS Maximising the fit between innovation and user requires consideration of how an innovation is communicated, collaboration between the developers and system users, and characteristics of the environment in which this process takes place. Effective diffusion involves the implementation of strategies through various settings by using a range of communication channels, which can enhance the durability of an innovation and ensure its long-term sustainability. Diffusion theorists view communication as a two-way process rather

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than one of merely persuading an audience to take action; a central PAR tenet. The two-step flow of communication emphasises the value of social networks over and above mass media for adoption decisions (Rogers, 1995).

DIFFUSION AS A MULTI-LEVEL CHANGE PROCESS Achieving satisfactory diffusion of an innovation involves a complex, multi-level change process (Osganian et al., 2003). The complexity arises from the need to consider change occurring at multiple levels, across many settings, and resulting from the use of numerous change strategies. At the level of the individual, family or small group, uptake of a health behaviour change innovation typically involves changes in lifestyle practices. At the organisational level, successful uptake of an innovation may require the introduction of particular programs, changes in policies, and modification in the roles of particular personnel. This is especially relevant for health behaviour change projects implemented among vulnerable populations, with an enforced need for innovation and creativity. The following is a case study in which the Theory of Diffusion Innovation model was used as a framework for a health intervention implemented among a regional-dwelling Indigenous population in Australia. Background of the project is provided, followed by a synopsis on how the specific Theory of Diffusion Innovation criteria were met.

CASE STUDY II; THE PIKA WIYA PROJECT The Pika Wiya study is a community-owned, oral health intervention based on PAR principles that aims to improve behaviours and attitudes affecting oral health and dental service utilisation among the Indigenous population in a regional setting of Australia. Phase I of the study involved implementing focus group methodology to elucidate community perceptions on oral health, and to develop a culturally-sensitive oral health education audiovisual tool to be used in Phase II, the intervention component of the study (in process).

BACKGROUND Indigenous people in Australia are those who identify as being Aboriginal, Torres Strait Islander or both. In the 2001 Census, Indigenous people represented 2.4 percent of the total Australian population (Australian Bureau of Statistics, 2001a). Indigenous people were believed to have lived in Australia for 100,000 years before European contact (Fullagar et al., 1996). They had a semi-nomadic, hunter/gatherer lifestyle and strong spiritual links with the land (Diamond, 2004). Marked lifestyle changes occurred in the post-colonial era due to the rapid introduction to industrialised society. Traditional lifestyles were discouraged and, up until the late 1960s, children with mixed parents [usually an Indigenous mother and nonIndigenous father] were placed in European homes. The impact of such policies on the social capital of Indigenous groups has been devastating. Rapid dietary changes also occurred in the post-colonial era, with traditional foods being replaced by rations, and more recently,

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convenience foods, many of which are high in fat and refined carbohydrates (Gracey, 2000). Other Western habits such as smoking cigarettes and alcohol consumption were also introduced (Clough, 2005). Increasingly sedentary lifestyles has meant that diabetes and other chronic conditions have became more prominent among Indigenous groups (Gracey et al., 2006). Such lifestyle changes have also had a marked impact on oral health, which has deteriorated considerably among Indigenous Australian groups in the last 20 years (Jansson et al., 2006). South Australia is the fourth-largest state in Australia, with the mid-north region having the state’s highest population density of Indigenous people (15.2 percent of total population). Such people represent 23 different language groups and mostly reside in the regional centre of Port Augusta and surrounding areas (Australian Bureau of Statistics, 2001b; Spencer Gulf Rural Health School, 2001). Although the overall population in South Australia’s mid-north region is decreasing, the Indigenous population increased 6.5 percent from 1996–2000 (Australian Bureau of Statistics, 2001c). At the time of the 2001 Census, over half the Indigenous population in this area were aged 25 years or less, and 15 percent were unemployed (Australian Bureau of Statistics, 2001a). There is an Aboriginal-operated health centre in Port Augusta, which from 2001 has included a dental health service (Parker et al., 2005). Following encouragement by the Aboriginal Health Centre’s Board of Management, an oral health promotion initiative that was community-owned and context-specific was developed. The aim of the project was to increase knowledge and awareness of the importance of good oral health to Aboriginal people in the mid-North region of South Australia, and to increase community capacity in maintaining an oral health promotion program, using PAR methodology under a Theory of Diffusion Innovation health behaviour change model. Focus group discussions were used to generate data for Phase I of the study, with invitations sent to members of a local Indigenous arts and crafts group (Indigenous adults employed to create arts/crafts products for exhihibition and sale), a chronic disease awareness group (Indigenous elders with chronic diseases who meet at the Aboriginal health service for support and education), and a young mothers Indigenous child care group (Indigenous mothers of children enrolled in an Indigenous preschool programme). Prompt questions were used to help guide discussions in suitable oral-health-related topics. These included: (a) knowledge of oral health; (b) the role of oral health in general health; (c) how the oral health of people known by participants has changed in recent times; (d) the causes of poor oral health; and (e) ways to prevent poor oral health at a community level. The qualitative approach to data gathering enabled holistic perceptions of Indigenous oral health and well-being to be captured. Participants provided details of the structure of Indigenous knowledge systems and concepts of oral health; the relationships between Indigenous and Western oral health paradigms; and the influence of family, socio-economic status, land ownership and religion on their community’s oral health belief systems, behaviours and self-care practices. A core category was identified and labelled “cultural adaptation”. Five additional sub-categories also emerged from the data; lifestyle changes, oral health behaviours, barriers to dental care, impact of poor oral health and oral health literacy. Participants portrayed how ongoing cultural adaptation was required to cope with the social impact of colonialism, living in missions, the stolen generation, loss of land, processes of assimilation and sustained disempowerment. It was explained that such historical legacy impacted on the health, including oral health, of community members, mainly through

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continued practices of being told what to do, where to live, how/when/if they would receive Government money and what health services were available to them. Participants felt they had little power over their oral health or oral health care decisions. According to the older study participants, oral self-care behaviours were not a part of traditional lifestyle. This may have translated to contemporary times, with participants commenting that behaviours conducive to oral health were not widely practiced, either by themselves or by other community members. Participants described how regular toothbrushing habits were difficult to instill in children because of the different number of households a child might stay in in any given week. Many barriers to seeking dental care were identified, including dental pain, fear, cost, waiting times and lack of culturally-sensitive dental health services. All participants had experienced negative life impacts resulting from poor oral health, and knew other community members, particularly children, whose poor oral health had similarly affected their life quality. Although some participants were aware of the importance of positive oral health behaviours such as brushing teeth and regular dental appointments, there appeared to be a general lack of understanding at a community level about measures required to achieve good oral health. A sense of powerlessness that good oral health was beyond the control of participants, both at an individual and a community level, pervaded much of the discourse. Based on the qualitative research findings, an interactive, context-specific oral health promotion audiovisual tool (DVD) was created, using an Indigenous film-maker and using focus group discussion participants as “actors”. The DVD was fully endorsed by the Board of Management. Phase II of the project – the intervention – involves a series of four intense, interactive and context-specific oral health education seminars, complete with a range of tools (posters, oral health promotional DVD, toothbrushing and other demonstration models, oral health education pamphlets, toothbrushes, toothpaste, disclosing tablets) being implemented to each of the three community groups involved in Phase I. The tailored messages to each specific group include: Arts and Crafts group: • • • •

The role of oral health and general health. The role of smoking and periodontal disease. The role of oral health and diet. The importance of regular dental check-ups, with a tour around the Aboriginal Health Centre dental clinic.

Chronic Disease Awareness group: • • • •

The role of oral health and general health. The role of diabetes and periodontal disease, the role of medication and dry mouth. The role of diet and oral health. The importance of regular dental check-ups, with a tour around the Aboriginal Health Centre dental clinic.

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Young Mothers group: • •

• •

The role of oral health and general health. Preventing early childhood caries, simple methods of toothbrushing children’s teeth, the role of fluoride and oral health, when to expect teeth to exfoliate, the role of orthodontic work, the “lift the lip” approach to detecting decay. The role of diet and oral health. The importance of regular dental check-ups, with a tour around the Aboriginal Health Centre dental clinic.

Materials used in the oral health education seminars include the full spectrum of oral health communication tools drawn from a range of everyday contexts; an assortment of written and audiovisual contexts that embrace different components of oral health promotion, oral health protection, dental disease prevention, oral health care and maintenance, and oral health systems navigation. Seminar materials range from the very basic (colour magazine articles advertising toothpaste) to reasonably complex (label on antibiotic container with administration details; how many tablets should be taken at one time; how many times a day should they be administered, when should the next dose should be taken). All seminar materials include images relevant to the Indigenous audience, using words generated in the focus group discussions and local language where possible. Communication strategies include giving meaningful examples, demonstrating procedures, asking participants to demonstrate a given procedure, asking individuals to re-state information in their own words, repeating information several times, presenting the most important information first and last, involving family members or other caregivers, encouraging discussion and involving humour. All participants have been invited to visit the Aboriginal Health Services dental clinic to meet the oral health personnel and to partake in a free dental check-up so that they might become more aware of their current oral health condition, and be less anxious to attend for dental care should it be warranted. Follow-up focus group discussions for evaluation purposes will be facilitated by the locally-employed Indigenous research assistant and the first author. Discussions will cover the same themes implemented in Phase I so that any changes in oral health knowledge, attitudes, self-care practices and use of services might be captured. A strong aim of the project is to strengthen the community through allowing participants’ ideas and suggestions in the focus group discussions to shape themes/messages in the audiovisual tool (Phase I) and oral health education seminars (Phase II). As with Phase I of the project, communication in the interactive oral health education seminars in Phase II style is being largely driven by the Aboriginal research assistants, with a focus on user-friendly demonstrations, one-on-one tuition when required, discussions and tours through the Aboriginal Health Centre dental clinic. The Aboriginal research assistants and other key community members involved in a leadership capacity in Phase I are driving the oral health education seminars and will do so also for the follow-up focus group discussions. It is hoped this will empower community members through auspices of the Ottawa Charter for Health Promotion, and encourage involvement in other self-determining health promotion initiatives (for example; diabetes control and management; early childhood nutrition).

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The following illustrates more specifically how the Theory of Diffusion Innovation is being used as a framework in the Pika Wiya study. Key innovation attributes were accentuated in the development stage of the Pika Wiya study, as well as in the development of the dissemination strategies (Table 1). Relative advantage was shown by emphasising that the program had demonstrated positive effects, such as improved community knowledge of oral health and increased motivation for regular dental care. The demonstrated effectiveness of the Pika Wiya study was presented in dissemination material as an advantage over the previously non-existing oral health promotion programs. Compatability of the program with current practice is evidenced by four key facts: (1) the National Aboriginal Health Strategy in 1989 identified oral health as a priority for Indigenous communities (National Aboriginal Health Strategy Working Party, 1999); (2) the National Aboriginal Community Controlled Health Organisation recommended that dental health and oral health promotion be incorporated into Indigenous primary health care services (National Aboriginal Community Controlled Health Organisation, 1998); (3) improving Indigenous oral health was listed as one of seven priorities in Australia’s National Oral Health Plan (National Advisory Committee on Oral Health, 2004), and (4) a key point that arose from a National Aboriginal and Torres Strait Islander Oral Health Workshop was to “increase oral health promotion activity with the aim of improving health outcomes for Indigenous people” (Commonwealth Department of Health and Aging, 2003). Oral health was also highlighted by the target audience as a priority area requiring action. Program complexity was minimised by developing materials that were informed by, and involve, members of the target audience, are context-specific, simple, colourful and fun. The program is easy to adopt to different settings (outdoor versus indoor use), audience sizes or session length. The oral health education component is formatted for easy use by health workers, with complete instructions and script, copies of powerpoint presentations and videos, and worksheet pages made available. Good trialability is evidenced by the fact that oral health educational materials are available during the dissemination phase as part of the oral health education package, and through the Pika Wiya Health Services Inc. website (in process). It is possible to show observability by illustrating the other attributes–relative advantage, compatibility, and complexity–through demonstration. Aboriginal health workers are able to observe the oral health education activities through professional presentations at the Aboriginal Health Centre, through audiovisual tool guides, and through hands-on training sessions. Innovation and flexibility, as well as PAR tenets such as two-way communication, are essential facets of ensuring the Diffusion of Innovation Theory is followed. The intervention allows improved social cohesion, indicating that the impact on social relations is a positive one, not causing a disruptive effect. Through the intervention the profile of oral health and oral health promotion is raised at a community level, with discourse about oral health-related topics increasing. There are many tangible benefits of the intervention, including but no limited to each participant receiving oral health-related products as part of the initiative. The project can be easily discontinued, thus emphasising the reversibility of the initiative. Much effort is placed on the intervention being articulated simply, thus reinforcing the communicability of the innovation. This is particularly achieved through employment of

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Indigenous research assistants to administer the initiative, who can speak the local language and convey messages in a culturally-sensitive, simple manner. Considering the aims of the initiative (improve behaviours and attitudes affecting oral health and dental service utilisation patterns), the time required to implement the initiative is minimal (two years). However, for the program to be truly sustainable, messages need to be conveyed on a continuous basis, which is why the Board of Management has strongly encouraged the dentist employed by the Aboriginal Health Centre to work on the project one day a week. There is minimal risk and uncertainty in the program, with the opposite occurring in some situations with Indigenous participants who had previously avoided utilising dental services because of fear or other reasons agreeing to have a dental check-up, and in some instances, receiving the necessary care. Commitment for the initiative was provided from the outset by the Board of Management, and a certain level of trust was consequently in place before the study’s commencement. The intervention would have been unsuccessful had this support not been present. The on-going relationship with the Indigenous research assistant and study participants means that commitment from a higher level is not as important following the initial phases of the study, although their support is frequently mentioned in the seminar discourses. Because the initiative is based on PAR methodology, in which modifiability is a central tenet, the agenda items are flexible and able to be adjusted at short notice to better suit the needs of the workshop participants in a given day (for example, Indigenous mothers requiring a distraction for their children at the beginning of the workshops, food required for the chronic disease group when workshops are planned for the afternoon and blood sugar levels are dropping).

MULTI-LEVEL CHANGE PROCESS Three key levels of the community are targeted for change in the Pika Wiya study; the physical environment, the information environment and the policy environment. Examples of change at the physical environment include the placing of oral health promotion posters at strategic points around the community (arts and crafts centre, Aboriginal Health Centre, preschool room), and making free drinking water available at places where vending machines are located. Change at the level of the information environment include point-of-food-purchase messages in local stores and tuck shops about health food choices in regards to oral health and take home messages about healthy oral self-care behaviours placed in target audience letterboxes. Change at the policy level to promote positive oral health behaviours involves reviewing existing policies relating to the Aboriginal Health Centre client oral health and then incorporating specific statements about providing access to healthy oral health choices (oral health check-up incorporated as part of general health check-up). There is a strong commitment by the Aboriginal Health Centre Board of Management to allow the employed dentist to spend one day per week working on the project, thus encouraging institutionalisation of the project. Community group leaders play a key role in each of these steps, for example, the arts and crafts leader constantly encourages other members to embrace

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the project, the diabetes awareness group took part in the audiovisual production, and members of the young mother’s group continue dialogue with mothers external to the group.

CONCLUSION There are many unanswered questions regarding the application of health behaviour theory and health education research among vulnerable populations. However, the evidence suggests that the most debatable questions concern application and not the fundamental utility of health behaviour models (Patrick et al., 2006). Measures of theoretical constructs often need to be altered for vulnerable groups, using a range of innovative diffusion methods such as role plays, debates, videos and interactive websites. Focus group discussions for exploratory purposes, and to allow insight into common language and jargon used, are invaluable as researchers are not often from vulnerable backgrounds themselves. PAR approaches are useful to ensure two-way communication, community ownership and sustainability. Contemporary health behaviour models, such as the PRECEDE-PROCEED planning model and the Diffusion of Innovation model, are useful but often need to be modified to better suit the needs of the vulnerable target audience. Although both are appropriate frameworks, it is essential to appreciate the very real differences between researchers and the researched, and for researchers to avoid adopting professionally-centric views that may alienate the very groups with whom they are hoping to help. Health education researchers interested in working with vulnerable populations would do well to consider not what makes investigations superior in terms of research methods, but what makes them superior in terms of health education outcomes.

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Burgess P, Morrison J. Country. In Social Determinants of Indigenous Health Editors Carson B, Dunbar T, Chenhall R, Bailie R. Sydney, Allen and Unwin, 2007. Cass A, Lowell A, Christie M, Snelling PL, Flack M, Marrnganyin B, Brown I. Sharing the true stories: improving communication between Aboriginal patients and healthcare workers. Med J Aust. 2002;176:466–470. Clough AR. Associations between tobacco and cannabis use in remote indigenous populations in Northern Australia. Addiction. 2005;100:346–353. Commonwealth Department of Health and Aging. National Aboriginal and Torres Strait Islander Oral Health Workshop: Workshop report and action plan. Canberra; Commonwealth of Australia, 2003. Crosby A. Suicidal Behaviors in the African American Community. J Black Psychol. 2006;32:1–9. Danis M, Patrick DL. Health, Policy, Vulnerability and Vulnerable Populations. In Ethical Dimensions of Health Policy ed Danis M, Clancy C, Churchill LR. New York: Oxford University Press, 2002. Pp 310–334. DeBruin D. Reflections of “Vulnerability”. Bioethics Examiner. 2001;5:1–7. Delva JD. Families and Health: Cross-Cultural Perspectives. New York; The Haworth Social Work Practice Press, 2001. Diamond J. Collapse: How Societies Choose to Fail or Succeed. Los Angeles: Viking Books; 2004; pp12–18. Dunn AL, Resnicow K, Klesges LM. Improving measurement methods for behavior change interventions: opportunities for innovation. Health Educ Res. 2006;21:121–124. Fitzpatrick M, Parkinson T, Ray N. East Africa- 6th Edition Melbourne: Lonely Planet, 2003, 520–521. Freire P. Pedagogy of the oppressed. New York: Seabury Press, 1970. Fullagar RLK, Price DM, Head LM. Early human occupation of northern Australia: archeology and thermoluminescence dating of Jinmium rock shelter, Northern Territory. Antiquity. 1996;70:751–73. Goodin RE. Protecting the Vulnerable: A Reanalysis of Our Social Responsibilities. Chicago, IL: University of Chicago Press, 1985. Gracey M. Historical, cultural, political, and social influences on dietary patterns and nutrition in Australian Aboriginal children. Am J Clin Nutrit. 2000;72:1361–1367. Gracey M, Bridge E, Martin D, Jones T, Spargo RM, Shephard M, Davis EA. An Aboriginaldriven program to prevent, control and manage nutrition-related "lifestyle" diseases including diabetes. Asia Pac J Clin Nutrit. 2006;15:178–188. Green LW, Johnson JL. Dissemination and utilization of health promotion and disease prevention knowledge: theory, research and experience. Can J Public Health. 1996;87:11–17. Green LW, Kreuter MW. Health Promotion Planning: An Educational and Ecological Approach. 3rd Edition. California; Mayfield, 1999. Green LW, Kreuter MW, Partridge K, Deeds S. Health Education Planning: A Diagnostic Approach. Mountain View, California: Mayfield, 1980. Hagey RS. The use and abuse of participatory action research. Chronic Dis Can. 1997;18:1– 4. Health Canada. Highlights from the Report of the Royal Commission on Aboriginal Peoples. Ottawa, Health Canada, 2006.

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Holan G, Mamber E. Extraction of primary canine tooth buds: prevalence and associated dental abnormalities in a group of Ethiopian Jewish children. Int J Paed Dent. 1994;4:25–30. Israel BA, Lichtenstein R, Lantz P, McGranaghan R, Allen A, Guzman JR, Softley D, Maciak B. The Detroit Community-Academic Urban Research Center: development, implementation, and evaluation. J Public Health Manag Pract. 2001;7:1–19. Israel BA, Schulz AJ, Parker EA, Becker AB. Review of community-based research: assessing partnership approaches to improve public health. Annu Rev Public Health. 1998;19:173–202. Jamieson LM. Using qualitative methodology to elucidate themes for a traditional tooth gauging education tool for use in a remote Ugandan community. Health Educ Res. 2006;21:477–487. Jansson H, Lindholm E, Lindh C, Groop L, Bratthall G. Type 2 diabetes and risk for periodontal disease: a role for dental health awareness. J Clin Periodontol. 2006;33:408– 414. Jolles S, Jolles F. African traditional medicine--potential route for viral transmission? Lancet. 1998;352:71. Jones RL. Black Psychology. 4th Edition. New York. Cobb and Henry, 2004. Kirunda W. “Ebino” (false teeth): how the problem was tackled in Tororo. Trop Doct. 1999;29:190. Kottow MH. The vulnerable and the susceptible. Bioethics. 2003;17:460–471. Kubukeli P. Traditional healing practice using medicinal herbs. Lancet. 1999;354:SIV24. Marin G, Burhansstipanov L, Connell CM, Gielen AC, Helitzer-Allen D, Lorig K, Morisky DE, Tenney M, Thomas S. A research agenda for health education among underserved populations. Health Educ Q. 1995;22:346-63. Morris ZS, Chang LR, Dawson S, Garside P. Policy Futures for UK Health. London, Radcliffe Publishing, 2005. National Aboriginal Community Controlled Health Organisation. Submission to the Senate Inquiry into Public Dental Services. Canberra; National Aboriginal Community Controlled Health Organisation, 1998. National Aboriginal Health Strategy Working Party. A National Aboriginal Health Strategy. Department of Health and Ageing, Canberra; Australian Government, 1999. National Advisory Committee on Oral Health. Healthy Mouths Healthy Lives. Australia’s National Oral Health Plan 2004–2013. Canberra; Australian Health Ministers’ Conference, 2004. Neuliep JW. Intercultural Communication: A Contextual Approach. 3rd Edition. California, Sage Publications, 2006. New Zealand Ministry of Health. Whakatātaka Tuarua: Māori Health Action Plan 20062011. Wellington, New Zealand Ministry of Health, 2006. Osganian SK, Parcel GS, Stone EJ. Institutionalization of a school health promotion program: background and rationale of the CATCH-ON study. Health Educ Behav. 2003;30:410– 417. Parker EJ, Misan G, Richards LC, Russell A. Planning and implementing the first stage of an oral health program for the Pika Wiya Health Service Incorporated Aboriginal community in Port Augusta, South Australia. Rur Rem Health. 2005;5:254.

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Partners in the BIOMED-II Project. The Barcelona Declaration Policy Proposals to The European Commission. 1998. Available at http://www.ethiclaw.dk/publication.html Patrick DL, Lee RS, Nucci M, Grembowski D, Jolles CZ, Milgrom P. Reducing oral health disparities: a focus on social and cultural determinants. BMC Oral Health. 2006;6:S4. Pindborg JJ. Dental mutilation and associated abnormalities in Uganda. Am J Phys Anthropol. 1969;31:383–389. Pope C, Mays N. Qualitative Research in Health Care London; BMJ Books, 2000. pp 1–10. Potvin L, Cargo M, McComber AM, Delormier T, Macaulay AC. Implementing participatory intervention and research in communities: lessons from the Kahnawake Schools Diabetes Prevention Project in Canada. Soc Sci Med. 2003;56:1295–1305. Resnicow K, Baranowski T, Ahluwalia JS, Braithwaite RL. Cultural sensitivity in public health: defined and demystified. Ethn Dis. 1999;9:10–21. Resnicow K, Braithwaite RL, Dilorio C, Glanz K. Applying theory to culturally diverse and unique populations. In Health Behaviour and Health Education. Theory, Research and Practice. San Francisco; John Wiley and Sons Inc, 2002. Pp 485–510. Rogers EM. Diffusion of Innovations. 4th Edition. New York. Free Press, 1995. Ruof MC. Vulnerability, Vulnerable Populations and Policy. Kennedy Institute of Ethics Journal. 2004;14:411–425 Simonds SK. Health education: facing issues of policy, ethics, and social justice. Health Educ Monogr. 1978;6:18–27. Smith BJ, Tang KC, Nutbeam D. WHO Health Promotion Glossary: new terms. Health Promot Int. 2006;21:340–345. Spencer Gulf Rural Health School. Working with Aboriginal People in Rural and Remote South Australia; a cultural awareness handbook for people working in the health professions. Whyalla: Spencer Gulf Rural Health School, 2001; 28 Ssali A, Butler LM, Kabatesi D, King R, Namugenyi A, Kamya MR, Mandel J, Chen SY, McFarland W. Traditional healers for HIV/AIDS prevention and family planning, Kiboga District, Uganda: evaluation of a program to improve practices. AIDS Behav. 2005;9:485–493. Stefanini A. Influence of health education on local beliefs. Incomplete success, or partial failure. Trop Doct. 1987;17:132–134. Stoneburner RL, Low-Beer D. Population-level HIV declines and behavioral risk avoidance in Uganda. Science. 2004;304:714–718. Sullivan EA, Abramowitz CS, Lopez M, Kosson DS. Reliability and construct validity of the psychopathy checklist - revised for Latino, European American, and African American male inmates. Psychol Assess. 2006;18:382–392. US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. Washington DC: US Government Printing Office, 2000. Wallerstein N. Power between evaluator and community; research relationships with New Mexico’s communities. Soc Sci Med.1999;49:39-53. World Health Organisation. The Ottawa Charter for Health Promotion. Geneva: World Health Organisation; 1986. World Health Organisation Uganda Health Profile http://www.afro.who.int/uganda /overview.html Accessed 31 March, 2005.

In: Progress in Education, Volume 17 Editor: Robert V. Nata

ISBN 978-1-60692-505-8 © 2009 Nova Science Publishers, Inc.

Chapter 5

HEALTH AND SCHOOL ATTENDANCE AMONG IMMIGRANT CHILDREN IN THE UNITED STATES Cecilia Obeng Department of Applied Health Science, Indiana University, 107 S. Indiana Ave., Bloomington, Indiana 47405-7000, USA

ABSTRACT The study explores the interconnectedness between health, and school attendance among African immigrant school-aged children by examining illnesses that their parents consider prevalent, ‘serious,’ or ‘ordinary’ and how such perceptions influence their decision to allow their children to miss or attend school. The data for the study were collected in Virginia and Indiana between 2005 and 2007 by the author and three research assistants. A total of one hundred and five families took part in the research, answering closed- and open-ended questions about their two hundred and forty (240) children. Results indicate that a majority of the immigrant parents surveyed in the study ensured that their children’s illness did not interrupt their school attendance. Most participants scheduled their children’s doctor’s appointments during non-school hours. Missing school was viewed as being a failure or inability on the part of a parent to properly socialize their child to enjoy hard-work. Some participants viewed missing school as not taking advantage of the opportunity they have in their new environment (USA). The study concludes that the immigrants’ cultures have considerable impact on their perceptions about health and school attendance. The study could form the basis for studying the link between health and schooling among different immigrant groups.

Keywords: school attendance patterns, attitudes, cultural influences, health, immigrants

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INTRODUCTION There is a dearth of knowledge on the close connection between health and school attendance among children the world over. The little that has been done has been on some American populations with recent immigrant populations often ignored. In their study of symptom profile and asthma control among urban minority school-aged children, Vargas et al.(2006) show that children with poorly controlled asthma are at high risk of school absenteeism, limited participation in activities, and in sleep disruption. Furthermore, the authors discovered the prevalence of poor asthma control among the children—a situation that they identified as being responsible for the poor school attendance and inferior quality of life of the children (see also, Levi et al. (2006). An important aspect of health and school attendance deals with parental perception of the severity of their child’s illness. In their study of social context influencing pain and pain behavior, Goubert et al. (2006) saw that parents’ thinking about the acuteness of their child’s pain significantly contributed their children’s school attendance as well as parental depression and anxiety. With respect to the positive impact of health improvement on school attendance, Mahawithange et al.’s (2007) study of the impact of Vitamin A supplementation on health status and absenteeism of schoolchildren, showed that, if properly managed, Vitamin A supplementation with an appropriate IU dosage (200,000 IU) over an appropriate time period (every 4 months over 13 months) has a strong potential of improving vitamin A status and school attendance of the children. Finally, in their work on anemia and school participation, Bobonis, Miguel, and PuriSharma (2006) demonstrated that such health intervention strategies as delivering iron supplementation and de-worming drugs to preschool children leads to an increase in preschool participation, reduction in absenteeism, and a curb in weight loss among the assisted children. The authors concluded that school-based health programs constitute an effective way of promoting school attendance. Given the connection between health and school attendance as espoused in the above literature, and in view of the dearth of knowledge about health and school attendance among school-aged immigrant populations, the present study investigates: (a) Illnesses that recent African immigrant parents believe are common among their school-aged children, (b) The parents’ perceptions about the illnesses, and (c) How such perceptions influence their children’s school attendance.

METHOD Site and Data The sites for this study were Virginia and Indiana. All participants from Indiana lived in Indianapolis and surrounding towns (fifty miles away from Indianapolis). The other participants lived in North Virginia, which is close to Washington D.C., USA’s capital. The

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data were collected from 2005 to 2008 and were collected from professionals like nurses, teachers, and lawyers and from nonprofessionals like cab drivers, janitors, fast food workers, and students. In all, four people were involved in the data collection— the author and three graduate research assistants. One graduate research assistant did the survey at Virginia and the other two graduate assistants worked at Indiana. The personal interviews were conducted by the principal investigator and one graduate assistant. All the data collection was done in English and took place after an approval from an institutional review board.

Subject Selection Participants were selected for this study through the snowball and purposeful sampling techniques (Patton, 1990). No incentives were provided to participants. Eligibility requirements included being an African immigrant parent with a child or children in school— preschool and school-aged children.

Procedure After participants were identified, they were approached by either the author or her graduate assistants through e-mails, personal interactions, and phone-calls. Consent forms were given to participants to read. Of the one hundred and five participants, sixty-six filled in the questionnaire with pen/pencils by themselves, fourteen participants had theirs filled in by either the author or her research assistants, and the remaining twenty-five were taperecorded by the principal investigator and one of the graduate research assistants who did face-to-face interviews with the participants. Questions were administered in participants’ homes.

RESEARCH QUESTIONS The research questions that guided this study elicited information on participants’ native countries of origin, how long they had been in the United States, the number of children that they had, the most common illness(es) that their child or children had, and the influence of their children’s illness on their school attendance.

Data Coding Three people were involved in the coding process, the author, a colleague, and a graduate research assistant. The coding was done using the constant comparative/constant comparison method. The data were first coded by the author and the doctoral research assistant into four broad themes. The author and a colleague then took portions of the data and compared the themes identified to determine their relevance and similarity (Schwandt, 2001). This process was done until all important categories were under specific themes. The coders read the data

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and the themes that were identified separately. After reading the data they compared all the comments to make sure each segment put under any of the themes “qualified” to be under that theme. Their comments were discussed until all themes and the segments under them were agreed upon (Lewis-Beck, Bryman, and Liao, 2004).

Data Analysis The analysis done for this study involves quoting of raw data from the research participants’ utterances to support the analytical claims that are made. This type of analysis helps to inform readers about the research participants’ perceptions about their health, and schooling, and it gives readers the knowledge about how the research participants viewed the health and education of their children in their own cultures. Since the analytical claims are based on participants’ words, the conclusions drawn from the data, therefore, come from the participants themselves. Thus, any conclusions that are drawn help to amplify participants’ voices instead of making them appear faceless in the study.

FINDINGS The findings of the paper address the following important issues: common illnesses of participants’ children (including the participants’ perception of what constitutes a serious illness and what motivates them to take their children to the clinic or hospital), and parents’ reported time of taking their children to the clinic/hospital.

DEMOGRAPHIC INFORMATION Of the one hundred and five participants who took part in this study, 80% (N=74) were African immigrants from West African countries. The remaining 20% (N=21) were from other parts of Africa. These participants answered questions on 240 children. A majority of the participants had three kids (see Table 1 below). Table 1. Participants’ Demographics Participants & Their Children Participants with 1 Child Participants with 2 Children Participants with 3 Children Participants with 4 Children Total

# Parent Participants 33 21 39 12 105

Total # Children 33 42 117 48 240

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COMMON ILLNESSES The common illnesses reported by participants are cold and flu, ear infection, bacterial infection, fever, nausea, and nose bleeding. These are represented on Figure 1 below. Common Illnesses Reported by Participants (Number and Percentage)

6.6%

Cold and Flu

9.9%

Ear Infection

9.9%

39.36%

Bacterial Infection Fever

12.11%

Nausea

6.6%

Nose Bleeding 24.23%

Other Problems

Figure 1. Common illness

From the above figure, we learn that 39% of the surveyed parents indicated that the most common form of illness found in their children was cold and/or flu. They noted that at times their children had a cold for between six and eight times per year. Some parents reported that there were times that their child’s cold or flu got so bad that they did not know what to do especially at night when their children struggled to breathe. A participant noted: At times nobody in my house would sleep for even an hour or so. My son struggled to breathe most of the time. He never finished one-fourth of his food the day before, so I could see that he was very hungry. My husband and my younger brother would try to persuade him to eat but were not successful. Any time that he started coughing or I saw fluid coming from the nose, I knew another sleepless night awaited us. What we didn’t want was for the school nurse to call us and to ask us to pick up our child from school because he was ill. It portrays us as being irresponsible. We therefore made sure he ate well and took his medicine.

Close observation of the data also shows that 24% of the participants’ children had symptoms of ear infection after their cold. A father noted:

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Once I know that her cold/flu goes beyond a week or more, then, I definitely knew the next thing she would complain about would be earache. I had to prepare my mind and work more hours to get money for her to see the doctor since there was no way an over-the-counter medicine would make her well. We were very careful not to let her have the illness for a long time without seeing the doctor since someone else in the family could also catch it. When so many people live together, you can support one another in times of illness and that is exactly what we did.

Nine percent mentioned nausea and nose bleeding as the common illness that affected their children whereas 6 percent of the surveyed participants reported bacterial infection as being the common illness found in their children. A man who had lived in the U.S. for three years wrote: He (referring to his son) had never had any problem with nose bleeding when we were at home [country of origin] but since our coming into this country, every year at least his nose bleeds twice or more. I always make sure he will not engage himself in any activity that will trigger his nose bleeding.

Twenty-four percent of the surveyed parents reported that the illness that led their schoolaged children to see the doctor was ear infection although cold/flu was the illness reported most by participants. Some parents from West Africa reported that in their culture the illnesses that they considered most serious were malaria and yellow fever. None of the parents reported that any of their children had such an illness in their new environment (the United States). For such parents, apart from malaria and yellow fever, no other disease should constitute the basis for their child missing school. Other African immigrants, especially from southern Africa, reported viral and bacterial infections as being illnesses that they were afraid of. For such immigrants, if their child contracted a viral and/or bacterial infection, then the child might miss school. The above observations are rooted in the participants’ cultures and worldview in the sense that malaria is prevalent in West Africa whereas HIV and AIDS are common in southern Africa. The above findings also indicate that even in their new environment the immigrants’ mindset about illness is shaped by the diseases in their home countries and that they are somehow still ‘afraid’ of the diseases that affect people in their native countries.

Time of Hospital Attendance From the data we observe that a majority of the participants (about 54.3%) reported that they set their children’s hospital/clinic appointments after three o’clock—that is, after the school hours. A little over thirty-one percent (31.4%) of respondents set their children’s appointments at between 9:00 a.m. and 12 Noon, whereas 14.3% set theirs at between 12 noon and 3:00 p.m. (see Figure 2). The reason given by the surveyed participants for setting this particular time for their child to see the doctor was that if a child was not in serious pain or had no communicable illness, then there was no need to let the child miss school. A participant who made every effort for his child not to miss school commented:

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I know my child has these multiple problems but I make sure she takes her medicine every evening before she goes to bed. I also make sure she gets enough sleep every day to be able to go to school. I’m from a family where my parents did not get any formal education but tried their best with their scarce resources to educate us (their eight children in total). I have every opportunity to help my children here in the United States since there are better facilities to support people.

Reported Time of Hospital Attendance (Number and Percentage)

33.31.4%

9AM-12PM 12PM-3PM

57.54.3%

After 3PM 15.14.3%

Figure 2 Time of Hospital Attendance

From participants’ utterances, we learn that their choice of time was motivated by their desire for their children not to miss any schoolwork in order for them to do well. A female participant wrote: In my culture going to school is like working. You do not want to miss so many hours of work in order to get a good paycheck. The same applies to school. I do not want my child to miss so many hours of school because missing so many hours of schooling will definitely affect her grades. There are a lot of opportunities in this country; opportunities you don’t find back home so missing school is like missing a great opportunity to do well in life.

DISCUSSION Based on the findings discussed in the previous section, it may be argued that, for the surveyed parents, the prevalence of flu and cold were problematic to them cognizant of the fact that in their native countries such illnesses were uncommon. The parents found the prevalence of cold and flu among their children problematic given the impact of these illnesses on their children’s schooling. In particular, the possibility of a school nurse

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summoning them to the school to pick up a child because of cold or flu was a situation they found difficult to comprehend and/or bear. Also, given the fact that some of these immigrants lived with extended family members, the prevalence of cold and flu was not only problematic to the children’s parents, but to everybody in the family—both nuclear and extended—since they all had to deal with it collectively by supporting one another. Furthermore, a close attention to the data and to the findings point to the fact that the surveyed participants’ view of the United States as a land of opportunity had considerable impact on their decision about the appropriate time for their children to see a physician as well as their decision to make a child miss school due to an illness. For most of the research participants, missing school meant not having a good grade and hence their decision to encourage a child who, in their opinion, was not very ill, to go to school. As one parent said, “Missing school is like missing work.” Thus, for them, missing school was like missing a paycheck, a rare but important lifetime opportunity. Finally, through the utterances of the research participants, the study has shown the various illnesses that are common among the surveyed immigrant participants’ children. The study has also shown the surveyed participants’ perceptions about the impact of such diseases on their children’s school attendance in particular, and the value the immigrant parents place on their children’s schooling in general.

CONCLUSION This study is of significance to health educators, medical practitioners, and social workers, as well as to teachers who deal with immigrant children. In particular, the findings of the study constitute a source of knowledge from which the above-mentioned professionals can learn about the impact of culture on health and school attendance among immigrant populations. Knowing about the parents’ perceptions about illnesses and how their cultures influence the decisions they make during a child’s sickness will help the professionals take appropriate and informed decisions. Thus, based on such knowledge, the professionals can make appropriate recommendations to the parents and other stakeholders in immigrant children’s welfare for the betterment of these children’s lives. This study could also form the basis for studying the link between culture, health, and schooling among other immigrant groups.

REFERENCES Bobonis, G.J., Miguel, E., and Puri-Sharma, C. (2006). Anemia and school participation. Journal of Human Resources. 41(4): 692-721. Goubert, L., Eccleston, C., Vervoort, T., Jordan, A., and Crombez, G. (2006). Parental catastrophizing about their child’s pain. The parent version of the Pain Catastrophizing Scale (PCS-P): a preliminary validation. Pain. 123(3): 254-263.

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Levi, M., Heffner, B., Stewart, T., Beeman, G. (2006). The efficacy of asthma case management in an urban school district in reducing school absences and hospitalizations for asthma. Journal of School Health 76(6): 320-324. Lewis-Beck, M.S., Bryman, A., Liao, T.F. (2004) Encyclopedia of Social Science Research Methods Vol 2. Thousand Oaks, CA: SAGE Mahawithange, S.T.C., Kannanga, K.K.N.P., and Wickremasinghe, R. (2007). Impact of vitamin A supplementation on health status and absenteeism of school children in Sri Lanka. Asia Pacific Journal of Clinical Nutrition. 16(1): 94-102. Patton, M.Q. (1990). Qualitative Evaluation and Research Methods. 2nd ed. Newbury Park, CA: Sage Publications. Schwandt, T.A. (2001). Dictionary of Qualitative Inquiry. 2nd ed. Thousand Oaks, CA: Sage. Vargas, P.A., Simpson, P.M., and Bushmiaer, M. (2006). Symptom profile and asthma control in school-aged children. Annual Allergy Asthma Immunology 96(6): 787-793.

In: Progress in Education, Volume 17 Editor: Robert V. Nata

ISBN 978-1-60692-505-8 © 2009 Nova Science Publishers, Inc.

Chapter 6

ACCESSING THE GENERAL PHYSICAL EDUCATION CURRICULUM FOR STUDENTS WITH SENSORY DEFICITS Roseanna Davidson, Effie Laman and Michael Shaughnessy

ABSTRACT Students in a regular physical education program typically learn skills through observation and practice. Teachers and specialists working with students who are sensory impaired with multiple disabilities face unique challenges. Because such students make up a small percentage of the population, physical education texts on adaptations, instructional strategies and activities for groups give only minimal information about working with them. Physical education teachers and activity leaders in the trenches are always on the lookout for appropriate, appealing games and activities for their students. It is apparent that even for students who are blind, multiply disabled or deafblind, no special curriculum and few, if any; specific activities exist only for them. Activities for these students are basically the same activities that have attracted students since time immemorial. These games are adaptations of familiar activities found in virtually every good physical education or motor-development curriculum. Even though the implementation of these activities results in specialized programs or special classes, the actual content and practice are easily accomplished, common-sense adaptations and accommodations that make the application of familiar activities appropriate for integrated and mainstreamed classes. These activities are educational and have both general goals and specific objectives. The authors are aware, however, that learning is accomplished most effectively in environments of enjoyment, pleasure and fun – we should all focus on the learner and learning (not the teacher and teaching).

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WISDOM FROM THE FIELD: HOW TO DO PHYSICAL EDUCATION Wisdom for the Classroom Teacher IN THE MAJORITY of programs, whether in residential schools for the blind or the deaf or in day school programs, there may not be a full- or part-time physical education teacher to consult with the staff. If you are fortunate enough to have a physical education teacher to work with, you should keep the following in mind. Since the physical education teacher’s background has been in motor activity, there may have been some exposure to the education of children with visual or hearing impairments, but the physical education teacher would certainly not have had a full program in special education as other members of the teaching staff have. When scheduling for motor skills instruction, the staff should have maximum input. The physical education teacher and the classroom teachers should cooperate in determining when their children will attend motor skills and physical education classes. The children may be at similar or varied levels of cognitive or motor function, and the classroom teacher may decide to send a child to be with a group that is more similar in cognitive or motor function than his classmates. These children will be going through a variety of cognitive and motor programs during their school day. Their activities will include sorting, sequencing, active movement and language skills that are taught by the classroom teacher. The teacher knows when each particular child shows maximal attention, motivation and stimulation, and may have a preference of times to work with specific children in the classroom, and times to have particular children work with the physical education teacher for motor skills instruction. It should be emphasized that physical education classes are open to the classroom teachers of children with multiple sensory impairments, as this promotes awareness, continuity, and reinforcement on the part of both the classroom and physical education teachers. Though the classroom teacher may sometimes send a para-educator, it is a great benefit for the teacher to come at frequent intervals in order to become aware of the motor program in which the pupils are involved. The classroom teacher can demonstrate the kind of communication employed with children in class, and request the physical education teacher to employ the same, providing continuity in this area of development. Reinforcement becomes reciprocal when the classroom teacher explains objectives for each child and the physical education teacher follows up. For example, if the teacher has the child with multiple sensory impairments learning the manual alphabet and the child is beginning to form and comprehend words in the classroom, the physical education teacher can begin finger spelling action words such as “run”, “jump”, and “hop” in the motor skills area, and may request that the classroom teacher do the same with that particular child in the classroom. Reinforcement, both cognitive and motor, becomes the focal point in the child’s learning experience. The children may learn to come to the motor skills room by themselves as a lesson in orientation and mobility.

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Communication among the members of staff, of which the physical education teacher is a part, is extremely vital in accomplishing this.

Wisdom for the Physical Education Teacher There is, and will always be, a need for physical education teachers in special education as long as there are exceptional children who have cognitive and motor needs to be fulfilled. Ultimately, the physical education teacher must promote his/ her own program. With all the technical aspects of devising the motor skills program and the theory behind it, how practical is it? Who makes it go? What makes it go, and how? The answer is the physical education teacher! It is thus incumbent upon the physical education teacher to learn everything possible regarding the characteristics of children with multiple sensory impairments. This must be done through reading, observing and listening to those persons involved in the teaching process, and particularly, through developing rapport with the staff. There is no end to the challenges that the child will present to the physical education graduate who has never worked with exceptional children, youth or adults. The physical education teacher, like the classroom teacher, must be multiply-prepared to teach, train and motivate these children. The physical education teacher must realize that the child has the basic needs of any “normal” child and must be given every opportunity to be exposed to experiences, as other children are exposed, with necessary modifications, adaptations and adjustments that bring the child as close to normal behavior as possible. The physical education teacher must be able to perform skillfully the activities which the children are taught, and be capable of demonstrating a high quality of movement when performing them. Stamina is a part of being fit and healthy, and the physical education teacher must have much of it. Some children are very passive and others are extremely active. Whichever characteristic they possess or exhibit, they can be very exhausting to work with. If the physical education teacher does not already have it, it will be necessary to develop the stamina to keep up, pick up, and catch up with these children. All in all, stamina and good health are vital to the teacher of children, but the physical education teacher must also have a high threshold of psychological security and emotional stability to cope with the many problems presented by children with multiple sensory impairments. Although many children exhibit similar behaviors, they each exhibit individual differences that are unique to each personality. The physical education teacher must be perceptive enough to pick up on these individual differences and respond to them accordingly. This will take some time. It will, however, put the physical education teacher in a position where the behavior of the young children being taught can be predicted, channeled, and controlled to a higher degree. This is very important, especially when working with several children at one time. It reflects the educational emphasis placed on individualized instruction within groups of children being taught. Individualized instruction, in this case, does not signify one-to-one instruction. It advocates the necessity to continue working with children in groups while simultaneously dealing with individual differences presented by each child in the group. When this is done

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properly, there is a smooth transition from one area of activity to another, and the focal points of the day’s lesson are covered. In extreme cases, it may be necessary for the physical education teacher to take a single child for instruction, with the idea of integrating the child into a group when that child is ready for group participation in the program. The physical education teacher must not be caught up in the trap of showing bias toward the higher functioning child; there must be concern for the total development of all children, regardless of their motor performance or motor ability. The teacher must strive daily to bring children of low motor ability into closer proximity with those who have a higher level of motor ability. The teacher must also provide new motor experiences for those children with existing high motor ability so that they will be challenged to use their acquired motor skills in even more complex problem-solving situations. The promotion of peer interaction and social development through motor skills should be an important concern of the physical education teacher. Motor activities that involve working with another child can be introduced to help low functioning multiply sensory impaired children improve social and peer interaction and cooperation. Lead-up games and activities also help the low functioning child improve in this respect. In this respect, the teacher’s attitude toward the child is of utmost significance. Children without sensory impairments at this primary age level have a high play urge. In children with multiple sensory impairments, it usually has to be brought out with the help of an adult. The physical education teacher is in a position to take advantage of this. In order to bring out the element of play in these children, the physical education teacher must discard the “adult attitude” usually assumed and come down to the level of these children with multiple sensory impairments. Let them “see” him or her in this role, as the role-playing becomes a part of the personality of the physical education teacher. If this is done well, the physical education teacher becomes the “fun skills specialist”, and rapport between the teacher and the child with multiple sensory impairments begins to develop. Some children may be involved in various kinds of behavior plans. The physical education teacher should be included in integrating those plans in the physical education program. The physical education teacher must see all of the children in the program. When there are staffings on particular children, the input from the physical education teacher should be requested and encouraged. Analyzing movement with accuracy and judgment helps in assessing and evaluating the children in the program. Physical education teachers have a lot of physical contact with the children and can also observe any abnormal behavior beyond routine conduct which might signify the child is ill, and not “just being uncooperative.” The physical education teacher must be aware of the biological as well as the chronological ages of the children. Biological age refers to the physical development of the neuromuscular system of the human organism. The physical education teacher must be creative and use imagination, especially with children who are at different levels of motor and cognitive development. Knowing the child’s biological age can help determine how much physical activity can be tolerated, as well as indicating the readiness on the part of the child, developmentally, to engage in a particular type of activity. This knowledge also safeguards against injury to the child. Many of the activities in a motor skills program require mutual movement between the child with multiple sensory impairments and the teacher. Movement experiences, in the

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beginning, come from bodily movement by parent or teacher. Motor skills can serve as a bridge for social relationships and peer interaction in this part of the child’s development. This means there is some lifting, positioning and tactile involvement on the part of the physical education teacher. Most children need physical positioning to stimulate movement in certain activities, and it is absolutely necessary for the physical education teacher and the classroom teacher as well, to develop the stamina required to teach these movement activities. Psychological health and emotional stability also must be considered. They are as important as the teacher’s physical health. There may be a personal need fulfillment on the part of the teacher working with children. The physical education teacher will often have to deal with behavior problems that children have. Knowing why the behavior problem occurred and what to do to bring the child out of it may take some considerable amount of brainstorming. Some children exhibit selfabusing or self-mutilating behavior, well as many other self-stimulatory behaviors that deter their attention span, making it difficult for the teacher to instruct them. Physical education can help diminish these behaviors, if they are caused by frustration, emotional stress and boredom. It is far better to correct than punish a child when unwanted behaviors occur. Reading the child’s files and meeting with the school clinical, health and related services staff can be of much help and provide future direction for the child’s motor program. Safety factors must be considered, and situations where severe bodily harm could result must be anticipated and guarded against. It is not always easy to cope with the multitude of problems children have. The length of time it takes for some children to acquire and retain certain basic skills can be frustrating to the physical education teacher. Many of these children are not toilet trained and may have accidents while in the motor skills class. The swimming pool may become a big “potty” for some children. It is necessary to deal with these problems, and the physical education teacher must assume an important part in this phase of the child’s development. Some sort of incentive to move must be created, such as stimulating the child’s interest in objects. The child must develop an awareness of her body. Confidence and trust must be established. To do this, the child must not only be aware of self but know that there is another person out there in whom trust and confidence can be placed. This is accomplished by being consistent, methodical, and repetitive in your approach. Have a set routine; hopefully anticipation and expectation will stir within the child. A physical education program should be devised so that the child moves toward and with things. The child moves toward the toy to acquire it and with the toy truck to make it go. Things should be inviting, such as a box to be filled, a ball to be rolled. Play with the child at certain times, in a certain way, in a specific place.

Wisdom for the Parent Parents Can Play a Significant Role as a Motor Skills Teacher of the Child with Multiple Sensory Impairments When parents and other family members are at home with their children, there are many opportunities for teaching motor skills. Ordinarily, parents play with their children on an incidental basis and perhaps do not include their child with multiple sensory impairments in

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these activities. Family participation is not only possible, but can be exciting and enjoyable, once it becomes apparent that the child with multiple sensory impairments can enjoy participation with the family. When you pick your child up at school where motor skills are taught, arrive early and watch your child perform. Go to swimming class and watch your child in the water. Do some of the activities with your child, right on the spot! Then proceed with your efforts at home. Remember that the teaching of motor skills must provide fun for the child. Fun in the child’s life helps to build communication and cognitive development. Children must know who they are, where they are, and what they do with their bodies. These are necessary steps in the process of perceptual motor development. There are five factors employed by teachers in the cycle of teaching motor skills to children with multiple sensory impairments [The five factors are: (1) Plan (2) Prescribe (3) Teach (4) Evaluate and (5) Reward.] The same cycle can be instituted into the child’s home environment if the parents are motivated to reinforce at home some of the motor skill activities the child is learning at school.

INTRODUCTION TO THE GENERAL PHYSICAL EDUCATION CURRICULUM The nation is concerned with a growing epidemic of obesity and the consequences of this epidemic. One way to help curb the epidemic is by increasing the physical activity levels of children and adolescents. One method to increase children and adolescents’ physical activity levels is to teach activities in which they are interested. This should be the role of a quality physical education program. Standards have been proposed to guide classroom and physical educators to provide educational opportunities for their students that will encourage them to remain physically active over the lifespan. Various curriculum models have been proposed in an attempt to meet these needs. This chapter will discuss the standards and curricular considerations for providing quality physical education to all students.

General Physical Education The importance of physical education for children and adolescents has changed over the decades since it was first introduced in the academic curriculum. Currently the role of physical education has become increasingly important due to the increased concerns with overweight and obesity in the population, and the effects of these concerns on the health of the nation (CDC, 2004). Healthy People 2010 (USDHHS, 2000) contains several objectives that address the importance of physical education. Overall, the objectives are to increase the amount of time spent in moderate to vigorous physical activity (MVPA) such that the individual will achieve and maintain a level of fitness; therefore preserving quality of life. Specifically, the objectives address the need for daily physical education that includes appropriate proportions of moderate to vigorous physical activity for children and adolescents. Additionally, the objectives place emphasis on addressing the needs of the

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nation’s diverse population, including factors such as age, gender, race and ethnicity, education, income, disability, geographic location and sexual orientation. What is Physical Education? Over the decades, physical education has gone through several paradigm shifts (Lacy and Hastad, 2003). Initially physical education was designed to help prevent diseases and injuries. The curriculum consisted of therapeutic exercise and training. In the early 1900’s there was a shift from a preventive purpose to sport oriented programs. The focus of this era was the teaching of sport skills and training for participation in various sports. In the 1950’s the pendulum began to swing back towards the fitness aspects. The shift was perpetuated by the results of a study, which found children in the United States to be less physically fit than the children in Europe. Although this shift began to incorporate extensive fitness testing, the curriculum of physical education remained sport oriented. Most recently the public health concerns associated with the rising rate of obesity and hypokinetic diseases (i.e., chronic diseases associated with a sedentary lifestyle), have caused health experts and physical educators to reevaluate the importance of physical education and the content of the physical education curriculum.

Figure 1. ActivityPyramid The reassessment of the role of physical education has resulted in the establishment of guidelines concerning the amount and intensity of the activities children should meet to improve health, wellness, and physical fitness. Guidelines have been established for children from birth to preadolescence (NASPE, 2002; NASPE/COPEC, 2004). The guidelines for school age children (NASPE/COPEC, 2004, pp.3 - 4) are:

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• •

•

Children should accumulate at least 60 minutes, and up to several hours of ageappropriate physical activity on all, or most days of the week. This daily accumulation should include moderate and vigorous physical activity with the majority of the time being spent in activity that is intermittent in nature. Children should participate in several bouts of physical activity lasting 15 minutes or more each day. Children should participate each day in a variety of age-appropriate physical activities designed to achieve optimal health, wellness, fitness, and performance benefits. Extended periods (periods of two hours or more) of inactivity are discouraged for children, especially during the daytime hours.

In addition to providing the previous guidelines, an activity pyramid, similar to the food pyramid was designed to help provide a visual representation of the amount and type of activities (see Figure 1). Examples of the intensities of various activities are listed in Table 1. However, the individual’s present level of performance may alter the intensity of these activities. Individuals with low levels of physical fitness will respond to the same activities with a higher intensity than individuals with moderate and high levels of physical fitness. Table 1. Standards of Physical Education

Standard 1

Standard 2 Standard 3 Standard 4 Standard 5 Standard 6

Demonstrates competency in motor skills and movement patterns needed to perform a variety of physical activities. Demonstrates understanding of movement concepts, principles, strategies and tactics as they apply to the learning and performance of physical activities. Participates regularly in physical activity. Achieves and maintains a health-enhancing level of physical fitness. Exhibits responsible personal and social behavior that respects self and other in physical activity settings. Values physical activity for health, enjoyment, challenge, self-expression, and/or social interaction. (NASPE, 2004, p. 11)

What is a Physically Educated Person? A physically educated person is one that possesses the skills, knowledge and attitudes to participate successfully in physical activity throughout the individual’s lifespan. According to the National Association of Sport and Physical Education (NASPE), a physically educated person possesses the following characteristics: Has learned skills necessary to perform a variety of physical activities; knows the implications of and the benefits from involvement in physical activities; does participate regularly in physical activity; is physically fit; and values physical activity and its contribution to a healthful lifestyle. (p. v)

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Based on the definition of a physically educated person, NASPE has provided objectives to standardize the physical education curriculum.

What are the Standards of Physical Education? The original standards were published in 1995 and have recently been updated. The most recent standards are: These standards are aligned with the objectives of Healthy People 2010, such that they allow for physical activity for the diversity of the nation’s population. The standards allow individuals to modify the specific performance objectives based on their present levels of performance, to meet each individuals needs. Types of Physical Education Curriculum There are a number of curricula that are utilized by physical educators to achieve the standards and guidelines set forth by NASPE and the Council on Physical Education for Children (COPEC). In the following sections, several of these curricula will be discussed. Although each curriculum has strengths, to adequately meet the standards and guidelines, classroom and physical educators should incorporate not just one, but several of the curricula. Movement Analysis Model The movement analysis model places the focus of study on the movement itself (Jewett, Bain, and Ennis, 1995). This model teaches students the biomechanical, physiological, and psychological principles associated with human movement. There are four basic questions that the students try to answer when using the movement analysis model: 1) “What is my body doing?” 2) “Where is my body going?” 3) “How is my body performing the movement?” 4) “What relationships are occurring as my body moves?” (Jewett, Bain, and Ennis, 1995). The importance of understanding the concepts and principles of human movement is the basis of this model. The students gain an understanding of how movements are learned and controlled, the mechanical principles that influence the movement patterns, physiological factors associated with training, psychological factors that affect movement, and aesthetics of movement. This model is a multidisciplinary model in that information from other academic disciplines is needed to gain an adequate understanding of the variables influencing performance. Often student assignments under this curriculum model are projects in which they must research and analyze his performance. At younger ages, exploratory activities and guided discovery can be used to gain an understanding of the interaction of the body with the environment and objects (Gallahue and Donnelly, 2003). Exploratory and guided discovery activities allow the students to experiment with body and space awareness, movement qualities, and the relationships associated with modifying various parameters (Melograno, 1996). The importance of this model is that it is multidisciplinary. Additionally, this model can facilitate several other approaches such as, the fitness model, multi-activity model, and the developmentally appropriate approach.

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Multi-Activity Model The focus of the multi-activity model, “… is to expose students to a variety of physical activity and sport.” (Himberg, Hutchinson, and Roussell, 2003, p. 224) The philosophy of this model is that students need opportunities to experience numerous activities, so that the probability of finding activities in which they are interested in to help promote a lifetime of physical activity. The positives of this approach to physical education are that the students receive exposure to numerous activities and sports. The probability of finding activities that all students enjoy is increased. Additionally, typical instructional time is limited and most of the time for each activity is spent on games or tournaments, providing increased opportunities for active participation. However, there are several negatives associated with this approach. Firstly, because of the large number of activities, most units are 2 or 3 weeks in length. This short period greatly reduces the amount of learning (instructional) and practice times. Secondly, with this approach, many of the same skills or sports are taught each year. Although this allows for additional practice, rarely are the students provided with intense instruction, therefore limiting the amount of understanding the students are able to obtain about any one particular activity. Sport Education Model Sports education model is based on the concept that students should be sport literate (Himberg et al., 2003; Jewett et al., 1995; Melograno, 1996; Metzler, 2000; Siedentop, 1994; Silverman and Ennis, 2003). The students are provided opportunities to learn more than just the skills associated with the sport; students learn in-depth knowledge associated with becoming a consumer of the sport. They experience various roles associated with the sport, such as coaches, statisticians, sports information directors, officials, managers, and players. Students are divided into teams at the beginning of the instructional unit, and they remain on the assigned team for the entire unit. The unit is typically eight to twelve weeks in length and is divided into seasons, preseason, competitive season, and postseason. During the preseason, the students learn and practice the skills associated with playing the sport. They also learn the rules and strategies associated with the sport, and what training is appropriate for the sport and why. During the season, typically the teams play in a round-robin tournament. This approach facilitates the concept of team affiliations and provides the students with opportunities to serve in roles of leadership. During the time the teams are not playing, the members fulfill various roles to facilitate the game. The sports education model allows modifications to match the student’s age and skill level. With this model, each consecutive year can result in increasing complexity to match the intellectual, physical and emotional abilities of the students. Following the competitive season, the students plan and participate in culminating events, such as award ceremonies and “banquets.” Although the sport education model allows for developmentally appropriate levels of participation for all students, there are some negatives associated with this model. This model requires large amounts of preparation and planning time. Without careful planning, the link between the sport and the fitness necessary for that sport may not be made. Although the units are longer with this model than in the multi-activity model, the seasons are still relatively short. The sport education model results in high levels of competition, which may place excessive preoccupation with those students that possess high skill levels. Because the focus of this model is on creating sport literate students, the sports that are typically chosen by the teacher are the traditional team activities (e.g., basketball, soccer, softball, etc.). Many of the

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lower skilled students are not successful with these activities and because the season requires a large amount of time, less time is available for other non-traditional activities.

Social Responsibility Model The social responsibility model is “…a humanistic model that de-emphasizes motor-skill development in favor of personal development such as self-control, self-motivation, selfresponsibility, respect for others, and genuine caring for others.” (Himberg et al., 2003, p. 225) The social responsibility model was proposed by Hellison (1995) who believes individuals must show respect for others and self-control. This model focuses on four levels of responsibility development. The first level involves the students understanding and respecting the rights of others, specifically the focus is on self-control in social settings. The second level focuses on participation in physical activities. The individual obtains opportunities to participate in various activities and to find those activities that interest the individual. The third level allows the students to pursue and increase their abilities in the activities of interest. If the students chose the activities, they are more likely to continue participation over the lifespan (i.e., self-direction). The final level requires the students to reach a level of self-actualization by caring for and helping others through participation in physical activities. The social responsibility model addresses the fifth and sixth NASPE standards. Fitness Model The original purpose of physical education was for the prevention of disease and injury and for the maintenance of well-being. However, over the years the teaching of sport replaced this original purpose. With a rise in hypokinetic diseases, diseases that result from a sedentary lifestyle, and the number of overweight/obese children and adolescents, the emphasis in physical education has returned to a concern of the health-related fitness domain (CDC, 2004, NASPE, 2004). The focus of the fitness model is on the development not only of the healthrelated fitness components, but also on the cognitive components associated with learning how to assess the various components and design fitness programs to improve the individual’s level of fitness (Himberg et al., 2003). The fitness model focuses on the five components of health-related physical fitness (Stillwell and Willgoose, 1997). Aerobic fitness or cardiorespiratory endurance is the ability of the body to transport and utilize oxygen by the working muscles. This component should be the basis of any fitness program, as it directly affects chronic diseases and conditions such as diabetes, heart and cardiovascular disease, high blood pressure, depression, anxiety and stress. Flexibility is a second component of health-related physical fitness. Flexibility is the range of motion though which a joint can move. Flexibility is joint specific, rather than a general level of flexibility. Muscular strength and endurance are two other components of physical fitness. Muscular strength is the maximum amount of force a muscle of group of muscles can produce for one repetition of the movement. Muscular endurance is the ability to produce submaximal contractions of a muscle or group of muscles repeatedly. Both muscular strength and endurance are crucial in maintaining activities of daily living and in the prevention of osteoporosis. The final component is body composition. Body composition is the ratio of lean body mass (i.e., muscles, bones, connective tissue, organs, etc.) to fat tissue. Body composition is how an individual is determined to be overweight or obese. When

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utilizing the fitness model, the students should be taught how to assess all five components and what exercises influence each of the components. The fitness model should also address the basic principles of training. Duration, frequency, intensity, specificity and reversibility are the most basic principles. The duration pertains to the length of the aerobic activity or the number of repetitions and sets for resistance and flexibility activities. Frequency pertains to the number of exercise sessions per week. Intensity is associated with the amount of resistance (weight) for resistance training or the pace of aerobic activities. Specificity is associated with the type of exercises that are included in a training program. Reversibility refers to the regression that occurs when an individual does not maintain a regular training program. When a regular training program is not maintained, any gains will be lost in a relatively short period. The fitness model allows for the meeting of the NASPE/COPEC (2004) guidelines for physical activity for children, as well as the standards of a physically educated person (NASPE, 2004). The students are taught the principles of training and the creation/modification of training programs to address weaknesses in the components of the health-related physical fitness. One point should be made in that incorporating only fitness activities will probably not encourage students to maintain a training program, unless the fitness activities incorporate enjoyable activities. Therefore, the Lifelong Physical Activity Model has been proposed (Himberg, et al., 2003). This model incorporates the learning of the health-related fitness domain with the opportunities for students to learn other activities and sports that interest them, and in which they can become skilled. The majority of the activities should be activities in which the students can continue to participate into adulthood, individual or dual activities, and that develop at least one component of health-related physical fitness. Several programs have been designed based on the fitness model. These include Child and Adolescent Trial for Cardiovascular Health (CATCH), Sports, Play, and Active Recreation for Kids (SPARK), and Middle School Physical Activity and Nutrition (MSPAN). CATCH is a program designed to address issues associated with physical activity, nutrition, and smoking behavior of children and their families (Nader et al., 1996). Research has found the CATCH program to be effective in improving the fitness and motor skill levels of students (McKenzie, Strikmiller, Stone, Woods, Ehlinger, Romero, and Budman, 1994; Nader et al., 1996, 1999). SPARK is a program in which physical educators incorporate the learning of motor skills, physical fitness and physical activities into the physical education curriculum. A selfmanagement program designed to make the students responsible for their physical activity outside of physical education. The results of research on the SPARK program indicate that for the SPARK schools, more time was spent in physical education and activities, with no reduction in academic performance (Sallis, McKenzie, Kolody, Lewis, Marshall and Rosengard, 1999). M-SPAN is an intervention program designed to incorporate information about physical activity and nutrition into the overall curriculum, not just to the physical education curriculum. The results of several studies (McKenzie, Marshall, Sallis and Conway, 2000a, 2000b) suggest that the intervention has effectively increased the amount of MPA and VPA of the students without increasing the time spent in physical education (i.e., increased quality and effectiveness of physical education).

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Developmental Model The developmental model (Gallahue and Donnelly, 2003) addresses the needs of the total child, addressing all four domains (i.e., cognitive, affective, psychomotor and health-related fitness). The basis of the developmental model is the individual. The overall goal is to meet the needs of each child by utilizing her strengths to improve her weaknesses. In the early grades, the emphasis is on discovery and exploratory activities. The activities that are chosen are “age-group appropriate” with enough variety to allow for varying skill levels and interests. In order to implement the developmental model, three basic elements must be considered; the individual, the task, and the environment (see Figure 2). Factors associated with the individual include things such as skill level, fitness level, previous experiences, practice opportunities, training and instruction, and disabilities. Factors associated with the task include the presence or absence of object manipulation and locomotion, degree of accuracy, the characteristics of the object or equipment, the activities associated with the task, selection of equipment, the complexity of the task, and the instructional techniques used. Environmental factors include both physical factors and psychological factors. Physical factors include items such as the surface, size of the playing area, equipment, temperature, humidity, and assistive devices. Psychological factors include the presence of an audience, acceptance and support of the audience, anxiety and stress. All of these elements should be included when designing programs because not only do these factors affect performance directly, but they also interact in a way that may result in a significant modification on the individual’s performance. The developmental model allows for modifications or variations to the task and the environment, which result in increased efficiency and effectiveness of each individual’s performance. The developmental model focuses on conceptual learning in which concepts associated with the skill, movement, activity and cognitive components are addressed. Additionally, perceptual-motor learning is associated with awareness of body and space, directionality, coordination, rhythm and sequence. Between these two approaches, many of the other models can be incorporated in the developmental model.

Task

Environment

Individual Performance Figure 2. Factors that Influence Performance (Copyright NASPE/COPEC, 2004, p. 11)

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Importance of Physical Education Research indicates that the role of physical education is a very important part of the curriculum (COPEC, 2001). Increased time for physical education has been shown to influence the fitness level of children, and that fitness level of children is associated with standardized test scores (NASPE, 2002; Sallis et al., 1999). The CDC (2004) emphasizes the importance of lifelong physical activity. One way to accomplish this goal is to provide quality physical education in which the students have the opportunities to experience a wide variety of activities and sports in an attempt maximize the individual’s participation in lifelong activities that are interesting and enjoyable to them.

Summary The role of physical education is vitally important to all children to ensure that they experience the greatest quality of life. Extra effort should be made to incorporate activities that are enjoyable, challenging, and interesting to all children, regardless of their skill and fitness levels within the framework of their specific abilities and disabilities. Table 2. Various activities and the associated intensities (Copyright NASPE/COPEC, 2004, p. 6) Activity Type Moderate Activities

Vigorous Activities

Intermittent Intensity Low-intensity games such as hop-scotch and four-square Playing low-activity positions in sports such as goalie in soccer or the outfield in softball Some chores and yard work Active games involving running, chasing, etc. Playing sports

Continuous Intensity Walking to school Bike riding Some chores and yard work Hiking Canoeing Self-selected activities such as jogging

EDUCATION LAWS Introduction Our world is changing every day. The changes come in many shapes and sizes some big, some small. Their effects can be perceived and experienced as both positive and negative. If we were not changing, we would not be growing. Changes in laws drive changes within the educational organization and ultimately, changes in how services are delivered to the individuals we serve. As professionals who serve individuals with many challenges, we must exhibit confident attitudes that do not shy away from change, but rather embrace and explore change. We must understand our history, where we are today, and where we are projecting to go. We must be

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willing to give changes a chance, as well as be willing to protect those we serve when we see that changes need particular amendments. With this in mind, we will start this chapter with a simple review of the history of special education law.

History of Special Education Law During the early and mid 20th century, many students with disabilities were completely excluded from public education. If the students with disabilities were admitted, they were generally not provided with an appropriate education. Schools were also responsible for classifying many students as having disabilities who actually did not. Frequently, these students were members of culturally or linguistically diverse groups. In the early 1970s, families, parent advocacy organizations, and civil rights lawyers began to sue state and local school boards, claiming the students’ rights to an equal education opportunity under the U.S. Constitution were being denied. When the Supreme Court made its decision in the school race-desegregation case (Brown v. Board of Education, 1954), the advocates argued that because Brown did not allow schools to segregate by race, schools should not be allowed to segregate by ability or disability. In 1972, the federal courts ordered the Commonwealth of Pennsylvania and the District of Columbia to provide a free appropriate public education to all students with disabilities. Education for those students also was mandated to be provided in the same schools and basically the same programs as students without disabilities, and certain procedural safeguards were put into place. Advocates began petitioning the Congress for a federal law that would guarantee students’ rights. The advocacy efforts proved effective and for more than 30 years, a law that Congress enacted in 1975 has governed the education of students with disabilities. Public law 94-142, now known as the Individuals with Disabilities Education Act, introduced the idea of “mainstreaming” and higher expectations. This law is frequently referred to as IDEA (Turnbull, Turnbull, Shank, and Smith, 2004).

IDEA IDEA established six principles that govern students’ education. • Zero-reject: A rule against excluding any student. • Nondiscriminatory evaluation: A rule requiring schools to evaluate students fairly to determine if they have a disability and, if so, what kind and how extensive. • Appropriate education: A rule requiring schools to provide individually tailored education for each student based on the evaluation and augmented related services and supplementary aids and services. • Least restrictive environment: A rule requiring schools to educate students with disabilities with students without disabilities to the maximum extent appropriate for the students with disabilities. • Procedural due process: A rule providing safeguards for students against schools’ actions, including a right to sue in court.

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Parental and student participation: A rule requiring schools to collaborate with parents and adolescent students in designing and carrying out special education programs (Turnbull, Turnbull, Shank, and Smith, 2004).

IDEA has changed and been reauthorized since it was first enacted. When it was initially enacted, students who were ages 6 to 18 were included. Now special education services span from birth through 21 years of age. In 1997, one of the fundamental changes made to IDEA was to recognize the critically important role that parents have (Murphy, 2003). The reauthorization also required students with disabilities to have access to the same standards as general education students (Elliot, 2003). IDEA is, at the time of this writing, currently undergoing another reauthorization. This is not a simple matter, and consensus seems elusive at best. When reauthorized by Congress, the Individuals with Disabilities Education Act will no doubt bring about many more changes in special education. Much work remains to be done in order to provide all students with IEP’s access to the general education standards and curriculum, and inclusion in assessment and accountability systems.

IDEA and Deafblindness Persons with deafblindness represent one of the lowest incidence disability populations served under IDEA. Currently, there are only approximately 12,000 students served under the Individuals with Disabilities Education Act of 1997. Although there are relatively few students who are challenged by deafblindness, these students often present the greatest challenge to educators in both instruction and large-scale assessment because of their concurrent vision and hearing impairments and frequent presence of additional disabilities (White, Garrett, Kearus, and Grisham-Brown, 2003). The U.S. Office of Special Education Programs has recognized the challenging needs of this population and has funded technical assistance projects in each state to help address the needs of students who are deafblind. Meeting the education needs of these children is challenging and requires an interdisciplinary approach among professionals as well as participation of parents and the students themselves (Griffin, Davis, and Williams, 2004). IDEA mandates that students with deafblindness be educated in the general education setting as much as appropriate. During the last decade, limited evidence has emerged providing models for embedding individual student-focused strategies in general education settings. One option is to train peer tutors. A second option is to embed instruction in the context of a cooperative learning group. A third alternative is to use observational learning where students learn daily routines by watching their peers perform various tasks (Browder and Cooper-Duffy, 2003). Many students with deafblindness have challenging behaviors that must be dealt with at school. Through amendments to the IDEA, federal law mandates the use of functional behavioral assessments and positive behavioral support plans to address challenging behaviors presented by students. The IDEA ’97 Amendments did not specify what constitutes a valid functional behavioral assessment. It is generally accepted that a functional behavioral assessment is not a single test or observation, but rather a multi-method strategy involving observations, interviews, and review of records regarding student behavior, its antecedents, and its consequences. The central goal of functional behavioral assessments is to identify

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environmental conditions that are associated with the occurrence and nonoccurrence of problem behaviors (Gresham, Watson, and Skinner, 2001). Under the regulations of IDEA 1997, all students must participate not only in the general curriculum but also in state- and district-wide assessments. This has proven particularly challenging for teachers who serve students with deafblindness. One answer has come in the form of alternate assessments, although this area is also filled with many questions about implementation. Students who cannot participate in general assessment systems, even with accommodations, may the opportunity to participate in alternate assessment systems (White, Garrett, Kearus, and Grisham-Brown, 2003).

No Child Left Behind Legislation During the administration of the President George H.W. Bush, the National Education Goals 2000 legislation passed and was continued by President William J. Clinton. It was a bipartisan effort and laid the foundation for the current legislation, No Child Left Behind. The National Education Goals Panel published every year for 10 years a National Education Goals Report. The current legislation signed on Jan. 8, 2002; No Child Left Behind (NCLB) is much more ambitious and may be thought of as a sort of Goals 2014. The goal of NCLB is that ALL children will be proficient in ALL subject matter by 2014 and qualified teachers highly trained in their subject matter by the year 2005-2006 will teach them ALL. Annual progress is expected by every state toward the 100% goal (Moores, 2004). There is much concern about just how the imminent reauthorization of IDEA will align and reinforce the No Child Left Behind legislation. The No Child Left Behind Act of 2001 goes far beyond any previous federal education mandate. Although the law is primarily a law for students in regular education, it also promises that students with disabilities will achieve at the same levels as other students by the year 2014 (Albritten, Mainzer, and Ziegler, 2004). IDEA and the NCLB Act both point in the same direction of accountability—outcomes over process, parental options, and use of empirically based teaching methods. These laws together provide an opportunity for general educators and special educators to work together to bridge the divide that exists between the two fields. Common areas to both fields that are impacted by NCLB include access to core curriculum, opportunity to learn, research-based teaching methodology, and database decision-making (Elliott, 2003). The law has several goals: • • • • •

All students in the United States will attain proficiency or better in reading and mathematics by the 2013-2014 school year All students with limited English proficiency (not deaf) will become proficient in English All students will be taught by highly qualified teachers by 2005-2006 All students will learn in safe, drug-free schools conducive to learning All students will graduate from high school (Steffan, 2004).

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The strength of NCLB is in forcing educators to confront disparate student achievement. Demographic groups - Black, Hispanic, Native American, Asian, Special Education, Limited English Proficient, Economically Disadvantaged, and White, must break out the test scores. Each group is examined for progress. The strength of examining each group is however, negated by the act’s single numerical goal for all groups and its requirement that each group reach 100% proficiency in 12 years, no matter the achievement level at which that group began (Rose, 2004). Perhaps the consideration of pre-test to post-test improvement or growth scores would be a more appropriate approach. One of the most significant implications of NCLB in terms of special education policy and practice is Adequate Yearly Progress (AYP) and the measured consequences for the school that occur when any group of students fail to meet AYP. Securing the resources needed to ensure that all students with disabilities reach proficiency on an achievement test will be challenging. To attain AYP, many students with disabilities are likely to require significantly more resources than are available today (Albritten, Mainzer, and Ziegler, 2004).

No Child Left Behind and Deafblindness To benefit fully from the directives of NCLB, the unique learning and assessment needs of students with deafblindness must be addressed. The majority of students with deafblindness are unable to participate in general assessment systems even with appropriate accommodations, because of the severity of their cognitive disabilities. As a result, states must provide alternate assessments to include these students in the accountability process. It is through these alternate assessment systems that many students with deafblindness will participate in large-scale educational assessments (White, Garrett, Kearns, and GrishamBrown, 2003). No more than 1% of the student population may be identified as needing alternate assessment systems under No Child Left Behind. No Child Left Behind assumes that there are valid, reliable research-based instructional practices that can eradicate the learning deficits of all students with disabilities (Albritten, Mainzer, and Ziegler, 2004). The NCLB requirement to assess all students in reading, math, and science is contrasted with the functional approach typical of skill acquisition research for the population of deafblind students. Although past research has demonstrated that students with severe disabilities can master functional skills and some academic responses, critical limitations include the following: • • •

Sparse literature for students with complex, multiple disabilities Limited range of functional academics and lack of reading comprehension measures Lack of research on teaching a broader range of academics to this population.

Teaching functional life skills and partial participation provide a strong research foundation for teaching students who are deafblind the skills necessary to participate in their daily routines. It is not clear from the research on skill acquisition how to meet the NCLB expectation to demonstrate progress in state academic content standards. Many states have chosen to use real-life (functional) indicators specifically for reading and math content standards in developing their alternate assessment that can be demonstrated in the context of daily routines. The requirement to address standards in reading, math, and science does not preclude a continued focus on functional skills (Browder and Cooper-Duffy, 2003).

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Research indicates that students who had greater opportunities for developing communication and social skills also had better outcomes on a statewide large-scale assessment. As educators, we are challenged to take inclusion to a higher level by creating ways for students with severe disabilities to not only access the general curriculum but also make progress within it. Finally, given that the majority of learning occurs in social situations, social interactions between students with deafblindness and children who do not have disabilities must be facilitated (White, Garrett, Kearns, and Grisham-Brown, 2003). White, Garrett, Kearns, and Grisham-Brown (2003) reported on alternate assessment scores that were examined in three different states. Each state’s assessment emphasized student choice making, communication skills, and social interactions. Two of the states required teachers to provide evidence of students’ work using student portfolios. The portfolios provided various types of evidence of the degree, to which students provided input on their academic performance, received instruction in natural settings, had opportunities for social interactions with nondisabled peers, and received appropriate and natural supports. In all three states, when students had more opportunities to practice communication and social skills in a variety of environments, assessment scores were better. In a standards-based assessment environment, curriculum alignment is necessary for students to succeed. Programs for students with severe disabilities should be no different. What we teach and how we teach should be reflected in how we evaluate what a student has learned. There is a clear commitment to improving American education in No Child Left Behind. There are some very positive elements in the legislation, which can have a positive impact on education of children with deafblindness if only because it requires us to raise our educational expectations, which, on the whole, are too low and underestimate the potential of the children, we serve (Moores, 2004). Another aspect of the NCLB Act that affects students who are deafblind is the aspect of “highly qualified” teachers. No Child Left Behind proposes that there will be a “highly qualified teacher in every classroom”. No matter what we do in law or no matter what we do in regulation, if we don’t have highly qualified, well trained, committed people working with our children, we will never get the kind of system that will allow all students to truly reach their potential (Murphy, 2003). Recent research has documented what educators and parents have long known: that children learn best from well-qualified, caring, and competent professional educators. However, in special education there is currently a shortage of at least 40,000 qualified special educators with low incidence areas such as deafblindness experiencing even greater shortages than other areas of special education (Albritten, Mainzer, and Ziegler, 2004). Teachers leave special education at almost twice the rate that other educators leave teaching in general (Albritten, Mainzer, and Ziegler, 2004). Many teachers in the field of deafblindness are nearing retirement age and the field of special education in general is experiencing a high exodus of its teachers as paperwork, overwhelming caseloads, and litigation take their toll. Funding is inadequate and there is currently no way to permit states to guarantee that every student with a disability has a highly qualified special education teacher. Under NCLB “highly qualified” means teachers must be certified in all subjects they teach. NCLB requires public school teachers of core academic subjects to attain “highly qualified” status by the 2005-2006 school year (Steffan, 2004). The NCLB definitions currently do not include special education among core academic subjects, thus special education teachers cannot teach their students core subjects such as math unless they hold

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dual certification in special education and the core subject areas they teach (Egnor, 2003). This creates quite a dilemma for students with significant cognitive disabilities who may need a more functional approach to a core subject such as math. Stories abound of students with significant cognitive challenges being required to sit in classes such as Algebra I when they are functioning at basic concept level because their special education teacher is not certified in math. Clearly, meaningful clarification is necessary to meet the needs of students. Paraprofessionals are another group that must become highly qualified if they work in Title I schools. Any paraprofessional hired since enactment of the law must have completed at least two years of study at an institution of higher learning; received a degree at the associate’s level or higher; and met a rigorous standard of quality as well as demonstrate through assessments that he or she can assist in the teaching of reading, writing, and mathematics. Incumbent paraprofessionals have four years to meet the standard. Under these strict requirements, one can only assume that many people will choose not to work in these often inadequately paying positions (Steffan, 2004). There are many challenges involved with the “highly qualified” component of NCLB, but steps are being taken to address those needs. There are initiatives designed to promote easy entry to the profession via alternative training routes for specific populations of teacher candidates (Brownell, Sindelar, Bishop, Langley, and Seo, 2002). Federal support has been put into place to address the personnel needs for students with high-cost low-incidence disabilities. Without this support, programs to prepare teachers for this population would be unlikely to exist. Some programs, such as student loan forgiveness programs that forgive up to a certain dollar amount for individuals who chose to teach in a “critical shortage area,” are also being put into place. Creativity and innovation must be used to address these many challenges as we move toward the education envisioned by the No Child Left Behind Act.

Summary It is important for us to look at our history, to look down the road that we have traveled, and see how far we have come in a relative few years. At the same time, we should look ahead and see how much further we have to go. We have come a long way since IDEA was enacted in 1975, not even three decades ago. The challenge is to continue the momentum despite the difficulties, as we continue our journey together. Together is a key word and is not easily achieved. A collaborative approach, where parents, general educators, special educators, and administrators genuinely share roles and responsibilities is needed to insure the best life for those who have dual sensory impairments. “Ownership” or responsibility for students with deafblindness must be shared across the school environment for true success. Given that students with deafblindness should learn skills within environments in which they will use those skills, it is important that they spend time outside of self-contained classrooms. If students are to be able to generalize their learning to multiple settings and to score well on state alternate assessments, special education teachers need to gain the administrative support necessary for access to, and instruction in, general education and other inclusive settings (White, Garrett, Kearns, and Grisham-Brown, 2003). As general education teachers, related service personnel, paraprofessionals, administrators, parents, and students cooperate more and more in planning, application, and evaluation, the students will be the winners. Even with the best of intentions, intensified

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competition for limited resources will surely test that collaboration as schools move toward accountability in reading and math (Albritten, Mainzer, and Ziegler, 2004). As Adequate Yearly Progress is implemented, special educators and parents will feel the pressure of competing outcomes. Decisions will have to be made on how to apportion limited time and resources. Further stress will be felt in the collaborative attempts if a school’s students with disabilities cannot reach the proficient level of their age mates, and NCLB punishes the school and the school district. As professionals, we must become aware of the implications and take stands to protect our students and our profession. Galluzzo (2004) suggests a simple premise: those closest to the problems of student achievement should be those closest to the solutions. He encourages educators to take the ideas they exchange with peers in casual conversations about teaching, learning, children, and schools, and to transform those ideas into public statements and actions demonstrating that teachers are at the center of education reform. As educators, we can help reshape the very ground rules of the system. Two of the most visible studies of the public’s attitudes toward education, the public Agenda’s national survey (2002) and the annual Phi Delta Kappa survey (Rose and Gallup 2003), concur that the public does not want teachers who merely teach to a standardized test (Galluzzo, 2004). Given that IDEA 1997 and NCLB mandate the participation of all students, including those who are deafblind, in large-scale assessments, it is unlikely that this issue will disappear. White, Garrett, Kearns, and Grisham-Brown (2003) make the following recommendations as together we strive to give our children with dual sensory impairments the very best we have to offer in the current educational climate of assessment and accountability. •

• •

Attention should be given to assuring that the unique learning needs of students who are deafblind are addressed throughout their educational career; not just at the time, the assessment is conducted. Communication needs and building social relationships should be addressed in daily programming. Use natural environments and multiple settings and materials to increase opportunities for communication and social relationships.

SENSORY IMPACT ON MOTOR DEVELOPMENT This section will describe the impact of sensory deficits on children’s motor skills (i.e., posture, gait, and balance) and provide intervention strategies that may be used to address individual needs.

Who are Students with Vision Loss? Vision assists children in the development of motor skills. The term often used to describe these skills, sensory-motor skills, illustrates the connection and importance of vision

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in this developmental area. Some children with multiple sensory deficits (i.e., visual and hearing impairment, vestibular and kinesthetic dysfunction) may develop motor skills just like children with sight while others will have developmental delays (Lavay, 1999). Children who are blind demonstrate similar developmental trends (as their peers who are sighted) in reaching postural milestones such as sitting and standing, yet tend to fall behind with locomotion milestones such as crawling and walking (Fazzi, 1997). [See Charts 3.1 and 3.2]. For children who are blind, these skills are without the benefit of observation and imitation. Timely intervention in motor skill development has assisted many children with visual impairments to develop normal motor skills (Blasch, LaGrow and Peterson, 1987; Brown and Bour, 1986; Rosen, 1987; Strickling and Pogrund, 2002). Chart 3.1. Fitness Issues Children Who are Visually Impaired or Blind Expend more energy in activities: running, walking, completion of daily living skills Have higher levels of body fat Prone to low activity level Lower levels of cardiovascular endurance Less muscular strength Less muscular endurance Less skilled at throwing Less skilled at catching Children Who are Visually Impaired or Blind Less skilled at striking Problems with body awareness Problems with spatial awareness Problems with body concepts

Children Who are Hard of Hearing or Deaf

Slower motor skill acquisition Prone to low activity level Lower cardiovascular endurance Less muscular strength Less muscular endurance Less skilled at throwing Less skilled at catching Children Who are Hard of Hearing or Deaf Less skilled at striking Problems with body awareness Problems with spatial awareness Problems with body concepts Lack of the concept of “play”

Children Who are Deafblind Expend more energy in activities: running, walking, completion of daily living skills Slower motor skill acquisition Prone to low activity level Lower limb, head control Less muscular strength Less muscular endurance Less skilled at throwing Less skilled at catching Children Who are Deafblind Less skilled at striking Problems with body awareness Problems with spatial awareness Problems with body concepts Lack of the concept of “play”

(Brown and Bour, 1986; Lieberman, 1999; 2002; McInnes and Treffry, 1997; Rosen, 1997; Stewart and Kluwin, 2001; Strickling and Pogrund, 2002).

According to Harrell and Akeson (1987), visual input deficits have an impact on motor development. Some of the possible effects of low vision on children’s motor abilities are perceptual delays, a lack of spontaneous self-initiated movements, difficulty with spatial accomplishments, and caution while exploring new environments. Furthermore, Halliday (1971) reports that children with a visual impairment may have poor eye-hand coordination. When compared to children with sight, children with sensory impairments expend more energy in activities such as running, walking, and completion of daily living skills. In

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addition, research has shown that children who are blind and deafblind have higher levels of body fat; lower levels of cardiovascular endurance, muscular strength, and muscular endurance; are less skilled at throwing, catching, balancing, and striking; and have problems with body and spatial awareness and body concepts (Strickling and Pogrund, 2002). These outcomes may be due to a tendency toward over-protectiveness, by parents and/or teachers, causing a lack of participation in physical activity, rather than due to heredity (Buell, 1973; Jankowski and Evans, 1991; Kobberling, Jankowski and Leger, 1989; Lieberman and Carron, 1998; Nixon, 1988; Winnick and Short, 1985; Winnick, 1985). Chart 3.2. Delayed Development Children Who are Visually Impaired or Blind Gross Motor Skills Fine Motor Skills Motor Speed Balance Head Control Creeping Crawling Standing Walking Catching Throwing Kicking Hopping Jumping Bouncing Skipping Leaping

Children Who are Hard of Hearing or Deaf Gross Motor Skills Fine Motor Skills Motor Speed Balance Catching Throwing Kicking Hopping Jumping Bouncing Skipping Leaping

Children Who are Deafblind Gross Motor Skills Fine Motor Skills Motor Speed Balance Head Control Creeping Crawling Standing Walking Catching Throwing Kicking Hopping Jumping Bouncing Skipping Leaping

(Brown and Bour, 1986; Lieberman, 1999; 2002; McInnes and Treffry, 1997; Rosen, 1997; Stewart and Kluwin, 2001; Strickling and Pogrund, 2002).

Common motor problems exhibited by preschool children with visual impairments include the following: Low postural tone; diminished shoulder, upper and lower extremity, and abdominal strength; frog-leg position while sitting; wide base of support while on all fours, standing or walking; head stacking; head deviated to one side; shoulder elevation and/or protraction; fisted hands and limited wrist rotation; anterior or posterior tilt of the pelvis; lumbar lordosis; scoliosis; toe-out; toe walking; flat feet; weight bearing on outside of feet; hyperextension of the knees; disorganized movement patterns; delayed righting reactions and equilibrium; high guard arm position while walking; lack of contralateral arm movement while walking; and inadequate weight distribution while walking (Brown and Bour, 1986; Rosen, 1997; Strickling and Pogrund, 2002). Many children who are deafblind also experience similar developmental delays in the acquisition of motor skills. Furthermore, syndromes (CHARGE, rubella, Cockaynne, and Usher’s) which can cause bone abnormalities, heart defects, anemia, and vestibular problems

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can cause deafblindness. The functional implications of these problems on motor development and skills are similar to the above-mentioned problems experienced by children with visual impairments (Lolli and Sauerburger, 2000; Silberman, 2000). In addition, children with sensory deficits may have “decreased proprioception and kinesthesia (the ability to sense the position and movement of the body and its parts” (Rosen and Joffee, 1995, p. 510).

Practical Intervention Strategies and Suggestions To facilitate effective motor development of children with multiple sensory deficits, intervention needs to concentrate “on the development of strategies to provide adequate sensory information about things that are distant” (Rosen and Joffee, 1995, p. 500). A transdisciplinary team comprised of parents, an early interventionist, an occupational therapist, a physical therapist, an orientation and mobility specialist, an intervener, an interpreter and a teacher of children with visual impairments will conduct an assessment of a child’s motor abilities, develop the goals and objectives related to motor skills, and provide the necessary intervention. Since each student develops and performs differently, this program needs to be highly individualized. Intervention strategies for infants and young children should include activities that help motivate the child to move and to keep moving. Activities that encourage the child to cross midline (clapping, holding a bottle with both hands), the demonstration of appropriate limb movement while walking, the use of a rocker board or a scooter board are helpful. Furthermore, activities such as games that involve arm swinging, weight training, and calisthenics are effective in the promotion of motor skill development. Walking, swimming, and running can also help children who are older (Rosen and Joffee, 1995). In addition, a variety of activities to develop fine-motor skills, eye-hand coordination and ear-hand coordination must be integrated into an instructional motor development program.

Who are Students with Deafness? Characteristics of Deafness A deaf person is one whose hearing is disabled to an extent that precludes the understanding of speech through the ear alone, with or without the use of a hearing aid. A hard-of-hearing person is one whose hearing is disabled to an extent that makes difficult, but does not preclude, the understanding of speech through the ear alone, with or without a hearing aid. (Moores, 2001, p. 11)

Hearing Loss Approximately 8.6% of the population in the United States has a hearing loss. That is 22 million sets of ears that have difficulty sending information to the brain (Turnbull, Turnbull, Shank, and Smith, 2004). A conductive loss involves the bones and muscles of the ear and can benefit from amplification. A neurological loss concerns the nerves involved in the inner ear and is less likely to benefit from amplification. Hearing loss can take place in every

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frequency and Hertz area of a sound wave. No two people will have the same exact hearing complications. The age of onset of loss, reason for loss and residual hearing all play important roles in determining what deafness means to each individual person (Bess and Humes, 2003).

Language and Communication Students with a moderate to low hearing loss will usually have intelligible speech average or above achievement and will not need an interpreter in the classroom. They can usually participate in any activities that interest them (Stewart and Kluwin, 2001). Some students with a low loss may not even wear a hearing aid and most do not use a sign system except to converse with other friends with deafness. Students who have a hearing loss that manifests later in life (advantageous-after the age of two years) may have intelligible speech and be an active reader even though they may have a greater loss than a congenitally (deaf at birth or by 6 months) deafened student. These students may learn sign language for casual communication but will fall back on speech if needed (Scheetz, 2004). Students with profound deafness may read below grade level, have unintelligible speech and may prefer to use a sign system to communicate on a regular basis. These students may or may not have anyone at home to sign with and will sign only with friends or teachers who sign. (Stewart and Kluwin, 2001) Psychosocial Dimensions There is a section of society known as the Deaf community. These groups of people, who have deafness or hearing impairment, are a functioning society with a language, social structure, schools and even a university. Many families want their children to go to a residential school for people with deafness (Moores, 2001). “Unlike most people who are born into their culture, Deaf children who have Deaf parents represent the minority in this culture (Andrews, Leigh and Weiner, 2004, p 27). Since the students are getting their information directly from the teacher and not through an interpreter, they are able to learn in an almost unrestricted learning environment. Language Language is a barrier that few hearing people are able or willing to cross to understand the Deaf community. Even in families, language can create an animosity between the signing and non-signing members of the family. Parents who do not sign have a very difficult time understanding their child with deafness’s emotional and educational needs (Marschark, Lang and Albertini, 2002). Sign language takes the forms of ASL (American Sign Language), MCE (Manually Coded English, i.e. S.E.E., S.E.E.II, and C.A.S.E), and Cued Speech (Easterbrooks and Baker, 2002). Many parents insist on an oral communication regime no matter what hearing the child can call on. Members of the Deaf culture maintain that sign language is “fully appropriate” for daily living (Marschark, Lang and Albertini, 2002, p104). Oralists insist that a hearing culture demands the spoken word (Stewart and Kluwin, 2001) for daily functioning. The speech patterns of many people with considerable deafness are flat and monotone, high-pitched and nasal, or otherwise difficult to understand. People who are hard of hearing may have specific sounds they find difficult to produce clearly.

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Education Education begins almost immediately after birth. Although many people would call the cries and reactions of an infant instinct, repeated successes become learning. Children with deafness who have hearing parents are at a distinct disadvantage in early intervention (Marschark, Lang and Albertini, 2002). Many parents do not realize their child has a hearing loss for several months. Babies with deafness babble just like hearing babies until about 6 months of age. Almost all sighted babies will react in some form to movement and a parent’s smiling face (Scheetz, 2004). By the time, a parent realizes there could be a hearing loss; the child may have lost several months of early language exposure. Early Childhood Intervention will build basic skills a child with deafness missed before the diagnosis of deafness was made. At this point, full parental support, education and cooperation is required to help get a child with deafness ready for school. A self-contained classroom may be the most appropriate setting for a child in the primary grades to help build language, speech and social skills. They will also begin learning how to use interpreter services correctly. Motor Development of Deaf Children The main setback that deaf children have to deal with from a motor-development perspective is the impairment of their balance and the delay in some of their abilities associated with balance. All children need the use of physical education classes in school to promote health, motor development, and social interaction. According to Jansma and French (1992), deaf children lead more sedentary or lower activity lifestyles than their hearing peers. [See Charts 3.1 and 3.2]. The importance of sport and physical education to deaf children lies in the fact that these activities provide a “training ground” for the child’s development of balance and motor skills. Compared to hearing children, deaf children experience developmental delays in some fundamental motor skills (Butterfield, 1988). Although deaf children can improve balance and motor skills by focusing on learning balancing techniques and improving body awareness, there remains a gap between the skills of hearing and deaf children.

Who are Students with Deafblindness? As of December 2003, the National Deaf-Blind Child Count reported 9853 students with deafblindness, between the ages of birth and 22 years in the United States. Who are these students and what is the deafblindness with which they are associated? Like students with normally developing sensory systems, students with deafblindness live with natural, adopted, or foster parents; in residential homes or group homes; and in homebound and hospital environments. They are from every ethnic and socio-economic background. They are children who need respect, to play, laugh, learn, run, jump, fall down and experience life. They are, in short, children.

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What is Deafblindness? The issue of deafblindness creates more complex problems than just adding blindness to deafness or deafness to blindness. (McInnes and Treffry, 1997). The combined sensory deficits results in exponentially greater barriers to learning that a single sensory loss. Deafblindness is not considered a multiple impairment (IDEA 34 CFR 300.7(c) (7)), as is mental retardation-blindness or mental retardation-orthopedic impairment. Deafblindness is a separate condition in and of itself. According to IDEA 34 CFR 300.7(c) (2), Deafblindness means concomitant hearing and visual impairments, the combination of which causes such severe communication and other developmental and educational needs that they cannot be accommodated in special education programs solely for children with deafness or children with blindness.

Several types of deafblindness exist and are caused by a number of different conditions. The better-known causes of deafblindness are Bardet-Biedl Syndrome, CHARGE Association, Down Syndrome, Usher’s Syndrome, other genetic disorders, and accidents and illness after birth. Maternal conditions that can disrupt the normal development of a baby are: Syphilis, Toxoplasmosis, Rubella, viral infections, and Herpes Simplex (Huebner, Prickett, Welch, and Joffee, 1995). Total deafness and total blindness happens less frequently than prevalent loss in one area and residual use in another. The Arizona Deafblind Project website lists the types of deafblindness as follows: • • • • •

totally deaf and totally blind (no light perception, over 80 dB hearing loss) deaf and visually impaired (residual vision, profound hearing loss) blind and deaf impaired (residual hearing, no usable vision) vision and hearing impaired (vision as primary disability) vision and hearing impaired (hearing as primary disability)

A student with a visual impairment factor in a multiple disability usually has the auditory system intact for gathering information. Likewise, a student with an auditory impairment element in a multiple disability allows the visual sense to lead in information gathering. Deafblindness, even with residual hearing and/or sight, severely limits the amount of information the student can garner from the environment.

What Special Needs do Children with Deafblindness Have? Socialization Children with deafblindness have the same needs as any other developing child. They need food, shelter, clothing, love and a sense of self and worth. Normally developing children get many of these needs met through incidental interaction with and reacting to the people and the environment around them. The child sees mother’s face or hears dad’s voice and reacts to them as a pre-communication activity. He sees a toy he wants and reaches for it as a precursor to crawling. He pulls himself up to see and then reach something on a table as a forerunner to walking. The child hears the doorbell and connects this with the fact that a

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friendly face or voice will soon be there. When the phone rings he will associate it with the fact, that mom has to put him down and go away for a short time. He learns that walking under the table hurts when he bumps his head and as a result, he becomes more aware of his own body in space. Of course, like all of us, it may take him more than one or two times to decide it is less painful to reach and feel what is in front before plunging ahead. All of these components help build good socialization skills and are learned through incidental interaction with the people and things around the child. A child with deafblindness needs a more “hands-on” approach to learning these appropriate social skills. A child with deafblindness needs a very comfortable, safe, and yet stimulating environment to explore. (McInnes and Treffry, 1997) Why would even a normally developing child want to explore his surroundings if every time he reached or crept around it was frightening, hurtful, or boring? It is frustrating to be warm, happy and cared for one instant and then laid on a cold bed or floor and left alone the next time. The child has no inkling that the phone has rung and mom has gone off to answer it. Fear, frustration, boredom, and anger can become associated with every movement or interaction with which the child with deafblindness is associated. When a child’s sensory system does not give them advanced notice that a person is approaching them, then the child will typically become startled and may respond by crying out from fear or anger. The child with deafblindness can have feelings of being attacked and hurt. The world of the child with deafblindness is frightening and nerve wracking. It becomes much safer “inside” and as a result, the child with deafblindness retreats into a personal shell. Unless the stress of living in this environment is relieved, the child with deafblindness can begin displaying symptoms of compulsions, phobias and hysterical reactions (McInnes and Treffry, 1997). Children with deafblindness will go through several stages of interaction. Some of these stages will last longer than others. McInnes and Treffry (1998) provide a list of stages of interaction. These interactions maintain that the child will: • • • • • • • •

resist interaction tolerate the interaction with the intervener, the communication professional who communicates to the child with deafblindness about the environment around them co-operate passively with the intervener enjoy the activity because of the intervener respond to the intervener lead the intervener through the activity once imitate the intervener, upon request initiate the action independently.

A child with deafblindness needs a reason to socialize, play with toys, crawl or walk. Children with deafblindness do not receive clear and consistent information from vision or hearing, and as a result, they turn inward to get the stimulation they desire. (Downing and Eichinger, 1990) This inward tendency can lead to inappropriate or undesirable behaviors. When a child with deafblindness is ready to enter into a school environment, his group of caregivers and people to interact with expands greatly. Parents need to take the time and effort to guide these new people through the same cues and communication and socialization schemas that the family and friends have worked so hard on for all the previous years. An

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entirely new group of people will need identifying characteristics. The child with deafblindness will find some of these on his own but will need help with others. His mother’s long hair, for example, has taught him that it is fine to touch but not grasp and pull hair so now he can explore his new teachers, caregivers and even select playmates safely and appropriately (Sauerburger, 1993).

Movement A child with deafblindness has as much or perhaps and even greater need for physical movement and activity. [See Charts 3.1 and 3.2] Many genetic conditions that can cause deafblindness can also cause low muscle tone (Huebner, Prickett, Welch, and Joffee, 1995). A student cannot participate fully in class if it is impossible for him to sit up long enough to get an idea of what is happening in the room around him. Positioning and posture are important in keeping the student comfortable, alert and safe (Haring and Romer, 1995) “Some authorities feel that there is a high degree of interdependence between motor development and all areas of emotional, social, and intellectual growth” (McInnes and Treffry, 1997, p. 94). Activities need to be more closely planned and supervised than with students without deafblindness but almost all activities can be adapted for students with deafblindness. If a student with deafblindness has a limited amount of vision or hearing then they may try to position themselves to take advantage of the senses they do have. This posture should not be changed but should be watched over time (Sacks and Silberman, 1998).

Reasons to Move Almost any soldier will affirm that calisthenics can be one of the most boring things in the world. Beneficial yet mindless and meaningless actions with no foreseeable goal will not usually keep a student’s interest either. Having a physical reason to move is very important especially if there are no sensory reasons to move. As stated at the beginning of the chapter, a child with vision sees a toy and reaches for it or hears a sound and tenses to be ready for what happens next. A child with deafblindness has no reason to move. A child with deafblindness needs mom’s face and hair in his hands, dad’s beard or cap, the dog or cat’s fur and body in close contact while he is safely held and supported. When playing reaching and stretching games there should be something familiar at the end of the reach. “If the student who is deafblind is not enjoying herself, or you, as a caregiver, are not enjoying yourself, it is likely that little communication or learning will take place (Miles and Riggio, p 92).

Practical Suggestions The following are samples of the methods that will increase a child with deafblindness’ communication and socialization: •

communicate with the child often and in a wide variety of situations

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• •

make sure the child has a sign name and that everyone who has contact with the child uses it every time they interact with the child make sure that everyone who works with the child has a distinguishing characteristic (several rings-even if only worn when working with the child, a special perfume, long hair, a special bracelet, a beard, etc…) that the child can identify give the child multiple opportunities to communicate with others by requiring a response to questions, choosing from options, and other turn taking activities allow the child to participate as much as possible in whatever activity you are engaged in make sure the child is aware of any changes that are about to take place by using calendar boxes, tactile cues, signs or any other number of cues (Stremel, 2001)

Start crawling activities with the toys in the child’s hand and slowly pull away, causing the child to reach and search. Hand over hand activities keep the child interested in what is happening (McInnes and Treffry, 1997).

ASSESSMENT OF THE PSYCHOMOTOR SKILLS AND PHYSICAL FITNESS The assessment of any child with a handicap or exceptionality is problematic, but the assessment of individuals who are sensory impaired is much more difficult. This problem is often compounded when the individual has multiple sensory impairments. Sattler (2001) while providing perhaps the most comprehensive text on assessment of children devotes precious little to assessing visually impaired, hearing impaired and nothing regarding deafblind. The purpose of this chapter is to discuss the evaluation of children who have visual or hearing impairment or deafblindness, and to review some of the assessment instruments that are relative to this population. The primary focus of this chapter will be on assessing the health-related fitness and psychomotor domains.

Assessment of the Psychomotor Skills and Physical Fitness In general, the vast majority of assessment instruments for all domains have been developed for students who possess normal vision and hearing. Tests, which yield specific age levels or mental age scores can hide or mask true skills, abilities and competencies of individuals with sensory impairments. This is why an understanding of adapted behavior scales and specialized test instruments is so crucial for this population. However, it should be remembered that students and adults who have multiple sensory impairments are diverse in their capabilities, learning, interests, motivation, experiences and communication skills thus there is no single “best” approach to assessment and evaluation for this population. Examiners must be guided by the referral question (e.g., progress, present level of functioning, regression) and by pragmatic, programming and other relevant concerns. Examiners must also be prepared for specific behaviors that may be manifested during the testing (e.g., repetitive or excess behaviors, a short attention span, self-injurious behaviors, disinterest, frustration and aggressive behavior, perseveration, self-stimulatory behavior, and echolalia).

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Concerns Laman and Davidson (2004) have reviewed the psychosocial evaluation procedures of children who are deafblind. They make several points regarding the quality of a psychological evaluation, some of which are important for physical assessments. Specifically, the evaluator should consider the following: 1. Identify specific educational concerns. 2. Use assessment tasks and activities that are meaningful and relevant to the educational objectives. 3. Use multiple procedures and instruments to obtain information about the student (e.g. observations, checklists, one-to-one learning tasks, interviews, etc.). 4. Involve teachers, parents and other related service providers in review of relevant concerns and information gathering. 5. Assess functional home and community skills. The evaluator must be cognizant that evaluation takes place in an environment, and that different environments may provide different challenges and different information. Evaluators need to be aware that various stimulations can result in various reactions and information such as, proprioceptive, tactile, kinesthetic, and other stimulatory channels, which may result in decidedly different responses and reactions. As mentioned in the introductory chapter in order to adequately assess an individual, three basic elements must be considered; the individual, the task, and the environment (see Chapter 1 - Figure 2). In review, factors associated with the individual include things such as skill level, fitness level, previous experiences, practice opportunities, training and instruction, and specific disabilities. Factors associated with the task include the presence or absence of object manipulation and locomotion, degree of accuracy, the characteristics of the object or equipment, the activities associated with the task, selection of equipment, the complexity of the task, and the instructional techniques. Environmental factors include both physical factors and psychological factors. Physical factors include items such as the surface, size of the playing area, equipment, temperature, humidity, and assistive devices. Psychological factors include the presence of an audience, acceptance and support of the audience, anxiety and stress. All of these elements should be included when designing an assessment program because not only do these factors affect performance directly, but they also interact in a way that may result in a significant modification of the individual’s performance. It is important that as many factors be controlled as possible so that a quality assessment can be accomplished.

Information Associated with the Individual Being Assessed It is difficult to predict future growth and development without a historical perspective on the student’s past growth. This is why accurate assessment and record keeping is so imperative, and why we need to train teachers in this realm. Present level of performance should be assessed in various realms, home, school, playground and other domains of relevance. Medical history and medications should also be included in the assessment report, and be considered when completing the assessment process.

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Security of the Individual with the Environment For optimal success, the teacher wants to assess the individual in an environment in which they feel safe. For example, Brian McManus (2002) has discussed the need for safety in terms of teaching children with visual impairments to swim. Swimming is an excellent cardiovascular exercise, but for those with vision impairments, and hearing impairments, safety is paramount. For deafblind students, they too need to feel that they are in a safe secure environment to perform optimally. Supervision is critical as some students may also be epileptic and instructors may not know this information. An in depth evaluation of the child’s motor skills, reactions to directions, and ability to move in their environment is crucial to educational success. Levels of Support of the Individual During the assessment procedure, evaluators need to ascertain the level or degree of autonomy or independence an individual possesses. Many students have good orientation and mobility skills, while others do not. Specifically, factors such as presence or absence of certain reflexes, postural stability, muscle tone, range of motion about specific joints, gait, and respiratory function should be considered in order to form a comprehensive physical education program. Characteristics of the Evaluator The procedures for evaluating progress for visual and hearing impairment individuals depend on a variety of variables. The evaluator should have an understanding of orientation and mobility skills and strategies as they apply to individuals with visual and hearing impairments and deafblindness. Additionally, a fluency in finger spelling, American Sign Language, and a grasp of Braille may also be helpful in certain instances. In some instances, it is incumbent upon the evaluator to seek out the skills of other professionals such as orientation and mobility specialists, educational audiologists, occupational and physical therapists, and ASL interpreters as needed.

Information Associated with the Assessment Instruments There are several factors associated with the assessment instruments that must be considered (Burton and Miller, 1998). These factors deal with issues of validity, reliability, and objectivity. Additionally, the assessment instruments may require a contrived environment or one that is more authentic in nature. Another consideration is the scoring and comparisons of the individual’s performance to either a larger population or to a predetermined standard. Each of these factors will be discussed in the following paragraphs.

Validity, Reliability and Objectivity Validity is the degree to which a test measures what it is stated to measure (Burton and Miller, 1998; Lacy and Hastad, 2003). One of several methods should validate an assessment instrument. Qualitative methods of determining validity include logical or face validity and content validity. Experts in the area should conduct qualitative methods of determining validity. Quantitative methods (i.e., construct, concurrent and predictive) use statistical

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procedures to determine the validity of an instrument. An adequate degree of validity is required when selecting an assessment instrument. Reliability is the repeatability of a test or the ability to obtain consistent results when testing the same individual under the same conditions. Typically, reliability is determined by testing an individual using a specific instrument and then repeating the testing for the same individual within an appropriate period of time, and analyzing the results using statistical techniques. Objectivity is a type of reliability that examines the consistency between evaluators. Reliability and objectivity are increased by following very detailed standardized instructions and calibrating all equipment, and are prerequisites for a valid assessment.

Traditional and Alternative Assessments Many of the standardized assessment instruments are designed to test individuals in an artificially designed environment. As previously mentioned, the environment may greatly influence the individual’s performance on certain tasks. To alleviate the constraints of these artificial environments, many professionals are recommending the use of alternative assessments (Lacy and Hastad, 2003). An alternative assessment is one that is non-traditional and is conducted in a “real-world” environment. Typically, alternative assessments use more qualitative scales than the quantitative scales used in the traditional assessment instruments. Checklists, rating scales, rubrics, task analyses, and portfolios are a few examples of alternative assessments. One problem with alternative assessments is often they are not standardized, decreasing the degree of reliability and objectivity. Norm-referenced and Criterion-referenced Assessment Instruments Norm-referenced tests (Lacy and Hastad, 2003) allow the individual’s performance to be compared to performance of other individuals with similar characteristics (e.g., age, gender, location, etc.). Norm-referenced tests typically report percentiles or standardized scores to help in assessing the individual’s performance. Criterion-referenced tests compare the individual’s performance to some predetermined standard (i.e., pass/fail). Both types of tests are valuable for a thorough assessment and evaluation of an individual’s capabilities.

Assessing the Domains of Learning Assessing the whole individual is important to an accurate evaluation. Although the affective (psychological and sociological factors) and cognitive (intellectual abilities) are important and will be addressed in this chapter, the focus will be on assessing the healthrelated fitness domain (physical fitness and physical activity) and the psychomotor domain (skill-related fitness, fundamental movement skills, sport-specific skills, and functional skills).

Health-Related Fitness Assessment With an increased concern with obesity in the entire population, the assessment of the health-related fitness is very important. Health-related components are aerobic (cardiorespiratory) endurance, muscular strength, muscular endurance, flexibility, and body composition (see Chapter 1). Additionally, assessing the individual’s amount of activity is

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crucial. Assessment instruments to evaluate the health-related fitness domain will be discussed.

FITNESSGRAM The FITNESSGRAM (Meredith and Welk, 2004) is a battery of tests that has been adopted by the American Alliance for Health, Physical Education, Recreation and Dance (AAHPERD) as the assessment tool for the Physical Best curriculum (AAHPERD, 1999). The FITNESSGRAM is designed to assess the components of health-related fitness (i.e., aerobic endurance, flexibility, body composition, and muscular strength and endurance). An evaluator can chose for each of the components of health-related fitness from several tests. Although the Physical Best curriculum provides activities and modifications for individuals with disabilities, the FITNESSGRAM does not directly provide modifications for individuals with disabilities. The manual for the FITNESSGRAM states that modifications can be made for individuals with disabilities, however no specific modifications are provided. Because no specific information for modifications is provided for the FITNESSGRAM, the Brockport Physical Fitness Test was designed. Brockport Physical Fitness Test The Brockport Physical Fitness Test (Winnick and Short, 1998) is a criterion-based test battery for assessing the components of health-related fitness of individuals with disabilities from age 10 years to 17 years. Specifically, the Brockport has been validated for individuals with mental retardation, spinal cord injury, cerebral palsy, blindness, congenital abnormalities, amputations and multiple disabilities. It has also been shown to provide an adequate level of reliability. The Brockport consists of 27 items from which the evaluator typically chooses 4 to 6 specific tests to measure the components of health-related fitness. The evaluator needs to allow time for the individual to have experience with unfamiliar tests to eliminate learning effects on the performance. The manual for the Brockport suggests that the evaluator conduct a task analysis, and modify the tests when needed to allow the individual to optimize performance. ACTIVITYGRAM The ACTIVITYGRAM (Meredith and Welk, 2004) is an assessment instrument for determining the level of an individual’s physical activity. The ACTIVITYGRAM is a software instrument based on the physical activity pyramid (see Figure 1). The individual may be asked to maintain an activity log, or provide self-reported recall of the activities and the intensities of those activities for a period of three days. Direct observation by an evaluator may also be used to assess individual’s physical activities and intensities. The individuals classify the intensities of the activities based on three levels of intensity, light (easy with little or no movement and consequently little or no increase in breathing rate), moderate (movement resulting in an increase breathing rate), and vigorous (hard effort with a significant increase in breathing rate). Any physical activity program should include moderate to vigorous activities on a regular basis. The ACTIVITYGRAM software will provide a summary of the individual’s activities and guidelines for improving the individual’s level of physical activity. Because individuals with disabilities often have low levels of physical fitness, activity levels can also be monitored by using pedometers if the individual is

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ambulatory and by the use of heart rate monitors. The heart rate monitor can provide a more accurate assessment of the intensity of the activity based on the individuals’ capacities.

Figure 3. Activity Pyramid (Copyright NASPE/COPEC, 2004, p. 11).

Psychomotor Domain Assessment Peabody Developmental Motor Scale The Peabody Developmental Motor Scales- Second Edition (PDMS-2) is a normreferenced test battery to assess early childhood (Birth to 5 years) motor development (Folio and Fewell, 2000). PDMS-2 facilitates an in-depth assessment and training program for fine and gross motor skills. Subtests include reflexes, stationary (balance and equilibrium), locomotion, object manipulation, grasping, and visual-motor integration. Additionally, it provides a fine and gross motor quotient and a total motor quotient. There is a software scoring and report system to facilitate the scoring and reporting process. Movement Assessment Battery for Children The Movement Assessment Battery for Children (Movement ABC) is a combination of a test and a checklist (Henderson and Sugden, 1992). Movement ABC is designed to measure motor impairment for children age 4 years to 12 years. The Movement ABC test assesses manual dexterity, ball skills (catching and bouncing), and balance (static and dynamic). The motor impairment scores can be interpreted directly or can be converted into percentile

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scores. Reliability and objectivity ratings range from .66 to .97. Validity has been established by criterion and constructs techniques. The Movement ABC Checklist is used to assess children between 5 and 11 years of age in natural settings. The checklist contains five divisions: child stationary – environment stable; child moving – environment stable; child stationary – environment changing; child moving – environment changing; and behavioral problems relating to motor difficulties. The Movement ABC is currently being used extensively by researchers at the University of Maryland who are examining children with Developmental Coordination Disorder, and is useful for screening, intervention planning and evaluation processes.

Ohio State University Scale of Intra Gross Motor Assessment The Ohio State University – Scale of Intra Gross Motor Assessment (OSU-SIMGA) is a criterion-referenced test battery (Loovis and Erising, 1979) that assesses the basic locomotor skills (walking, running, jumping, hopping, and skipping), object control skills (throwing, catching, striking, and kicking), and ladder and stair climbing skills of children 2.5 years to 14 years. The OSU-SIGMA assesses the motor skill patterns using a qualitative scale, which provides a basis for the present level of performance. The results of the assessment can then be used to design a program addressing the process of the movement pattern rather than only the product (result) of the movement. Bruininks-Oseretsky Test of Motor Proficiency The Bruininks-Oseretsky Test of Motor Proficiency (BOT) is a norm-referenced test battery (Bruininks, 1978) consisting of eight subtests that assess static and dynamic balance, running speed and agility, bilateral coordination, strength, visual-motor coordination, response speed, visual-motor control, and upper limb speed and dexterity. There are two versions of the BOT, a short form and a long form. The short form consists of 14 items while the long form consists of 46 items. It is designed to be used with children 5 years to 14.5 years. The BOT is used for assessing both gross and fine motor skills, motor program planning and evaluation. The BOT has been validated using both content and construct methods with construct validity measures ranging from .56 to .93 for the various tests at various age groups. Reliability and objectivity measures are somewhat low with a range of .55 to .89; therefore, caution should be used when interpreting results of subsequent assessments. Test of Gross Motor Development-2 The Test of Gross Motor Development-2 (TGMD-2) is a norm-referenced test battery (Ulrich, 2000) designed to assess fundamental motor skills of children 3 years to 10 years. The TGMD-2 consists of two subtests, the locomotor subtest (run, gallop, hop, leap, horizontal jump, and slide) and the object control subtest (striking a stationary ball, stationary dribble, catch, kick, underhand roll and overhand throw). Each skill is divided into three to five components regarding the movement pattern (i.e., process). The components are rated as either present (1) or absent (0). The sum of the skill scores on two trials are used to obtain subtest and composite scores, which can be converted to percentiles and age-equivalents. The reliability and objectivity measures for the TGMD-2 range from .85 to .98. The TGMD-2 was

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determined to be a valid assessment by using content, criterion-prediction and construct methods.

Adapted Physical Education Assessment Scale The Adapted Physical Education Assessment Scale (APEAS) is a comprehensive normreference test battery (Seaman, DePauw, Morton and Omoto, 1989). It is designed to assess children between the ages of 5 and 12 years of age. The APEAS assesses locomotor skills (agility run, hopping and vertical jump), object-control skills (target throw), posture, endurance (6-minute run), balance, abdominal strength (curl-ups), ocular control and motor planning. Reliability and objectivity coefficients range from .39 to .96 (Seaman, 1982) with validity established by face validity. Additionally, the APEAS was found to have high discriminating ability. Mobility Opportunities Via Education Mobility Opportunities Via Education (M.O.V.E.) is a “…top-down activity-based curriculum designed to teach students basic functional motor skills needed for adult life in home and community environments.” (Kern County, 1990, p. i) A top-down model identifies the desired outcome of a training program, determines the individual’s present level of performance toward reaching that outcome, and identifies an incremental progression toward that outcome. The M.O.V.E. curriculum consists of a curriculum that focuses on functional skills and provides assessment techniques via a task analysis to measure very small units of attainment of the outcome. The specific assessment areas addressed with M.O.V.E. are maintenance of sitting position, move while seated, stand, transition from sitting to standing, transition from standing to sitting, pivot while standing, walk forward, transition from standing to walking, transition from walking to standing, walk backward, turn while walking, walk up steps, walk down steps, walk on uneven ground, walk up slopes, and walk down slopes. Each component consists of four levels of success. These components are believed to be important in the execution of functional skills such as, eating, toileting, dressing and grooming, communication, bathing, social activity, and leisure activities. Cognitive Domain Assessment Since no formal tests of intelligence have been standardized for use with deafblind children, many examiners will often adapt other instruments for use with this population. They will employ specific subtests, which in their clinical judgment or opinion are appropriate for use with either visually impaired or hearing impaired. When such adaptations occur, the standardization process has been compromised. Any modifications (i.e., enlargement, amplification, etc.) should also be noted in the report. The Stanford Binet 5 (Roid, 2003a, 2003b) has recently been released and this intelligence test has separate sections in the manual and the interpretive manual regarding the deaf and hard of hearing and those with motor skill deficits. Roid indicates that: …testing will be most successful when the examiner takes time to study the history requirements of the individual prior to the testing session. Test directions may need to be adapted or special accommodations to the administration procedures may be required. If necessary, the examiner should request assistance from other professionals with skills in sign language or other communication methods (p. 14)

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Salvia and Ysseldyke (1995) have indicated that if the subject’s hearing difficulties or loss have not been identified before the testing, then the individual may give wrong answers to basic questions, appear distracted or off task, and during testing will often request that questions or directions be repeated. The examiner’s manual of the Stanford Binet 5 (Roid, 2003b) has a separate appendix on the use of the Stanford Binet Intelligence Scales, with deaf and hard of hearing individuals. This appendix is divided into three parts: general issues; guidelines for special communications; and subtest appropriateness across subgroups. Subsections address modes of communication, American Sign Language, Simultaneous Communication and cued speech. Still another section of the manual offers thirteen specific recommendations and cautions and procedural concerns relative to the use of the Stanford Binet 5 with the hearing impaired and deaf and the use of an interpreter/translator. There is no information in either the examiner’s manual or the interpretive manual about the use of the Stanford Binet 5 with visually impaired or blind. There are sections however, on the use of the Stanford Binet 5 for testing individuals with unique backgrounds (such as communication disorders, orthopedic impairments and motor skill deficits). Obviously, examiners must use their clinical judgment, make necessary accommodations when needed and appropriate and specify cautions regarding the results of the scores.

Multiple Domain Assessments and Other Sources Information Multiple Domain Assessments Bennett, Hughes, and Hughes (1979) have discussed in depth assessment techniques for deafblind children using the Callier Azusa Scale (CAS) is a well known instrument that allows the examiner to compare the child’s development in a number of domains (motor, perceptual, language, daily living skills, and socialization) with basically the typical development for deafblind children from birth to approximately 9 years. The test is helpful both with assessing the present level of performance and program planning, and as a posttest to assess behavioral change or basic growth after interventions. There are 16 subscales of the CAS and these provide an age-equivalent score rather than a full scale I.Q. Adaptive Skill Assessments There is a number of adaptive behavior measures used for individuals with severe disabilities and these can be adapted to suit the student. The Vineland Adaptive Behavior Scales (Sparrow, Balla and Chicchetti, 1984) employs an interview technique for individuals between the ages of birth to 6 years. Content areas include gross and fine motor skills as well as language. Social/Emotional, self-help, independent living, vocational and recreational skills are also assessed. The American Association on Mental Deficiency (Lambert, Windmiller, Cole, and Figueroa, 1975) has published Adaptive Behavior Scales utilizing observation and interview aspects, and covers birth to 6 years. It assesses gross/fine motor skills, sensory skills as well as language, social emotional, self-help, independent living, vocational, recreation, and leisure skills.

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Information from Parents Parents, with a little training in observation, are able to participate meaningfully in their child’s assessment and evaluation processes. Parents spend a vast amount of time watching and observing their child. They are invaluable assets and have a wealth of information about the behaviors and responses of their child. They have intimate knowledge of their child’s preferences, how their child spends time, and most importantly, what types of activities their child enjoys. They generally have a comprehensive understanding of their child’s learning styles and abilities, how their child, navigates and explores the environment. Parents should be actively involved in the assessment process by providing lists of what their child does at home and videotapes for documentation purposes. Recent medical and medication history as well as health history is important. If the child is on medication, this information is salient and relevant to the overall report. It is imperative that parents and evaluators communicate openly and honestly throughout the assessment and planning processes.

Direct Observation Direct observation is one of the most important tools in the educator’s armamentarium. The evaluator is able to observe responses, interactions with peers, interactions with inanimate objects (e.g., balls, toys, etc.) and motor behavior in a wide variety of settings (e.g., swimming pool, gymnasium, park, and playground). Those involved in the daily or frequent assessment of those students with deafblindness often develop their own alternative assessments (e.g., rating scales, checklists, rubrics, etc.) with specific purposes based on the age and/or developmental level of the individuals they are assessing. Evaluators should be able to break tasks down into the smallest components by conducting a task analysis. Based on the task analysis and observations of the child’s abilities, the evaluator can then logically and systematically organize an instructional curriculum. Rosen has indicated that when observing a student there are a number of general areas to consider in addition to the specific behaviors identified on the observation checklist: Body language (e.g. posture, gait, mannerisms, gestures, facial expressions); Personal grooming skills and dress (e.g. style, age appropriateness, clothing care, appropriateness to setting); Interaction with peers, family members and authority figures, (e.g. work supervisors, teachers, dorm staff); Mobility, in familiar and unfamiliar areas, including use of mobility aids; Ability to manipulate materials and tools; Organizational skills and adaptive techniques; Use of aids and appliances, including low vision devices; Functional use of vision hearing and gross and fine motor skills ;Problem solving and decision making skills (Reference, p. 359)

Summary and Conclusions In order for progress to occur in the health-related fitness and psychomotor domains, the instructor must know what is the child’s current level of performance with regards to mobility, level of functioning, and the influence of the environment on performance. The assessment report should provide quality information by adequately describing present level of functioning and performance; the degree of progress for skills within the psychomotor and health-related fitness domains; environmental factors that enhance or interfere with performance; behavioral, attentional, and communication concerns; cognitive concerns;

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specific recommendations for curriculum planning and future assessments; and a variety of reference materials related to the child’s specific needs. With the results of quality and comprehensive assessment, professionals should be able to construct a quality Individual Education Plan to provide an appropriate physical education commensurate with the abilities.

PHYSICAL EDUCATION AND THE IEP Specific purposes of the Physical Education general curriculum are to learn skills and knowledge necessary to participate in a variety of physical activities learn ways to establish and maintain a healthy lifestyle for wellness, realize the effects of physical activity on one’s mind and body, and to learn interpersonal skills during physical activity (Connecticut State Department of Education, 1998). The National Longitudinal Transition Study-2 Update, through the United States Department of Education (2000), followed progress of youth, age 13-16, as a longitudinal study. The result of this study is a national picture of experiences and achievements of students. In a survey of 5,598, one hundred families of students who are deafblind were contacted concerning participation in physical education. Of these 100 students, 72.9% reported receiving some type of PE instruction. Strategies for the student to access the general curriculum for physical education should be the role of the IEP committee. The IEP committee has the responsibility of designing an appropriate plan. Since each student with deafblindness has different strengths, the IEP process is a perfect opportunity to plan for an enjoyable, safe and educational access to the regular classroom. To design and implement an IEP for physical education, the team must provide benchmarks and evaluation to include: • • • • •

assessment communication present level of performance annual goals based on the general curriculum professional development for staff

Keeping the regular education standards as the basis for planning the individual educational plan will keep the committee focused on the general curriculum and modifications or adaptations needed for each child. In order to assure that the IEP contains goals for physical education, the general curriculum must be accessed in order to provide a continuum of educational opportunities that will allow the child a chance to succeed in the physical education experience.

Assessment Each IEP team member has the responsibility of assessing the Physical Education level of the student to determine if any modifications or interventions are needed to access the general curriculum. Some of the assessments may be formal, some may be by observation, some may

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describe functional skills, and some may identify particular physical strengths. Etiology assessment is needed to determine safety issues related to student participation in any activity. Parents as well as professionals can provide information for the assessment of skills and methods to access the general curriculum. The assessment section of the IEP should include also describe the school facilities and equipment to determine any needs within the Physical Education classroom for providing an environment which can be accessed. The assessment information used to determine accommodations in the classroom should be consistent year-to-year and measure student success through each of the physical education benchmarks. IEP can then be used each year as an assessment relating to future goals. Using the IEP assessment in a sequential manner can provide an organized, documented pathway for each child.

Communication When developing the benchmarks for the child with deafblindness, communication must always be considered. The student should be aware of the activity in the physical education classroom, realize the individual expectations, and have a way to communicate the sequence of events. Strategies to teach environmental information must be included in the educational plan. Through information about the specific etiology and communication needs, the strategies used in other educational settings can be modified for the physical education classroom. Remembering that incidental learning about the environment may be lacking for students with concomitant hearing and vision loss, communication is vital for enjoyment and understanding of the physical education classroom experience. Since physical education is often a group activity, communication is also a social benchmark. Team members may need to know specific signs or cues so the student with hearing and vision loss can participate with the group. The student needs to have time to learn to trust persons in the group so there is a bond for communication. Consistency of schedule, use of predictable activity cues and participatory activities will assist in the student understanding the realm of the expectations in the physical education class (Sacks and Siblerman, 1998). By participating in the group with well-defined communication strategies, the student can access the curriculum is a socially appropriate self-directed way.

Present Level of Performance By combining information from the formal and informal assessments presented by the IEP team members, the student’s level of performance can be determined. The question for the team is “can this student’s needs be addressed within the general physical education class? If not, why not?” (Council for Exceptional Children, 1999). By answering this question, the opportunities for accessing the general physical education curriculum will be noted with specific interventions and modifications for each student. When the level of performance is determined and noted in the IEP, the Physical Education teacher and any other persons involved in the student’s day can identify the role each plays to make the class accessible.

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Annual Goals Based on General Curriculum The annual goals for Physical Education should be based on the general curriculum requirements and modified as determined by the IEP team. By using the general curriculum as a map, any plan can be interesting and varied for the student. With modifications and interventions noted in the IEP, the general curriculum is used from year to year as another way to measure success and growth of the student.

Professional Development A very important issue that must be addressed is professional development. The persons involved in assuring that a student accesses a specific curriculum should have information about the implications of hearing and vision loss and how environmental information is obtained. Through a simulated activity specific to physical education, the qualified physical education teacher, teacher assistants, and communication personnel, as well as fellow students, can learn how modifications and interventions help the student. The professional development or sensitivity training should be noted in the IEP as an instructional strategy. A goal for this instructional strategy should include a product of more ways to open doors for access to the Physical Education curriculum. Communication specific to the student involved should be included (van Dijk, 1986) so the physical education instruction team all use similar signs or gestures for the prescribed activity. Safety issues should be embedded in these activities to correlate to safety issues within the general curriculum.

Sequential Benchmarks The term “physical education” includes special physical education, adapted physical education, movement education, or motor development (CEC, 1999). Since physical education is a developmental process as much a reading or math, the benchmarks should be sequential and follow the general curriculum. The qualified physical education professional should lead this section and allow the team to provide accommodation information or communication techniques. The IEP team must include the measurable annual goals with benchmarks for short-term objective and the sequence must meet the needs of the child for motor development as well as the goals presented within the general curriculum. Each benchmark can begin from the regular physical education class requirements and be modified for the student. The measurable goals and short-term objectives of the general curriculum should be the skeleton for the physical education plan so the student has the opportunity to experience the various physical education activities and succeed in certain areas just as the non-disabled peers. If the general curriculum is used as the framework for the IEP plan, it will be easier to measure success and plan each year according to the school schedule. Each year the IEP committee should write a statement to explain the extent to which the student will or will not participate with the non-disabled students in the regular class utilizing the physical education

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general curriculum goals for the year. Student progress can be documented according to the general curriculum and planning can continue in the general education continuum.

HOW IS PHYSICAL EDUCATION DIFFERENT FROM ORIENTATION AND MOBILITY? Orientation and mobility skills are interrelated skills that are essential for the promotion of positive outcomes for students with multiple sensory impairments. According to Hill and Ponder (1976), the successful use of orientation and mobility skills enables students to function safely, efficiently, and independently in any environment in which they find themselves. Furthermore, self-esteem may be impacted in a positive manner when a child is able to be oriented in the environment and has effective mobility skills (Tuttle and Tuttle, 1996; Welsh, 1997). Components of an effective orientation and mobility curriculum, eligibility for services, professionals who provide services, assessment issues, tools and equipment, practical suggestions for professionals, and the relationship of orientation and mobility to physical education are discussed in this chapter. In addition, a case study is provided to illustrate orientation and mobility services for a student with multiple sensory impairments.

Definition of Orientation and Mobility (OandM) Hill and Ponder (1976) define orientation as “the process of using the senses to establish one’s position and relationship to all other significant objects and one’s environment and relationship to all other significant objects in one’s environment” (p. 3). They define mobility as ‘the capacity, the readiness, and the facility to move – the ability to move within one’s environment” (p. 115). Orientation and mobility skills are interrelated. If a person with multiple sensory impairments does not possess the cognitive ability to know where he is in his environment, then it is difficult for him to move in a purposeful manner to get his needs met. However, if a child with sensory impairments is able to be oriented and has effective mobility skills then his level of self-esteem may be affected in a positive way potentially leading to an increase in self-esteem (Tuttle and Tuttle, 1996; Welsh, 1997). “A positive self-concept can be both a cause and an effect of success in mobility….If a person has developed a negative self-concept as a result of some of the natural reactions associated with visual loss in our culture, this attitude may reduce the likelihood that the person will aspire to achievement of success in independent travel” (Welsh, 1980, p. 226). Hill and Ponder (1976) state that “the ultimate goal of orientation and mobility, then, is to enable the student to enter any environment, familiar or unfamiliar, and to function safely, efficiently, gracefully, and independently by utilizing a combination of these two skills” (p. 1). The 1997 amendments to the Individuals with Disabilities Education Act, 34 CFR Part 300.24 (b) (6), Assistance to States for the Education of Children with Disabilities, state that orientation and mobility services are “provided to blind or visually impaired students by qualified personnel to enable those students to attain systematic orientation to and safe movement within their environments in school, home, and community; and….includes teaching students the following, as appropriate:

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Spatial and environmental concepts and use of information received by the senses (such as sound, temperature and vibrations) to establish, maintain, or regain orientation and line of travel (e.g., using sound at a traffic light to cross the street); • To use the long cane to supplement visual travel skills or as a tool for safely negotiating the environment for students with no available travel vision; • To understand and use remaining vision and distance low vision aids; and • Other concepts, techniques, and tools.” The National Agenda for the Education of Children and Youths with Visual Impairments, Including Those with Multiple Disabilities discussed the need for children with visual impairments to be assessed and to receive instruction in a disability-specific core curriculum (Corn, Hatlen, Huebner, Ryan, and Siller, 1995). Corn et al. (1995) mentioned that “The first disability-specific need to be isolated, described, and offered as a school subject in public schools was instruction in orientation and mobility” (p. 12). They advocate for orientation and mobility instruction to be provided if children with visual impairments are to be independent and safe while traveling. Table 2. Traditional Orientation and Mobility Curriculum Components Orientation and Mobility Component Concept development Sensory training

Mobility skills

Orientation systems

Solicitation of aid

Use of community resources and public transportation Safety issues

Assistive technology

Example of Specific Skills of the Components Names and functions of body parts Spatial concepts Awareness and location of sounds Awareness of furniture in a child’s bedroom Use of low vision aids to see a traffic light Trailing Street crossings using a long white cane Use of an adaptive mobility device Use of a clock system Compass directions Use of tactual/low vision maps Learning vocabulary related to orientation and mobility Learning where to stand on a street corner to ask someone for help Requesting information from a bus driver Experience with city buses Use of nondrivers identification when traveling Self-defense techniques Choice of appropriate clothing to wear in different weather conditions Use of long white cane Use of an adaptive mobility device Use of a global positioning system

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Orientation and Mobility Curriculum The components of a traditional orientation and mobility curriculum include concept development, sensory training, mobility skills, orientation systems, solicitation of aid, use of community resources and public transportation, safety issues, and use of assistive technology (Griffin-Shirley, Trusty and Rickard, 2000). Examples of the above-mentioned components are included in table 2. Components of this orientation and mobility curriculum should be introduced as early as possible with a child with sensory impairments. Early intervention is crucial for a child with sensory impairments to be safe and efficient when traveling independently. Anthony, Bleier, Fazzi, Kish, and Pogrund (2002) suggest that the components of an orientation and mobility program for infants, toddlers, and preschoolers needs to include: mastery of the concepts of body image, spatial constructs, means and ends, object permanence, motor development, environmental and community awareness, formal orientation and mobility skills, fine and gross motor skills, and purposeful and self-initiated movement. As children with sensory impairments mature, these same components should be addressed within an orientation and mobility curriculum, but at a more advanced level. For example, a 5-year-old child with deafblindness may learn how to familiarize herself with different rooms in her home and school, whereas, the same child at the age of 12 may learn how to cross a street in a residential area while using a long white cane. Description of People Who Receive Orientation and Mobility Services This focuses only on orientation and mobility for persons with multiple sensory impairments including, a vision loss. To receive orientation and mobility services a child or an adult must have a visual impairment. Other professionals may provide children and adults with other disabilities with travel instruction. For example, a teenager with mental retardation may be taught by a travel trainer how to travel from her school to a job site on a city bus. Legislation provides criteria for professionals to determine if a child is eligible to receive orientation and mobility services. The Individuals with Disabilities Education Act (IDEA) (P.L. 99-147) called for services for children, birth to age three, who were at risk of developmental delays. Specifically, the 1997 amendments under P.L. 105-17 of IDEA listed vision services, provided by an orientation and mobility specialist, as an early intervention service. In addition, in order to qualify for special education services, students in public schools must have a visual impairment that adversely affects their educational performance (1997 amendments to IDEA, 34 CFR Part 300.7 (c) (13)). When children with vision problems reach the age of 16 they may be eligible for rehabilitation services. To receive such services they must be legally blind. Legal blindness is defined as, a central visual acuity of 20/200 or less in the better eye with the use of a correcting lens. An eye which is accompanied by a limitation in the fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees shall be considered for purposes of this paragraph as having a central visual acuity of 20/200 or less” (Social Security Act, Sec. 216. [42 U.S.C. 416] definitions (i) (1) A). Once a child is determined to have a visual impairment the team of professionals responsible for planning the provision of services to the child (individualized education programming team) will decide if this child needs to be referred to an orientation and mobility specialist for an assessment. Once the orientation and mobility assessment is completed, the orientation and mobility specialist reports his findings to the team members. If

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the orientation and mobility specialist determines the child needs orientation and mobility instruction, the team makes the final recommendation for this related service. The amount of time allocated for instruction, the location of instruction, the goals and objectives are written into a plan for the child (i.e., Individual Family Service Plan, (IFSP), Individual Education Program, (IEP)). Training then commences.

Sites Where Orientation and Mobility is Provided Orientation and mobility services may be provided in a child’s home, school, workplace, or community setting. For preschool children, the IFSP will specify the general areas where the orientation and mobility instruction is to occur. Some parents may want their child to learn how to travel within their home as the first priority, whereas, other parents may want their child to learn how to be independently mobile within his preschool. Professionals Who Provide Orientation and Mobility Services Qualified orientation and mobility specialists who receive their training at universities or colleges provide orientation and mobility services. The Association for the Education and Rehabilitation of the Blind and Visually Impaired or the Academy has traditionally certified these professionals for Certification of Vision Rehabilitation and Education Professionals and recently, the National Blindness Professional Certification (U. S. Department of Education, 2004). The child’s parents, early interventionists, classroom teachers, teachers of children with visual impairments and paraprofessionals may also be involved in assisting children with sensory impairments to learn how to travel. These individuals will help reinforce and monitor the skills taught by the orientation and mobility specialists. In some instances a parent, a classroom teacher, or a teacher of children with visual impairments will actually teach specific orientation and mobility skills such as sighted guide, self-protective techniques, trailing, and room familiarization. Smith and Levack (1996) suggest that parents may be “the direct implementers of some IEP objectives” (p. 26). Orientation and mobility specialists provide instruction to the parents in how to teach specific orientation and mobility concepts and skills. Parents, in turn, teach their children the same concepts and skills. Collaboration among the team members is necessary for the child to progress with orientation and mobility instruction. Transdisciplinary teaming provides the vehicle for effective collaboration. In general, when a transdisciplinary model is used, the orientation and mobility specialist is not the direct implementer of instruction. The orientation and mobility specialist teaches the other team members (who are responsible for instruction) the specific orientation and mobility skills to be taught and effective teaching strategies to use. Once the direct implementers of instruction have mastered the content to be taught, the orientation and mobility specialist can role release to them. However, the orientation and mobility specialist is still responsible for the child’s performance outcomes and needs to monitor the instruction and the child’s progress on a regular basis (Smith and Levack, 1996).

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Special Considerations for Children with Sensory Impairments Who Receive Orientation and Mobility Services Erin (1989) encourages vision professionals (i.e., orientation and mobility specialists, teachers of children with visual impairments) to look at life programming when planning for the transition to adulthood. She stresses the concept of education being a lifelong process. With this concept in mind, orientation and mobility services for children with multiple sensory impairments may be required for many years, as well as provided to these students at different times throughout their lives. For example, as a child transitions from home to school, to a rehabilitation setting, to a worksite, and eventually, to a group home, she will need assistance learning how to travel in each of these new environments. An orientation and mobility specialist can demonstrate (to the student’s direct care staff and teachers in each setting) the orientation and mobility skills needed by the student to travel safely and independently. The orientation and mobility specialist may develop videotapes of the specialist familiarizing the student with these new places, in addition to written instructions, as reminders of the specific skills introduced during the demonstration. To ensure the success of an orientation and mobility program for a person with multiple sensory impairments, caregivers (i.e., parents, daycare staff, group home staff) and teachers must be actively involved. Therefore, the orientation and mobility specialist often assumes the role of consultant, instructor, team member, model trainer, advocate, information and resource specialist, and equipment dispenser. In some cases, a child will only need consultative services from an orientation and mobility specialist, while in other situations an adult will require direct instruction from the specialist. For example, a one-year old who is deafblind, may receive consultative services from an orientation and mobility specialist. The orientation and mobility specialist suggests ways the parents can help the young child be motivated to crawl and reach out with her hands to locate her toys. In another situation, a 30year old woman with deafblindness and a cognitive deficit, may be taught by her orientation and mobility specialist how to cross streets (with assistance from the general public) to get to her new worksite from her group home. The orientation and mobility specialist will assess a child using assessment tools and checklists, observing in natural contexts and various environments, reviewing student’s portfolios, and interviewing people who routinely interact or care for the student (i.e., parents, teachers, paraprofessionals, direct care workers in daycares) or the student (Bailey and Head, 1993; Smith and Levack, 1996). Possible assessment instruments include informal assessment instruments developed by orientation and mobility specialists, the Peabody Mobility Scale, the Brigance Diagnostic Inventory of Basic Skills (gross motor, fine motor, non-ambulatory) the Callier-Azusa Scale, the Functional Skills Screening Inventory (O’Neill et al., 1997), the INSITE Program, the Oregon Project for Visually Impaired and Blind Preschool Children, the Reynell-Zinkin Developmental Scales for Young Visually Impaired Handicapped Children, The Hill Performance Test of Positional Concepts, Assessing Infants who are Visually Impaired or Deafblind for Functional Vision and Orientation and Mobility, The Basic Concept Inventory, The Tactile Test of Basic Concepts, TAPS Comprehensive Assessment and Ongoing Evaluation, the Preschool OandM Screening, and The Body Image of Blind Children (Griffin-Shirley et al., 2000). Sensory skills, concept development, motor development, environmental and community awareness, and formal orientation and mobility

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skills are areas assessed during an evaluation. Questions to be answered during an assessment of students with multiple disabilities include: • • • • •

How does the student use information about the environment? What is the student’s communication system? What makes the student want to move? What are the movement tasks the student performs during daily routines at home, school, work, or in the community? How does the student let you know she is happy in moving around the environment? (Joffee, 1995)

The social context of a travel environment (identification of the people who encourage travel of a student), the physical demands of the environment (the physical layout of a classroom, open spaces a student has to cross, and how do other students travel in school hallways) and the physical, mental and emotional skills of a student are also areas of concern during an assessment. Bailey and Head (1993) advocate using a task-discrepancy analysis when assessing a student. The procedure to conduct this type of analysis is: • • • •

Assess environmental or route features; List the skills required to travel in that environment; Complete a task analysis of each skill; Assess the discrepancy between present abilities and skill demand of the given task.

One team member may complete the actual assessment. Following an assessment, a report is written and the results are submitted to the team of professionals working with the student. The team will then decide if orientation and mobility services are warranted. If services are deemed necessary, the team decides on the annual goals and objectives specific to orientation and mobility for the student. The team will indicate the how, where, and when of service delivery in the student’s individualized program (i.e., IFSP, IEP). When serving persons with visual impairments, team members need to have knowledge of the working procedures of the various professions the team members represent. This knowledge can assist team members to be supportive of each other to meet the needs of their students (Heward, 2003). When planning a program and lessons an orientation and mobility specialist will address the following areas: • • • • •

Types of orientation and/or mobility tools (marshmallow tip on end of cane) a student will use Use of artificial landmarks (use of a spoon placed to the right of a cafeteria door to identify the cafeteria) and functional travel routes Types of communication systems (sign language, communication board, hearing aids) Training of parents, teachers, direct care staff and paraprofessionals regarding the orientation and mobility tools and skills a student will use When to role release to direct care staff, teachers, paraprofessionals

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Safety issues Types of environmental modifications to make to ensure safety and to promote mobility of a student Modification of traditional mobility and cane skills (use of diagonal cane technique and constant contact cane technique rather than two point touch cane technique) Ways to effectively position students to promote visual efficiency and travel What environments and time schedules to use when providing orientation and mobility training (Griffin-Shirley and Brown, 2001; Joffee, 1995; Rogow, 1988; Smith and Levack, 1996).

There are many assumptions, concerning the education of students with exceptionalities and teaching strategies, that orientation and mobility specialists commonly hold with regard to teaching students with sensory impairments and include the following: • • • • • •

•

• •

The student’s needs determine the training sequence. Team members should have high but realistic expectations for the travel of a student. The orientation and mobility specialist must be flexible and use humor when designing and conducting lessons. Orientation and mobility instruction occurs during the student’s normal daily and weekly routines and activities. Rapport built on trust and respect must be developed with the student. Different kinds and levels of prompts (hand-over-hand, touch, object, model, verbal) are routinely used during instruction. These prompts are reduced as a student progresses. Physical guidance, fading, backward and forward chaining, and shaping are teaching strategies used with people with multiple disabilities including those with mental retardation (Alberto and Troutman, 2003). Initially short lessons (10-15 minutes) may be all a student is able to tolerate. Orientation and mobility skill practice and consistent feedback from professionals monitoring progress is crucial for a student to master orientation and mobility skills needed for safe travel (Griffin-Shirley and Brown, 2001; Joffee, 1995).

Common orientation and mobility tools and equipment a student may use during lessons include: • • • • • • • • •

fanny packs, backpacks appropriate clothing and footwear for indoor and outdoor travel memory devices medical identification (necklaces, bracelets, cards) money and method for organizing bills and coins wheelchairs crutches canes (long white cane, support canes, adaptive mobility devices) walkers

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orthotics/prosthetics switches, toys adaptive travel devices (scooters) low vision devices electronic travel devices (Mowat Sensor, Laser cane, Polaron) (Griffin-Shirley and Brown, 2001).

An orientation and mobility specialist should ask the following questions prior to prescribing a tool such as a long cane or encouraging a student to use a tool: • • • • •

Does the tool encourage the child to move? Is the child safe with the tool? Is the tool age-appropriate, socially/environmentally appropriate and acceptable? Can the child use more than one tool at a time? Can the child care for the tool (Pogrund and Rosen, 1989)?

Joffee and Ehresman (1997) describe three functional levels of travel for people with multiple impairments. Functional Level 1 travelers are individuals who engage in route travel and use public transportation. Functional Level 2 include travelers who are rote travelers indoors and are able to negotiate some outdoor routes. Functional Level 3 includes those who must have supervision while traveling. These individuals may use a sighted guide, an adaptive mobility device and/or tactile landmarks. In summary, students with multiple sensory impairments will fall into one of these three levels.

Relationship of Orientation and Mobility to Physical Education and Adaptive Physical Education Physical Education (PE) and Orientation and Mobility (OandM) are more alike than different. For example, the National Agenda for the Education of Children and Youths with Visual Impairments, Including Those with Multiple Disabilities cites recreation and leisure skills, social interaction skills and orientation and mobility as subjects of the disabilityspecific core curricula. Most students with multiple sensory impairments are candidates for adaptive physical education and for orientation and mobility services. Best, Bigge, Musante, and Macias (2005) state a “successful physical education program for individuals with exceptional needs is one that: • • • • •

Is modeled after the regular-educational program, with necessary adaptations to ensure that the individual participant experiences success. Provides challenges and not frustrations. Allows the individual to carry the learned activities into the home, community, and the general education environment. Encourages integration with nondisabled peers in a cooperative environment. Is composed of activities that have been selected to individuals as well as the groups’ needs.” (p. 339).

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The goal of an adaptive physical education program is for individuals to become physically fit by developing physical and motor skills so they participate in recreational and leisure time activities and successfully complete activities of daily living (Best, et al. 2005). Similarly, the goal of orientation and mobility training is to enable people with visual impairments “to move independently, safely, and purposefully through the environment” (Blasch et al., 1998, p. 1). For example, learning how to crawl and walk is part of an orientation and mobility curriculum, and an orientation and mobility specialist teaches adapting for a child’s vision loss to facilitate this type of movement to a student with a visual impairment. Students with multiple sensory impairments have the same needs and desires as other children – to lead happy, fulfilled lives. Therefore, as children mature they may want to have families, be employed, and create an extensive support network. Receiving adaptive physical education and orientation and mobility instruction can help students better achieve these goals, which may lead to a greater sense of life satisfaction. Loumiet and Levack (1991) discuss the positive impact play and leisure activities have on the lives of students with visual impairments. “Many play and leisure activities promote life skills that are an important part in students’ abilities to make satisfying lives for themselves” (p. 21). The skills gained in other curricular areas by students with visual impairments can be applied during play and leisure activities. When a child learns to add and subtract he can keep score while playing basketball. The same is true for orientation and mobility. For example, the math skill of making change can be used when a student goes on an orientation and mobility lesson to purchase a bus ticket to go to a baseball game. The visual skills (i.e., magnification, focus, distance) students with low vision use in a photography class can be generalized to an orientation and mobility lesson in which a child is asked to visually locate pedestrian walk signs while using his telescope. Sports, recreation and leisure activities involve orientation and mobility skills and vice versa. For example, when a person takes a leisurely walk he needs to know where he is going, the route to be traveled, and how to remain safe on the walk. Similarly, when a person bowls, he needs to have the motor skills and the strength to throw the bowling ball as well as the orientation skills to know where the alley is in relationship to his body and where the pins are in relation to the alley and him. The two curriculum areas, orientation and mobility and adaptive physical education, overlap in many ways. These common elements include the use of assessment tools and procedures, service delivery methods, instructional strategies, use of assistive technology, and environmental modifications. Some common assessment tools that both orientation and mobility specialists and adaptive physical education (APE) specialists may use are the Brigance Diagnostic Inventory of Basic Skills (specifically Brigance Gross Motor, the Brigance Non-ambulatory, and the Brigance Fine Motor), the Purdue Perceptual Motor Survey, and the Bayley Scales for Infant Development (Strommer, 1996). The assessment process involves use of standardized tests, inventories and informal assessment instruments, direct observation, interviews with people involved with students, and the review of students’ portfolios. In summary, both types of professionals use authentic assessment procedures. Adaptive physical education and orientation and mobility are related services under IDEA. Since children with disabilities are integrated into the public schools, adaptive physical education, and orientation and mobility specialists travel to various schools to provide

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consultation and direct instruction to these students. The itinerant model of service delivery requires professionals to travel (sometimes long distances) to see their students. Thus, less time is available for direct instruction. However, for students with multiple sensory impairments this model can be very effective as instruction is provided in the environments where they travel and play. Lessons can be designed and carried out where the actual travel routes are located. Recreational activities and opportunities can also be explored within a student’s community. When using the itinerant model of service delivery, professionals face challenges. It is difficult to have time-efficient lessons when instructors have to travel to many different settings to conduct lessons. The professionals’ caseloads and geographic area of responsibility may be large, thereby, creating a situation in which students are seen less often for services (Best, et al. 2005; Blasch, Crouse and Bina, 1997). Orientation and mobility programs and adaptive physical education programs for students with multiple sensory impairments are both based on individualized education program (IEP) planning, with a transdisciplinary approach in which team members collaborate to identify goals and to develop an appropriate instruction program for each child (Best et al., 2005; Crouse and Bina, 1998; Levack and Smith, 1996; Westling and Fox, 2004). Improvement in a student’s physical and motor fitness, leisure skills, game and sport skills, perceptual motor skills, self-concept and social competency, dance and aquatic skills are examples of IEP goals for a student in an adapted physical education program. Goals for orientation and mobility may include improvement in the use of public transportation, the use of senses to travel, safe and efficient travel in various environments, the ability to remain oriented while traveling within the home and school, and the use of low vision aids and/or orientation aids. Instructional strategies used by both orientation and mobility specialists and adaptive physical education specialists include: an individualized instructional approach, task analysis, appropriate language and communication cues, modeling, prompting, role releasing, opportunities for repetition and successful experiences, short instructional periods at appropriate times, team teaching, and teaching when the student will use a skill or concept. Additionally, teaching functional skills that are age-appropriate, using a multi-sensory approach in natural environments so routines can be established and adhered to be essential for this population (Prickett and Welch, 1995; Joffee, 1995). In addition, when teaching children with multiple sensory impairments these professionals may need to learn how to work with interpreters for people with deafblindness. The above-mentioned strategies have been shown to be effective with students with multiple disabilities (Best et al., 2005; Joffee and Ehresman 1998; Levack and Smith, 1996; Westling and Fox, 2004). The use of assistive technology is commonplace for both types of specialists. Assistive technology devices may include: communication devices (i.e., communication board, voice output device, computer); devices used for activities of daily living (reacher, adaptive eating utensils); mobility devices (a long white cane, walker, scooter, wheelchair); and assistive technology for recreation (a bowling rail, playing cards in Braille, an adapted snow ski for a person with paraplegia). According to Westling and Fox (2004) other examples of assistive technology include: low vision aids, Braille, adaptive mobility devices, dycem, object cues, tactual symbols, low vision and tactual maps, and a calendar box. Collaboration with other team members (a physical therapist, an occupational therapist, an assistive technology specialist) is vital in gaining the appropriate knowledge needed by adaptive physical

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education and orientation and mobility specialists to instruct and monitor their students in the use of assistive technology. The use of color-coded items for easy location of objects, increased or decreased lighting, and the use of color contrast are examples of environmental modifications frequently made for persons with low vision. Ensuring the safety of an environment is of primary concern to specialists. Making sure an area is free of restrictive equipment, the use of padding on equipment, arranging boundaries for motor activities, reducing distractions, and checking the temperature indoors and outdoors are other environmental concerns instructors may have (Best et al., 2005; Lieberman, 2002; Westling and Fox, 2004).

Practical Suggestions Listed below are some suggestions and tips for professionals to use when working with students with multiple sensory impairments.

Prior to an Activity • • • • • • • • • •

Review the student’s functional low vision evaluation, orientation and mobility report, and any other pertinent information Observe and ask the child what she can see; what conditions, positions, and locations are needed to optimize vision, and the location she needs to be positioned to see well Allow the child to explore the environment where an activity will occur, pointing out hazards like goal posts and bleachers Use touch to demonstrate skills Use a buddy to assist with motor activities like running Adapt equipment Slow the action down – use a balloon rather than a ball for throwing and catching For tag games place bells on the person who is it Keep in close contact with the student at all times Use vibrating, high contrast, and/or audible toys and recreational equipment

Use of Play • • • • • • • • • •

Structure play environments Play environments need to be complex and accessible Play encourages interactions with others Assessment can occur during play Encourage play Encourage a child to use her body parts Explore different types of vehicles Read books about sun, wind, transportation, etc. Use household items for toys Pretend with your student

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Discuss daily routines (e.g. getting ready for school) Adhere suction cups to a baking pan to create a boundary for play Arrange furniture to provide boundaries for play Use a sound source (chimes) for orientation Increase contrast for eating utensils, bedding, clothing, etc. Mark stairs with contrasting surface, fan, or gate Provide time for solitary play Reinforce OandM techniques taught in school

Safety Tips • • • • • • • • • •

• • • •

Discuss the impact a visual impairment can have on child’s personal safety with team members Have a child wear reflective clothing Read books on street safety Teach a child how to have a confident posture while standing or moving Identify appropriate and inappropriate people to solicit aid from Discuss appropriate conversations to have when in public places or using public transportation Use role-playing to teach accepting and refusing assistance Practice using the Internet and the telephone to receive information Practice note-taking to take telephone messages Promote problem-solving skills: “What do you do when the bus driver does not let you off at the right stop?” or “Dad is late picking you up after band practice. What do you do?” Encourage parents to enroll their child in a self-defense course Obtain appropriate identification (nondrivers ID) Suggest strategies for carrying money, cellular phone, etc. Teach a child how to call for help (911) and learn evacuation procedures

Structuring Home Life to Encourage Mobility • • • • • • • • • • • •

Organize an environment with furniture and familiar objects to be used as landmarks Mark various areas with different floor coverings Limit the number of objects along a route in hallways Reduce glare by choosing appropriate window treatments and lighting Keep doors and cupboard doors completely open or closed Involve students in rearranging furniture Use fences, hedges, and play equipment to create walkways, boundaries Provide organized storage areas for orientation and mobility tools Provide organized storage areas for OandM tools Expect child to engage in household chores Provide many concrete experiences: trips to store, bank, fair, zoo Use a calendar box system

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Laugh, be patient, and remember learning is lifelong Encourage parents to get respite care so they can go on a date

Positioning and Handling • • • • •

Inform the student about your movements and purposes Grant postural security through supports Check body alignment Check that wheelchair wheels are locked, when stationary Locate sources of persistent distraction and modify to enhance focus (Griffin-Shirley, Trusty and Rickard, 2000; Griffin-Shirley and Brown, 2001; Letcher, 2004).

Summary This chapter presented a range of information on orientation and mobility for students with multiple sensory impairments including suggested components of an effective orientation and mobility curriculum, eligibility criteria for services, professionals who provide services, assessment issues, tools and equipment, practical suggestions for professionals, and the relationship of orientation and mobility to physical education. Various systematic strategies for promoting efficient assessment, program and lesson planning, service delivery, as well as practical suggestions to consider prior to engaging in activities, positioning and handling techniques, the use of play, safety tips, and structuring home life to encourage mobility, were discussed. In addition, a case study was provided as an illustration of a student with multiple sensory impairments who needed orientation and mobility services. Orientation and mobility instruction and physical education for students with multiple sensory impairments share many similarities. Receiving both adaptive physical education and orientation and mobility instruction can help promote personal independence and help students achieve life goals.

ADAPTED PHYSICAL EDUCATION FOR STUDENTS WITH SENSORY DEFICITS This section will discuss the importance of physical activity for hearing impaired and visually impaired students, as well as provide teaching suggestions and modification suggestions for physical activity. Bouchard and Shephard (1994) indicate that any bodily movement that is produced by the muscles that results in an increase of expenditure over the resting energy is considered physical activity. They also suggest that health is: A human condition with physical, social, and psychological dimensions, each characterized on a continuum with positive and negative poles. Positive health is associated with a capacity to enjoy life and to withstand challenges; it is not merely the absence of

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Adapted Physical Education Physical Education for individuals with disabilities was specifically defined in P.L. 94142, and that definition was retained in the Individuals with Disabilities Education Act (IDEA). Auxter, Pyfer, and Huettig (2001) defined adapted physical education as the “art and science of developing, implementing, and monitoring a carefully designed physical education instructional program for a learner with a disability, based on a comprehensive assessment, to give the learner the skills necessary for a lifetime of rich leisure, recreation and sport experiences to enhance physical fitness and wellness” (p. 3). Short (2000) indicates “if students with disabilities are to receive the free, appropriate education guaranteed by IDEA, physical education must be included in their IEP’s” (p. 52). Many times, however, students are assigned to physical education courses as a means of convenience, rather than necessity. Due to this placement method, it is imperative that physical educators are included in the IEP team to assist in the appropriate placement of students within the physical education program. In order for a child to successfully participate in play, games, leisure activities, and the activities of daily living, they must have a grasp on basic locomotor movements. One can have a good definition of adaptive physical education if you change the word ‘adaptive’ to ‘modified’. Effective instructors within the physical education discipline will modify their curriculum to enhance success for ALL children—not just those with disabilities. Physical activity should be as appropriate for a person with a disability as it is for a person without a disability. Developing and implementing an individual physical education program (IPEP) and teaching to a defined physical education curriculum is usually achieved through the design of a long-term (more than 30 days) program to meet the learner’s unique and individual needs. Basic adaptation concepts could include simplifying the lesson plan, shortening the amount of time allotted for each activity, modifying the rules to include all individuals, or assigning a peer to assist the student with the exceptionality. By simplifying the lesson plan, the student may not feel as pressured to accomplish an insurmountable level of performance, or unrealistic objective, thus allowing for a greater level of success. Shortening the amount of time is beneficial for those students whose attention span may not be conducive to extended activities. This will allow for a higher level of success, because those students will be allowed to be successful at short, intense activities. One extremely beneficial modification is as simple as modifying the rules of the game or activity: making sure that all students touch the ball before an attempt for a goal is made; having more students on a team than the actual game requires; and maybe not calling every foul or error. These simple modifications of rules will allow more students to be involved, while still participating in the ‘spirit’ of the activity. Peer assistants are beneficial both for the adapted student and for the peer assistant. Both students begin to develop an understanding of each other as well as the ability to take leadership responsibilities.

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Benefits of Adapted Physical Education Movement and play have been linked to the development of physical, linguistic, cognitive, social and emotional areas. Through play and movement, children learn how to manipulate and talk about objects, their own actions, and how to interact with their peers and other individuals. Lyon (1997) indicates that “play also affords children the opportunity to work through and learn to deal with their feelings and emotions in situations which are nonthreatening and under their control” (p. 11). Self-esteem is built through the enhancement of physical activity. Further, as one achieves a certain degree of skill and competence, one’s self confidence increases and small success builds on success. Educators should attempt to gradually increase expectations and use behavioral principles, such as shaping and modeling, and reinforcing successive approximations, to ensure success. As with any physical education program, there are significant benefits, such as increased motor development, social skills, and the development of healthy lifestyle habits. Yet with adaptive physical education, there are other significant benefits that are developed through a quality physical education program. Such benefits could include, but not be limited to: • • • • • • •

The development of equilibrium, sensory discrimination and integration, and sensory-motor function The development of locomotor and nonlocomotor skills The development of object-control skills The development of play, leisure, recreation, and sport skills The development of physical fitness for maintenance of daily living skills and health/wellness The development of a repertoire of movement skills necessary for independent living The development of physical and motor prerequisites to vocational skills required for independent living. (Auxter, Pyfer, and Huettig, 2001, p. 4)

As a unique and essential part of the total education program, physical education can significantly enhance all aspects of development including health, physical fitness, movement knowledge, academic performance, goal setting, self-esteem, stress management, autonomy, independence, social skills, and enjoyment. Physical, social and cognitive skills that are learned through physical education can then be transferred from the instructional setting and applied to family and community settings. Individual progression through the physical education curriculum can easily include the shaping of appropriate social and emotional skills. Through physical education and training, the students can then develop an awareness of the benefits of regular involvement in lifetime activity. Positive participation in these physical activities will encourage students to continue physical activities with their families, friends, or in other recreational settings.

Developing the IEP Sherrill and Hughes (2004) suggest that the physical education pre-assessment or the development of the IEP should focus on identifying the type of balance problems and the

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motor skills, body parts, and postures that are interfered with the most. “With meaningful intervention and abundant movement opportunities, children learn to compensate for balance deficits” (p. 710). The physical educator plays an important role in the development of an IEP, as they may be more aware of the specific abilities and skills of the student. By using their training in motor development, movement pedagogy, biomechanics, and anatomy and physiology, the physical educator can assess the present level of performance and needs and also be able to recommend goals to the IEP/multidisciplinary team that will implement activities to meet the needs of the students. As with the development of any IEP, decisions must place a greater emphasis on the curriculum and must focus on the functional ability of the students to become more outcome based.

Students who are Deaf and Hard of Hearing Teaching Strategies There are multiple methods for providing experiences that will heighten the effectiveness of the physical education learning environment for a hearing-impaired student. Such methods could include the use of precise visual models, peer teaching opportunities, independent learning packages, hands-on demonstrations, exposure to communication, and kinesthetic feedback. Kinesthetic feedback can be accomplished by moving the student through the desired positions of the task, which incorporates both visual and kinesthetic sensory opportunities. “Moving the child in this fashion helps the student feel the temporal-spatial relationship of movements associated with a skill. Using both visual and kinesthetic instruction provides opportunities for two avenues of sensory information. A quick visual model followed by physical prompting of the behavior may facilitate learning” (Auxter, Pyfer, and Huettig, 2001, p. 603). The use of modeling and shaping are effective for enhancement of skills with a hearingimpaired student, and actually with all adaptive students. Modeling techniques, a process wherein the instructor demonstrates the appropriate behavior or skill to be learned, is frequently done within the physical education setting, with or without adaptive students. Good physical education instructors are constantly demonstrating correct form and technique as well as appropriate behavior concepts. Shaping, the technique of gradually molding responses to a final desired pattern by reinforcing successive approximations of it, is another technique that is frequently used within the physical education setting. Encouragement is given during the development of a skill in order to reinforce that behavior and then to increase the desired performance of that particular skill. Instructional Modifications The following are suggestions for modifications that can be incorporated into a curriculum to allow the hearing-impaired student to be more successful in physical activity. • • •

Use an interpreter; Stand still while giving instructions; Minimize background noise;

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Use visual cues; Copy lesson plans; Use clear signals for starting and stopping activities; Face the student; Use visual attention getters; Use body language, facial expressions, and gestures; Demonstrate often; Provide a visual or pictorial schedule of events; Learn as much sign language as possible.

Students with Blindness and Low Vision Teaching Strategies Since the child who has visual limitations must depend on receiving information through sensory media other than vision, the physical educator must promote the students’ confidence through auditory and kinesthetic stimuli. Confidence is increased by allowing the student to experience the correct feel of the movement. This is accomplished through manual manipulation of their bodies and auditory cues such as specifically describing the motion of the skill. “Also, because the child with visual limitations has little or no understanding of spatial concepts, such as location, position, direction, and distance, skin and muscular sensations that arise when the student is moved through the activity area provide the information needed to participate” (Auxter, Pyfer, and Huettig, 2001, p. 629). The development of confidence through movement should also allow the students to develop a feeling of acceptance as individuals; which can be accomplished through the adaptation of the physical education program, through the use of additional or specialized activities, or special equipment. Success builds on success, and instructors should program for such success. Instructional Modifications The following are suggestions for modifications that can be incorporated into a curriculum to allow the visually impaired student to be more successful in physical activity. • • • • • • • • • •

Change the ball color to one that contrasts more sharply with the background; Demonstrate within the student’s field of vision; Use audible balls and buzzers; Ask the student “What can you see?”; Develop positive attitudes toward students with visual impairments; Encourage participation; Challenge students so they feel successful; Use correct and distinct verbal instructions; Physically move the students through the movement; Use descriptive verbal instruction;

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Use light colored equipment, preferably white, yellow, or orange, unless dark is needed to provide contrast; Use sighted guides, a tether, or a guide wire.

Students who are Deafblind Teaching Strategies Wheeler and Griffin (1997) suggest that the physical educator plays a critical role in the development of communication and language skills in students who are deafblind. They further suggest four phases of this development as follows: •

•

•

•

Resonance. In this phase, the physical educator mirrors and expands on movements the student initiates. For example, if the student is holding a ball, the teacher may grasp the ball as well and begin to move it in a circular path. Coactive movement. In this phase, the emphasis is on the physical relationship between the teacher and the student, including frequent touch and physical contact between the two. It also includes movements done together—for example, sitting, singing, rocking, and playing “row, row, row your boat.” Nonrepresentation reference. In this phase, the teacher helps the student develop the basis of body image by encouraging the student to replicate the position of a threedimensional object—the teacher, a doll, a teddy bear, or a “Gumby”. Deferred imitation. The teacher, in this phase, asks the student to imitate a series of body positions, which become increasingly complex. An example of this activity is playing “angels in the snow”. (p. 388)

Instructional Modifications The following are suggestions for modifications that can be incorporated into a curriculum to allow the students who are deafblind to be more successful in physical activity. • • • • •

Change rules, equipment, or environment; Use multiple teaching modes; Encourage making choices; Be flexible, patient, and creative; Link movement to language.

Patience, supervision, consultation and collaboration are all imperative salient aspects of this endeavor. Journals, conferences and conventions further provide an opportunity for ongoing professional development.

Summary One of the main purposes of Adaptive Physical Education is to ensure that all students are allowed to have the opportunity to develop physical and motor fitness and to develop

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fundamental motor skills and patterns. Auxter, Pyfer, and Huettig (2005) suggest, “the goal of a physical education program for students with disabilities is the development of motor behaviors that assist ultimate functional responses in the community environments” (p. 151). Through the use of simple modifications, the hearing and visually impaired students are able to become more successful in a physical education setting, thus increasing the possibility of a more positive health condition.

DEFINITIONS Appropriate education: A rule requiring schools to provide individually tailored education for each student based on the evaluation and augmented related services and supplementary aids and services. Cerebral Palsy: A term used to describe a medical condition that affects control of the muscles. Cerebral means anything in the head and palsy refers to anything wrong with control of the muscles or joints in the body. If someone has cerebral palsy it means that because of an injury to their brain (that's the cerebral part) they are not able to use some of the muscles in their body in the normal way (that's the palsy part) (Hudson & Brown, 2003, p. 525). CHARGE Association or Syndrome: "C" for coloboma, "H" for heart defects, "A" for atresia choanae, "R" for retardation of growth and development, "G" for genitourinary problems, and "E" for ear abnormalities (CHARGE Association Syndrome website http://www.dpo.uab.edu/~birmie/charge.htm). Deaf-blindness: Concomitant hearing and visual impairments, the combination of which causes such severe communication and other developmental and educational needs that they cannot be accommodated in special education programs solely for children with deafness or children with blindness. Deaf person: One whose hearing is disabled to an extent that precludes the understanding of speech through the ear alone, with or without the use of a hearing aid. Diplegia: Some children have CP just in their legs or much more severe in their legs than in their arms. This is called diplegia. Di means two, so in diplegia only the two lower limbs are affected. As you probably can guess, the difficulty for children with diplegia is using their legs, so walking and running may be hard for them. Because their upper bodies are usually not affected they have good ability to hold themselves upright and good use of their arms and hands (Stedman, 1997, p. 240). Disorganized movement patterns: A child has trouble moving from standing to squat without collapsing. Evaluation (Clinical): A dynamic process in which the physical therapist makes clinical judgment based on data gathered during the examination (Guide, 2001, p. 687). Evaluation (Education): The process of determining to what extent the educational objectives are being realized (Mahoney, 2003 p. 16). Examination: A comprehensive screening and specific testing process leading to diagnostic classification or, as appropriate, to a referral to another practitioner. The examination has three components: the patient/client history, the systems review, and tests and measures (Guide, 2001, p. 687).

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Fundamental motor skills: Basic patterns of movement that are used in various sports and physical activities. Fundamental movement skills require the coordination of multiple body parts (Gallahue & Donnelly, 2003). Global Positioning System: An electronic position-sensing technology based on orbiting satellites which communicate with portable transmitters and receivers that, in interaction with a geographic information system, can inform users of their exact location and relationship to landmarks or coordinates. Hard-of-hearing person: One whose hearing is disabled to an extent that makes difficult, but does not preclude, the understanding of speech through the ear alone, with or without a hearing aid. (Moores, 2001, p11) Head stacking: A student rests his head down or back Health-related physical fitness includes: “…components of physical fitness that have a relationship with good health” (Lacy & Hastad, 2003, p. 107). The components include cardiorespiratory (aerobic) fitness, muscular strength, muscular endurance, bodyRcomposition and flexibility. High guard arm position while walking: A child’s hands are up while walking. History: A systematic gathering of data—from both the past and the present—related to why the patient/client is seeking the services of the physical therapist (Guide, 2001, p. 687). Intervener: 1. Communication support person who can communicate to the student with deafblindness what is happening in the environment around them, engage in spontaneous conversation with the student and assist the student in interacting with other people (Miles & Riggio, 1999). 2. A person to facilitate the access of environmental information usually gained through vision and hearing, but which is unavailable or incomplete to the individual who is deafblind (Alsop 2002). Intervention: the purposeful interaction of the physical therapist with the patient/client and, when appropriate, with other individuals involved in patient/client care, using various physical therapy procedures and techniques to produce changes in the condition (Guide, 2001, p. 688). Itinerant teacher model: A model in which the instructor moves from place to place (e.g. from home to home, school to hospital, or school to school) to provide instruction and support to students with special needs. Learning Objectives: A statement of specific expectation of student behaviors derived from the learner, contemporary society, and subject specialists. Learning objectives can be from the cognitive, psychomotor, or affective domains (Marsh & Willis, 1999) Least restrictive environment: A rule requiring schools to educate students with disabilities with students without disabilities to the maximum extent appropriate for the students with disabilities. Lumbar lordosis: Swayback. Mobility: The capacity, the readiness and the facility to move. The ability to move within one’s environment. Moderate physical activity (MPA): Movements that can be continued for a relatively long period of time without undue fatigue. MPA would be equivalent to a brisk walk (NASPE, 2004). Nondiscriminatory evaluation: A rule requiring schools to evaluate students fairly to determine if they have a disability and, if so, what kind and how extensive.

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Orientation: The process of utilizing the remaining senses in establishing one’s position and relationship to all other significant objects in one’s environment. Parental and student participation: A rule requiring schools to collaborate with parents and adolescent students in designing and carrying out special education programs (Turnbull, Turnbull, Shank, & Smith, 2004). Physical activity: Any movement of the body created by the contraction of skeletal muscles resulting in increased expenditures of energy (Lacy & Hastad, 2003). Physical fitness: The product or result of physical activity (Lacy & Hastad, 2003). Physical Therapist (PT): A person who is a graduate of an accredited physical education program and is licensed to practice physical therapy (APTA, 2000, p. 116). Procedural due process: A rule providing safeguards for students against schools’ actions, including a right to sue in court. Role release: Training in which the orientation and mobility specialist teaches paraprofessionals, parents, and appropriate others specific skills and then releases them to perform that procedure. The specialist remains responsible for the outcomes of these specific intervention strategies and remains in regular contact with the persons carrying out the program. Rote Travel: travel characterized by movement from one landmark to another along a known path with little knowledge of the spatial relationships of the landmarks to one another and little flexibility in the route traveled from one location to another. Scoliosis: Sideways curvature of the spine. Shaping: In behavioral learning theory, the molding of a behavior so that it gradually comes to approximate the desired end state. Shoulder elevation and/or protraction: Shoulders are rounded forward. Sighted Guide Technique: The primary travel method in which persons with a visual impairment use the assistance of someone who has vision. Essentially, in this technique, the person with a visual impairment holds on to the sighted person’s arm in a particular fashion while the two walk along together. Skill-related physical fitness includes: Components that allow individuals to participate successfully in sports and other physical activities. These components are agility, balance, coordination, power, speed and reaction time (Lacy & Hastad, 2003). Spastic Cerebral Palsy: If muscle tone is too high or too tight, the term spastic is used to describe the type of cerebral palsy. Children with spastic CP have stiff and jerky movements because their muscles are too tight. They often have a hard time moving from one position to another or letting go of something in their hand. This is the most common type of CP. About half of all people with CP have spastic CP (Hudson & Brown, 2003, p. 525). Toxoplasmosis: A parasite affecting rodents and cat feces if the cat has ingested an infected rodent Trailing: The act of using the fingers to follow a surface to determine one’s position in space, to locate a specific objective, and/or to get a parallel line of travel. Transdisciplinary team model: a team approach in which professionals from different disciplines cooperate and collaborate during assessment and planning phases of designing a student’s educational program and offer ongoing support and input. Vigorous physical activity (VPA): Movement performed at high intensity while expending large amounts of energy (NASPE/COPEC, 2004). VPA exceeds going for a “brisk walk”

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In: Progress in Education, Volume 17 Editor: Robert V. Nata

ISBN 978-1-60692-505-8 © 2009 Nova Science Publishers, Inc.

Chapter 7

CONFORMANCE EVALUATION OF STANDARDS FOR THE PROFESSIONAL PRACTICE OF INTERNAL AUDITING: AN ASSESSMENT OF AN INSTRUMENT’S VALIDITY AND RELIABILITY Mohd Ariff Bin Kasim, Siti Rosmaini Bt Mohd Hanafi Universiti Tenaga Nasional

Asmah Abdul Aziz, Isahak Bin Kasim Universiti Teknologi MARA

Dawson R. Hancock University of North Carolina at Charlotte, Charlotte, North Carolina 28223-0001, USA

ABSTRACT The internal audit profession has become more important after the collapse of various giant corporations. In fact, it is mandatory for public companies in Malaysia to have an internal audit function. The effectiveness of these internal audit functions is significant to ensure proper discharge of responsibilities by internal auditors. The best measure of internal audit effectiveness is through the level of conformance towards the Internal Audit Professional Practice Framework (PPF). The present study concludes that most of the existing instruments measuring internal audit effectiveness suffer major weaknesses that limit its value. The development process of the new instrument to quantitatively measure the effectiveness of internal audit functions was clearly highlighted. The PPF was utilized in the development of the new instrument. A new approach of measurement was used as a solution to existing instruments. The results indicated that the new instrument was highly reliable and conforms to the existing framework suggested by IIA.

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Keywords: Internal Auditing, Quality Conformance, Professional Practice Framework (PPF), Quality Assessment Manual.

AN OVERVIEW OF INTERNAL AUDITING The demand for both external and internal auditing is the result of the need to have some means of independent verification to reduce record-keeping errors, asset misappropriation, and fraud within business organizations. As business activities grew in size, scope, and complexity, a critical need for a separate internal assurance function that would verify the accounting information used for decision-making by management emerged. Management needed some means of evaluating not only the efficiency of work performed for the business but also the honesty of its employees. The internal audit function became responsible for careful collection and interpretive reporting of selected business facts to enable management to keep track of significant business developments, activities, and results from diverse and voluminous transactions. The existence of well-publicized articles on corporate failure around the world suggests weak corporate governance as being a major source of the failures. This suggests that auditors both external and internal, audit committee and board of directors have not properly discharged their professional and statutory responsibilities. The Malaysian government responded to this issue by taking serious effort by strengthening the existence of corporate governance mechanism to address the challenges emerging from the globalization and to restore investor’s confidence. In addition, as a measure to improve corporate governance in Malaysia, Bursa Malaysia recognizes the importance of internal auditing and the roles of internal auditors in the governance process of an organization. It is a mandatory requirement by Bursa Malaysia for the audit committee to include a summary of the internal audit activities performed during the year or in the absent of such function, to explain how it was able to discharge its functions in its annual report. In addition, the Malaysian Code of Corporate Governance (2007) required companies to establish internal audit functions to undertake regular monitoring of key control and procedures and companies, which do not have separate internal audit functions, should from time to time review the need of such function. The Institute of Internal Auditors (IIA) of the Unites States developed a new Professional Practices Framework (PPF) in 2002 to meet the response of the expending market for high quality internal audit services. In case of Malaysia, the guidelines on Internal audit function was launched in 2002 by IIAM to strengthen Malaysia’s framework of corporate governance. The guideline also serves as the benchmark and best practices for internal audit practitioners in Malaysia. In fact, the recent announcement by Bursa Malaysia on the amended Listing Requirements (IIA, 2008) had mandating the internal audit function of all public listed companies. In addition, the listing requirement also required the audit committee to review the competency of internal audit function. This expansion of the existing audit committee functions, to an extent, creates a problem that justifies the present study. The issue or research questions raised are how is the audit committee going to assess the competency of internal audit function? What would be the basis to measure level competency of internal audit function? Is it possible to quantitatively measure the competency of internal audit function?

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These are two main questions or issues that need to be resolved in ensuring the implementation of the revised listing requirement which will be effective on 31 January 2009. The next section highlights the review of existing instruments measuring quality or effectiveness of internal audit and development process of the instrument measuring internal auditors’ degree of conformance towards PPF. The justification for the need of the new instrument, basis of the development as well as the structure was clearly presented. The primary objective of the study is to construct a valid and reliable instrument to quantitatively measure the level of conformance of internal audit towards the Professional Practice Framework (PPF).

JUSTIFICATION FOR NEW INSTRUMENT The first step in the attempt of developing an instrument measuring quality of internal audit department is by reviewing the existing instruments used as a measure of quality. There are various approaches utilized to measure the quality of internal audit but none of these attempts to quantify the measures. Almost all of the instruments surveyed, as listed in Table 1, utilized categorical measure as well as binary of “Yes” or “No” which limit the data for descriptive statistics. Most of the results obtained from the instruments were limited to the presentation of percentage of each category. In addition, few of the instruments listed in Table 1 used a five-point Likert-based scale of excellent, good, fair, poor and not available. Few of the surveys, for example IIA (2006c), required the respondents to describe and explain in words their response on each of the instrument attributes. Thus, primarily provides qualitative data. The qualitative data is undeniably important but it is very subjective and thus may not permit normal statistical analysis without necessary transformation. Most of the instruments adopted the IIA PPF as a basis for their measurement of quality but unfortunately, the entire Attributes Standard and Performance were not adopted. The adoption of a full set of standards, i.e., Performance Standard and Attributes Standard are believed to be able to provide better coverage of quality. The only instrument concerned with both standards is Tool 19 (IIA, 2006d). Its covers all standards from 1000 to 2600. A major limitation of this instrument was the use of categorical measure. The respondents are required to indicate each component of the standards based on three scales of Generally Conform (GC), Partially Conform (PC) and Does Not Conform (DNC). This method of measurement once again limits the ability to perform various statistical tests as the data gathered were nominal in nature. Overall observation of the existing instruments measuring the quality of internal audit function revealed three main weaknesses. First, there is no consistency on the attributes used to tap the construct, i.e., the quality of internal audit. Second, most of the instruments do not incorporate the whole of IIA PPF as a basis of measuring quality. Finally, all of the instruments do not attempt to quantify their measures and this is evidenced by the use of categorical scales.

Table 1: List of Existing Instruments on Quality of Internal Audit No. 1

Author (Sciarra, 2006a)

Scales -Likert-based 1, excellent 2, good 3, fair 4, poor 5, N/A -Likert-based

Component Assessed -knowledge and skills -training -information -miscellaneous

Cont. -various aspect of each categories were assessed

Limitations -very general questions asked -not based on PPF -subjective measures

2

(Sciarra, 2006b)

-relationship with management -audit staff -scope of audit works -audit process and report -management of internal audit activities -value added

-various aspect of quality assessed -detail question for each attributes

-questions may result in bias interpretation -subjective measures -not based on PPF

3

IIA, (2003)

-categorical

-based on PPF -serve as basis to measure effectiveness -provide detail attributes

- subjective measures -Limit answer to Yes or No. -Not based on PPF

IIA, (2006c)

-assessor ‘s opinion -very subjective

-purpose, authority and responsibilities -independence -objectivity -proficiency -due professional care -quality assurance and improvement in internal audit function -providing assurance and generating improvement in the organization -Internal Assessment of: - ongoing review - periodic review -External assessment: -general consideration -timing -scope of external assessment

4

-based on PPF and code of ethics -CAE is identified as the person responsible for internal assessment.

-only the way in which such evaluation need to be perform. -there is no specific question to tap individual components assessed. -subjective measure

5

IIA (2006b)

-subjective answer -eg: Explain Describe - categorical

6

IIA (2007)

-categorical -GC, generally conform -PC, partially conform

-organizational and environment -background of the organization -risk management -Governance -accountability and oversight -The internal audit activities -background of internal audit activities -internal audit practice environment -relationship with senior management and board -management of activities -information technology.

-mainly for external quality assessment -very comprehensive -provide detail items in each elements

-very subjective measures -all are open ended questions

-planning -purpose, authority and responsibilities -internal assessment -professional development -quality assurance improvement program -policies and procedures -resource management -organizational independence -proficiency -risk management -recording of information -engagement supervision -communicating results -engagement planning

-provide detail element based on PPF -serve as external assessment for standard 1300 -detail evaluation on standard 2010 to 2200

-categorical in nature -some of the standards are not covered

Table 1: List of Existing Instruments on Quality of Internal Audit (Continued) No. 7

Author IIAM (2007)

Scales Component Assessed Cont. -subjective- based on respondents’ -positioning & Audit own description Strategies (40%) - audit charter - sponsorship/ funding - independence -process/ enabler (30%) -risk assessment and audit planning -audit methodology -audit engagement -audit tools and technology -audit resource capability (30%) - roles and responsibilities -manpower planning -professional development

-cover both attribute standards and performance standards of the PPF. -Assigned weight to each category.

Limitations -respond are very subjective. -limit the ability to analyze the data. -Mainly qualitative in nature.

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Considering the above limitations, the design of a new valid and reliable instrument that quantitatively measures quality of internal audit is obviously the primary objective of the study. The new instrument that needs to be developed should be able to overcome the above limitations as well as aim to provide quantitative measure for quality. Technically, the use of Tool 19 seems to be the best basis for the new instrument. This is further supported by the recommendation made by Bruce Turner (2007) that Tool 19 is the best measure currently available for measuring the effectiveness of internal audit. Detail coverage of PPF Standard becomes the main reason for the use of Tool 19. Tool 19, should the overall results report GC, is an indicator that the quality of internal audit is very high. The result that reported PC obviously signifies lower level of quality while DNC connotes lowest level of quality. Apparently, the best measure of quality for internal audit reflected from the degree of conformance of the internal audit towards the IIA’s PPF. The new internal audit conformance instrument was developed based on Tool 19 from the IIA Quality Assessment Manual 5th Edition (IIA, 2006d). However, as previously highlighted on the limitation of Tool 19, the new instrument used percentage of conformance as a measure of quality; thus, enabled the ratio type of data to be collected which may trigger further statistical analysis. The next part of this section discusses the details of development process for the new instrument.

BASIS OF DEVELOPMENT The development of the new instrument aims to measure the quality of internal audit based on two main sources of PPF and Quality Assessment Manual. The new instrument is known as Conformance Evaluation of Standard for the Professional Practice of Internal Auditing. The next paragraph discusses both sources in detail. The PPF, issued by IIA, serves as a main reference for internal auditor. The PPF comprises four main components including the definition of internal auditing, the standards, the code of ethics and other guidelines. The standards were further divided into Attributes Standard and Performance Standard. The Attributes Standard highlights the organization as well as the entity performing the internal audit activities. The Performance Standard describes more of the nature of internal audit activities. Both of these standards provide a basis to measure internal auditor’s performance. The PPF had listed three main purposes of the standard (IIA, 2006a). First, to provide fundamental principles of practice for internal auditor. Second, to establish a framework for internal auditor to discharge their value added activities. Third, to provide a basis for the internal audit’s performance evaluation. And finally, to improve the process and operation of the organization. As highlighted in the third purpose, the PPF serves as a basis to measure internal audit’s performance. The new instrument will rely entirely on the PPF in designing the attributes to measure quality of internal audit. Table 2 exhibits all standards that were used in designing questions for the new instrument based on the question number appeared in the instrument. The secondary source for development was the Quality Assessment Manual (IIA, 2006d) that serves as the complement that provides an important basis for the development of the new instrument. The manual provides principle guidance on the conformity of the PPF. The

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manual consists of five chapters covering various aspects of quality assessments for internal auditors as well as various samples of reports and assessment tools. As previously reported, Tool 19, which is part of Quality Assessment Manual, was utilized for the development which involves matching the detailed explanation on the quality assessment based on the PPF. Table 2: Attribute and Performance Standards of the Instrument Question No.

Standards PPF

1 2 3 4 5 6 7 8 9 10 11 12

1000 1110 1120 1130 1210 1220A1 1230 1300 1311 1312 1320 1340

13 14 15 16 17 18 18 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37

2010 2020 2030 2040 2050 2060 2100 2110 2130 2201 2210 2220 2230 2240 2310 2320 2330 2340 2410 2420 2430 2440 2500 2600 2600

Standards Title Attribute Standards Purpose, authority and responsibility Organizational independence Individual objectivity Impairments to independence or objectivity Proficiency Due professional care Continuing professional development Quality assurance and improvement program Internal assessment External assessment Reporting on the quality program Disclosure of non-compliance Performance Standards Planning Communication and approval Resource management Policies and procedures Coordination Reporting to board and senior management Nature of work Risk management Governance Engagement planning: planning consideration Engagement objectives Engagement scope Engagement resource allocation Engagement work program Performing the engagement: identifying information Analysis and evaluation Recording information Engagement supervision Communicating results: criteria for communication Quality of communications Engagement disclosure of non-compliance with standards Disseminating results Monitoring progress Resolution of management’s acceptance of risks Resolution of management’s acceptance of risks

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THE STRUCTURE OF QUALITY CONFORMANCE INSTRUMENT The new instrument was developed with the aim to quantitatively measure the quality of internal audit. The instrument was termed as Conformance Evaluation of Standards for the Professional Practice of Internal Auditing. This section describes the structure of the instrument which is divided into four parts presented in Figure 1. The cover letter accompanying the instrument specifies the aim of the study and what the instrument is intended to measure. Respondent was also formed on the basis of which the instrument was designed. The later part of the letter ensures the confidentiality of data provided. The letter ends by thanking the respondent for their cooperation. Conformance Evaluation of Standards for the Professional Practice of Internal Auditing

Cover Letter

Section 1

Respondent Details (5 questions) • • • • •

Employment Category Primary Functional Title Gender Size of organization Working experience

Section 2

Conformity of IIA International Standards, PPF (37 questions)

Section 3

Contact Information

Comments on Internal Audit (3 questions)

• Attribute standards (Std. 1000 – 1340) (12) • Performance standards (Std. 2010 – 2600) (25)

Figure 1. Structure of New Quality Conformance Instrument

The second part, Section 1, of the instrument focuses on the respondent’s details. Sufficient instruction for the respondent was provided in this section to assist them with completing the instrument. In addition, a remark was stated that it should take five minutes to complete the instrument. There are five questions in this part, such as the respondents’ gender, employment category, primary functional title, size of the organization and working experience. The third part of the instrument, Section 2, is the main structure of the instrument. It comprises of 37 questions that were designed based on the PPF and Tool 19 of the Quality Assessment Manual. These 37 questions are the main attributes to measure the degree of conformance of internal audit department to PPF. This section begins by providing a brief introduction to the respondent. The aim of the instrument of measuring the extent to which the internal audit conforms to the PPF. The basis on which the questions were designed was re-emphasizing instructions for respondent to complete. There are 12 questions designed based on standard 1000 to 1300 of the Attribute Standards. These questions i.e., 1 to 12 cover entire element of purpose, authority, responsibility, independence, proficiency, due care and quality assurance. Question 13 to 37 covers the Performance Standards 2000 to 2600. Section 3 of the instrument presents two open ended questions. These questions required the respondent to suggest any other quality assurance issues to be highlighted and to provide their opinion on the overall quality of

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internal audit department. Finally, the author’s contact information was presented aimed to enable the respondent to post any inquiries.

INSTRUMENT MEASUREMENT The previous section highlighted limitations of the existing instrument. It mainly focuses on the measurement method used. The new instrument should be able to anticipate all the limitations with the aims of providing quantitative measure of quality conformance. Initially, it is important to identify the types of data gathered whether they are ordinal, ratio, nominal or interval. According to Keller and Warrack (2000), if data can be ordered or ranked preferentially, those data are considered as ranked data and are said to have an ordinal scale. The responses using Likert-based scale is considered as non-quantitative data because the data are ranked based on preferences. In addition, Douglas (2006) suggested that we are unable to differentiate the magnitude of the differences between the ranks. For instance, is the difference between “strongly disagree” and “disagree” the same as the difference between “strongly agree” and “agree.” Therefore, we can only conclude that rating 1 is better than rating 2 or 3 and 4, but we cannot determine how much better the rating is quantitatively. Thus, it is clear that the data obtained using the above scale is ordinal in nature, which triggers for non-parametric tests. Kimbrough (2006) provided substantial improvements by designing an instrument that incorporates a more objective measurement. Instead of using a traditional Likert-based scale, which the above argument considered as non-quantitative, Kimbrough introduced a more objective scale aimed to provide quantitative measure. By using Kimbrough’s scale we can determine the differences between the ranks. For instance, the difference between the ranks was 25% and similar percentage was maintained throughout the scale. This may be correct for Kimbrough to argue such scale may provide quantitative measures. An example of Kimbrough’s scale is as follows: 1 0%

2 25%

3 50%

4 75%

5 100%

The above scale was further modified to ensure that ratio data can be collected. The modified scale enables the respondent to indicate any percentage on ERM implementation from 0% to 100%. 0 percent represents that no ERM activity was implemented and 100 percent denotes maximum implementation of ERM activity. An example of the modified scale is as follows: Modified Scale Approximate percentage of ERM implemented 0%

100% With regard to ERM, your organization: evaluate the frequency of risk event

% implemented

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The modified scale is considered appropriate and able to provide a high degree of data i.e., ratio data. In addition, the scale enables respondents to indicate any number of individual questions, thus allowing the ratio type of data to be collected. Statistically, ratio type data is the highest quality of data permitting various tests (Keller, 2000; Salkind, 2008; Steed, 2003). Furthermore, statisticians also proposed a similar scale which may warrant the collection of ratio data. Thus, the modified scale will be utilized as a measurement tool to gather quantitative data in the present instrument.

REVIEW OF VALIDITY This section describes the process and procedures adopted to review the validity of the instrument. The first draft of the instrument was emailed to Michelle Scott, Director of Research and Analysis, IIA USA mainly to review the validity of questions measuring the intended construct on 2 July 2007. The reviewer confirms that the PPF and Quality Assessment Manual are the most appropriate source of information to be relied upon in the development of the instrument. Thus, there is no issue of the instrument’s validity measuring what it purported to measure as it is based on well established frameworks. Similar comments were received from IIAM’s Technical Director. Two separate focus group interviews were performed to improve the instruments and obtain opinions on other relevant aspects to be included in the instrument. The first interview was conducted on 12 June 2007 at Park Royal Hotel, Kuala Lumpur. A group of nine participants holding Chief Audit Executive (CAE) positions participated in the informal interview in conjunction with the IIAM’s ERM training. They were required to comment on the instrument measuring quality of internal auditors. Overall conclusion of the session resulted in revising the instrument for simplicity. The second focus group interview was conducted to support the initial interview on August 20-21, 2007. A group of 22 internal auditors holding various positions and from various industries participated in the session. The session was conducted during the 2007 National Conference on Internal Auditing held at Kuala Lumpur Convention Centre. The diverse compositions of participants are expected to provide valuable comments on the instruments as well as issues concerning the present study. The participants were asked to comment on the measurement scales and all of them did not encourage the use of Likertbased scales. The scales are said to influence respondents decision making where they are keen not to make any decision. For instance, in a five-point or seven-point scale, the respondents tend to indicate 3 or 4 respectively. The second major issue raised during the session was the basis used in the development of the instruments. The use of IIA PPF and Quality Assessment Manual was supported by all of the participants. In fact, one of the presenters in the conference emphasized the use of Tool 19 as the best measure to assess internal audit quality (Bruce, 2007). The participants of the interview session suggested that the number of questions concerning particular elements should not be more than 30 simple questions.

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DATA COLLECTION Data collection process is critical in evaluating the reliability of research instruments. For the purpose of this study, the data collection was executed via the UNITEN’s accounting students who went for their industrial attachment on 3rd December 2007. They were 100 students attached to various accounting firms as well as giant corporations all over Malaysia for the period of six months. The students serve as an agent for distributing the research instruments to internal auditors, accountants, as well as external auditors in their attached organizations. The diverse location of the students’ attachment is hoped to satisfy the assumption of random sampling. Each student was provided with four copies of the instrument as well as a return paid envelope with a printed address of the author. All the instruments were printed in booklet form of A5 size (width: 14.8 cm and height: 21 cm). A total of 400 copies of instrument measuring internal audit conformance were distributed in 100 A5 size envelopes. The distribution of instrument through the UNITEN industrial training students conducted in the past revealed a steady 60 percent response rate.

DETERMINATION OF SAMPLE SIZE Determination of sample size is something that cannot be neglected. Before performing any factor analysis it is crucial to have an appropriate sample size. In fact, this is always overlooked by many researches in social science (Osborne, 2004). According to Tabachnick and Fidel (2001), the use of insufficient sample size to perform factor analysis will eventually result in extraction of erroneous factors. There were various guidelines concerning the appropriate number of sample size before attempting any factor analysis. In general, large samples are better than smaller samples. Larger samples tend to minimize probability of errors, maximize the accuracy of population estimates and ultimately improve the generalizability of the results. There are two approaches recommending the guidelines for sample size, one by suggesting the minimum number of subjects or respondents and the second approach suggests the ratio of subjects to items or variables. Barnett and Kline (1981) suggests that the sample size should be from an N of 50 to 400. Another study by Comfrey and Lee (1992) reported that sample size may be determined based on the following scales of 50- very poor; 100poor; 200- fair; 300- good; 500- very good and 1000 or more- excellent. Ledakis (1999) further reported a minimum number of 200 is required before attempting any factor analysis. The second approach is by using ratio of subject to variables or items. A ratio of 15 respondents or 30 respondents for every one variable is recommended in the study of multiple regressions where the generalization of the results is critical. With regard to factor analysis, few studies suggest a minimum subject to item ratio of at least 5:1 (Gorsuch, 1983; Hatcher, 1994). It is surprising to note that many studies utilizing factor analysis did not seriously consider these sample size guidelines. By analyzing published literature that uses factor analysis, Osborne and Anna (2004) revealed that most articles utilized samples which are lower than the ratio of 5:1. In addition, conclusions were drawn based on this questionable analysis. Another study that surveyed 1076 peer-reviewed, published journal articles in psychology revealed that 40.5 percent of the studies that utilized factor analysis used less

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than 5:1 respondent to item ratio (Costello, 2003). Considering all the recommendations as well as the importance of performing factor analysis with appropriate sample size, the present study utilized a 5:1 ratio of respondent to items. According to Osborne and Anna (2004) the determination of sample size for pilot tests are equally important as the sample size for study. A ratio of five respondents for every single question is considered appropriate particularly for performing factor analysis and reliability test. The instrument which consists of 12 questions measuring Attribute Standards and 25 questions for Performance Standards. The minimum sample size required is 60 for Attribute Standards and 125 for Performance Standards. A total of 400 copies of the instrument measuring quality of internal audit were distributed and hoped to satisfy the suggested sample size requirement by considering 60% respond rate.

REVIEW OF RELIABILITY This section highlights all the analysis performed with an aim to test the reliability of the instruments developed. The instrument was further divided into measurement for Attribute Standards and Performance Standards. Detailed discussions on the reliability test as well as factor analysis will be presented separately for Quality conformance: Attribute Standards and Quality Conformance: Performance Standards.

STATISTICAL TEST FOR RELIABILITY Generally, an instrument is reliable when it measures what it is suppose to measure and statistically represents the degree of its consistency. There are various statistical tests available to test the reliability of an instrument but the present study limits the discussion on Cronbach’s alpha. It is important to understand types of scores used in the Cronbach’s alpha as a basis of interpretation on the reliability of an instrument. Scores are the respondent’s answer to items on an instrument which can be classified as the true score and the error score. The error score can be further categorized as systematic error which is affected by the research methodology used. The second category is termed as random error due to random character of the respondents. A reliable instrument will have smaller error (i.e., both random and systematic) components in relation to the true score component, which reflects the ratio of the true score to the total score. Cronbach’s alpha, measures the level of reliability of an instrument based on the value of alpha. A smaller value denotes less reliable instrument as it does not measure the true score. Thus, the higher value of alpha is preferred. Alpha equals 1.0 when all items measure only the true score and there is no error component while the value of alpha equals zero when only an error component was measured instead of the true score. According to Garson (2008), it has become standard that a moderate cut-off value of alpha of 0.60 is common in exploratory research. However, in most cases the value of alpha should be at least 0.70 or higher in order to achieve adequate scale (Eide, Geiger, & Schwartz, 2001; Salkind, 2008). In fact, many researchers require a cut-off of 0.80 to be considered as a good scale (Carmines, 1979). Another issue in Cronbach’s alpha test is the

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number of items in an instrument tested. The value of alpha increases as the number of items in the scale increases thus indicated that an instrument with fewer items would result in lower alpha and an instrument with more items may result in higher value of alpha. Therefore, one of the methods to increase the value of alpha is by increasing the number of items in a particular instrument. It is important to note that comparison of alpha levels between scales with differing numbers of items is not appropriate.

RESULTS AND INTERPRETATION This section highlights the number of response as well as the result of statistical tests. It is important to recall that the primary objective of this study is to develop a valid and reliable instrument to quantitatively measure the conformance of internal auditors towards their Professional Practice Framework. Table 3 reported the number of response received in the study. Table 3: Number of Respond Received Instrument

No. of Questions

Distributed

Return

Rejected (blank)

Usable

12

Response Required (ratio1:5) 60

Attribute Standards Performance Standards

400

196

22

174

25

125

400

196

22

174

As there are two separate instruments (Attribute Standards and Performance Standards), two sets of reliability tests were performed to analyze the instruments’ internal consistency. Cronbach’s coefficient alpha was utilized for all set of analysis. As presented in Table 4, the alpha value for both parts of the instruments measuring Attribute standards and Performance standards reported the value of coefficient alpha of 0.988 and 0.994 respectively. Table 4: Results of Reliability Tests

Attribute Standards

0.988

Cronbach’s Alpha Based on Standardized Items 0.988

Performance Standards

0.994

0.994

Instrument

Cronbach’s Alpha

The above results were expected as the developments of all instruments in the present study were based on the existing well constructed framework. For Example, the design of instruments to measure quality of internal audit department were based on the exiting framework issued by IIA known as the Professional Practice Framework as well as Tool 19 from Quality Assessment Manual.

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FACTOR ANALYSIS Factor analysis is a statistical approach that can be used to analyze interrelationship among large numbers of variables or items and to explain those variables based on their common underlying dimensions or factors. The analysis involved condensing the information contained in a number of original variables into the smaller set of dimensions known as factors with a minimum loss of information. In fact, it contributes to the development of a reliable instrument as it tests the extent to which the questions or variables designed tap into the same construct. There are various types of factor analysis but the present study limits the discussion to Principal Axis Factoring (PAF) which is also known as Principal Factor Analysis (PFA) (Field, 2005; Salkind, 2008). Factor analysis is also used to uncover the underlying structure from a set of variables. It reduces attribute space from a larger number of variables to a smaller number of variables or better known as factors. This factor will then be utilized to achieve the main research objectives. Factor analysis could be used for multiple reasons but the following are among the three main reasons for utilizing factor analysis in the present study. The first is to validate the instrument by demonstrating that its constituent items load on the same factor, and to drop proposed scale items which cross-load on more than one factor. Second, to reduce a large number of variables to a smaller number of factors for modeling purposes and finally, to select a subset of variables from a larger set based on which original variables have the highest correlations with the principal component factors.

CRITICAL CONSIDERATION IN PERFORMING FACTOR ANALYSIS As highlighted earlier, Factor analysis is an important statistical analysis that was utilized to reduce and simplify complicated and large number of variables into simple variables. However before attempting any factor analysis, it is critical to consider various steps and assumptions involved in generating reliable results from the factor analysis. This section discusses the steps and considerations that serve as a basis to guide the interpretation of results obtained from factor analysis based on recommendations made by previous research such as Costello (2003), Field (2005), Garson (2008) and Salkind (2008).

Sample Size The review of literature on the acceptable sample size in performing factor analysis was clearly highlighted in previous section (i.e., pilot test). Based on the literature, a general conclusion may be drawn by utilizing a ratio of five respondents for every one variable. Concurrence with various studies on sample size for factor analysis, Steed (2003) have suggested an absolute minimum ratio of five participants to one variable, but not less than 100 participants per analysis, although, a sample size of 200 or more is preferred. It is important to note that the word variables in the sample size ratio highlighted does not refer to the research variables of the study. Instead, it refers to the number of questions included in the instrument to measure particular construct (Ledakis, 1999).

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In the present study, few affords were made to ensure the above sample size requirement was satisfied. A total of 400 copies of questionnaires for each instrument were distributed (i.e., 400 copies for ERM and 400 copies for IA Conformance). In order to improve the response rate, three SMS to remind the students to return the questionnaires were sent to all 100 students. The first was on 23 November 2007, second on the 9 December 2007, third SMS reminding the students to return the questionnaires before 31 January was sent on 5 January 2008. The first envelopes with four sets of questionnaires were received on 18 December 2007 and more envelopes received from that date till 12 January 2008. However, the response or the numbers of questionnaires returned were not very encouraging as only 20% from the total 400 copies were returned. Another attempt was made via phone call where each of the 100 students was contacted on 12 January 2008 to remind and request them to cooperate by returning the questionnaires before 31 January 2008. After the phone call, more envelopes were received as at 31 January 2008. On the first week of February another four envelopes were received and no other envelopes received after 10 February 2008. By 10 February 2008, a total of 196 copies of questionnaires were received from the 400 copies distributed. However, only 174 copies of the returned questionnaires were usable while 22 copies were returned blank. Although the response rate was only 49% the sample size requirement was fairly satisfied. There are 12 questions measuring the Attribute standards which required a minimum of 60 respondents and present pilot test managed to have 174 responses. The second section of the instrument which measures Performance standards consists of 25 questions. Thus, the total respond of 174 responses was more that the minimum requirement of 125 responses required in satisfying the sample size requirement. Finally, with regard to the sampling requirements for factor analysis, it was clearly indicated that the present study adopted the ratio of five respondents for every one variable. Although a more stringent requirement is available, the adoption of the above ratio was fairly justified via various findings such as (Field, 2005; Osborne, 2004; Steed, 2003). The total questionnaires received were more than the minimum sample size required based on the 5:1 ratio.

Types of Data and Normality According to Ledakis (1999) and Steed (2003), all data utilized for Factor analysis must be at least interval in nature. The Interval data mainly provides quantitative information which the distance between the numbers on the measurement scale is consistent for all levels. An example of an Interval measurement scale is the temperature scale. The distance between 30 degrees and 50 degrees is consistent as the distance between 60 degrees and 80 degrees. The present study utilized Ratio scales which satisfied the above requirement for measurement scales. In contrast to the interval scales, Ratio scale do have a fixed zero point. In addition, the numbers on the measurement scale is equal for all levels and a meaningful zero point that permits for the interpretation of ratio comparisons. Measurement of time is an appropriate example of ratio scales. The difference between two hours and three hours is exactly the same as the difference between eight hours and nine hours. In addition, it may be claimed two hours is twice as long as one hour (Keller, 2000).

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As described in the earlier section, all the data collected in the present study are ratio in nature thus satisfy the requirement. Kolgomorov-Smirnov (KS) test was utilized in the present study to test the normality of all variables to be utilized in performing Factor Analysis. There are two set of variables tested for the normality which are 1) variables for ERM implementation; 2) variables on roles of internal auditor in ERM; 3) variables measuring conformance towards Attribute standards and 4) variables measuring conformance towards Performance standards. The KS test tests the Null hypothesis that states, test distribution is normal. Should the p-value is 0.50) Factor Item The Question any non-compliance will be reported to the CEO or audit 2.12 committee. 2.6.4 the probability of significant error or non-compliance. the assurance of risk management, control and governance 2.6.3 processes. 2.6.5 cost and benefits analysis in performing their duties.

0.948 0.947 0.941

the CAE execute periodic review via self-assessment.

0.934

2.8

the CAE established periodic quality assessment program.

0.933

2.6.1

the amount of work to be performed.

0.924

2.6.2

the materiality on specific assurance tasks.

0.919

2.4 2.1 2.2 2.11 2.7 2.3 2.5

external quality assurance assessment is conducted every five years. internal auditor discloses to appropriate parties any incidences that affect their independence. had established an internal audit charter that is consistent with the standards. the CAE reports directly to the Audit Committee. the result of external assessment is reported to the audit committee. all internal audit staff have the opportunity to improve and update their knowledge and skills by attending training and conferences. internal auditor practices unbiased attitude all the time in performing their duties. all internal audit staff are equipped with knowledge and skills required to perform their duties.

% of Variance Explained

0.949

2.9

2.10

Factor 1: Attribute Standards

Loadings

0.916 0.910 84.473 0.907 0.896 0.887 0.887 0.883 0.830

Cumulative variance explained

84.473

Table 6: Factor Loadings for Quality Conformance: Performance Standards Factor description and variables (Loading >0.50) Factor Item The Question the CAE ensures all resources approved in audit plan are 2.15 efficiently deployed. there are policy and procedures established to guide all 2.16 internal audit activities. 2.25.1 objective the CAE audits plan and resources required to the board for 2.14 approval. the conclusion made by internal auditor is based on careful 2.28 analysis and evaluation. significant risk exposure 2.25.2 Factor 1: the annual planning of internal audit activities is designed Performance Standards 2.13 based on risk assessment. internal audit activities assessed the effectiveness and 2.20 efficiency of information and control system. the CAE reports to the board or audit committee to resolve 2.37 the issue should the dispute continues. performance of audit activities as against the plan is 2.18 periodically reported to the board. the CAE is responsible to communicate the final results of 2.34 audit activity. the engagement objectives must seriously consider the risk, 2.22 control and governance processes. 2.21.3 communicate risk information within the organization 2.35 2.25.3

the CAE established monitoring procedures to ensure all recommendations made are performed by the management. adequacy and effectiveness of risk management

Loading

% of Variance Explained

0.960 0.955 0.951 0.951 0.950 0.948 0.948 0.944 0.944 0.944 0.943 0.943 0.943 0.942 0.936

85.882

Factor description and variables (Loading >0.50) Factor Item The Question 2.27 internal audit assessed the quality of information required to achieve the engagement objective. 2.21.1 instill ethical values 2.19 2.36 2.23 2.17 2.33 2.24 2.21.2 2.29 2.25.4 2.26 2.31 2.3 2.32

the internal audit activities facilitate the organization’s ERM. when management decided to accept risks beyond the organisation’s risk tolerance, CAE will hold discussion with management to resolve the issue. the scope of internal audit activities must be able to satisfy the necessary need for internal auditor to perform their task. the CAE promotes information sharing and improve coordination with other entities. reason and impact of any non-compliance of standards by internal auditors are clearly disclosed. the allocations of necessary resources are critical to ensure the achievement of engagement objective. review organization’s performance the internal auditor carefully maintains all facts supporting their conclusion. opportunity to provide significant improvement internal audit work programme includes details of procedures and documentation to achieve engagement objective. the objectives, scope, conclusion, recommendations and action plan are included in the audit report. review of internal audit working paper is a means for quality improvement. accurate, clear, concise, complete, and timely are the characteristics of internal audit report.

Loading 0.936

% of Variance Explained

0.935 0.931

0.928 0.924 0.922 0.919 0.910 0.909 0.903 0.887 0.872 0.867 0.844 0.819

Cumulative variance explained

85.882

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Quality Conformance, Performance Standards The second cycle of factor analysis in this study involves all variables that measure the Performance Standards of the PPF. The results of correlation matrix table revealed all of the variables had the value of more than 0.30 which indicate the suitability of the data set for factor analysis. The KMO test indicated a result of 0.860 and Bartlett’s test is significant at 0.000. The anti image covariance matrix revealed that all the measurement of sampling adequacy are well above the acceptable level of 0.50 i.e., range of 0.726 to 0.951. The result based on the commonalities table range from 0.670 to 0.921. The similar pattern of result as in the analysis for Attribute Standards was replicated. There is only one factor extracted with eigenvalue of 25.765. This factor had explained 85.882% of the variances (Table 6). Factor loadings range from 0.960 to 0.819.

CONCLUSION In an attempt to develop a valid and reliable instrument to quantitatively measure the level of conformance by internal auditors, the study analyzed the existing instruments. Thorough processes were undertaken to ensure the validity of the instrument developed via expert reviews. The results from quality conformance conform to the existing Professional Practice Framework. The two factors resulted from the analysis, perfectly fit into the Attribute and performance standards. This is perhaps due to the development of instrument to that was based on PPF (IIA, 2006a) as well as Tool 19 from IIA’s Quality Assessment Manual (IIA, 2006d). The analysis of reliability including factor analysis was performed separately for Attribute Standards and Performance Standards. This is due to the distinct nature of questions for each set of instruments. The result from Cronbach’s alpha for each set of instrument i.e., Attribute Standards and Performance Standards were highly favorable with value of 0.980 and 0.994 respectively. In addition, the result from factor analysis does not alter the existing structure of the PPF. All questions that measure Attribute Standards loaded perfectly on one and only one factor. Similar results were replicated for Performance Standards. The results revealed only one factor which all items loaded perfectly on it. Thus, supports and confirms the exiting structure of PPF designed by IIA that segregate between Attribute Standards and Performance Standards.

FUTURE RESEARCH The present study limits the research setting to auditing practitioners in Malaysia. It is interesting and would be a valuable contribution to the literature if future research could test the instrument at different research settings. In addition, future research may also utilize other statistical tests to assess the reliability of the instrument.

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AUTHORS’ NOTE This research was funded by Universiti Tenaga Nasional (UNITEN) Research Fund (J510050055). The instrument is available upon request. All correspondence should be addressed to [email protected]

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IIA. (2007). IIA Standard 1312- External Quality Assessments: Results, Tools, Techniques and Lessons Learned. Retrieved 18 November, 2007, from Available from: http://www.theiia.org/research/research-reports/chronological-listing-researcgreports/downloadable-research-reports/?i=261 IIA. (2008). Bursa Malaysia's Amended Listing Requirements. IIAM, Keeping in Touch, January - March 2008, 3. IIAM. (2007). 2007 Best Internal Audit Practice Award (BIAPA). The Institute of Internal Auditors Malaysia. Keller, B. W. G. (2000). Statistics for management and economics (5th ed.). CA: Duxbury, Thomson Learning. Kimbrough, R. L. (2006). The relationship between perceptions of organizational culture and implementation of enterprise risk management. Unpublished Ph.D., The University of Alabama in Huntsville, United States -- Alabama. Ledakis, G. (1999). Factor Analytic Models of the Mattis Dementia Rating Scale in Dementia of the Alzheimer’s Type and Vascular Dementia Patents., Drexel University. MICG. (2007). Malaysian Code on Corporate Governance (revised 2007): Malaysian Institute of Corporate Governance (MICG). Osborne, J. W. A. B. C. (2004). Sample size and subject to Item ratio in principal components analysis. Practical Assessment, Research and Evaluation, 9(11). Salkind, S. B. G. a. N. J. (2008). Using SPSS for Windows and Macintosh analyzing and understanding Data (5th ed.). Upper Saddle River, New Jersey: Pearson Education. Sciarra, D. (2006a). Quality Staff Survey. Retrieved 18 November, 2007, from Available from: www.theiia.org//download.cfm?file=15317 Sciarra, D. (2006b). Quality Client Survey. Retrieved 18 November 2007, from www.theiia.org/download.cfm?file=76048 Steed, S. J. C. a. L. G. (2003). SPSS Analysis without anguish, version 11.0 for windows (Version 11.0 ed.): John Wiley & Sons Australia. Tabachnick, B. G. F., L. S. (2001). Using Multivariate Statistics (4th ed.). New York: Harper Collins. Yarnold, B. a. (1995). Principle components analysis and exploratory and confirmation factor analysis. In Reading and understanding multivariate analysis: American Psychological Association Books.

In: Progress in Education, Volume 17 Editor: Robert V. Nata

ISBN 978-1-60692-505-8 © 2009 Nova Science Publishers, Inc.

Chapter 8

AT-RISK PRESCHOOLERS BECOME BEGINNING READERS WITH NEUROLOGICALLY INTEGRATED ALPHABET INSTRUCTION Donita Massengill Shaw1,* and Mary Lou Sundberg2,+ 1

University of Kansas, Department of Curriculum & Teaching , 449 J. R. Pearson Hall, 1122 West Campus Road, Lawrence, Kansas 66045, USA 2 Sunform Alphabet Systems, P. O. Box 0523, Lake Bluff, Illinois 60044-0523, USA

ABSTRACT The purpose of this study was to determine the effectiveness of a neurologically integrated approach in teaching 22 at-risk preschoolers their letter sounds by comparing the results to preschoolers who received traditional ball-and-stick letter-naming. Three sequential phases to teaching the experimental method include imagery, auditory, and integration and sound blending. Students received pre-, mid- and post-tests for sound recall and word blending. Analysis of covariance and descriptive statistics measured growth. Results indicate that significant changes occurred in the experimental students’ knowledge of letter sounds and word blending compared to students who received the traditional approach. Reasons for their superior performance are mentioned. It is recommended to explicitly teach at-risk children their alphabet knowledge through a neurologically integrated approach that mirrors brain development.

* +

Contact information: (785) 864-9671; [email protected] Contact information: 1-800-667-3676; [email protected]

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INTRODUCTION Preschool. During these formative years, young children begin to emulate adults by “pretend reading” as they learn about the world of print. Emergent readers begin to recognize letters and understand words are made of sounds; alphabet knowledge is a fundamental skill. In the last decade, we have come to better understand the importance of literacy experiences in preschool (Raban & Ure, 1999). Preschool programs may produce positive effects and lead to stronger academic growth, especially for children who come from at-risk homes where language and literacy may not be prevalent (Conyers, Reynolds, & Ou, 2003; Reynolds, Temple, Robertson, & Mann, 2003; Snow, Burns & Griffin, 1998). Short-term and long-term benefits have been documented as a result of preschool interventions (Burchinal, PeisnerFeinberg, Pianta, & Howes, 2002; Durlak, 2003; Morrison, Bachman, & Connor, 2005). Alphabet skills learned in these early years are so important for life success, and yet many children struggle to break the code. In her attempts to help these students, the second author of this chapter developed an alphabet approach. The results of this approach have produced phenomenal alphabet gains for first graders (author, 2007; author in press). Because the neurologically and developmentally appropriate method appeals to developing brains, we wondered if preschoolers could benefit from early intervention. Therefore the purpose of this chapter is to compare the aforementioned innovative alphabet approach with a traditional ball-and-stick letter-naming phonics curriculum on the performance of 4 year-old at-risk children in an inner city preschool.

THEORETICAL FRAMEWORK To meet the goals of this study, it is of value to understand the research on alphabet knowledge and at-risk preschool learners. Information about this neurological approach is also presented.

Alphabet Knowledge Children need to understand that words are made of sounds. The broad term for this understanding is phonological awareness, which is the consciousness of sounds within words (Blachman, 2000). It is an auditory understanding and not directly tied to print. Research shows that phoneme awareness remains a strong predictor of reading ability and that children who lack in this phonemic awareness remain poor readers (Blachman, 1984; Hoien, Lundberg, Stanovich, & Bjaalid, 1995; Wagner, Torgesen, Rashotte, Hecht, Barker, Burgess, Donahue & Garon, 1997). Furthermore, research suggests that phonemic awareness is more effective when the phoneme (sound) and the grapheme (letter) are combined in instruction (Ball & Blachman, 1991; Bradley & Bryant, 1985; Ehri & Wilce, 1987). This phonemegrapheme correspondence is phonics; understanding the sound-symbol association is necessary for literacy processes. Foy and Mann (2006) discovered that rudimentary levels of phonological awareness helped children learn letter-sound associations. More explicit

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phonological awareness was bi-directionally linked with letter-sound and letter-name knowledge. Research has documented that letter-sound knowledge is critical for decoding and recognizing words; children who struggle to learn letter-sound knowledge will often be delayed in their overall reading ability (Duncan & Seymour, 2000). Further, “letter-sound knowledge may ultimately be a better predictor of subsequent reading-related skills than is letter naming” (McBride & Chang, 1999, p. 7). This may be in part because letter-sound knowledge is similar to phonological awareness. Learning symbols (graphemes) is fundamental to skilled reading and writing. Yet, for beginning readers and writers, there is a lot to learn about letters; letters have names, sounds and shapes and the three are not logically connected. For example, the letter name for “c” is pronounced “see,” its pure phoneme should be correctly pronounced /k/ and its shape is an almost-closed “o.” To complicate matters, only eight letters of the alphabet have names from which the sounds can be derived (e.g., b, d, j, p, t, k, v, z) and numerous letter names are similar. For instance, b, e, p, d, t, c, g, v, and z all have the “ee” as the final sound in their name. Additionally, several letter names begin with a short /e/ sound (e.g., f, m, n). Many letters make more than one sound (e.g. “c”) depending on surrounding letters. When learning a letter’s shape, there are vertical, horizontal and diagonal intersections and up-down and circular movements to coordinate. Complex alphabet knowledge is best learned through naturalistic, fun, and game-like manner (Delpit, 1988). This claim is further supported by Hannaford (1995) who asserts that by age five, children’s logical hemisphere of their brain has not matured sufficiently for them to learn their letters through a linear, logical process with few mnemonic images. As children grow, their brain and body develop in a certain sequence. The gestalt hemisphere usually has a dendrite growth spurt between ages four and seven, whereas the logical hemisphere typically grows rapidly between seven and nine years of age. Therefore, young children who have been taught to learn their numbers and letters in a linear, logical fashion with few images may experience high levels of stress. Logical instruction defies natural development of brain functions and children have to work very hard at learning alphabet knowledge. Children need to learn letters through association, image, emotion and spontaneous movement. Bear, Invernizzi, Templeton & Johnston (2004) stated that children should learn through “active exploration of the relationships between letter names, the sounds of the letter names, their visual characteristics, and the motor movement involved in their formation” (p. 107). Adams (1990) recommended that children learn the visual shapes of individual letters through a keyword/picture display before learning the sounds of the letters.

At-Risk Preschool Learners One factor that may create conditions less than ideal for learning literacy is poverty (Allington, 1991). Duncan and Seymour (2000) found low socio-economic status (SES) to be associated with students’ ability to learn letter sounds and their ability to decode and recognize words. Dodd & Carr (2003) discovered that SES played a significant role in children’s performance on letter-sound recognition, recall and reproduction. Age and gender were not key factors in their research. A study completed by Molfese, Modglin, Beswick, Neamon, Berg, Berg, & Molnar (2006) evaluated the skills of 57 four-year old low-income children who attended a pre-

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kindergarten program. A number of tests were administered in the fall (October-November) and spring (April-May). These included general cognitive measures, phonological awareness assessments, environmental print tests and early reading measures. Surprisingly, half of the students showed little or no growth in letter identification despite instruction. For the students who learned approximately 7 letters, their letter identification scores correlated with their phonological processing, ability to detect rhyme, and knowledge of environmental print. It has been found that at-risk children require more instructional time (Hanson & Farrell, 1995) and often need to receive letter-sound instruction that is longer in duration and more explicit and more intense (Blachman, 2000). Molfese et al., (2006) discovered that young children who possess less cognitive ability are at greater risk for making little or no gains in letter knowledge skill, possess less awareness of environmental print, and experience less mastery of reading. These children may need “special instructional attention by preschool teachers to receive more explicit instruction in these skill areas” (p. 302). Foster (2004) conducted a study in which he determined that students’ reading performance was linked to the number of risk factors in students’ lives. Foster recommended that schools may need to reevaluate their instructional methods and identify research-proven approaches. If students are not mastering the concepts and skills through the established approaches, schools should make changes in their methods of instruction, even if they differ significantly from previous methods. DeBaryshe & Gorecki (2007) evaluated the effectiveness of preschool emergent literacy enrichment curriculum. They worked with three Head Start Centers. One center used the traditional Head Start curriculum. Another center supplemented students’ learning with experimental math and the third center provided enrichment in experimental reading. Those in the literacy environment showed greater gains in phonemic awareness and writing. No group differences were found on expressive vocabulary. These results convey the importance of curriculum for early literacy programs. Connor, Morrison, and Slominski (2006) investigated the experiences provided to preschoolers and how they contribute to young children’s skill and language development. There were 156 preschoolers (approximately 38% of total enrollment) who were tested in the fall and spring on alphabet, letter-word recognition, and vocabulary. Twenty-five teachers completed questionnaires and received observations. Substantial variability was found in the amount and types of language and activities that occurred in the classroom. Connor, Morrison and Slominski discovered the more time spent in code-related activities (e.g. rhyming, writing letters) the greater alphabet and letter-word recognition. Students who received more meaning-focused activities such as book reading and play showed more vocabulary growth.

A New Integrated Alphabet Approach This integrated alphabet approach is a practical, instructional methodology that simultaneously teaches phonemic awareness, letter sounds and letter formations. It was created on the principles of developmental and neurological mechanisms of learning in young children (Dennison & Dennison, 1989; Hannaford, 1995). Rather than teach skills in isolation, the integrated alphabet approach serves as an intersensory feedback system that triggers visual/auditory/motor responses and integrates them into reading, writing, and

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spelling. This methodology utilizes carefully selected visual images in conjunction with precisely crafted stories as a springboard to transform abstract symbols into meaningful letters which elicit specific consonant and short vowel sounds and integrated hand movements for writing. The methodology goes a step beyond multisensory learning (the actions of seeing, saying, and doing) to a term that can be coined intersensory. This intersensory learning is taught in four phases. First, imagery is used to introduce students to a mnemonic symbol that represents both a sound and a letter. This means that the object’s beginning sound and its shape are identical to the letter sound and letter shape, respectively. During the second phase, students learn the correct phoneme for each picture. Third, students join together the abstract letter with the sound to make a sound-symbol correspondence, followed by blending sounds into words. During the fourth phase, students are subsequently taught how to integrate the written elements. Through these phases, visual-auditory-motor learning works together. The new alphabet system does not isolate the phases, so phonics and handwriting cannot be separated. This integration of learning takes the new alphabet system beyond the multisensory to make it intersensory. The principle of multifaceted learning exposure is applied to each letter of the alphabet. Each letter of the alphabet has its own device, which is comprised of stationary and movable parts; notched cardboard and acetate slide back and forth, left and right. How and when these parts are moved determines how the information is disseminated during the four phases. This alphabet concentrates on the pure phoneme associated with consonants and the short vowels, which typically are the most difficult for children to master. Therefore, the twenty-six letter set is essential and complete for students to learn beginning reading/writing/spelling skills.

Purpose The new integrated approach was designed to teach children alphabet knowledge based on their developmental and neurological needs. The teaching of phonemes, graphemes and motor movement has been integrated into one approach. It was developed to assist all students, including those at-risk, in gaining alphabet skills to avoid their falling behind in their academic achievement. Previous research has documented the method’s effectiveness (author, 2007; author, in press). Because struggling readers need more explicit and intense instruction (Blachman, 2000; Molfese, et al. 2006) and schools may need to evaluate their methods of instruction (Foster, 2004) we have chosen to use this approach in an at-risk preschool center during children’s foundational years. The traditional method of ball-andstick letter-naming instruction was taught in one classroom. The second classroom implemented the innovative and integrated alphabet method. Therefore, the purpose of this study was to determine the effectiveness of this neurologically integrated approach in teaching at-risk preschoolers their letter sounds by comparing the results to children who received the traditional approach.

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METHODOLOGY Participants Four-year old students in an inner city preschool were assigned to two classrooms. The control classroom had 22 students enrolled in a full-day preschool. The experimental classroom had 22 students in a half-day preschool. The learner population was comprised of African American students who came from economically disadvantaged homes. Each classroom had one head teacher and one aide. The head teacher in the traditional classroom had used a ball-and-stick letter recognition/letter-naming method for many years. The head teacher in the experimental classroom was trained in the integrated method before school started.

ASSESSMENT PROCEDURES Students were individually tested three times during the year: pretested in September, tested mid-year in February and post-tested in May. The procedures for pre-, mid- and posttesting were identical and included assessment of sounds and words. An outside assessor, the second author of this paper, conducted all the assessments for reliability purposes. To evaluate sound knowledge, the trained tester held a card with one letter on it and asked the child to tell her the sound, not the letter name. The child’s response (whether correct or incorrect) was documented for all 26 letters of the alphabet. Next, the tester had an 8 ½ x 11 paper with 12 words: cat, zip, hum, van, jug, fox, web, lid, red, yell, sock, quit. The assessor pointed to one word and asked the student to read it. After a child missed three words in a row, assessment ceased.

INSTRUCTIONAL MATERIALS AND PROCEDURES Experimental Twenty-six individual devices, or cards with overlays, were used to disseminate the information of the twenty-six letters of the alphabet. Each teaching tool had a picture that began with the sound of that letter. Color illustrations were used to verify the visualized image created by the visual clues and mnemonically assist students in learning the name of the picture and the letter’s sound. These visual images, combined with stories, worked in conjunction with directional arrows. The image and arrows supported students in properly forming the letters by emphasizing the need for the student to start at a specific point and cross the midline. The visual devices that included visual clues, color illustrations and directional arrows stimulated sound recall and letter formation. For this study, three of the four sequential phases were taught: imagery, auditory, and integration and sound blending. In the first phase, students were introduced through imagery to a symbol that represented both a sound and a letter. This meant that the object’s beginning

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sound and its shape was identical to the letter sound and letter shape, respectively. During the second phase, students learned the correct phoneme for each picture. Third, students joined together the abstract letter with the sound and began to sound blend. The multifaceted learning was applied to each letter of the alphabet. Following is an example with the letter “c.” First, students are introduced to an abstract symbol representing a picture which stimulates imagination. This quick phase teaches all 26 pictures in approximately ten 20-minute sessions. The teacher presents the picture with a brief story or description (emphasizing alliteration), followed by the teacher simultaneously tracing the letter (picture) to prepare students for the motor plan (fourth phase). The students are introduced to the imagery of a symbol that represents both a sound and a letter. This means that the object’s beginning sound and its shape are identical to the letter sound and letter shape, respectively. For example, letter “c” shows a picture of a cat, the contour of its face with an open jaw grabbing at the mouse. The cat’s face represents letter “c,” and the students learn that “c” is “cat catching.” During the second phase, students learn the correct phoneme for each picture. This phase usually takes approximately ten to fifteen 20-minute sessions. Once the students know all the picture names, they then segment and learn to produce the correct sound (or pure phoneme) for the initial consonants and short vowels. They learn that the initial sound of cat says /k/ and when they see the image of the cat catching, they pronounce the pure phoneme /k/. Third, is the integration phase which usually is learned in two or three 20-minute sessions. Students join together the abstract letter with the sound to make a sound-symbol correspondence. The picture of the cat is removed and the students must learn the abstract symbol “c” is a picture of a cat and says /k/. After learning several letters/sounds, students are able to blend them together into words.

Control The teacher in the control classroom had been teaching preschool for a number of years. She always taught students to learn the name of the letter and the sound of the letter simultaneously. A traditional ball-and-stick manuscript was used in instruction and supported by visuals such as the letter chart. The teacher used creative games and songs to teach the letters of the alphabet. Earobics was the supplemental program used. Earobics is a research-proven program. Ninety-seven percent of students who receive the instruction achieve significant improvements in reading (Earobics, 2007). Earobics website states it is the most validated and quantifiable reading intervention program. The approach combines research-based strategies, engaging technology and multi-media. It claims be multisensory and uses music, audiocassettes, videotapes, and talking CDs that keep students engaged. Picture word cards and letter-sound cards combined with little books, big books and leveled readers offer beginning readers a variety of tools. Overall, Earobics is a comprehensive reading program that teaches all critical areas outlined by the National Reading Panel (Earobics, 2007).

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Data Analysis We used quantitative methods to analyze data. We knew we had a quasi-experimental sample so we chose to run independent samples t-tests to determine there were no group differences for sounds (M = .80, .00) and words (M = .00, .00) control and experimental respectively. Thereafter we conducted analysis of covariance. For the ANCOVA, the posttest was the dependent variable (the same for both groups), the pre-test was the covariate and the method was the independent variable (variable that could be manipulated). We ran ANCOVA for the total number of sounds correctly produced, and then we also conducted an ANCOVA for the number of words read correctly. We also ran descriptive statistics to show the means across both control and experimental groups for total sounds correctly produced and total number of words read correctly.

RESULTS The purpose of this study was to analyze the effectiveness of an integrated alphabet approach in teaching at-risk preschool students their letter sounds and assist them in reading words.

LETTER SOUNDS We used analysis of covariance to determine if there was an improvement in students’ ability to correctly produce sounds for each letter of the alphabet over time, and if there was a change, whether the groups differed in how much their sound production had improved from pre to post-tests. Overall, across the two groups (control and experimental) taken together, there was a significant change in sound production ability during the course of the intervention, F (1, 31) = 12.61, p =.00. The interaction effect testing whether the groups differed in how much they improved over time based on the approach was also significant, F (1, 31) = 140.94, p = .00. Descriptive statistics show pre-test sound scores for the control group (M = .80; SD = 1.61), and the experimental group (M = .00; SD = .00). The post-test revealed an increase for both the control (M = 9.44; SD = 5.13) and experimental (M = 23.79; SD = 2.46) groups. Figure 1 illustrates the mean scores for the number of correctly produced sounds (post-test) for the two groups.

Blending Sounds into Words We used analysis of covariance to determine if there was an improvement in students’ ability to blend sounds into words over time, and if there was a change, whether the groups differed in how much their reading had improved from pre to post-tests. Overall, across the two groups (control and experimental) taken together, there was not a significant change in

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reading ability during the course of the intervention, F (1, 29) = .17, p =.68. The interaction effect testing whether the groups differed in how much they improved over time based on the approach was significant, F (1, 29) = 5.89, p = .02.

Number of sounds learned

Sounds 25 20 15 10 5 0 control

experimental Method

Figure 1. Post-test results for sounds

Descriptive statistics show pre-test word reading scores for the control group (M = .05; SD = .22), and the experimental group (M = .00; SD = .00). The post-test revealed an increase for both the control (M = .44; SD = .98) and experimental (M = 1.67; SD = 1.78) groups. Figure 2 illustrates the mean scores on the number of words read (post-test) for the two groups.

Number of blended words

Words 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 control

experimental Method

Figure 2. Post-test results for words

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CONCLUSION This study was a school year intervention posed to help at-risk preschoolers prepare for kindergarten by providing them with direct instruction in sound knowledge and word reading. A number of studies have shown that low socioeconomic status affects students’ performance on learning the alphabet (Dodd & Carr, 2003; Duncan & Seymour, 2000; Molfese et al., 2006). Children who come from disadvantaged homes have experienced less exposure to print and possess weaker alphabet knowledge (Bear, Invernizzi, Templeton, & Johnston, 2004). Despite the external factors that make learning more challenging, the students who received the experimental teaching method showed positive gains in their letter-sound knowledge and reading ability. Preceding studies have documented preschoolers from low-SES families learn, on average, 29% (Bowey, 1995) to 38% (Molfese et al, 2006) of their letter sounds. In this research, students who received the traditional approach learned 36% of their letter sounds, which falls into the averages previously reported. In contrast, the students who received the integrated alphabet approach learned 91.5% of their letters. As educators, we expect all students to mature and learn over time. Yet the positive success rate of students who received the experimental approach is unusual and noteworthy. There are reasons to support why the children who received the integrated alphabet approach outperformed those who received traditional phonics instruction. First, this new integrated alphabet approach attempts to logically connect the letter sound, shape and name by providing a keyword/picture, so the three aspects of learning are not separate or abstract. Young children learn best with pictures and mnemonic hooks (Adams, 1990; Hannaford, 1995). Since most of human’s learning comes through the visual route (Fiske & Taylor, 1984), the curves, colors, size, and lines portrayed in the picture positively affected students’ consciousness of features and visual memory. Learning letters through image improves retention. One possible reason may be the “emotional” connection children have with images. Vail (1996) wrote, “Emotion, the on/off switch for learning, has the power either to open or close pathways, doorways, or windows to learning.” When young children see the pictures rather than an abstract letter, their ability to be emotionally engaged opens the pathway in their brain. Second, the approach strengthens phonemic awareness through alliteration (e.g. the cat catching) and by teaching students the pure phoneme. Children without phonemic awareness cannot develop letter knowledge (Juel, 1996). The integrated approach also combines the phoneme with the grapheme. Although phoneme awareness is auditory and not directly tied to print, research has shown the benefits of bridging the sound-symbol association (Ball & Blachman, 1991; Bradley & Bryant, 1985; Ehri & Wilce, 1987). Juel (1996) says students must unlock the relationship between the sounds of the words and the letters which they read and write. It is the integration of phonemic awareness and letters that assists children in decoding unknown words in text (CIERA, 1998). Third, the approach integrates students’ learning of letter sounds and names so the tasks and processes are not isolated. The ability to recognize letters has been a strong predictor of reading success (Bowers, Sunseth, & Golden, 1999; Bramlett, Rowell, & Mandenberg, 2000). McBride-Chang (1999) found differences between letter-naming and letter-sound knowledge. The association of letter names/sounds is not a simple one. McBride-Chang wrote both were

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“developing in substantially overlapping though different ways” (p. 9) and contribute unique variance to reading-related skills. The integrated alphabet approach used in this study teaches students first to recognize letters through imagery. Then sounds and motor movements are emphasized before teaching students the name of the letter. This sequence of instruction is developmentally appropriate (Hannaford, 1995). Fourth, the approach explicitly teaches the alphabet through four phases. Direct instruction of alphabet knowledge has been found to be essential (Blachman, 2000; DeBaryshe & Gorecki, 2007; Hanson & Farrell, 1995; Molfese et al. 2006). Snow, Burns and Griffin (1998) said that reading failure may be prevented by providing explicit instruction in letters and their sounds. The explicitness of each phase as previously outlined truly contributes to the success of students. Fifth, the approach is systematic in building connections. Each phase builds on the previous one and all the skills (phonemic awareness, decoding, handwriting) are intertwined in a deliberate and accessible manner. The integrated method teaches the letters based on their motor plan. Rather than starting traditionally with A and finishing instruction with Z, students learn letters that are related such as c, o, a, d. Learning is all about making connections. Every encounter with something new requires the brain to connect it to an existing memory category of networked neurons. The neurons make the brain a thinking and learning organ. Learning is functional when the brain can link new material to other associations (Jensen, 2005). Teaching to the human brain is based on a real understanding of how the brain works. It elevates teaching into a challenging field (Caine & Caine, 1994). We recognize this study targeted a small group of students in an inner-city preschool. The sample size prevents the findings to be generalized to all preschool populations. We also note that follow-up reading assessments of the students as they progressed through kindergarten and first grade are not included in this study. There are several possibilities for future research. It would be worthwhile to conduct a similar study in a number of preschool classrooms to increase sample size and determine findings based on multiple populations of learners. Nationally recognized phonemic awareness assessments could be used to determine the amount of growth and whether it is significant. Ideally, conducting a long-term study, following the students through grade three or four, would provide information about the longterm effects on students’ literacy development. In sum, it was the goal of this new integrated approach to provide preschoolers with meaningful, as well as developmentally and neurologically appropriate methods to learn their alphabet. At-risk students who received this intervention were able to master alphabet knowledge in a relatively short amount of time. The new alphabet approach assists students in their memory retrieval by providing a picture for each sound. Further, it is an intersensory approach that integrates visual/auditory/motor responses. In conclusion, this study supports previous research showing the link between letter sound and blending; this knowledge is the foundation for reading and writing.

REFERENCES Adams, M. J. (1990). Beginning to read, thinking and learning about print. Cambridge, MA: MIT Press.

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Dodd, B., & Carr, A. (2003). Young children’s letter-sound knowledge. Language Speech, and Hearing Services in Schools, 34 (2), 128-137. Duncan, L. G., & Seymour, P. H. K. (2000). Socio-economic differences in foundation-level literacy. British Journal of Psychology, 91, 145-166. Durlak, J. A. (2003). The long-term impact of preschool prevention programs: A commentary. Prevention and treatment, 6, 32. Earobics. Retrieved from www.earobics.com October 17, 2007. Ehri, L. C. & Wilce, L. (1987). The influence of spellings on speech: Are alveolar flaps /d/ or /t/? In D. Yaden & S. Templeton (Eds.), Metalinguistic awareness and beginning literacy: Conceptualizing what it means to read and write (pp. 101-114). Portsmouth, NH: Heinemann. Fiske, S. T., & Taylor, S. E. (1984). Social cognition. Reading, MA: Addison-Wesley. Foster, W. A. (2004). No child left behind: Group at-risk composition and reading achievement. The Journal of At-Risk Issues, 10 (1), 1-6. Foy, J. G. & Mann, V. (2006). Changes in letter sound knowledge are associated with development of phonological awareness in pre-school children. Journal of Research in Reading, 29 (2), 143-161. Hannaford, C. (1995). Smart moves. Arlington, VA: Great Ocean Publishers. Hanson, R. A., & Farrell, D. (1995). The long-term effects on high school seniors of learning to read in kindergarten. Reading Research Quarterly, 30, 908-933. Hoien, T., Lundberg, I., Stanovich, K. E., & Bjaalid, I. (1995). Components of phonological awareness. Reading and Writing: An Interdisciplinary Journal, 7, 171-188. Jensen, E. (2005). Teaching with the brain in mind. Alexandria, VA: Association for Supervision & Curriculum. Juel, C. (1996). Phonemic awareness: What is it? The Leadership Letters: Issues and Trends in Reading and Language Arts. Silver Burdett & Ginn. McBride-Chang, C. (1999). The ABCs of the ABCs: The development of letter-name and letter-sound knowledge. Merrill-Palmer Quarterly, 45 (2), 285-308. Molfese, V. J., Modglin, A. A., Beswick, J. L., Neamon, J. D., Berg, S. A., Berg, C. J., & Molnar, A. (2006). Letter knowledge, phonological processing, and print knowledge: skill development in nonreading preschool children. Journal of Learning Disabilities, 39 (4), 296-305. Morrison, F. J., Bachman, H. J., & Connor, C. M. (2005). Improving literacy in America: Guidelines from research. New Haven, CT: Yale University Press. Raban, B. & Ure, C. (1999). Literacy in the preschool. ERIC Document ED 445 317. Retrieved from www.sofweb.vic.edu.au/eys/pdf/rescres.pdf August 20, 2007. Reynolds, A. J., Temple, J.A., Robertson, D. L., & Mann, E. A. (2003). Age 21 cost-benefit analysis of the Title 1 Chicago child-parent centers. Educational Evaluation and Policy Analysis, 24, 267-303. Snow, C. E., Burns, M. S., & Griffin, P. (Eds.). (1998). Preventing reading difficulties in young children. Washington, D. C.: National Academy Press. Vail, P. L. (1996). “Words fail me:” How language works and what happens when it doesn’t. Upper Saddle River, NJ: Modern Learning Press. Wagner, R. K., Torgesen, J. K., Rashotte, C. A., Hecht, S. A., Barker, T. A., Burgess, S. R., Donahue, J., & Garon, T. (1997). Changing relations between phonological processing

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In: Progress in Education, Volume 17 Editor: Robert V. Nata

ISBN 978-1-60692-505-8 © 2009 Nova Science Publishers, Inc.

Chapter 9

LEARNING FROM DIFFERENCES. THE MASTERS STUDY-COURSE IN EDUCATIONAL MANAGEMENT AT LUDWIGSBURG PEDAGOGICAL UNIVERSITY Ulrich Müller* Pedagogical University of Ludwigsburg, Faculty of Educational and Social Sciences, Institute of Educational Management Postfach 220, D-71602 Ludwigsburg, Germany

ABSTRACT New challenges in the education sector require competent leadership of educational institutions as well as professional personnel management and development. Since the winter semester 03/04 the Pedagogical University of Ludwigsburg has been offering a further-training Masters course in education management which qualifies participants for managerial functions in the education sector. In the study-course attention is focused on the acquisition of holistic and general managerial competence through self-guided, interactive and process-oriented learning, closely adapted to individual professional requirements in daily practice and the occupational biography of the participants. A special feature of the project: Participants come from three distinct walks of educational life: school, adult and further education, and from business companies: "Learning from the differences". This paper reports on the background to the project and describes the curricular and methodological architecture of the study course.

* E-Mail: [email protected] Internet: www.bildungsmanagement.ph-ludwigsburg.de

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1. INTRODUCTION: EDUCATION MANAGEMENT IN A CHANGING WORLD Great changes like the globalization of the economy, introduction of new technologies or the permanent transformation of our ways of life and business into a form with a future perspective present the political actors, business companies and organizations, and also the individual with great challenges. In order to meet these challenging new tasks considerable efforts must be made to bring about basic changes in orientation. Life-long learning is in demand. Educational institutions ranging from schools via adult education to further in-service training within companies must meet these new demands. It is essential to transform our educational institutions from "learning factories" into varied and inspiring "learning landscapes". Traditional forms of learning, and conventional concepts and methods are inadequate. In order to awaken and tap the whole potential of human learning, a new learning culture is necessary, which

• enables interactive and personality-forming types of learning to take place • utilizes innovative and creative learning techniques • exploits and integrates a whole variety of learning venues: i.e. in addition to the • •

"classical" seminar and lecture rooms, also the workplace, museums, libraries and virtual learning spaces, for example, supports and furthers self-organized learning utilizes the manifold potential of new media, but without ignoring their limitations

In educational institutions, a bureaucratic-style administration is no longer adequate to the task of setting the necessary reforms in motion: a modern form of management is needed which is both visionary and effective. This is all the more the case inasmuch as generous financial support and funding is not often available for new tasks and functions. It is rather those responsible for educational institutions who have to deal alone with changes in basic conditions of operation, getting by as best they can – and that means, as a rule, on slim budgets.

2. DESCRIPTION OF THE PROJECT 2.1. Study organization and curricular conception Goals The Masters Study course in education management is intended for executive and junior managerial staff in the education sector. It aims to convey and train the general skills and knowledge necessary to fulfil managerial and executive functions. (See, on the following, Schweizer/Melenk/Rath/Unseld 2002). Professional competence comprises sub-competences in the social, personnel, technical and methodological fields. To carry out managerial functions successfully, it is not sufficient simply to have comprehensive knowledge (for instance, of communication processes) at one’s

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disposal. It is necessary in addition to be able to put this knowledge into practice in appropriate situations requiring interaction, e.g. in conversation and dialogue with other staff .The study course expressly aims to account for these communicative dimensions. It is located in the space between the theoretical standards expected of an academic course, on the one hand, and the demands of practice-relevant transferable learning on the other, which among other things also requires intensive training of practical competences in dialogue training.

Learning from Differences The project is particularly characterized by the fact that three practical areas are addressed and accounted for within the course-range on offer: adult education, school education, and company training. Under the motto "learning from differences" the course brings teachers, adult education instructors and those responsible for company training schemes together. Varied professional qualifications and biographies mean that participants bring with them into the course elements from cultural backgrounds of completely diverse systems. In this way training and management topics can be approached in an authentic manner from the holistic perspective of life-long learning on the basis of broad and genuine experience and education. This requires that both students and teachers display a high degree of willingness to deal with differences constructively and see them as an opportunity to expand their own horizons. The willingness and ability to co-operate on an interdisciplinary basis is also one of the central goals of the course. And it can only be achieved through the heterogeneous composition of participant groups. Study Organization and methodological Architecture The course is designed on a part-time work-tandem basis, and intended to cater for working participants from the whole of Germany and beyond. In order to do justice to the individual personal and professional situations of the participants, as well as take account of the high-grade content and learning objectives of the course, a blended learning conception was developed, combining and integrating various study-forms and media, such as face-toface seminars, correspondence study-packages, and e-learning (cf. in the following Scheizer/Rath/Melenk/Unseld 2002, Müller 2003 and 2004, Iberer/Müller/Wippermann 2006). Three face-to-face phases per semester take place in the form of compact seminars lasting two, three and six days respectively. Between these seminar phases are self-learning and transfer phases. During these periods course participants acquire new knowledge in preparation for the next topic field, they reflect on their daily professional life, test the transferability of course contents in relation to their own fields of educational or management practice, and work on problems and tasks concerning the interrelationship of theory and practice. They maintain contact to each other and to their instructors via the learning-port of the course. Correspondence materials and e-learning (see below) help them to prepare seminar phases and deal with post-seminar assignments. "Seminar phases are thus relieved of the burden of having to convey knowledge in lecture-form and can address themselves to task which only they can perform: the development of personal and social skills, the construction of a group dynamic, the employment and testing of individual capacities in team-oriented tasks" (Schweizer 2002, p.247). The self-learning and transfer phases, as the following

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illustration shows, constitute a bridge, as it were, between the professional practice of the participants and the study-course. All participants are employed in educational institutions or departments. This occupational process is the basis and starting-point of the learning process and is thus one of the most important resources of the course. The illustration following gives an overview of the didactic and methodological architecture:

Figure 1: The didactic-methodological architecture (Müller 2006)

Project structure The course is designed and carried out by an association of organizations. Under the aegis of Ludwigsburg pedagogical University, the following institutions are involved: the Baden-Württemberg Managerial Academy, the Baden-Württemberg Company Education Trust, the Education trust of the Diocese of Rottenburg-Stuttgart, and the University of Hohenheim. In addition there is also a close co-operative tie to the Ministry of Culture and Education of the Federal State of Baden-Württemberg, which is involved via government deputation of teaching and managerial staff in a project group dealing with the course construction. Co-operation by representatives of the project partners in conception and planning, as well as the involvement of teaching staff from the associated organizations, ensures that the course is connected with and relevant to managerial and educational practice in the three fields concerned, i.e. adult education, the private economy and school. The Baden-Württemberg State Trust is sponsoring the development of the study-course on the basis of a project running for five years (State Trust 2005, p.47) Overview of modules Within an encompassing framework of four semesters ten compulsory modules and two optional modules must be studied: [1] [2] [3] [4] [5]

Executive functions and personnel management Managerial competence and personality development Communication and co-operation Organizational development Educational process management

Learning From Differences [6] [7] [8] [9] [10] [11] [12]

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Quality development and maintenance Business studies/managerial functions Basic legal issues Information and communication technologies Project management Optional module Optional module

2.2. Didactic-methodological architecture The main objective of the study course is the conveying and training of general interactive competence for managerial functions. Participants have already acquired technical competence and pedagogical skills in their first degree study courses and/or through their professional experience. A considerable number of participants additionally have managerial experience. One can therefore assume the presence of motivation and result-orientation which is well above-average, which means that participants have high expectations of the course. "Study modules must combine high standards of expectation and a strong relevance to practical application with economic exploitation of limited resources." (Schweizer 2002, p.238). Against this background, a didactic-methodological design was developed to train managerial competence through holistic, interactive and process-oriented learning which is essentially under the individual control of the participants themselves. Course content and teaching and learning methods must provide sufficient free space to enable a highly heterogeneous body of students with high expectations to determine the finer adjustments to their own professional practice and biography themselves.

Figure 2. Selected methods (Müller 2006)

The course utilizes three distinct levels of learning: learning in practice, self-learning and transfer phases, and seminar periods. In the context of the general methodological architecture

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portrayed, a multiplicity of distinct methodological elements is used. A selection of them is described more closely in the following. Within the framework of the education management course, procedural considerations have a double function. On the one hand, of course, there is the conveyance of business management content and objectives, such as budgeting and book-keeping. But in addition to this technical side there is also the function of teaching and learning methodological competence (cf. Selzer 2001). By learning and working within the context of blendedlearning architecture (aspiring) education managers experience a new learning culture in model form related to themselves, and so receive the opportunity of reflecting upon it.

Learning in practice All participants are employed in education institutions or departments. This workprocess is the basis and starting-point of the learning process. Within the course, participants receive a variety of suggestions as to how they can get to grips with task functions and problem issues from their own professional practice. They work on individual learning projects from their own professional practice and use the interaction situations which arise for their own technical and personal development. The objective is to encourage participants to set a selflearning-process in motion by which they can use appropriate strategies and procedures to reflect on their own professional practice. By relating these to conditions for their own personal, individual development, they purposefully construct their own learning process. The interactive requirements of daily professional life become the basis of reflection on one’s own activity precepts, procedures and professional attitudes and set a resulting development process in motion accordingly. In the process the acquisition of "external" skills necessary for coping with managerial situations become linked to one’s own personality development. The confrontation with professional tasks provides the opportunity for holistic self-development in both personal and leadership terms. When professional situations requiring action are interpreted and exploited as learning opportunities, this also comprises having to deal with the unplannable, with events and situations that occur spontaneously and unforeseen, ranging from the desirable via the adverse to the massively detrimental. For instance, a critical dialogue with a "difficult colleague", harbouring great conflict potential, is not just "got over with" quickly, just to de-fuse the situation. Importance is attached in the course to viewing such situations as a challenge and coping with them successfully as a contribution to the development of one’s own skills and competence. The key question then is "What can I learn from this situation?" In the sense of personality training, this could for one participant mean developing a more relaxed attitude, an "elastic firmness" in handling situations where there is resistance and adversity, while for someone else it may mean overcoming an inner "harmonyorientation" towards others which is too strong and hampers direct action. In this case an important learning effect is to reach a point where the conflict is not avoided but purposefully sought out and actively solved. This needs practice and training (cf. Müller 2002). Learning diary In these kinds of self-organized learning process, a learning diary can be a source of great support (cf. Alsheimer/Müller 1999, Müller 2004). Students record important experiences, observations, successes and failures, questions, issues and problems, etc. they in effect carry on a dialogue with themselves on important issues which occupy them mentally in the course

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of their daily professional life and learning. The process of writing supports and focuses reflection and thus assists in ordering and comparing experiences, making the subconscious partly conscious - and often has an additionally positive effect in reducing the emotional stress. Diary records constitute a document that makes individual and personal development comprehensible over a longer period of time. Keeping a diary can constitute a general methodological cornerstone, connecting the various levels of learning with one another: it is introduced in the seminar phase and then runs parallel to self-organized learning, internships and projects. In this way important issues addressed first of all by participants alone in their diaries can be taken up during coaching and subjected to more in-depth treatment. The writing process serves digestion of both practical experience and theoretical knowledge. It is therefore here that in a certain way the subjective theories of the students "materialize" themselves and slowly broaden into personal experience and knowledge.

Coaching What is particularly accentuated in the course is the development of personal competences as the basis of successful management. For this reason continuous personal coaching is an integral part of the course, taking place in two of the three seminar phases per semester. The coaching itself is done by professionals. A whole course of students is divided into equal groups of ten participants, who stay together for coaching during the course of at least a year. As the principle of "learning from differences" is also applied to the coaching process, groups are formed in such a way that the three practice fields adult education, company training and school education are accorded roughly equal representation in each group. This provides the opportunity to gain more profound insight into the professional daily life of participants in fields different from one’s own. The cultural differences between these fields display themselves here particularly prominently and make for a fruitful enrichment of mutual learning experience. Coaching provides effective guidance and support on issues arising in the professional practice of the participants. Learning and working experience from the self-learning and transfer phases, as well as from participants´ own working day, can be reflected upon in the group. Support is thus provided for the individual’s development process in a personal and managerial sense. In addition ideas and suggestions are conveyed regarding the application of coaching methods and other coaching elements to students´ own managerial and educational work (cf. also Schweizer 2001). Internship A internship of at least four weeks in length must be completed during the four-semester course. Here also the principle of "learning from the difference" is realized, as the practical is done in a professional field different from one’s own. Participants from school, for instance, must complete their practical in an adult education institution or in a company. Internships abroad are expressly encouraged and supported through the international contact networks of the project partners. Internships abroad can also be done within one’s own professional field. This organized "looking over the garden fence" helps to broaden horizons, build up a network of useful contacts, and find innovative ideas and new solutions for one’s own organization. Participants on internships are supervised by association representatives who also provide support in seeking appropriate positions for internships.

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Projects Project management is an important instrument of effective general management. The course conveys the theoretical background and necessary instrumental techniques in the seminar phases. The application of these is practised and trained in a project that participants carry out during the course, and which they must document. Project work is also supervised in small groups of participants from mixed fields. E-learning Electronic media can take on important functions in learning and teaching processes and provide a variety of fascinating possibilities. However, they cannot replace personal teaching entirely. For this reason the learning architecture of the course integrates elements of personal and media communication in a blended learning concept. The use of learning forms based on electronic components is also made dependent on the requirements of individual participant-orientation. For the more students expectations and needs are met by what the e-learning system provides, the more it can be expected that they will participate in computerized communication and co-operation and give each other assistance and support. The better their individual situativ conditions of learning are taken into account, the more likely it is that they will study successfully using electronic tools. The students on our courses are to a very high level professionally and privately involved, and many already hold managerial positions. With executive target groups especially, particular account must be taken of participants´ relatively limited time budget and other specific professional strictures and challenges (see Reinmann-Rothmeier/Mandel 2001, p.72). Even more than with other target groups, it must be assumed that with business executives and managers

• e-learning is only accepted if the time element is relatively well defined and can be • •

appropriately co-ordinated with professional and family duties; high expectations of content and method are present. This attitude is based largely on the complex demands and the consequent pressure to succeed that these participants are subject to; executives and high-ranking managerial staff tend to be swamped by information of all kinds. They therefore strongly expect to perceive any e-learning elements employed to be of immediate assistance and goal-directed in usefulness.

In the light of these considerations, we see the chances for e-learning less in the workingthrough of set tasks and contents, and rather in communication-oriented, case-based scenarios, and models in which the participants can design learning projects with each other, and bring their own expertise to bear on the process (see on this point the detailed treatment of Iberer/Müller/Wippermann 2006). Thus for example in the module project management every participant works on their own project originating in their own immediate work and function field. For this they use project-management tools made available online in a pool which is gradually expanded. Participants support and advise each other in small groups chaired and guided by one of the lecture staff. Available to every small group via the learning port is their own protected workfield, providing among other things a document store and an exchange forum. In this

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workfield important documents such as the project brief or the project structure plan are stored. The learning port is kept available to participants after completion of their courses as an alumni-port. The community of learning that has developed over the two years of common working and learning changes into a community of practice, intended to be maintained beyond the duration of the study period.

Study packages An important element in connection with the self-learning and transfer phases is the study packages with correspondence materials. Due to the fact that printed texts are easier to read than those on a computer screen, study packs even in the age of hypermedial learning materials have their raison d´être and can take on important didactic functions. The most essential point, however, is that the various learning media involved should be closely linked up to each other in complementary fashion. Function of the study packages in the Masters course in education management is to portray the topics of the individual modules in their systematic contexts and so present an overview of the necessary knowledge (cf. Gloger/Krummenauer 2005). Readers are presented with a mathematical "grid" in which new information can be inserted for ordering purposes. The correspondence materials are intended to stimulate participants to read further on the topic and learn more. Additionally, they can be utilized as works of reference. The planning game Against the background, firstly, of tight budgets, and secondly of increasing financial autonomy of educational institutions from governmental finance administrations, education management is becoming more and more an educational business economy (cf. Decker 1995, p.133 ff). In order to cope with the central pedagogical functions, business management functions such as budgeting and investments must also be fulfilled. Much importance is attached to these factors on the Ludwigsburg course. Knowledge of business administration, e.g. as regards costing and invoicing in the educational sector (cf. Langer/Schweizer 2005), is taught on the one hand via correspondence materials, and on the other hand via a comprehensive computer-based business planning game (cf. Schweizer 2004). The planning game is based on a mathematical market and production model. Working in teams, the participants manage (fictitious) companies in which they take on managerial roles such as financial director, production chief, and so on. The various teams act as competitors in a simulated market. It is precisely the planning game which particularly contributes to the objective of tutoring general managerial competence. For it takes account not only of business administrative but also of social and communicative skills. The methodological design of the game is conceived accordingly. Participants make decisions in their teams under great stress. They are constantly being flooded with information and have to prepare and take decisions together with their fellow team-members. Moderation and visualization procedures are also used. The teams are advised by a coach, who observes the group interaction, chairs communication and operation discussions and gives feedback.

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Case studies The acquisition of managerial competence cannot occur throughout the course in such a sophisticated manner as in the planning game. For this reason another well-known and effective method of interactive learning is employed at other points in the course, i.e. the case study (cf. Gmelch 2001). In case studies participants themselves acquire the knowledge basis for coping with problems. Here too knowledge is acquired in true-to-life contexts in which the measures called for and applied are authentic. Conclusions The course has found a positive echo on the education market. On average there are three applicants per study-place. The project has succeeded in attracting not only the Pedagogical University’s "classical" clientele from the field of school teaching, but also target groups from adult education and company training spheres. On the pilot course in the autumn of 2003, certainly, schoolteachers were numerically the dominant group. Since then, however, (fortunately) numbers of applicants from the other educational fields have gradually redressed the balance. Although there were more teachers from schools on the first course held, numbers from the other fields were already starting to reach parity with them on the second and third courses. Participant composition within the three fields is also very varied. All school-types and form-grades are represented, the most diverse kinds of institution from the field of adult education (evening institutes, education foundations of Catholic and Protestant churches, various other associations and organizations, the Goethe-Institute, and so on), and from the mercantile sector hospitals, large companies, small middle-echelon firms from varied sectors of the economy, corporation consultants, etc. Even if there are applicants and participants from the whole of Germany (and occasionally even from outside the country), the focal catchments’ area is nevertheless Baden-Württemberg. In this respect more efforts must be made to "widen the net". The positive echo on the education market can certainly be traced back to the fact that the Pedagogical University has excellent connections in education circles via its associated partners, i.e. the Managerial Academy, the Baden-Württemberg Company Education Trust, and the Education Trust of the Diocese of Rottenburg-Stuttgart. The University also enjoys a high level of acceptance among individual education practitioners in these institutions. The first student group started their studies in Oct. 2003, receiving their Masters qualification in July 2004. The second and third generations started in autumn 2004 and autumn 2005. There is an internal evaluation system applied during studies to all modules. Additionally there was also a questionnaire survey of the whole course after graduation of the first generation (cf. Krummenauer/Müller 2005). The following summary of the results is based in the main on this data. Further surveys for every course group are planned at 12monthly intervals. If student verdicts, graduate numbers and their success in the labour market are taken as a measure, then the course must be seen as extremely successful. Of the 30 students who took up their studies in 2003, 27 acquired a Masters Degree in the summer of 2005, in other words 90%. The course received the grade of 1.4 in the general assessment. Already during the course 12 participants, 44%, were able to improve their position professionally. The most important factors in the success of the course, according to the participants, were

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• the close connection between the course and the individual’s professional practice • the transferability of tasks during the self-learning and transfer phases in the in• • • • •

course examinations the principle of "learning from differences", which leads to a rich exchange of knowledge and experience between the three professional groups the stimulation to pursue one’s own personality development, especially through coaching the constancy of the learner-groups the intensive personal supervision the learning culture experienced on the course

What turns out to be critical, in the judgement of the students, is the partly rather difficult compatibility of the course with family and job, and also the very reserved levels of support given by employers (45.5% say that they had neither financial nor time-benefit support from their employer). A further positive result is the effect of the projects on the education scene. The close links of the course with professional practice have generated a great many innovative ideas which are realized in practicals and projects and have been partly underpinned theoretically in Master theses. These studies have led to a lot of long-term plans. What is particularly positive is that a considerable number of these plans go beyond the limits of the individual education systems. For instance, a participant from school and a participant from a company initiated an intensive local learning collaboration which in the meantime is firmly institutionalized. The learning port of the first study group is being continued as an "alumni-port", so that documentation of all these projects will continue to be at the disposal of graduates in future, inspiring them to make plans of their own and supporting them in their realization.

4. SUMMARY AND PROGNOSIS In the third year of course work (relating to autumn 2005) a very positive interim result can be noted. Ludwigsburg Pedagogical University, the association of partners and the Baden-Württemberg State Trust have succeeded well in placing the Ludwigsburg course in education management on the education market. The first graduates have assessed the course very positively and are able to use the qualification to advantage on the labour market. The experience gathered so far and the comprehensive evaluation results must be worked into plans for future improvements to the course.

REFERENCES Alsheimer, Martin/Müller, Ulrich (1999): Tagebuch schreiben. In: GdW-Ph, Systemstelle 7.40.20.18 Gmelch, Andreas (2001): Fallmethode. In: In: Schweizer, Gerd/SELzER, Helmut M. (Hg): Methodenkompetenz lehren und lernen. Dettelbach: Röll, S. 113-120

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Gloger, Hannelore/Krummenauer, Astrid (2005): Autorenanleitung für Studienbriefe. Pädagogische Hochschule Ludwigsburg: Institut für Bildungsmanagement (internes Arbeitspapier) Iberer, Ulrich/ Müller, Ulrich/ Wipppermann, Sven (2006): Blended-Learning in der Management-Qualifizierung (in Vorbereitung) Krummenauer, Astrid/Müller, Ulrich (2005): Master-Studiengang Bildungsmanagement. Abschlussevaluation Kurs I. Pädagogische Hochschule Ludwigsburg: Institut für Bildungsmanagement (internes Arbeitspapier) Landesstiftung Baden-Württemberg (2005): Geschäftsbericht 2004. Landesstiftung BadenWürttemberg gGmbH: Stuttgart Langer, Matthias/Schweizer, Gerd (2005): Kosten- und Leistungsrechnung in Bildungsinstitutionen. Pädagogische Hochschule Ludwigsburg: Institut für Bildungsmanagement (Studienbrief) Müller, Ulrich (2002): Selbstbildung als Weg. Berufliches Lernen zwischen westlicher Bildungstheorie und östlicher Kampfkunstphilosophie. In: Schettgen, Peter (Hg.): Heilen statt Hauen! Aikido-Erweiterungen in Therapie und Bildungsarbeit. Augsburg: Ziel, S. 87-100 Müller, Ulrich (2003): Weiterbildung der Weiterbildner. Professionalisierung der beruflichen Weiterbildung durch pädagogische Qualifizierung der Mitarbeiter. (zugl. Habilitationsschrift Universität Eichstätt) Kovac: Hamburg. Müller, Ulrich (2004): Führen lernen. Eine didaktisch-methodische Rahmenkonzeption für handlungs- und transferorientierte Management-Qualifizierung. In: Bender, Walter (u.a.) (Hg.): Lernen und Handeln - Eine Grundfrage der Erwachsenenbildung. Schwalbach/Ts.: Wochenschau, S. 387- 398. Rheinmann-Rothmeier, Gabi (2003): Didaktische Innovation durch Blended Learning. Leitlinien anhand eines Beispiels aus der Hochschule. Bern u.a.: Verlag Hans Huber, S. 27-31. Rheinmann-Rothmeier, Gabi/Mandl, Heinz (2001): Virtuelle Seminare in Hochschule und Weiterbildung. Drei Beispiele aus der Praxis. Bern u.a.: Verlag Hans Huber. Schweizer, Gerd (2001): Coaching. In: Schweizer, Gerd/Selzer, Helmut M. (Hg): Methodenkompetenz lehren und lernen. Dettelbach: Röll, S. 65-70 Schweizer, Gerd/Melenk, Hartmut/RATH; Matthias/Unseld; Georg (2002): Ein Studienkonzept zum Bildungsmanagement. In: MELENK, Hartmut u.a. (Hg.): Perspektiven der Lehrerbildung – das Modell Baden-Württemberg. 40 Jahre Pädagogische Hochschulen. Breisgau: Fillibach, S. 237 – 250. Schweizer, Gerd (2004): Planspielunterlagen. Pädagogische Hochschule Ludwigsburg: Institut für Bildungsmanagement (Studienmaterialien) Selzer, Helmut M. (2001): Methoden steuern Lernprozesse. In: Schweizer, Gerd/Selzer, Helmut M. (Hg): Methodenkompetenz lehren und lernen. Dettelbach: Röll, S. 9-30 This article is translated from Müller, Ulrich (2006): Berufsbegleitende Qualifikation für Führungsaufgaben im Bildungsbereich: Das Projekt Masterstudiengang Bildungsmanagement an der Pädagogischen Hochschule Ludwigsburg. In: Grundlagen der Weiterbildung – Praxishilfen. Loseblattsammlung, Systemstelle 9.20.20.29. Neuwied: Luchterhand.

In: Progress in Education, Volume 17 Editor: Robert V. Nata

ISBN 978-1-60692-505-8 © 2009 Nova Science Publishers, Inc.

Chapter 10

TEACHERS, LEARNERS AND CURRICULUM John Chi-Kin Lee1, Michael Williams2 and Leslie Nai-Kwai Lo1 1

Chinese University of Hong Kong, Hong Kong 2 University of Wales Swansea, UK

INTRODUCTION In a traditional, technical paradigm of school management, schools are often perceived as bureaucracies implementing carefully specified curriculum and instructional procedures to produce standardized products known as students. This paradigm is compatible with a behavioristic view of learning in which both curriculum and instruction are broken down into small, sequential steps dictated by teachers (Darling-Hammond, 1998). Educational reform in the new century calls for a different approach to school improvement in which teachers are encouraged to employ a wide repertoire of teaching strategies in order to enable students to construct their own knowledge. Using this approach, teachers seek to change teacher-proof curricula into bridges between, on the one hand, learners’ diverse conceptions, interests, motivations, learning modes and experiences, and, on the other, their goal of teaching for understanding. Some scholars, including Darling-Hammond (1998), argue that more attention needs to be given to "the development of schools as inquiring, collaborative organizations…to strengthen teacher education and certification processes, to create knowledge-building institutions such as professional development schools, to decentralize school decision-making, to support collegial teacher development, to redesign local assessment practices, and to create learning networks among teachers and schools" (p.646). In a thorough review of the English language literature, Sammons, Hillman and Mortimore (1997) identified eleven key factors for school effectiveness. This was extended by Stoll and Mortimore (1997) who concluded that the following eleven factors are complementary for school effectiveness and school improvement: participatory leadership; shared vision and goals; teamwork; a learning environment; emphasis on teaching and learning; high expectations; positive reinforcement; monitoring and enquiry; pupils’ rights and responsibilities; learning for all; and partnerships and support. These factors, to some 50

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extent, have relevance for teachers, learners and curriculum in the context of school improvement. We have sought to highlight this relevance in Table 4.1. Table 4.1 Complementary factors for school improvement (adapted from Stoll and Mortimore, 1997: 18-19) Factors School improvement (facilitating conditions) (1) Participatory leadership • Headteacher as motivator and guide • Teacher involvement in leadership roles and decision-making • Teachers as change agents (2) Shared vision and goals • Vision building • Use of evolutionary planning process • Working for the whole school’s good (3) Teamwork • Teacher involvement and empowerment • Opportunities for collaboration and collegiality (4) A learning environment • Orderly and secure environment • A positive ethos • A place where ‘risk taking’ is encouraged (5) Emphasis on teaching and learning • A focus central to teachers’ and pupils’ concerns • Varied and appropriate repertoire • Teachers learning and practising new strategies (6) High expectations • High expectations about adults and pupils • Aspirations and success criteria shared (7) Positive reinforcement • Behavior policy maintained and monitored • Celebration • Appreciation and recognition of teachers • Capturing teacher enthusiasm (8) Monitoring and enquiry • Setting, monitoring and evaluating success criteria • Classroom research techniques used by teachers • Ongoing review and necessary adaptation (9) Pupil rights and responsibilities • Involvement of pupils in management of learning • Eliciting pupils’ views (10) Learning for all • Teachers as continuing learners • Coaching and mentoring • Peer observation and feedback • ‘Critical friendships’ (11) Partnerships and support • Schemes to involve parents and community • External support • Developing networks and clusters

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While all school effectiveness factors are significant in providing a framework within which teachers and classroom teaching and learning operate, scholars vary in the importance they attach to each of them. Pollard (2002: 392), for example, suggests that the factors of concentration of teaching and learning, purposeful teaching (Factor 5 in Table 4.1) as well as high expectations (Factor 6) are "most significant for fostering pupils’ learning and progress". MacGilchrist, Myers and Reed (1997) contend that professional high-quality leadership and management (Factor 1), a concentration on teaching and learning (Factor 5) and development of a learning organization (Factor 10) are most conducive to the development of an effective school. In this chapter we explore some of these claims with particular reference to teachers, learners and curriculum.

TEACHERS Teachers in improving and reforming schools are simultaneously reconstructing approaches to both learning and teaching. Apart from the shift from teaching at the center to learning at the center, teachers are making fundamental shifts in the following directions: from managed work to leadership; from technical work to inquiry; from control to accountability; from classroom to whole school focus and from individualism to professional community (Miller, 1998).

Importance of Instructional Leadership in School Improvement According to the meta-analysis findings of Wang and her colleagues (1993), three key ‘proximal’ variables, namely psychological, instructional and home environments, are found to correlate with higher levels of student achievement. The implication is that that while there is a need to engage parents and students as active participants in the school improvement process, there is also a need to expand the teaching and learning repertoires of teachers and students respectively (Hopkins, 2003). Recent studies of school improvement have shown that a substantial proportion of the variation in school effectiveness was related to withinschool differences, particularly at the subject departmental level. Good or effective departments tend to adopt strategies such as reinforcing values regarding high expectations of student achievement, involving students, using external support, taking risk and celebrating and sharing successes to keep the department moving (Harris, 2000; Turner, 2003). Elmore (1995) further argued that a school needs to focus on its organizational conditions, particularly its approach to staff development and planning as well as to the conduct of teaching and learning. This echoes the concept of instructional leadership, which many scholars have addressed (e.g., Dimmock and Lee, 2000; Hallinger and Murphy, 1985; Lee and Dimmock, 1999; Sheppard, 1996). One of the most significant interpretations of instructional leadership by Hallinger and Murphy (1985) focuses on three broad categories: defining the school mission; managing the instructional program; and promoting school climate. In parallel with this interpretation, Hopkins (2003) suggests three domains of instructional leadership: defining the values and purposes of the school; managing the program of teaching and curriculum; and establishing the school as a professional learning

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community. With regard to defining the values and purposes of the school, Hopkins refers to a broader notion of learning. This notion includes not only the progress of students as learners but also the learning of teachers and leaders as well as the organizational learning of the school. For the management of teaching and curriculum programs, the school may refer to a number of well-developed models of both teaching and curriculum that generate promising levels of student learning and facilitate students in their construction of knowledge. It is, however, worthwhile noting that models of teaching are really models of learning and that any specific teaching strategy needs to be fully integrated within a curriculum in order to achieve maximum impact on learning. As regards the establishment of a professional learning community, a school may re-orient its staff development towards providing opportunities for and implementation (collective inquiry).

Teachers Learning To Change Previous research shows that teacher effects seem to dominate school effects in accounting for differences in effectiveness. As the authors of a report of the Centre for Educational Research and Innovation of the Organisation for Economic Co-operation and Development (CERI/OECD, 1998: 23) commented, "It is often repeated that teachers ought to be the leading agents of change, but are instead the main obstacles to it". Later in the same report (p. 24) it is argued, "If teachers are to be empowered to implement reforms, it is necessary to create a supportive climate in their school". A recent study on revisiting after five years effective schools in disadvantaged areas in the UK revealed the importance of staff development as one of the levers of change and improvement. These effective schools were found to pay much attention to the appointment, induction and professional development of teachers (Maden, 2001). Teachers need to change their ways of thinking as well as their pedagogical orientation if they are to satisfy the requirements of curriculum reform. Teachers’ expectations may vary in different societal contexts. For teachers in Chinese societies, the common goal is to provide what they perceive to be ‘high quality’ education for their students. The prevailing definition of high quality education, and therefore the meaning of teachers’ work, is the attainment of high academic standards as demonstrated by students’ achievement in public examinations, reflecting community expectations (Lo, 2003). Any model of teacher change must take contextual factors into consideration. As argued by Lo (2003), empowerment of teachers, which includes both intrinsic and extrinsic power, in Chinese schools should be understood in the context of hierarchy, acquiescence, and conformity. Teachers, for example, tend to maintain surface harmony rather than engage in open dispute. Decisions are made before committees convene. In this context, teachers may find it much more rewarding to invest their time and energy in strengthening their ‘intrinsic power’ which is related more directly to their immediate tasks of teaching. In Chinese societies, teachers rely on student test scores and examination results as concrete proof of their competence and explicit testimony of their efficacy. In contrast, the emphasis in the Western literature on teacher empowerment in terms of ‘extrinsic power’ including status gain, knowledge gain, participation in decision-making for the school community might not be a dominant theme for Chinese teachers. Nonetheless, across different societies, issues of collegiality and further education and training present a web of

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challenges and opportunities for teachers and principals to launch school improvement. This generates the need to develop professional learning communities to which we now turn.

Development of Teams and Professional Learning Communities In many school improvement projects, such as the Coalition for Essential Schools, teams play an important role in two aspects: introducing team teaching as instructional change and enhancing greater collaboration between teachers; and involving teachers in governance and in managing the reform process itself (Friedman, 1997). In the Improving the Quality of Education for All (IQEA) in the UK as well as in the Accelerated Schools Project (ASP) in the USA and Hong Kong the establishment of school-improvement groups or cadres is essential for sustaining school improvement (Hopkins, 2003; Levin, 1996; Lee et al., 2002). In the case of the IQEA, the cadre group members are mainly involved in out-of-school training sessions on capacity-building and teaching and learning, planning meetings in school, consultancy to school working groups, and observation and in-classroom support. Previous research suggested that factors such as conflicts, lack of time, poorly clarified roles and inadequate training might deter a team from focusing on instruction. To overcome these barriers, the California School Leadership Team Professional Development Program in the USA, based on a social constructivist perspective of learning, encourages each team "to engage in a process of inquiry and investigation of its own conditions and establish outcomes within its school and district context" (Chrispeels and Martin, 2002: 334). The team assumes different roles ranging from communicators, staff developers, problem-solvers, and leaders/decision-makers. Another project known as ‘The Mifne’ launched by the Joint Distribution Committee – Israel experimented with the application of a team approach to school practice. The team approach exhibited the following salient features (Friedman, 1997): •

•

•

The team was the primary unit for organizing the teaching task. The team members kept track of each other’s activities and students’ learning progress so that they can communicate and work together to handle students’ problems. The team adopted a very flexible role structure on both the individual and the group levels. They worked together with specialists and experts. In addition to teaching, the team worked on 'product development' and professional support. There was integration between structural and instructional change. The team acted as a semi-autonomous unit that emphasized inquiry of the school’s own practice.

Success in this case study may be related to the empowering leadership style of the principal and/or the school culture before the team approach was introduced. The intrinsic motivation and involvement of teachers were also critical factors for success. A recent study of educational change in Ontario, Canada, highlighted the need for ‘good teamwork’, asserting that a "team without trust rarely succeeds" (Hargreaves, Earl, Moore and Manning, 2001: 194). In addition, the allocation of professional time for teachers to plan, talk about and review the changes they are undertaking should be a higher priority than short in-service training sessions.

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A concept closely related to the team approach is the ‘professional learning community’ and this has attracted much attention in the literature. Definitions of it vary from "a learning community to include the participation of many stakeholders (parents, community members, business people) in the school planning process" to building a learning community to "engage schools and teachers in an active process of knowledge creation and improvement of practice" and "the community of learners working together within a school to determine common vision, set goals and objectives, provide support, monitor progress, and adjust practices based on student and school needs" (Huffman, 2000: 84; Mitchell and Sackney, 1999: 2). Many studies have pointed to the benefits of a professional community, including: a positive effect on staff morale and teacher commitment as well as teacher efficacy (e.g., Bryk and Driscoll, 1988); helping teachers address the uncertainty and risk-taking in non-routine teaching implicit in many school reform initiatives (e.g., Rowan, Raudenbush and Cheng, 1993; Newmann and Associates, 1996); and improving student learning and engagement (Lee and Smith, 1996). A recent study has shown that moderate, positive effects of school-sponsored development on professional community obtain at both the school and individual teacher levels. This suggested that individual teachers benefit from their own participation as well as from the participation of other colleagues. In addition, professional development sponsored by non-school agencies has no statistically significant effect on professional community at either the school or teacher level (Grodsky and Gamoran, 2003). To nurture a professional learning community, it is important to cultivate shared values and vision, promote shared personal or deprivatized practice, encourage reflective dialogue and collective creativity, provide supportive conditions that are conducive to collaboration, shared leadership and student learning. In a study of an elementary school in the USA, it was found that the following factors assisted staff to form communities of learners: strong and shared leadership, responsible decision making, systematic staff development, site-based management, collaboration, and a common focus (Huffman, 2000: 92). In the case of a high school, teachers generally take their subject context to define their work and professional identity. A study by McLaughlin and Talbert (2001) showed that strong and weak teacher communities mediated institutional traditions in teaching in a different manner. In the case of strong professional communities, depending on the culture of practices and collective beliefs, some might enforce traditional methods of teaching that emphasized the transmission of predetermined course material, while others might encourage teacher collaboration to reinvent practice. In the case of weak teacher communities, the prevalence of individual values and beliefs might either encourage individual innovation or enact traditions that do not question their practices and students’ poor performance. Based on their findings, they suggested that leaders may adopt the following measures to foster a teacher learning community: • • •

Recruit good, expert teachers who are strongly committed to the profession and collaboration with colleagues to the school Establish professional community to experiment, to change, to take charge of continually improving their practice Support teacher community and collaboration through retreats, ad hoc assignments to cross-school committees as well as formal and informal channels of communication. Give attention to the promotion of warm social relationships.

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In this context the list of working guidelines produced by the CERI-OECD (1998: 100102) for the professional development of teachers is particularly helpful: (1) The more complex a professional activity becomes, the more policy interventions have to take into account the views of the practitioners and leave space for local adaptation. (2) The closer in time, space and resource an intervention is with respect to actual teaching and learning activities, the more influence it has. (3) Innovations move along the social network of personal acquaintance. (4) Innovations in complex situations cannot be cloned. (5) The challenges of complex situations demand the production of local professional knowledge in situ. (6) Co-operation develops only if it is needed. (7) Innovations of complex professional practices demand a systemic approach.

Learners Silcock (1993) argues that "the key factor in pupil - and hence school - effectiveness is not teaching but pupil learning" (Bottery, 2001: 151). A dominant issue in school improvement is raising the overall levels of achievement for all students and, in particular, under-performing groups. Many studies have shown that ethnic and gender differences in educational achievement needed to be addressed in school improvement. In London, UK, for example, evidence has been collected to show that girls tend to outperform boys at each key stage of schooling. In addition, Caribbean, African and Portuguese pupils appeared to be the main underachieving ethnic groups compared to English/Scottish/Welsh groups (Demie, 2001). The findings also revealed that there was a strong relationship between the stages of fluency in English and the achievement of bilingual students. This suggested that more English language support would be required to overcome the disadvantage of language for the underachieving ethnic groups so as to help them raise their levels of educational achievement. Across the Atlantic, a review (Taylor and Lorimer, 2002/2003) indicated some troubling trends for boys, such as having lower scores in language arts, being more likely to be labeled as learning disabled, having more discipline problems, and having a declining rate of college enrollment. Researchers in England, Australia and the USA have found that using more technology and computer education could help to raise achievement in boys, with fewer discipline problems in the classroom. Other measures include: •

• •

Using multiple literacy strategies such as posting an extensive book list geared toward boys’ interests, and sharing their opinions about books in a forum on the website; integrating teaching of reading with teaching of writing; and providing assignments and reading materials that related to their interests and authentic real-life application. Developing male mentoring relationships Incorporating more action-oriented, physical activities and employing active learning strategies such as role-playing, debates, field trips, and investigations

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Investigating single-gender schools and classes

While recent studies show that girls tend to outperform boys, there is a well-documented decline in girls’ self-esteem during their adolescent years (Jobe, 2002/2003). More importantly, the widening of student achievement gaps with the progress of schooling may be related to factors other than gender and race. These include parenting practices and variations in attitudes towards the school among students. In the US, the term ‘at-risk’ students was coined to refer to those "who have experienced difficulty or, in fact, failure in their careers as learners" and who are "culturally deprived, low income, dropout, alienated, marginal, disenfranchised, impoverished, underprivileged, disadvantaged, learning disabled, low performing, low achieving, remedial, urban, ghetto, language impaired" (Manson and Jefferson, 2001: 9). At-risk students, to a certain extent, imply links between learning difficulties and the complexities of poor socio-economic backgrounds. A long-term study on student achievement in Baltimore, USA, showed that marked summer learning differences in school breaks rather than differences in school-year learning rates accounted for the widening of the gap between poor and middle-class students (Entwisle and Alexander, 1996). Cooper and Associates’ study further revealed "summer remedial programs, typically designed for Title I students [poor and disadvantaged students], have as much effect on achievement as programs with similar goals conducted over the course of an entire year" (Borman, 2002/2003: 52). This argues for the need to provide more opportunities for poor and minority students to extend their learning through the summer months to stop the summer learning slide. Apart from summer school, there are two main strategies for accelerating school-year learning in the USA. The first strategy is the reduction of class size, which has shown positive results in closing the achievement gap for minority students. The other is the adoption of Title I, comprehensive or whole-school models (e.g., Success for All, Comer’s School Development Program, and Accelerated Schools) as well as the federal Comprehensive School Reform Program (Borman, 2002/2003). A well-known model of school improvement is the School Enrichment Model (SEM), which represents a positive orientation to students, teaching, curriculum and schooling (Renzulli and Reis, 1985; Johnson, 2000). The key components of this model include: •

•

•

The Total Talent Portfolio: individual file folders revealing the strengths and interests of each student in the school as well as assessment of student preferences in instructional style, learning environment, thinking style, and expression style. Curriculum Modification Techniques: ‘curriculum compacting’ that refers to the elimination of content which students have mastered; and integrated instructional themes for promoting the interconnection of knowledge and skills. Enrichment Learning and Teaching: using general exploratory experiences and group training activities to be directed towards individual and group investigations of real problems. Students were arranged in co-operative groups known as enrichment clusters to engage in activities timetabled in the regular school day but cutting across grade and ability levels (Renzulli and Purcell, 1995).

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Another framework known as the Working on the Work (WOW) by Schlechty (2002) highlights the importance of student’s authentic engagement in school improvement. To help student engagement, teachers may pay more attention to the following attributes (pp. 116122): •

•

•

•

• • • •

Product focus: students’ tasks and activities are linked in the minds of both teachers and students to performances, products, and exhibitions about which the students care and on which students place a high value. Clear and compelling product standards: students understand and commit themselves to the standards by which their projects, performances, or exhibitions will be evaluated. Protection from adverse consequences for initial failures (a safe environment): success is expected and failure is understood as a necessary part of learning. The fear of harm or harassment from fellow students and demeaning comments from teachers is negligible. Affirmation of performances: parents, siblings, peers, public audiences and younger students are positioned to observe, participate in, and benefit from student performances and their products. Affiliation: students are given opportunities to work with others on products, group performances and exhibitions that they and others judge to be of significance. Choice: Students have considerable choices or numerous options in what they will do and how they will go about doing these things in order to learn. Novelty and variety: the range of tasks, products, and exhibitions is wide and varied, and the technologies that students are encouraged to employ are varied as well. • Authenticity: student tasks and work have meaning and significance in their own lives now and are related to consequences to which they attach importance.

Listening to Student’s Voice for School Improvement Students’ perspectives on schooling are often neglected in school improvement agendas. An extensive study of secondary school students’ perspectives on school improvement identifies the following strategies (Rudduck, Day and Wallace, 1997: 85-86): • • • • • •

giving each year of secondary schooling a distinct identity that offers progress in terms of autonomy and responsibility; creating time for students to make dialogue about learning; making time for teachers to talk individually with students about problems in schoolwork; helping students explore standards for judging quality work in different subjects; starting ‘futures’ counseling in small groups so that students can think about the long-term influence of commitment to learning on their prospects; helping students understand the meaning of ‘working hard’ or ‘working harder’ in different subjects;

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strengthening the procedures and good work practices relating to homework (or ‘extra work’); responding to the problem of ‘catching up’ for students who have missed work; helping students manage the multiple demands of homework, course work, and revision; formalizing opportunities for students to support one another in learning; offering lunch-hour or after-school clinics to help students grasp schoolwork.

In another UK study of pupils’ views, McCall and his colleagues (2001: 76-79) reported that students emphasized the following areas: • • • •

teacher support for learning: having high expectations (but not comparing with others), giving praise and encouragement; relationships with teachers: referring more to discipline and control; pupil empowerment: the feeling of being listened to, playing a part in the life of the school or participating in its planning and decision-making; pupil-pupil relationships: concern for bullying and the bad behavior of the minority that was detrimental to the majority.

Quality educational outcomes are best achieved by enhancing student motivation through participation (For a fuller discussion of motivation issues, see CERI/OECD, 2000). A recent case study of a co-educational comprehensive government high school in Sydney, Australia, found that the curricular dimension, which enhanced student participation, was related to student theorizing. This refers to the phenomenon that students criticized teaching practice, approaches to learning, classroom management and assessment, and the nature of classroom environments. In addition, students put forward their ideas on better practice. On the other hand, the following aspects were found to inhibit student participation (Wilson, 2002): •

•

•

primacy of institutional values: values which tended to be meritocratic; teachers who worried about poor examination results and were hesitant to use active learning approaches and group work; curriculum as the province of the professional: teachers made decisions about curriculum development and there were little choices or opportunities for students to help decide the teaching content or learning experiences; spoonfeeding: teacher practice of providing unmotivated or under-performing students structured, unchallenging repetitive low-level classwork, which deterred students from engaging in critical and creative thought and expression.

CURRICULUM Redesigning Curriculum and Improving Instructional Program Coherence Curriculum in this chapter is taken to mean curriculum and instruction. In redesigning a curriculum for school improvement, it has been suggested that a school should consider

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creating ‘slack conditions’ such as schoolwork extending over twelve months and across eight hours as well as recreational and community-based cultural activities moving to the heart of the day (McDonald, 1999). In the case of the ATLAS Project in the USA, schools have cultivated a pastoral environment in which students care about each other and enjoy more autonomy while the schools are less tolerant of misbehavior. Instructional hours in two schools were reduced with more face-to face contact between teachers and students. In addition, these schools lacked subject departments and instead comprised cross-disciplinary teams. With regard to elements of curriculum design, teaching and learning were emphasized across all dimensions of school life. A school-based accountability system was established to empower students to take control of their own learning progress. Different modes of teaching and learning were offered ranging from domain projects, long-term interdisciplinary projects, problem-based learning, Socratic seminars and cases, cognitive apprenticeships, and courses emphasizing intellectual experiences. Recent studies in the UK have shown that the secondary school curriculum has tended to be undermanaged and underled. Dimmock and Lee (2000: 354) have argued that "strong, robust, rigid, and bureaucratic organizational structures centering on subject departments are deeply entrenched, and in the absence of curriculum leadership from senior administrators, are likely to remain so…The perpetuation of this status quo does not augur well for the successful implementation of the new curriculum in the future". To improve curriculum leadership and management, it is suggested that the issue of connectivity, which refers to "operational interdependence between key players acting in a concerted, consistent, and coherent way for the successful implementation of the new curriculum", needs to be addressed (Dimmock and Lee, 2000: 355). In particular: • • •

•

connectivity can be achieved by curriculum differentiation by level and on the basis of student outcomes; connectivity between teachers can be achieved by working in teams in an ongoing cycle of feedback, support, and evaluation; and connectivity between leadership, management and curriculum can be achieved by providing appropriate organizational structures, allocating necessary human and other resources, building a collaborative culture, working in teams, and building a sense of community; connectivity between curriculum, computer technology, professional development and informed practice needs to be strengthened to support the implementation of the curriculum.

Apart from redesigning curriculum, enhancing the connectivity between curriculum, leadership and organizational structures, there are calls for improving instructional program coherence, which has shown higher gains in student achievement in a study of Chicago elementary schools. Instructional program coherence refers to "a set of interrelated programs for students and staff that are guided by a common framework for curriculum, instruction, assessment, and learning climate and are pursued over a sustained period" (Newmann et al., 2001: 299). In that study, the schools showing higher instructional program coherence revealed a stronger principal leadership that focused on the following areas: establishing the common instructional framework; providing resources such as high-quality curriculum and

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assessment materials; enhancing extensive collaboration among staff; and emphasizing one or a few core school improvement goals. It is advised that schools should invest in efforts to reach consensus on selected, focused learning outcomes, highlight the co-ordination of school improvement endeavors within schools and provide common planning time for staff to allow the sustained implementation of the common instructional framework. In addition, the district or states should make efforts to promulgate standards for curriculum and assessment. In addition to the concepts of connectivity and coherence, Creemers and Reezigt (1996: 215-216) suggest improvement in the quality of instruction through the following criteria: •

• •

•

Consistency: At the school level, conditions for effective instruction related to curricular materials, grouping procedures and teacher behavior are in line with each other. Cohesion: All members of the school team reveal consistency of effectiveness characteristics. Constancy: Effective instruction is maintained between teachers and grades. Consistency and cohesion are promised over longer periods of time. Control: It is related to the evaluation of student achievement and teacher behavior as well as to the maintenance of an orderly and quiet climate. This requires teachers to be responsible for effective instruction.

CONCLUDING REMARKS: OTHER UNRESOLVED ISSUES Apart from the major issues discussed above, there are still unresolved ones relating to teachers, learners and curriculum for school improvement. For example: •

•

•

•

•

How can we address the issue of inequities in teacher quality for poor and minority students in order to reduce the gap in achievement compared with more affluent students? (Haycock, 2002/2003) How can we make use of assessment as one of the most powerful levers for enhancing student learning and bringing about positive curriculum change? (Earl and LeMahieu, 1997) How can we make good use of information and communications technology to facilitate the lifelong learning of both teachers and students and contribute to curriculum renewal? How can we take account of cultural contexts as well as school-based contexts in planning the curriculum as well as engaging teachers and students in an interactive teaching-learning process? How can we involve parents, the tertiary institutions and the government agencies as partners in school improvement? (Lee, 2002; Lee, Lo and Walker, 2004)

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INDEX

A abdominal, 137, 151 abnormalities, 102, 103, 137, 148, 175 Aboriginal, 94, 95, 96, 97, 98, 99, 101, 102, 103 abstinence, vii, 1, 23 academic, 40, 47, 65, 73, 120, 123, 126, 132, 133, 171, 183, 216, 219, 226, 231, 244 academic growth, 216 academic performance, 126, 133, 171 academics, 81, 132 access, 9, 11, 20, 21, 23, 24, 62, 80, 81, 99, 130, 131, 133, 134, 154, 155, 156, 176 accidents, 119, 141 accommodation, 156 accountability, 67, 70, 130, 131, 132, 135, 192, 243, 251, 253 accounting, 188, 198, 244 accreditation, 65 accumulation, 122 accuracy, 118, 127, 145, 199, 204 acetate, 219 achievement, viii, 31, 32, 34, 35, 39, 51, 52, 58, 81, 132, 135, 139, 157, 183, 210, 219, 226, 227, 243, 244, 247, 248, 252, 253, 254 achievement test, 132 Acquired Immune Deficiency Syndrome (AIDS), v, vii, 1, 2, 3, 6, 7, 8, 9, 11, 14, 15, 23, 24, 25, 27, 28, 29, 84, 88, 89, 90, 92, 103, 110 action research, 100, 101 activities, ix, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, 136, 138, 139, 140, 143, 144, 145, 148, 151, 153, 154, 155, 156, 163, 164, 165, 166, 167, 169, 170, 171, 172, 173, 176, 177, 185 activity level, 120, 136, 148, 182 ad hoc, 56, 246

Adams, 217, 224, 225 adaptation, 28, 82, 95, 170, 173, 247

adjustment, 25, 42 administration, 97, 131, 151, 179, 182, 230, 237 administrative, 87, 134, 237 administrators, 134, 251 adolescence, 25 adolescents, 26, 27, 120, 125, 180, 181 adult, x, 2, 16, 33, 34, 35, 38, 40, 43, 71, 118, 151, 159, 161, 182, 229, 230, 231, 232, 235, 238 adult education, 230, 231, 232, 235, 238 adult learning, 71 adult population, 2 adulthood, 88, 126, 161 adults, 24, 33, 40, 41, 45, 59, 95, 117, 144, 159, 179, 216 advertising, 97 advocacy, 129 aerobic, 126, 147, 148, 176, 181 aesthetics, 123 aetiology, 89 Africa, 28, 87, 101, 108, 110 African American, v, vii, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 101, 103, 220 African American women, 2, 5, 7, 13, 19, 21, 22, 23, 24, 25, 26, 28, 29 African Americans, 2, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 18, 20, 23, 24, 25, 26, 27, 28, 29 African-American, 4, 26, 27, 28, 29 afternoon, 99 after-school, 250 age, 2, 6, 11, 23, 25, 29, 41, 47, 118, 121, 122, 124, 127, 130, 133, 135, 139, 140, 144, 147, 148, 149,

256

Index

150, 151, 152, 153, 154, 159, 164, 166, 180, 217, 237 agent, 16, 33, 46, 48, 49, 199 agents, 34, 47, 50, 244 aggressive behavior, 144 aid, 138, 139, 158, 159, 168, 175, 176 air, 168 Alabama, 213 Alberta, 255 alcohol, 14, 20, 22, 95 alcohol consumption, 14, 95 allies, 17 alpha, 200, 201, 211 alternative, 47, 82, 83, 91, 130, 134, 147, 153, 205 alternative hypothesis, 205 alternatives, 10, 88, 89, 90 Alzheimer, 213 amendments, 129, 130, 157, 159 American culture, 23 American Educational Research Association, 212 American Psychological Association, 213 American Sign Language, 139, 146, 152 anaemia, 88 anatomy, 172 anemia, 106, 137 Anemia, 112 anger, 142 antecedents, 86, 130 antibiotic, 97 anti-scientific, 47 anxiety, 106, 125, 127, 145 apartheid, 76 apathy, 57 appendix, 152 application, ix, 6, 12, 16, 24, 40, 53, 100, 115, 134, 233, 235, 236, 245, 247 applied research, 212 appraisals, 35 aquatic, 166 archeology, 101 argument, vii, viii, 1, 31, 32, 33, 35, 36, 38, 39, 40, 41, 42, 43, 46, 52, 56, 58, 59, 197 Arizona, 141 arson, 205 artificial, 147, 162 Asia, 76, 101, 113 Asian, 11, 72, 132 assertiveness, 29, 81 assessment, x, 26, 29, 66, 85, 86, 87, 91, 92, 130, 131, 132, 133, 135, 138, 144, 145, 146, 147, 148, 149, 150, 151, 152, 153, 154, 155, 157, 159, 161, 162, 165, 169, 170, 171, 177, 179, 180, 181, 191,

192, 194, 195, 208, 212, 220, 238, 241, 248, 250, 251, 252, 253 assessment procedures, 165 assessment techniques, 151, 152 assessment tools, 161, 165, 194 assets, 153 assignment, 65 assimilation, 95 assistive technology, 159, 165, 166 associations, 84, 216, 225, 238 assumptions, 17, 35, 36, 53, 82, 84, 163, 202, 204 asthma, 106, 113 astronomy, 39 athletes, 23 Atlantic, 247 ATLAS, 251 atresia, 175 attachment, 198 attention, x, 12, 19, 32, 35, 89, 112, 116, 119, 144, 170, 218, 229, 241, 244, 246, 249 attitudes, vii, 1, 5, 6, 11, 12, 16, 17, 19, 26, 27, 52, 53, 62, 66, 67, 70, 72, 78, 81, 86, 94, 97, 99, 105, 122, 128, 135, 173, 234, 248 auditing, 188, 194, 211 Australia, 61, 79, 84, 94, 95, 98, 100, 101, 102, 103, 213, 247, 250 authority, 47, 48, 49, 83, 153, 191, 192, 195, 196 autonomous, 245 autonomy, vii, 31, 32, 33, 34, 35, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 51, 52, 53, 54, 56, 57, 58, 80, 146, 171, 237, 249, 251 avoidance, 41, 103 awareness, 24, 68, 69, 72, 73, 74, 80, 88, 89, 90, 91, 92, 95, 100, 102, 103, 116, 119, 123, 127, 136, 137, 140, 159, 161, 171, 216, 218, 224, 225, 226, 227

B babies, 140 background noise, 172 bacterial, 109, 110 bacterial infection, 109, 110 bad behavior, 250 baking, 168 bank, 168 barrier, 139 barriers, 3, 4, 7, 11, 12, 15, 62, 76, 80, 95, 96, 141, 181, 245 basic needs, 117 basketball, 124, 165 battery, 148, 149, 150, 151, 180 beer, 88

Index behavior, vii, 1, 3, 4, 5, 6, 9, 10, 11, 14, 15, 17, 18, 19, 20, 21, 23, 25, 26, 27, 28, 29, 101, 106, 117, 118, 119, 126, 144, 152, 172, 177, 178, 182, 184, 252 behavior of children, 126 behavioral assessment, 130 behavioral change, 152 behavioral intentions, 5, 19 behavioral problems, 150 behaviours, viii, 72, 79, 80, 81, 84, 85, 86, 91, 94, 95, 96, 99 belief systems, 95 beliefs, vii, 1, 5, 6, 8, 9, 10, 12, 14, 15, 16, 17, 19, 20, 25, 46, 47, 48, 49, 50, 57, 66, 81, 84, 86, 87, 89, 103, 246 benchmark, 155, 156, 188 benchmarks, 154, 155, 156 benefits, viii, 3, 24, 31, 37, 40, 43, 55, 58, 70, 71, 74, 76, 98, 122, 171, 208, 216, 224, 246 benevolence, 40, 58 benign, 8 bias, 18, 118, 191 Bible, 57 bilateral, 150 bilingual, 247 bioethics, 80 biological, 45, 56, 118 biology, 34, 39 biomechanics, 172 bipartisan, 131 birth, 9, 10, 25, 121, 130, 139, 140, 141, 152, 159, 182 birth control, 9, 10, 25 black, 27, 66 Blacks, 8, 9, 26 blame, 26, 69 bleeding, 109, 110 blindness, 141, 148, 159, 175, 181, 183, 184 blood, 15, 20, 99 blurring, 18 body composition, 125, 147, 148 body concept, 136, 137 body fat, 136, 137 body image, 159, 174 body language, 173 bone, 137 boredom, 119, 142 Borneo, viii, 61, 62, 63, 64, 67, 69, 74, 75, 76 Boston, 178, 179, 183, 184 boys, 247, 248, 255 Braille, 146, 166 brain, x, 138, 175, 215, 217, 224, 225, 227 brain development, x, 215

257

brain functions, 217 brainstorming, 119 Breast, 27 breathing, 148 breathing rate, 148 British, 183, 227 British Columbia, 183 Brown v. Board of Education, 129 bulbs, 42 bullying, 250 bureaucracy, 253 buses, 158 Bush, 131 Bush, President George W., 131 business, x, 36, 49, 55, 188, 229, 230, 234, 236, 237, 246 business management, 234, 237

C California, 29, 101, 102, 184, 245 Canada, 80, 101, 103, 183, 245 Canberra, 100, 101, 102 cancer, 27 Cancer, 27 candidates, viii, 31, 45, 134, 164 cannabis, 101 capacity, 28, 47, 50, 52, 56, 83, 86, 92, 95, 97, 157, 169, 176, 181, 245 capacity building, 83 capital, 94, 106 carbohydrates, 95 cardboard, 219 cardiovascular, 125, 136, 137, 146, 182 cardiovascular disease, 125 career development, 71 caregiver, 143 caregivers, 97, 142, 161 Caribbean, 247 case study, 77, 87, 94, 157, 169, 238, 245, 250, 254, 255 catchments, 238 Catholic, 238 Caucasian, 8 Caucasian population, 8 causal model, 28 CBPR, 82, 83 CDC, 2, 17, 20, 21, 24, 25, 120, 125, 128, 179 cellular phone, 168 Census, 94, 95, 100 cerebral palsy (CP), 148, 175, 177 certificate, viii, 61, 62 certification, x, 134, 241

258

Index

Change, 173, 174 channels, 92, 93, 145, 246 check-ups, 96, 97 chemical, 45, 56 Chicago, 26, 101, 212, 226, 227, 251, 254 childhood, 97, 149, 226 children, viii, ix, x, 69, 71, 88, 89, 94, 95, 96, 97, 99, 101, 102, 105, 106, 107, 108, 109, 110, 111, 112, 113, 116, 117, 118, 119, 120, 121, 122, 125, 126, 128, 130, 131, 133, 135, 136, 137, 138, 139, 140, 141, 144, 145, 146, 149, 150, 151, 152, 158, 159, 160, 161, 165, 166, 170, 171, 172, 175, 178, 179, 180, 181, 182, 183, 184, 185, 215, 216, 217, 218, 219, 224, 226, 227, 228 China, 254 Chinese, 244, 254 choice making, 133 Christianity, 18 Christians, 47 chronic, 95, 99, 121, 125 chronic disease, 95, 99, 121, 125 chronic diseases, 95, 121, 125 cigarettes, 95 citizens, 35, 42, 43, 44, 47, 49, 52, 53, 54, 55, 56, 57, 58 civil rights, 129 class size, 248 classes, ix, 90, 115, 116, 134, 140, 248 classical, 230, 238 classification, 175 classified, 86, 200 classroom, 116, 117, 119, 120, 123, 133, 139, 140, 154, 155, 160, 162, 218, 219, 220, 221, 226, 243, 245, 247, 250, 255 classroom environment, 250 classroom management, 250 classroom teacher, 116, 117, 119, 160 classroom teachers, 116, 160 classrooms, 134, 220, 225 clinical, 7, 78, 119, 151, 152, 175 clinical judgment, 151, 152, 175 clinical trial, 7, 8 clinical trials, 7, 8 clinics, 11, 90, 250 Clinton, 131 clothing, 141, 153, 158, 163, 168 clusters, 248 Co, 180, 232, 247, 253 CO2, 55 coaches, 124 cocaine, 25 coding, 107 cognition, 227

cognitive, 3, 23, 65, 67, 72, 75, 116, 117, 118, 120, 125, 127, 132, 134, 147, 153, 157, 161, 171, 176, 181, 218, 251 cognitive ability, 157, 218 cognitive deficit, 161 cognitive development, 118, 120 cognitive impairment, 181 cognitive process, 23, 67 coherence, 251, 252, 254 cohesion, 98, 252 cohort, 46, 182 collaboration, 28, 93, 135, 160, 166, 174, 239, 245, 246, 252 college students, 4, 6, 26, 28, 29 colleges, 21, 160 colon cancer, 27 colonial, 94 colonialism, 95 colors, 224 Columbia, 129, 183 commitment, 133 Commonwealth, the, 129 communalism, 84 communication, viii, 6, 9, 23, 24, 28, 66, 68, 70, 79, 84, 92, 93, 97, 98, 100, 101, 116, 120, 133, 135, 139, 141, 142, 143, 144, 151, 152, 153, 154, 155, 156, 162, 166, 172, 174, 175, 183, 195, 230, 233, 236, 237, 246 communication processes, 230 communication skills, 24, 68, 84, 133, 144 communication strategies, 155 communication systems, 162 communication technologies, 233 communities, 9, 11, 18, 26, 29, 72, 81, 82, 83, 84, 87, 89, 90, 98, 103, 245, 246 community, vii, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 17, 18, 19, 23, 24, 28, 29, 71, 80, 81, 82, 83, 85, 86, 88, 89, 90, 91, 92, 94, 95, 96, 97, 98, 99, 100, 102, 103, 139, 145, 151, 157, 158, 159, 160, 161, 162, 164, 166, 171, 175, 237, 243, 244, 246, 251, 253, 254 community-based, 28, 88, 102, 251 compassion, 27 compatibility, 98, 239 competence, x, 171, 229, 230, 232, 233, 234, 237, 238, 244 competency, 122, 166, 188 competition, 124, 135 competitive, 124 competitiveness, 81 complement, 194 complementary, 237, 241 complexity, 46, 62, 94, 98, 124, 127, 145, 188

Index compliance, 195, 208, 210 complications, 15, 38, 89, 90, 139 components, 3, 28, 88, 97, 125, 126, 127, 142, 147, 148, 150, 151, 153, 159, 169, 175, 176, 177, 191, 194, 200, 213, 236, 248 composite, 150 composition, 125, 227, 231, 238 compositions, 198 comprehension, 84, 132 compulsion, 33, 54, 56, 70 compulsory education, vii, 31 compulsory science education, vii, viii, 31, 33, 35, 37, 41, 42, 50, 51 computation, 205 computer, 42, 166, 237, 247, 251 computer education, 247 computer technology, 251 Computers, 77 concentrates, 219 concentration, 243 conception, 43, 44, 49, 68, 75, 230, 231, 232 conceptualization, 4, 27 concrete, 168, 226, 244 concurrency, 13 condom, vii, 1, 4, 6, 7, 9, 10, 12, 13, 14, 15, 17, 19, 21, 22, 23, 24, 29 condoms, 4, 5, 6, 10, 13, 14, 16, 19, 20, 21, 22 conductive, 138 conductor, 42 confidence, 4, 64, 65, 119, 171, 173, 188 confidentiality, 196 conflict, 22, 55, 73, 234 conformity, 50, 194, 244 confrontation, 234 confusion, 15 congress, 129, 130 Congress, iv, 129, 130 conjecture, 56, 57 Connecticut, 154, 179 connective tissue, 125 connectivity, 251, 252 conscious awareness, 64 consciousness, 216, 224 consensus, 130, 178, 252 consolidation, 66 conspiracy, 6, 8, 9, 10, 19, 23, 24, 28 Constitution, 129 constraints, 69, 147 construct validity, 103, 150 construction, 34, 57, 231, 232, 244 constructivist, 34, 44, 63 consultants, 55, 238 consulting, 88

259

consumers, 20 consumption, 95 content, ix, 115, 121, 132, 146, 150, 151, 160 continuing, viii, 5, 40, 61, 78 continuity, 11, 116 contraceptives, 10 contractions, 125 control, 3, 5, 6, 7, 8, 20, 21, 26, 33, 69, 80, 81, 83, 86, 96, 97, 101, 106, 113, 125, 136, 150, 151, 171, 175, 188, 208, 209, 220, 221, 222, 223, 233, 243, 250, 251 control group, 5, 6, 222, 223 controlled, 10, 28, 29, 106, 117, 123, 145 conviction, 57, 88, 89 cooperative learning, 130 coordination, 127, 136, 138, 150, 176, 177, 210 Coping, 41 copyright, iv, 127, 128, 149 corporate governance, 188 corporations, ix, 187, 198 correlation, 19, 39, 204, 205, 206, 207, 211 correlation coefficient, 205 correlations, 39, 202, 204 cost-benefit analysis, 227 coughing, 109 counseling, 249 country of origin, 110 couples, 13, 26 course content, 66, 231 course work, 239, 250 courts, 129 covariate, 222 coverage, 9, 11, 28, 66, 189, 194 covering, 194 crack, 29 creativity, 94, 246 credibility, 70 criminal justice, 18 criminals, 40 critical thinking, 65, 70, 73, 76, 78 cross-cultural, 253 crying, 142 cues, 142, 144, 155, 166, 173 cultural, 6, 7, 8, 10, 18, 24, 27, 69, 73, 77, 80, 81, 83, 84, 95, 101, 103, 105, 231, 235, 251, 252 cultural differences, 235 cultural factors, 80 cultural influence, 105 cultural norms, 6, 18 cultural values, 84 culture, viii, 10, 18, 71, 79, 80, 83, 84, 87, 110, 111, 112, 139, 157, 246, 251 curricular materials, 252

Index

260

curriculum, ix, x, 32, 34, 36, 39, 40, 42, 45, 46, 47, 52, 54, 55, 57, 58, 59, 74, 115, 120, 121, 123, 126, 128, 130, 131, 133, 148, 151, 153, 154, 155, 156, 157, 158, 159, 165, 169, 170, 171, 172, 173, 174, 179, 181, 182, 184, 216, 218, 226, 241, 242, 243, 244, 248, 250, 251, 252, 253, 254 curriculum change, 252 curriculum development, 250 cycles, 55

D daily living, 125, 136, 139, 152, 165, 166, 170, 171 danger, 48 data analysis, 64 data collection, viii, 5, 64, 66, 79, 91, 107, 198 data gathering, 95 data set, 204, 205, 207, 211 database, 131 dating, 101 deafness, 139, 140, 141, 175, 179 death, 27, 92 deaths, 90 decay, 45, 97 deciduous, 87, 89 decision makers, 76 decision making, 73, 153, 198, 246 decision-making, 131 decisions, 21, 44, 52, 53, 54, 55, 56, 57, 86, 94, 96, 112, 172, 237, 250 decoding, 217, 224, 225 defects, 137, 175 defense, 158 deficiency, 25 deficit, 82, 161 deficits, 132, 135, 136, 138, 141, 151, 152, 172 definition, 17, 123, 170, 194, 204, 205, 244 degree, viii, 4, 44, 51, 52, 57, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 117, 127, 133, 134, 143, 145, 146, 147, 153, 171, 189, 194, 196, 197, 200, 204, 206, 231, 233 delays, 12, 136 delivery, 62, 66, 75, 83, 87, 162, 165, 166, 169 Delta, 135 demand, 33, 41, 42, 162, 188, 230, 247 demographic, 80 dendrite, 217 denial, 7, 8 density, 87, 95 dentist, 99 Department of Education, 154, 160, 179, 184 Department of Health and Human Services, 80, 81, 103, 184

dependent variable, 222 depression, 106, 125 desire, 2, 12, 14, 22, 70, 71, 72, 74, 88, 111, 142 desires, 86, 165 detection, 12, 81 determinism, 81 developed countries, 80 developed nations, 81 developing brain, 216 developing countries, 62 development, ix, 115, 116, 118, 119, 120, 125, 135, 136, 137, 138, 140, 141, 143, 145, 149, 150, 152, 154, 156, 158, 159, 161, 165, 171, 172, 173, 174, 175, 180, 182, 183, 184, 185 developmental delay, 136, 137, 140, 159 developmental process, 156 diabetes, 84, 95, 96, 97, 100, 101, 102, 125 Diabetes, 24, 103 diagnostic, 175 Diamond, 94, 101 diaphragm, 15 diarrhoea, 87, 89, 90 diet, 89, 96, 97, 182 dietary, 94, 101 differentiation, 251 diffusion, 9, 28, 92, 93, 94, 100 diffusion process, 92, 93 digestion, 235 dignity, 80 direct action, 234 direct observation, 165 directionality, 127 directives, 81, 132 disability, 121, 129, 130, 133, 141, 158, 164, 170, 176 disabled, ix, 50, 115, 138, 156, 175, 176, 185, 247, 248 disabled students, 156 disadvantaged students, 248 disappointment, 69 discipline, 34, 170, 247, 250 disclosure, 195 discourse, 89, 96, 98 discrimination, 7, 10, 24, 25, 80, 171 disease, 125, 170 diseases, 10, 24, 88, 95, 101, 110, 112, 121, 125 disputes, 55 dissatisfaction, 69 disseminate, 220 distance education, 76, 77 distraction, 99, 169 distribution, 137, 199, 204, 253 District of Columbia, 2, 129

Index diversity, 81, 123 doctor, ix, 10, 67, 68, 69, 105, 110 doctors, vii, 1, 9, 23, 24, 50, 67 doors, 156, 168 dosage, 106 download, 212, 213 draft, 198 drinking, 99 drinking water, 99 drug abuse, 28 drug use, 2, 3, 14, 16, 20, 21, 22, 26, 27 drugs, 17, 20, 25, 106 dry, 96 dualism, 76 due process, 129, 177 durability, 93 duration, 14, 89, 126, 218, 237 duties, 208, 236

E ears, 56, 138 earth, 25, 57 eating, 151, 166, 168 Ebino, 87, 88, 90, 91, 102 echolalia, 144 ecological, 82 economic, 37, 39, 40, 41, 55, 62, 72, 80, 81, 95, 140, 217, 227, 233, 248 economic status, 95, 217 economically disadvantaged, 220 economics, 39, 55, 84, 213 economy, 41, 87, 206, 230, 232, 237, 238 education, iii, v, vi, vii, viii, ix, x, 1, 6, 11, 20, 21, 23, 26, 27, 28, 29, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 66, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 87, 88, 89, 90, 91, 92, 94, 95, 96, 97, 98, 100, 101, 102, 103, 108, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 128, 129, 130, 131, 132, 133, 134, 135, 140, 141, 146, 148, 151, 154, 155, 156, 157, 158, 159, 160, 161, 163, 164, 165, 166, 167, 169, 170, 171, 172, 173, 175, 177, 178, 179, 180, 181, 182, 183, 184, 185212, 213, 226, 229, 230, 231, 232, 234, 235, 237, 238, 239, 241, 244, 245, 253, 254, 255 Education for All, 245 education reform, 135 educational assessment, 132 educational attainment, 20, 27 educational career, 135 educational institutions, x, 39, 229, 230, 232, 237

261

educational objective, 145, 175 educational research, vii educational settings, 155 educators, vii, 75, 112, 120, 121, 123, 126, 130, 131, 132, 133, 134, 135, 170, 224 efficacy, 81, 86, 100, 113, 244, 246 efficiency, 127, 163 effluent, 55 eigenvalue, 206, 207, 211 eigenvalues, 206 Eigenvalues, 206 elders, 95 e-learning, 231, 236 E-learning, 236 election, 57 electives, vii, 31 electricity, 42 electronic, iv, 164, 176, 236 electrostatic, iv elementary school, 246, 251 eligibility criteria, 169 embryonic, 35 emotion, 217 emotional, 20, 117, 119, 124, 139, 143, 152, 162, 171, 224, 235 emotional stability, 117, 119 emotions, 8, 171 employees, 188 employers, 39, 239 employment, 38, 39, 43, 50, 51, 53, 75, 92, 98, 196, 231 empowered, 244 empowerment, 18, 21, 24, 83, 91, 244, 250 encouragement, 88, 95, 183, 250 endurance, 125, 136, 137, 147, 148, 151, 176 energy, 82, 136, 169, 177, 244 engagement, 28, 47, 49, 56, 83, 192, 193, 195, 209, 210, 246, 249, 254 England, 76, 180, 247 English, 107, 131, 132, 139, 241, 247 enlargement, 151 Enlightenment, 70 enrollment, 218, 247 enslavement, 33 enterprise, 213 enthusiasm, 34, 68 envelope, 199 environment, viii, ix, 18, 21, 42, 55, 62, 63, 69, 70, 72, 75, 79, 82, 93, 99, 105, 110, 120, 123, 127, 129, 133, 134, 141, 142, 145, 146, 147, 150, 153, 155, 157, 158, 162, 164, 165, 167, 168, 174, 176, 177, 192, 218, 249, 251 Environment, 146

262

Index

environmental, 80, 81, 84, 85, 86, 87, 131, 153, 155, 156, 158, 159, 161, 162, 163, 165, 167, 176, 218 environmental conditions, 80, 131 environmental factors, 85, 86, 87, 153 epidemic, vii, 1, 3, 6, 28, 120 epidemiological, 26, 86 epistemological, 46, 47 epistemology, 46 equilibrium, 137, 149, 171 equipment, 127, 145, 147, 155, 157, 161, 163, 167, 168, 169, 173, 174 equity, 9 ERIC, 179, 227 ethical, 7, 18, 36, 44, 53, 210 ethical issues, 18 ethicists, 80 ethics, 43, 52, 63, 66, 103, 191, 194 Ethiopian, 102 ethnic groups, 15, 247 ethnicity, 121 etiology, 155 Eurocentric, 81 Europe, 121 European, 80, 94, 103 European Commission, 103 evacuation, 168 evaluation, 129, 134, 144, 145, 146, 147, 150, 153, 154, 162, 167, 175, 176, 181, 182 evening, 111, 238 evidence, 9, 11, 17, 29, 39, 57, 58, 65, 83, 100, 130, 133, 247 evil, 53 examinations, 239, 244 execution, 151 executive function, 230 executive functions, 230 exercise, vii, viii, 31, 32, 33, 37, 43, 47, 52, 53, 57, 121, 126, 146, 181 expectations, 129, 133, 155, 163, 171 expenditures, 177 expert, iv, 11, 47, 211, 246 expert teacher, 246 expertise, 42, 47, 49, 236 experts, 47, 55, 93, 121, 245 exploitation, 7, 233 exposure, 15, 18, 26, 69, 73, 91, 116, 124, 140, 172, 209, 219, 224 Exposure, 69 extraction, 88, 89, 90, 91, 92, 199 extrinsic, 43, 44, 244 eye, 2, 68, 136, 138, 159 eyes, 69

F face validity, 146, 151 facial expression, 153, 173 facilitators, 24, 89 factor analysis, 199, 200, 202, 203, 204, 205, 206, 207, 211, 212, 213 failure, ix, 10, 16, 51, 68, 103, 105, 188, 225, 248, 249 fairness, 18 false, 47, 51, 57, 87, 102 false teeth, 87, 102 family, 8, 9, 11, 12, 21, 29, 69, 70, 71, 74, 84, 94, 95, 97, 103, 110, 111, 112, 119, 120, 139, 142, 153, 160, 171, 179, 180, 182, 226, 236, 239 family income, 11, 29 family members, 97, 112, 119, 153 family planning, 8, 9, 103 farmers, 84 fast food, 107 fat, 95, 125 fatalism, 15 fatigue, 176 fear, vii, 1, 12, 13, 15, 18, 21, 22, 24, 96, 99, 142, 249 February, 203, 220 feces, 177 federal, 129, 130, 131 federal courts, 129 federal law, 129, 130 feedback, 163, 172, 218, 237, 251 feelings, vii, 1, 84, 142, 171 feet, 137 females, 25, 26, 87 feminist, 83 fertility, 7 fever, 87, 89, 90, 109, 110 film, 96 finance, 237 financial support, 230 firms, 198, 238 first generation, 238 fish, 52 fitness, 120, 121, 122, 123, 124, 125, 126, 127, 128, 144, 145, 147, 148, 153, 166, 174, 176, 177, 178, 181, 185 FITNESSGRAM, 148, 182 flexibility, 62, 92, 98, 125, 126, 147, 148, 176, 177 Florida (FL), 179, 180 flow, 44, 75, 94 fluid, 109 fluoride, 97 focus group, 22, 64, 84, 88, 89, 90, 94, 96, 97, 198

Index focus groups, 84 focusing, 11, 85, 140, 245 food, 34, 99, 109, 122, 141 footwear, 163 Ford, 6, 26 forgiveness, 134 formal education, 20, 111 Fox, 62, 71, 72, 77, 166, 167, 185 framework, 128, 156 fraud, 40, 188 free, 129, 131, 167, 170 freedom, viii, 17, 31, 34, 35, 51, 54, 58 Frequency, 126 friends, 139, 142, 171 frog, 137 frustration, 4, 68, 69, 119, 142, 144 fulfillment, 119 functional approach, 132, 134 funding, 7, 9, 50, 193, 230 Funding, 133 furniture, 158, 168 futures, 38, 249

G gait, 135, 146, 153 Gallup, 135 games, ix, 115, 118, 124, 128, 138, 143, 167, 170, 221 gas, 55 gay men, 24 gender, 6, 18, 29, 121, 147, 196, 217, 247, 248, 253 gender differences, 247, 253 gender role, 18 general education, 130, 134, 157, 164, 178 general knowledge, 33, 58 generalizability, 199 generalization, 199 generation, 64, 95 genetic, 48, 141, 143 genetic disorders, 141 Geneva, 103 genocide, 9 geography, viii, 33, 61 geology, 34 Germany, 229, 231, 238 gestalt, 217 gestation, 14 gestures, 153, 156, 173 gingival, 90 girls, 247, 248, 254 glass, 88 Global Positioning System, 176

263

global warming, 55 globalization, 62, 77, 188, 230 goal setting, 171 goal-directed, 236 goals, ix, 37, 50, 51, 52, 54, 81, 115, 131, 138, 154, 155, 156, 157, 160, 162, 165, 166, 169, 172, 216, 231, 241, 246, 248, 252 going to school, 111 Gore, 3, 29 governance, 188, 208, 209, 245 government, iv, 6, 7, 8, 9, 23, 26, 55, 57, 84, 91, 188, 232, 250, 252 Government, 184 grades, 111, 127, 140, 238, 252 Grant, 169 gross domestic product, 87 group work, 250 grouping, 252 groups, ix, 4, 5, 7, 13, 14, 16, 17, 18, 20, 21, 23, 24, 55, 79, 80, 81, 82, 83, 84, 86, 88, 89, 90, 91, 92, 94, 95, 96, 100, 105, 112, 115, 117, 129, 132, 139, 150, 164, 206, 222, 223, 231, 235, 236, 238, 239, 245, 247, 248, 249 growth, x, 132, 143, 145, 152, 156, 175, 180, 215, 217, 218, 225, 226 growth spurt, 217 guidance, 71, 163, 194, 235 guidelines, 121, 122, 123, 126, 148, 152, 182, 188, 194, 199, 247

H handicapped, 179, 183 handling, 16, 169, 234 hands, 55, 98, 137, 138, 142, 143, 161, 172, 175, 176 handwriting, 219, 225 happiness, 43, 44, 53, 54, 58 harassment, 249 harm, 8, 15, 18, 119, 234, 244, 249 harmful, viii, 18, 69, 79 harmony, 234, 244 Harvard, 226 hazards, 167 head, 56, 136, 137, 142, 175, 176, 220 Head Start, 218 healing, 18, 102 health, v, viii, ix, 3, 5, 7, 8, 9, 10, 11, 12, 15, 18, 21, 24, 25, 26, 27, 28, 29, 61, 62, 66, 67, 69, 75, 76, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 92, 94, 95, 96, 97, 98, 99, 100, 101, 102, 103, 105, 106, 108, 112, 113, 117, 119, 120, 121, 122, 125, 126, 127, 140, 144, 147, 148, 153, 169, 171, 175, 176, 178, 180, 181, 182, 183, 184

264

Index

health behaviours, viii, 79, 85, 95, 96, 99 Health Belief Model (HBM), 3 health care, viii, 9, 10, 11, 12, 15, 26, 27, 61, 62, 67, 69, 75, 80, 82, 87, 96, 97, 98 health care professionals, 67, 69 health care system, 62, 75 health clinics, 10 health education, v, viii, 21, 27, 28, 79, 80, 81, 83, 84, 92, 94, 96, 97, 98, 100, 102, 103 health information, 9, 21, 25 health problems, 86 health services, 11, 15, 21, 80, 81, 96 health status, 15, 80, 82, 106, 113 healthcare, 6, 7, 10, 27, 101 hearing, 116, 130, 136, 138, 139, 140, 141, 142, 143, 144, 146, 151, 152, 153, 155, 156, 162, 169, 172, 175, 176, 178, 183, 184 hearing impairment, 116, 130, 136, 139, 144, 146, 178 hearing loss, 138, 139, 140, 141 heart, 125, 137, 149, 175, 251, 253, 255 heart rate, 149 height, 199 hemisphere, 217 herbs, 102 heredity, 137 heterogeneous, 231, 233 heterosexuals, 16 heuristic, 12, 15 high blood pressure, 125 high risk, 16, 20, 21, 22, 106 high school, 20, 131, 179, 227, 246, 250 higher education, viii, 13, 61, 62, 78 high-level, 57 high-risk, 2, 9, 13, 14, 17, 21, 22 hips, 119, 135 hiring, 55 Hispanic, 132 history, 128, 134, 145, 151, 153, 175, 184 HIV, v, vii, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 84, 88, 89, 103, 110 HIV infection, 6, 13, 15, 17, 19, 20, 21, 23, 24, 26, 27 HIV test, 13, 25, 26, 28 HIV/AIDS, v, vii, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 13, 14, 15, 16, 19, 20, 23, 24, 25, 26, 27, 28, 29, 84, 88, 89, 103 holistic, viii, x, 20, 79, 95, 229, 231, 233, 234 holistic approach, 20 homebound, 140 homeless, 11, 27 homes, 94, 107, 140, 216, 220, 224

homework, 47, 65, 250 homosexuality, 18 honesty, 188 Hong Kong, 241, 245, 254 hopelessness, 15 horizon, 36 hospital, 10, 11, 12, 65, 88, 89, 90, 91, 92, 108, 110, 140, 176 hospital death, 90 hospitalizations, 113 hospitals, 7, 15, 238 House, 27, 100, 180, 181 household, 167, 168 households, 96 housing, 18 human, 15, 43, 80, 82, 101, 118, 123, 169, 224, 225, 226, 230, 251 human brain, 225, 226 human condition, 169 human experience, 82 Human Kinetics, 178, 179, 180, 182, 183, 184, 185 human nature, 80 humans, 47, 55, 80 humidity, 127, 145 husband, 109 hygiene, 89 hypothesis, 47, 55, 204, 205

I id, 44, 66, 78 ideas, 135 identification, 9, 17, 158, 162, 163, 168, 218 identity, viii, 61, 72, 73, 74, 75, 77, 82, 246, 249 ideology, 91 idiosyncratic, 33, 34 Illinois, 215 illusion, 14 imagery, ix, 215, 219, 220, 221, 225 images, 69, 73, 97, 217, 224 imagination, 118, 221 imitation, 136, 174 immigrants, ix, 105, 108, 110, 112 impairments, 116, 117, 118, 119, 120, 134, 135, 136, 137, 138, 141, 144, 146, 152, 157, 158, 159, 160, 161, 162, 163, 164, 165, 166, 167, 169, 173, 175, 179, 180, 181, 182, 183, 184 implementation, ix, 87, 90, 92, 93, 102, 115, 131, 189, 197, 203, 204, 213, 244, 251, 252 impulsive, 65 in situ, 89, 171, 247 incentive, 86, 119 incentives, 107

Index incidence, 17, 130, 133, 134 inclusion, 16, 45, 130, 133 income, 11, 13, 28, 121, 248 incompatibility, 47 independence, 146, 169, 171, 191, 192, 193, 195, 196, 204, 208 independent variable, 204, 222 Indiana, viii, 105, 106 indicators, 21, 87, 132, 254 indigenous, 101 Indigenous, 84, 94, 95, 96, 97, 98, 99, 100, 101 individual development, 234 individual differences, 117 individualism, 243 individualized instruction, 117, 166 Individuals with Disabilities Education Act (IDEA), 129, 130, 131, 134, 135, 141, 157, 159, 165, 170, 180 indoctrination, 48, 54, 58 induction, 244 industrial, 198 infancy, 180 infants, 88, 138, 159, 182 Infants, 161, 179, 180 infection, 2, 13, 17, 19, 20, 25, 109, 110 infectious, 88 infectious diseases, 88 infinite, 43 Information, 145, 146, 152, 153 information sharing, 210 information technology, 192 inheritance, 50 injection, 2, 3, 14, 16, 17, 20, 21, 27, 29 injuries, 121 injury, iv, 118, 125, 175 inmates, 103 inner ear, 138 innovation, 92, 93, 94, 98, 101, 134, 246 Innovation, viii, 79, 92, 93, 94, 95, 98, 100, 240, 244, 253 input, 116, 118, 133, 136, 177 insight, 67, 100, 235 instinct, 140 institutionalisation, 99 institutions, x, 9, 18, 39, 62, 75, 230, 232, 234, 238, 241, 252 instruction, x, 67, 116, 117, 118, 124, 127, 130, 133, 134, 145, 154, 156, 158, 159, 160, 161, 163, 165, 166, 169, 172, 173, 176, 184, 196, 216, 217, 218, 219, 221, 224, 225, 226, 241, 245, 250, 251, 252, 253 instructional activities, 81 instructional methods, 218

265

instructional practice, 132 instructional procedures, x, 241 instructional techniques, 127, 145 instructional time, 124, 218 instructors, 146, 166, 167, 170, 172, 173, 231 instruments, ix, 82, 88, 89, 144, 145, 146, 147, 148, 151, 161, 165, 187, 189, 198, 200, 201, 211 insurance, 11 integration, x, 149, 164, 171, 215, 219, 220, 221, 224, 245 integrity, 80 intelligence, 151 intensity, 121, 122, 126, 128, 148, 177 intentions, vii, 1, 5, 6, 19, 134 interaction, 10, 12, 13, 118, 119, 122, 123, 140, 141, 142, 153, 164, 176, 222, 223, 231, 234, 237 interaction effect, 222, 223 interactions, 65, 107, 133, 142, 153, 167 interdependence, 143, 251 interdisciplinary, 130, 231, 251 interest, 119, 125, 126, 139, 143 interference, 33 internal consistency, 201 international, viii, 61, 62, 69, 72, 178, 235 Internet, 168, 229 internship, 235 interpersonal skills, 154 interpretation, 8, 48, 57, 83, 191, 200, 202, 203, 204, 207, 243 interpreting, 150 interrelationships, 204 interval, 197, 203 intervention, 6, 16, 20, 24, 26, 28, 29, 83, 84, 85, 87, 89, 91, 94, 96, 98, 99, 103, 106, 126, 135, 136, 138, 140, 150, 159, 172, 176, 177, 178, 179, 182, 216, 221, 222, 223, 224, 225, 226, 247 intervention strategies, 85, 87, 106, 135, 177 interview, 152, 198 interviews, 64, 107, 130, 145, 165, 198 intimacy, 22 intravenously, 20 intrinsic, 43, 44, 46, 48, 80, 244, 245 intrinsic motivation, 245 intrinsic value, 43, 44 intuition, 84 inventories, 165 investment, 93 iron, 106 irritation, 21 Islam, 9, 18 Islamic, 76 island, 62, 63 isolation, 62, 66, 218

Index

266 Israel, 82, 83, 102, 245 issues, 126, 146, 152, 155, 156, 157, 158, 159, 163, 169, 182, 184

J January, 25, 189, 203, 213 Japanese, 77 Jefferson, 248, 254 job satisfaction, 77 job training, 18 jobs, 38, 51 joints, 146, 175 Jordan, 63, 71, 73, 76, 112 judge, 39, 43, 48, 58, 249 judges, 48 judgment, 118 justice, 103, 231 justification, viii, 31, 32, 39, 43, 46, 48, 49, 52, 54, 56, 189

K Kierkegaard, 81, 100 kindergarten, 218, 224, 225, 226, 227 kinesthetic, 136, 145, 172, 173 King, 16, 27, 28, 103 knees, 137

L labour, 75, 238, 239 labour force, 75 labour market, 238, 239 land, 94, 95, 112 landscapes, 230 language, 80, 83, 84, 95, 97, 99, 100, 116, 139, 140, 151, 152, 153, 162, 166, 173, 174, 182, 185, 216, 218, 226, 227, 241, 247, 248 language development, 182, 185, 218 language skills, 116, 174 large-scale, 130, 132, 133, 135 Latino, 25, 26, 103 Latinos, 11, 25 law, 66, 129, 131, 133, 134, 180, 181 laws, 45, 128, 131, 179 lawyers, 107, 129 lead, 6, 12, 17, 20, 22, 40, 66, 140, 141, 142, 156, 165, 216 leadership, x, 97, 124, 170, 229, 234, 241, 243, 245, 246, 251, 253, 254, 255 leadership style, 245

lean body mass, 125 learners, x, 216, 225, 241, 242, 243, 244, 246, 248, 252 learning, ix, x, 42, 46, 54, 59, 64, 72, 76, 77, 80, 82, 115, 116, 120, 122, 124, 125, 126, 127, 130, 131, 132, 133, 134, 135, 139, 140, 141, 142, 143, 144, 145, 148, 153, 155, 161, 165, 169, 172, 177, 180, 183, 184, 217, 218, 219, 220, 221, 224, 225, 227, 229, 230, 231, 232, 233, 234, 235, 236, 237, 238, 239, 241, 243, 245, 246, 247, 248, 249, 250, 251, 252, 253, 254, 255 learning culture, 230, 234, 239 learning difficulties, 248 learning environment, 139, 172, 241, 248 learning outcomes, 252 learning process, 232, 234, 252 learning styles, 153 learning task, 145 legal issues, 233 legislation, 131, 133 leisure, 151, 152, 164, 165, 166, 170, 171, 181, 182 leisure time, 165 lens, 67, 68, 159 lesions, 2 lesson plan, 169, 170, 173 liberal, 37, 43, 50 liberal education, 37, 43, 50 liberty, 59 life changes, 92 life expectancy, 87 life quality, 96 life satisfaction, 165 lifelong learning, 252 lifespan, 120, 122, 125 lifestyle, 17, 91, 94, 95, 96, 101, 122, 154, 171 lifestyle changes, 94, 95 lifestyles, 86, 94, 140 lifetime, 10, 14, 21, 112, 124, 170, 171 likelihood, 7, 11, 15, 20, 53, 157, 205 limitation, 70, 75, 159, 189, 194 limitations, 16, 132, 173, 189, 197, 230 linear, 204, 217 linguistic, 50, 171 linguistically, 129 linkage, 93 links, 14, 39, 43, 93, 94, 239, 248 listening, 117 literacy, 50, 51, 87, 95, 216, 217, 218, 225, 226, 227, 247 literature, viii, 3, 4, 6, 16, 27, 31, 32, 35, 36, 39, 41, 44, 47, 52, 54, 57, 65, 69, 78, 106, 132, 199, 202, 206, 207, 211, 241, 244, 246 litigation, 133

Index liver, 15 local community, 91 location, 11, 72, 73, 75, 121, 147, 158, 160, 167, 173, 176, 177, 199 locomotion, 127, 136, 145, 149 London, 76, 77, 102, 103, 184, 247, 253, 254, 255 long distance, 166 long period, 13, 176 longitudinal studies, 35 longitudinal study, 154, 228 long-term, 2, 81, 82, 93, 170, 216, 225, 227, 239, 248, 249, 251 long-term impact, 227 lordosis, 137, 176 Los Angeles, 101 loss of control, 33 love, 23, 141 low risk, 6 low-income, 28, 29, 217 low-level, 250 lumbar, 137

M machines, 99 Madison, 181, 253 magazines, 9 magnetic, iv mainstream, 47, 83 maintenance, 5, 23, 93, 97, 125, 151, 171, 182, 233, 252 major cities, 15, 17 malaise, 89, 90 malaria, 110 Malaysia, ix, 61, 62, 63, 64, 69, 72, 73, 75, 76, 187, 188, 198, 211, 213 males, 25, 87 malicious, 8 management, x, 64, 65, 66, 68, 81, 91, 97, 113, 126, 171, 188, 191, 192, 195, 209, 210, 213, 229, 230, 231, 232, 233, 234, 235, 236, 237, 239, 243, 244, 246, 251, 253, 254, 255 mandates, 130 mandible, 88 manifold, 230 manipulation, 127, 145, 149, 173 man-made, 9 manpower, 193 market, 40, 188, 237, 238, 239 Mars, 139, 140, 182 Maryland, 150 masculinity, 18 mask, 144

267

mass media, 81, 94 mastery, 159, 218 materialism, 81 mathematical, 237 mathematics, 59, 131, 134 matrix, 35, 205, 206, 207, 211 maxilla, 88 Mean, 182 measurement, ix, 101, 187, 189, 197, 198, 200, 203, 207, 211 measures, 20, 38, 96, 132, 146, 150, 152, 175, 189, 191, 192, 197, 200, 203, 206, 218, 226, 238, 246, 247 mechanical, iv, 123 mechanics, 42 media, 15, 25, 69, 81, 94, 173, 221, 231, 236, 237 medical care, 11 medication, 96, 153 medications, 7, 145 medicinal, 102 medicine, 81, 88, 102, 109, 110, 111 memory, 163, 225 memory retrieval, 225 men, vii, 1, 2, 10, 12, 13, 16, 17, 18, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, 87, 89, 91 mental age, 144 mental health, 18 mental retardation, 141, 148, 159, 163 mentoring, 247 meritocratic, 250 message comprehension, 84 messages, vii, 1, 7, 8, 17, 18, 22, 23, 24, 83, 84, 96, 97, 99, 168 meta-analysis, 16, 243 methodology, 131 metropolitan area, 26 Mexican-Americans, 4, 28 Mexico, 103, 181 minorities, 20 minority, 8, 9, 11, 20, 25, 26, 53, 106, 139, 248, 250, 252 minority groups, 8 minority students, 248, 252 misappropriation, 188 misleading, 46 missions, 55, 95 mixing, 14 mobility, 116, 138, 146, 153, 157, 158, 159, 160, 161, 162, 163, 164, 165, 166, 167, 168, 169, 177, 178, 179, 180, 181, 183, 184, 185 modalities, 62 Model, 123, 124, 125, 126, 127 modeling, 70, 73, 166, 171, 172, 202, 207

Index

268

models, viii, 6, 79, 81, 82, 85, 89, 96, 100, 120, 127, 130, 172, 182, 236, 244, 248 modules, 232, 233, 237, 238 momentum, 134 money, 50, 51, 64, 69, 96, 110, 163, 168 monitoring, 163, 170 monograph, 32 monotone, 139 morale, 246 morbidity, 170 mortality, 26, 27, 29, 170 mothers, 27, 89, 95, 99, 100 motion, 125, 146, 173, 230, 234 motivation, 5, 37, 44, 52, 57, 71, 81, 86, 98, 116, 125, 144, 233, 250 motor activity, 116 motor behavior, 153, 175 motor control, 150 motor coordination, 150 motor function, 116, 171 motor skills, 116, 117, 118, 119, 120, 122, 126, 135, 137, 138, 140, 146, 149, 150, 151, 152, 153, 159, 165, 166, 172, 175, 176 mouse, 221 mouth, 96 movement, 74, 83, 116, 117, 118, 119, 122, 123, 125, 127, 137, 138, 140, 142, 143, 147, 148, 150, 156, 157, 159, 162, 165, 169, 171, 172, 173, 174, 175, 176, 177, 185, 217, 219 MPA, 126, 176 multidimensional, 23, 86 multidisciplinary, 123, 172 multiple regression, 199 multiplicity, 234 multivariate, 213 muscle, 125, 143, 146, 177 muscles, 125, 138, 169, 175, 177 music, 83, 221 Muslim, 72

N naming, ix, 215, 216, 217, 219, 220, 224, 226 nation, 37, 39, 43, 77, 79, 120, 123 national, 135, 154, 179 Native American, 132 natural, 5, 48, 133, 135, 140, 150, 157, 161, 166, 217 natural environment, 135, 166 natural selection, 48 nausea, 109, 110 needles, 20, 88 neglect, 8 negotiating, 24, 158

neonatal, 26 nerve, 142 nerves, 138 Netherlands, 253, 254 network, 13, 14, 165, 235 neurons, 225 New Jersey, 184, 213 new media, 230 New Mexico, 103, 181 New York, iii, iv, 25, 27, 59, 60, 76, 100, 101, 102, 103, 178, 179, 180, 181, 183, 184, 185, 212, 213 New Zealand, 80, 102 newspapers, 9, 15, 28 Nixon, 137, 183 No Child Left Behind (NCLB), 131, 132, 133, 134, 135, 179, 182, 184 normal, 117, 136, 141, 144, 163, 175, 189, 204 normal development, 141 normal distribution, 204 norms, 5, 6, 18, 24 North Carolina, 1, 25, 187 not-for-profit, 88 nuclear, 112 nurse, 63, 64, 65, 66, 67, 68, 69, 72, 73, 77, 109, 111 nurses, viii, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 107 nursing, 29, 61, 62, 64, 67, 68, 69, 70, 71, 72, 73, 74, 76, 77 nutrition, 97, 101, 126

O obese, 125 obesity, 120, 121, 147 object permanence, 159 objectives, ix, 115, 116, 120, 123, 138, 145, 156, 160, 162, 175, 176 objectivity, 57, 146, 147, 150, 151, 191, 195 obligation, 35 obligations, 58 observable behavior, 206 Observation, 153 observational learning, 130 observations, 38, 81, 110, 130, 145, 153, 218, 234 occupational, x, 138, 146, 166, 229, 232 offenders, 7, 25 Ohio, 150, 181 online, 32, 44, 59, 77, 236 open spaces, 162 operator, 88 oppression, 72, 76 optics, 42 optimal health, 122

Index optimism, 57 oral, 84, 94, 95, 96, 97, 98, 99, 102, 103, 139 oral health, 84, 94, 95, 96, 97, 98, 99, 102, 103 oral tradition, 84 Oregon, 161 organ, 225 Organisation for Economic Co-operation and Development (OECD), 244, 247, 250, 253 organism, 118 organization, 28, 128, 188, 191, 192, 194, 196, 197, 209, 210, 230, 235, 243, 253 organizational culture, 213 organizations, x, 8, 129, 188, 199, 230, 232, 238, 241 orgasm, 22 orientation, 116, 138, 146, 157, 158, 159, 160, 161, 162, 163, 164, 165, 166, 167, 168, 169, 177, 178, 179, 181, 183, 184, 185, 230, 233, 234, 236, 244, 248 osmosis, 71 osteoporosis, 125 Ottawa, 80, 97, 101, 103 outpatient, 10 output, 166 outrage, 33 oversight, 192 over-the-counter, 110 overweight, 120, 125 ownership, viii, 79, 91, 95, 100, 134 oxygen, 125

P Pacific, 11, 113 Pacific Islanders, 11 pain, 12, 40, 43, 96, 106, 110, 112 paper, viii, x, 32, 40, 42, 44, 46, 52, 55, 59, 61, 62, 64, 65, 66, 74, 75, 108, 181, 210, 212, 220, 229 paradigm shift, 121 parasite, 47, 177 parental support, 140 parenting, 248 parents, viii, ix, 94, 105, 106, 108, 109, 110, 111, 112, 119, 120, 130, 133, 134, 137, 138, 139, 140, 145, 153, 160, 161, 162, 168, 169, 177, 243, 246, 249, 252, 254 Paris, 253 Parkinson, 101 participation, 118, 120, 121, 124, 125, 128, 130, 132, 135, 137, 154, 155, 171, 173, 177, 182 Participation, 179 partnership, 82, 83, 102 partnerships, 13, 14, 82, 241 pass/fail, 147

269

passive, 34, 117 pastoral, 251 pathways, 224 patient care, 63, 66, 70, 71 patients, 6, 7, 11, 26, 65, 66, 68, 75, 87, 90, 101 pedagogical, 232, 233, 237, 244 pedagogy, 46, 83, 172, 226 pedestrian, 165 peer, 24, 86, 91, 118, 119, 130, 170, 172, 199 peer influence, 86, 91 peers, 130, 133, 135, 136, 140, 153, 156, 164, 171, 183, 249 pelvis, 137 pendulum, 121 Pennsylvania, 76, 129 percentile, 149 perception, 3, 13, 19, 22, 69, 84, 86, 106, 108, 141 perceptions, viii, ix, 4, 10, 15, 18, 25, 76, 83, 88, 94, 95, 105, 106, 108, 112, 213 performance, x, 4, 38, 51, 62, 118, 122, 123, 126, 127, 133, 145, 146, 147, 148, 150, 151, 152, 153, 154, 155, 159, 160, 170, 171, 172, 193, 194, 209, 210, 211, 215, 216, 217, 218, 224 periodic, 191, 208 periodontal disease, 96, 102 permit, 133, 189 personal, viii, 23, 32, 61, 62, 67, 81, 86, 107, 119, 122, 125, 142, 168, 169, 231, 234, 235, 236, 239, 246, 247 personal autonomy, 32 personal goals, 81 personal life, 67 personality, 117, 118, 230, 232, 234, 239 persuasion, 23 pessimism, 48, 49, 57 Philadelphia, 77, 178 philosophers, 36, 40, 47 philosophical, 47, 49 philosophy, 32, 41, 44, 45, 46, 47, 49, 52, 54, 124 phone, 107, 141, 142, 203 phonemes, 219 phonological, 216, 218, 226, 227 physical activity, 118, 120, 122, 123, 124, 126, 128, 137, 147, 148, 154, 169, 171, 172, 173, 174, 176, 177, 180, 181, 182 physical education (PE), ix, 115, 116, 117, 118, 119, 120, 121, 123, 124, 125, 126, 128, 140, 146, 154, 155, 156, 157, 164, 165, 166, 167, 169, 170, 171, 172, 173, 175, 177, 179, 180, 181, 182, 183, 184, 185 physical environment, 99 physical factors, 86, 127, 145

270

Index

physical fitness, 121, 122, 125, 126, 147, 148, 170, 171, 176, 177, 185 physical health, 119 physical therapist, 138, 146, 166, 175, 176, 178 physical therapy, 176, 177 physicians, 2, 11, 23 physics, 34, 39, 45 physiological, 123 physiological factors, 123 physiology, 172 pig, 24 pigs, 9 pilot study, 27 planning, viii, 74, 79, 84, 85, 87, 88, 93, 100, 103, 124, 134, 150, 151, 152, 153, 154, 157, 159, 161, 162, 166, 169, 177, 192, 193, 195, 209, 232, 237, 238, 243, 245, 246, 250, 252 plausibility, 35 play, 27, 52, 87, 88, 90, 91, 99, 118, 119, 124, 136, 139, 140, 142, 165, 166, 167, 168, 169, 170, 171, 182, 183, 218, 245 pleasure, ix, 115 policy, 132 policy makers, 20, 75 policy-makers, 75 political, 54, 62, 72, 80, 101, 230, 253 politics, 68, 83 poor, 6, 9, 12, 27, 62, 71, 72, 73, 81, 84, 89, 95, 96, 106, 136, 189, 191, 199, 216, 246, 248, 250, 252 poor health, 89 poor performance, 246 poor readers, 216 population, vii, ix, 1, 2, 3, 4, 8, 9, 10, 12, 13, 14, 15, 17, 19, 20, 21, 28, 39, 82, 83, 84, 85, 87, 94, 95, 100, 115, 120, 123, 130, 132, 134, 138, 144, 146, 147, 151, 166, 199, 220 population density, 95 population group, 100 portfolios, 133, 147, 161, 165 positive attitudes, 173 positive reinforcement, 241 posture, 135, 143, 151, 153, 168 poverty, 15, 80, 81, 217 power, viii, 11, 42, 57, 72, 79, 83, 91, 96, 177, 224, 244 power relations, 83 pragmatic, 144 praxis, 65 prayer, 12, 90 prediction, 29, 151, 204 predictive model, 4 predictors, 81, 226 preference, 116

pregnancy, 10, 25 pregnant, 27 pregnant women, 27 prejudice, 17 preparation, iv, 5, 38, 124, 231 preschool, 95, 106, 107, 137, 160, 183, 216, 218, 219, 220, 221, 222, 225, 226, 227 preschool children, 106, 137, 160, 227 preschoolers, ix, 159, 179, 215, 216, 218, 219, 224, 225 pressure, 67, 135, 236 pressure sore, 67 preventative care, 11 prevention, 4, 5, 6, 7, 9, 12, 15, 16, 17, 18, 21, 24, 25, 26, 27, 28, 29, 81, 97, 101, 103, 125, 227 preventive, 23, 121 primacy, 250 primary, 118, 140, 141, 144, 167, 177 primary care, 100 priorities, 34, 45, 78, 86, 98 private, 11, 88, 232 probability, viii, 11, 31, 53, 124, 199, 208 problem behaviors, 131 problem solving, 65 problem-based learning, 251 problem-solver, 245 problem-solving, 86, 118, 168 problem-solving skills, 168 procedures, x, 77, 97, 145, 146, 147, 151, 162, 165, 168, 176, 188, 192, 195, 198, 206, 209, 210, 220, 234, 237, 250, 252 production, 63, 100, 222, 237, 247 profession, ix, 38, 67, 68, 69, 70, 71, 72, 73, 75, 134, 135, 187, 246, 253 professional development, x, 62, 154, 156, 174, 192, 193, 195, 241, 244, 246, 247, 251, 253 professional educators, 133 professional qualifications, 231 professionalism, 255 professions, 103, 162 profit, 88 prognosis, 90, 239 program, ix, 18, 23, 27, 62, 63, 69, 76, 77, 78, 83, 84, 85, 86, 87, 89, 90, 91, 92, 95, 98, 99, 101, 102, 103, 115, 116, 117, 118, 119, 120, 125, 126, 138, 145, 146, 148, 149, 150, 151, 152, 159, 161, 162, 164, 165, 166, 169, 170, 171, 173, 175, 177, 192, 195, 208, 218, 221, 243, 251, 254 programming, 18, 135, 144, 159, 161 programs, ix, 115, 116, 121, 125, 126, 127, 129, 130, 134, 141, 166, 175, 177, 179 promote, 10, 88, 99, 117, 124, 134, 140, 163, 165, 169, 173, 183, 246

Index property, iv proposition, 36, 85 prosthetics, 164 protection, 14, 15, 19, 66, 97 protocol, 87, 92 proximal, 243 psychological, 15, 20, 81, 82, 84, 117, 123, 127, 145, 147, 169, 243 psychology, 199 psychopathy, 103 psychosocial, 83, 145, 185 public, ix, 7, 9, 10, 11, 18, 23, 26, 27, 69, 70, 91, 102, 103, 121, 129, 133, 135, 158, 159, 161, 164, 165, 166, 168, 187, 188, 244, 249 public companies, ix, 187 public education, 129 public health, 7, 9, 10, 23, 26, 102, 103, 121 Public Health Service, 7 public schools, 158, 159, 165 public sector, 70 pulp, 55, 56, 57 pulp mill, 55, 56, 57 punishment, 40 pupil, 247, 250 pupils, 116, 241, 243, 247, 250, 254

Q qualifications, viii, 51, 61, 62 qualitative research, 76, 77, 96 quality assurance, 191, 192, 196, 208 quality improvement, 210 quality of life, 86, 92, 106, 120, 128 questionnaire, 107, 238 questionnaires, 202, 203, 218

R race, 26, 27, 121, 129, 248 racial groups, 14 racism, 10, 24, 81 radical, 44, 59 radio, 9 rail, 166 random, 199, 200 range, 11, 32, 47, 57, 82, 86, 89, 90, 92, 93, 96, 97, 100, 125, 132, 146, 150, 151, 169, 204, 205, 207, 211, 231, 249 rating scale, 147, 153 ratings, 150 reaction time, 177

271

reading, 9, 65, 66, 70, 108, 117, 131, 132, 134, 135, 156, 216, 217, 218, 219, 221, 222, 223, 224, 225, 226, 227, 228, 247 reading assessment, 225 reading comprehension, 132 reading difficulties, 227 reality, 15, 22, 69 reasoning, 65 recall, x, 148, 201, 215, 217, 220 recognition, 63, 67, 69, 70, 75, 85, 217, 218, 220 record keeping, 145 recreation, 152, 164, 165, 166, 170, 171, 179 recreational, 152, 165, 167, 171, 251 reduction, viii, 7, 14, 23, 25, 27, 28, 29, 33, 34, 37, 38, 39, 79, 92, 106, 126, 248 refining, 43 reflection, 2, 16, 65, 72, 83, 234, 235 reflexes, 146, 149 reforms, 32, 230, 244 regional, 84, 94, 95 registered nurses, 62, 63, 71, 75, 76, 77 regression, 126, 144 regular, ix, 12, 96, 97, 98, 115, 126, 131, 139, 148, 154, 156, 160, 164, 171, 177, 188, 248 regulation, 133 regulations, 131, 180, 181 rehabilitation, 81, 90, 159, 161, 184 rehearsing, 32 reinforcement, 86, 116 rejection, 73 relationship, 4, 5, 9, 13, 14, 21, 22, 24, 26, 29, 99, 157, 165, 169, 172, 174, 176, 177, 180, 181, 191, 192, 204, 213, 224, 247, 253 relationship maintenance, 24 relationships, 12, 13, 15, 19, 21, 22, 40, 73, 83, 86, 95, 103, 123, 177, 204, 217, 247, 250 relative size, 13 relevance, 8, 107, 145, 233, 242 reliability, v, 103, 146, 147, 148, 150, 151, 187, 198, 199, 200, 201, 211, 212, 220 religion, 84, 95 religions, 18 religious, 18, 47, 57, 84 repeatability, 147 repetitions, 126 report, 145, 147, 149, 151, 153, 162, 167 reproduction, 217 research, v, vii, viii, 6, 7, 9, 16, 17, 24, 25, 26, 27, 28, 35, 43, 48, 51, 53, 56, 57, 58, 63, 64, 66, 71, 72, 73, 74, 75, 77, 79, 80, 81, 82, 83, 84, 92, 96, 97, 99, 100, 101, 102, 103, 105, 107, 108, 112, 123, 126, 131, 132, 133, 137, 184, 188, 198, 200,

Index

272

202, 207, 211, 212, 213, 216, 217, 218, 219, 221, 224, 225, 226, 227, 244, 245, 255 researchers, viii, 6, 11, 18, 19, 20, 58, 73, 79, 82, 83, 86, 100, 150, 200 residential, 116, 139, 140, 159 resistance, 126, 234 resource allocation, 195 resource management, 192 resources, 24, 35, 51, 62, 82, 86, 87, 132, 135, 158, 159, 209, 210, 232, 233, 251 respiratory, 146 responsibilities, ix, 134, 170, 187, 188, 191, 192, 193, 241 responsibility, 125, 134, 154, 166, 180 responsibility for learning, 254 responsiveness, 9 retardation, 141, 175 retention, 56, 77, 224 retirement, 133 retirement age, 133 rewards, 69 Reynolds, 216, 226, 227 rhetoric, 51, 53, 56 rhythm, 127 rights, 125, 129 rings, 141, 144 risk, ix, 2, 3, 4, 5, 6, 11, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 81, 86, 89, 93, 99, 102, 103, 159, 192, 193, 197, 208, 209, 210, 213, 215, 216, 218, 219, 222, 224, 225, 227, 243, 246, 248, 254 risk assessment, 193, 209 risk behaviors, 17, 18, 20, 25, 28, 29 risk factors, 26, 27, 81, 218 risk management, 192, 208, 209, 213 risks, 4, 17, 21, 25, 195, 210 risk-taking, 6, 246 RNs, 77 rodents, 177 role-playing, 118, 168, 247 rotations, 206 routines, 130, 132, 162, 163, 166, 168 rubella, 137 rubrics, 147, 153 rural, 5, 25, 29, 80, 84, 87, 88 rural areas, 88 rural communities, 29 Rutherford, 16, 26 Ryan, Jack, 158, 179

S safeguards, 118, 129, 177

safety, 10, 146, 155, 156, 159, 163, 167, 168, 169 salary, 40 sample, 5, 6, 15, 17, 19, 20, 29, 91, 199, 202, 203, 206, 222, 225 sampling, 64, 107, 199, 203, 205, 207, 211 satisfaction, 11, 51 scarce resources, 111 scatter, 204 scatter plot, 204 scheduling, 116 schema, 35, 36, 38 schemas, 142 scholarship, 6, 16, 21, 24 school, vii, viii, ix, x, 21, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 45, 46, 51, 52, 53, 55, 56, 57, 59, 76, 99, 102, 105, 106, 107, 109, 110, 111, 112, 113, 116, 119, 120, 121, 126, 128, 129, 130, 131, 132, 133, 134, 135, 139, 140, 142, 145, 155, 156, 157, 158, 159, 160, 161, 162, 165, 166, 168, 175, 176, 177, 179, 180, 182, 218, 219, 220, 224, 227, 229, 230, 231, 232, 235, 238, 239, 241, 242, 243, 244, 245, 246, 247, 248, 249, 250, 251, 252, 253, 254, 255 school climate, 243 school community, 244 school culture, 245, 255 school learning, 255 school management, x, 241 school work, 245 schooling, ix, 33, 37, 41, 50, 52, 54, 56, 105, 108, 111, 112, 247, 248, 249, 253 science, vii, viii, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 76, 132, 170, 181, 199, 206 science education, vii, viii, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58 scientific, 26, 33, 44, 45, 46, 47, 48, 49, 50, 51, 53, 54, 55, 56, 57, 62, 83, 89, 90, 91, 206 scientific knowledge, 33, 47, 48, 50, 51, 53, 54, 55, 56 scientific method, 44, 49 scientific understanding, 45 scientists, 38, 43, 46, 47, 48, 49, 50, 55, 93 scoliosis, 137 scores, 19, 132, 133, 144, 147, 149, 150, 152, 200, 207, 218, 222, 223, 247 seals, 55 search, 144, 212 secondary, 180 secondary school students, 249 secondary schools, 254, 255

Index secondary students, 254 security, 117, 169, 179 sedentary, 95, 121, 125, 140 sedentary lifestyle, 95, 121, 125 selecting, 147 self, 119, 122, 125, 126, 128, 134, 136, 140, 141, 144, 148, 152, 155, 157, 158, 159, 160, 166, 168, 171, 184 self esteem, 24 self-actualization, 125 self-assessment, 208 self-care, 95, 96, 97, 99 self-concept, 157, 166 self-contained classrooms, 134 self-control, 125 self-determinism, 81 self-efficacy, 5, 6, 81, 86 self-esteem, 21, 22, 157, 171, 248 self-expression, 122 self-help, 152 self-management, 81, 126 self-report, 14, 17, 148 semantic, 47 Senate, 102 sensations, 173 sensing, 176 sensitivity, 68, 83, 84, 85, 103, 156, 226 sensory impairments, 116, 117, 118, 119, 120, 134, 135, 136, 144, 157, 159, 160, 161, 163, 164, 165, 166, 167, 169 sensory systems, 140 sequencing, 116 series, vii, 35, 90, 96, 174 service provider, 18, 145 services, iv, 7, 11, 18, 19, 23, 80, 81, 87, 88, 90, 96, 97, 98, 99, 119, 128, 129, 130, 140, 157, 159, 160, 161, 162, 164, 165, 166, 169, 175, 176, 178, 188, 226 severity, 3, 12, 106, 132 sex, vii, 1, 5, 6, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 27, 29 sexual activities, 14 sexual activity, 21 sexual behavior, 3, 4, 5, 6, 9, 13, 17, 18, 22, 24, 25, 29 sexual contact, 2, 13, 21 sexual experiences, 4, 13, 22 sexual health, 6, 28 sexual identity, 17, 18 sexual intercourse, 4 sexual orientation, 18, 121 sexual risk behavior, 6, 29 sexuality, 18

273

sexually transmitted diseases (STD), 2, 6, 14, 22, 23, 24, 26 Sexually Transmitted Infections, 26 shame, 7 shape, 97, 217, 219, 221, 224 shaping, 163, 171, 172 sharing, 70, 73, 243, 247 sheep, 47 shelter, 22, 101, 141 short period, 124, 126 shortage, 133, 134 short-term, 156, 216 shoulder, 137 shy, 128 siblings, 249 SIGMA, see Support for Improvement in Governance and Management in Central and Eastern European Countries, 150 sign, 62, 139, 143, 151, 162, 173 signals, 173 significance level, 205 signs, 6, 144, 155, 156, 165 similarity, 107 single test, 130 sites, 106 skeletal muscle, 177 skeleton, 156 skill acquisition, 132, 136 skills, ix, 24, 33, 38, 43, 50, 51, 52, 53, 54, 57, 62, 64, 65, 66, 70, 73, 80, 81, 84, 86, 91, 115, 116, 117, 118, 119, 120, 121, 122, 124, 126, 132, 133, 134, 135, 136, 137, 138, 140, 142, 144, 145, 146, 147, 149, 150, 151, 152, 153, 154, 155, 157, 158, 159, 160, 161, 162, 163, 164, 165, 166, 167, 168, 170, 171, 172, 174, 175, 176, 177, 178, 180, 184, 191, 208, 216, 217, 218, 219, 225, 226, 230, 233, 234, 237, 248 skills training, 24 skin, 173 sleep, 12, 27, 106, 109, 111 smoking, 95, 96, 126 SMS, 202 soccer, 124, 128, 181 social, 4, 8, 14, 15, 16, 18, 20, 24, 29, 35, 48, 49, 50, 62, 72, 80, 81, 82, 83, 84, 86, 91, 92, 93, 94, 95, 98, 101, 103, 106, 112, 118, 119, 122, 125, 133, 135, 139, 140, 142, 143, 151, 152, 155, 162, 164, 166, 169, 171, 179, 183, 199, 230, 231, 237, 245, 246, 247 social behavior, 122 social capital, 94 social change, 82 social cognitive model, 4

274

Index

social cohesion, 98 social construct, 245 social context, 24, 106, 162 social development, 118 social environment, 93 social inequalities, 82 social influences, 24, 101 social justice, 103 social network, 24, 94, 247 social norms, 24 social problems, 8 social relations, 83, 93, 98, 119, 135, 246 social relationships, 83, 119, 135, 246 social responsibility, 125 social security, 179 Social Security, 159, 179 social situations, 133 social skills, 133, 140, 142, 171, 231 social status, 72 social structure, 139 social support, 86, 91 social work, 112 social workers, 112 socialization, 71, 73, 142, 143, 152 socially, 155, 164 society, viii, 2, 8, 19, 31, 39, 40, 41, 42, 43, 51, 53, 58, 72, 73, 84, 94, 139, 176 sociocultural, 26, 62, 63, 75 socioeconomic status (SES), 217, 224 sociological, 147 software, 42, 64, 148, 149 solar, 55 solutions, 82, 85, 86, 89, 135, 235 sorting, 116 sounds, ix, 47, 139, 158, 215, 216, 217, 218, 219, 220, 221, 222, 223, 224, 225 spastic, 177 spatial, 136, 137, 159, 172, 173, 177 special education, 116, 117, 129, 130, 132, 133, 134, 141, 159, 175, 177, 226 specialists, ix, 115, 146, 160, 161, 163, 165, 166, 167, 176, 184, 245 species, 48 specificity, 34, 126 spectrum, 97 speech, 65, 138, 139, 140, 152, 175, 176, 227 speed, 150, 177 spelling, 116, 146, 219, 226 spermicide, 21 spheres, 238 spinal cord, 148 spinal cord injury, 148 spine, 177

spiritual, 84, 94 sports, 21, 121, 124, 126, 128, 176, 177, 181, 183 Sputnik, 32 Sri Lanka, 113 stability, 117, 119, 146 stabilization, 5 staff, 116, 117, 119, 153, 154, 161, 162 staff development, 243, 244, 246 stages, 4, 16, 28, 72, 73, 93, 142, 247 stakeholders, 112, 246 standardization, 151 standards, v, 47, 68, 120, 122, 123, 125, 126, 130, 132, 133, 154, 183, 189, 187, 192, 193, 194, 195, 196, 200, 201, 203, 207, 208, 209, 210, 211, 231, 233, 244, 249, 252, 253, 254 State Department, 154 statistical analysis, 189, 194, 202 statistics, x, 2, 48, 189, 215, 222, 223 status of children, 181 statutory, 188 stereotypes, 17 stigma, 18, 25 stigmatization, 17 stigmatized, 18 STIs, 14, 25 storage, 168 strategic, 93, 99 strategic planning, 93 strategies, ix, x, 6, 12, 23, 25, 27, 34, 37, 52, 73, 81, 85, 87, 88, 91, 93, 94, 97, 98, 115, 122, 124, 130, 135, 138, 146, 155, 160, 163, 165, 166, 168, 169, 177, 178, 180, 221, 234, 243, 247, 248, 249, 253 strength, 125, 132, 136, 137, 147, 148, 150, 151, 165, 176 stress, 44, 81, 119, 125, 127, 135, 142, 145, 171, 217, 235, 237 stretching, 143 strictures, 236 strikes, 45, 48 Structural Equation Modeling (SEM), 212 structuring, 169 student achievement, 132, 135, 243, 248, 251, 252 student behavior, 130, 176 student group, 238 student motivation, 250 students, vii, ix, x, 31, 32, 33, 34, 35, 37, 38, 39, 40, 41, 42, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 58, 59, 73, 75, 76, 77, 78, 107, 115, 120, 123, 124, 125, 126, 128, 129, 130, 131, 132, 133, 134, 135, 139, 140, 143, 144, 146, 151, 153, 154, 155, 156, 157, 158, 159, 161, 162, 163, 164, 165, 166, 167, 168, 169, 170, 171, 172, 173, 174, 176, 177, 181, 183, 184, 185, 198, 202, 203, 215, 216,

Index 217, 218, 219, 220, 221, 222, 224, 225, 231, 233, 235, 236, 238, 239, 241, 243, 244, 245, 246, 247, 248, 249, 250, 251, 252, 254 study, 121, 123, 134, 151, 154, 157, 169, 183 subgroups, 14, 16, 152 subjective, 5, 6, 189, 191, 192, 193, 235 subsistence, 41 substance abuse, 18, 27 substance use, 25 substances, 17 success rate, 224 successive approximations, 171, 172 sugar, 84, 99 summer, 238, 248 superstitious, 89 supervision, 164, 174, 192, 195, 239 supervisors, 153 supplemental, 221 supply, 53, 54, 179 Support for Improvement in Governance and Management in Central and Eastern European Countries (SIGMA), 150 suppression, 33, 37, 43 suppressor, 32, 56 Supreme Court, 129 surface structure, 83, 84, 85 surprise, 21 Survey, 165 survival, 27, 29, 90 surviving, 71 susceptibility, 3, 4 sustainability, 93, 100 swelling, 90 Sydney, 184 symbolic, 63 symbols, 166, 217, 219 sympathy, 44 symptom, 89, 106 symptoms, 88, 89, 90, 109, 142 synthesis, 72 Syphilis, 2, 28, 29, 141 systematic, 157, 169, 176, 200, 205, 225, 237, 246 systems, 78, 93, 95, 97, 130, 131, 132, 158, 159, 162, 175, 231, 239

T tactics, 122 talent, 253 tangible benefits, 98 target population, 5, 18, 82, 83, 84, 85 targets, 59 taxes, 40

275

tea, 100 teacher support, 250 teachers, ix, x, 47, 49, 55, 56, 107, 112, 115, 116, 117, 118, 120, 131, 133, 134, 135, 137, 139, 143, 145, 153, 160, 161, 162, 218, 231, 238, 241, 242, 243, 244, 245, 246, 247, 249, 250, 251, 252, 254 teaching, ix, x, 115, 116, 117, 119, 120, 121, 125, 131, 132, 133, 134, 135, 146, 157, 160, 163, 166, 169, 170, 172, 174, 180, 181, 184, 215, 219, 220, 221, 222, 224, 225, 232, 233, 234, 236, 238, 241, 243, 244, 245, 246, 247, 248, 250, 251, 252, 253, 255 teaching process, 117, 236 teaching strategies, x, 160, 163, 241 team members, 89, 155, 159, 160, 162, 166, 168, 245 technical assistance, 130 technological, 62 technology, 42, 158, 159, 165, 166, 176, 193, 221, 247, 252 teeth, 87, 88, 89, 96, 97, 102 telephone, 168 television, 9 temperature, 127, 145, 158, 167, 203 temporal, 172 tension, 44 tertiary education, viii, 39, 61, 62 test scores, 128, 132, 244 testimony, 47, 48, 55, 244 tetanus, 88 Texas, 180, 181, 184 textbooks, 48 theoretical, 2, 6, 24, 77, 83, 100, 231, 235, 236 theory, vii, viii, 1, 2, 3, 4, 5, 9, 10, 12, 16, 20, 21, 23, 24, 26, 27, 37, 55, 57, 61, 63, 64, 66, 71, 73, 76, 77, 92, 100, 101, 103, 117, 177, 184, 231 therapeutic, 121 therapy, 176, 177, 179 thermoluminescence, 101 thinking, 32, 52, 56, 57, 64, 65, 66, 67, 70, 73, 77, 78, 106, 225, 244, 248 Thomson, 213 threat, vii, 1, 16, 23 threatened, 80 threatening, 171 three-dimensional, 174 threshold, 117 time, vii, viii, ix, 1, 2, 11, 12, 13, 18, 19, 21, 22, 23, 31, 32, 33, 34, 37, 40, 45, 46, 48, 54, 55, 56, 57, 58, 59, 66, 69, 71, 76, 81, 84, 86, 92, 93, 95, 97, 99, 106, 108, 109, 110, 111, 112, 115, 116, 117, 119, 120, 122, 124, 126, 128, 130, 134, 135, 139, 140, 141, 142, 143, 147, 148, 151, 153, 155, 160, 163, 164, 166, 168, 170, 176, 177, 182, 188, 203,

276

Index

206, 208, 218, 222, 224, 225, 231, 235, 236, 239, 244, 245, 247, 249, 252 timing, 191 tissue, 125 title, 196 tobacco, 101 toddlers, 159 tolerance, 73, 210 top-down, 151 toxic, 55 toys, 142, 144, 153, 161, 164, 167 tracking, 56 trade, 38 tradition, 90 Traditional, 147, 158 traditional healers, 87, 88, 90, 91, 92 traditional practices, 100 traffic, 158 training, x, 4, 21, 23, 24, 40, 45, 65, 71, 98, 121, 123, 124, 126, 127, 134, 138, 140, 145, 149, 151, 153, 156, 158, 159, 160, 163, 165, 171, 172, 191, 198, 199, 208, 226, 229, 230, 231, 233, 234, 235, 238, 244, 245, 248 training programs, 126 traits, 179 trans, 20 transactions, 188 transfer, vii, 31, 40, 65, 72, 231, 233, 235, 237, 239 transformation, viii, 45, 61, 64, 71, 72, 73, 74, 75, 76, 77, 189, 230 transition, 62, 118, 151, 161 transition to adulthood, 161 transitions, 161 transmission, 3, 14, 17, 19, 21, 24, 26, 29, 34, 88, 89, 102, 246 transparency, 35 transport, 91, 125 transportation, 158, 159, 164, 166, 167, 168 travel, 80, 157, 158, 159, 160, 161, 162, 163, 164, 165, 166, 177 treatment programs, 28 trend, 62, 68 trial, 28, 29, 66, 182 trial and error, 66 triggers, 197, 218 trust, 11, 21, 41, 47, 48, 55, 86, 99, 119, 155, 163, 232, 245 tuition, 97 tutoring, 237 two-way, 93, 98, 100

U ubiquitous, 87 Uganda, 84, 87, 88, 100, 103 UK, 102, 241, 244, 245, 247, 250, 251, 254 uncertainty, 93, 99, 246, 253 undergraduate, vii, 31, 54 unemployment, 40 uninsured, 11 United States (US), v, 2, 6, 27, 47, 84, 105, 107, 110, 111, 112, 121, 131, 138, 140, 154, 179, 183, 213 universe, 45 universities, viii, 61, 62, 160 urban, 5, 28, 29, 106, 113, 248, 254 US Department of Health and Human Services, 25, 80, 81, 103 users, 20, 42, 93, 176

V vaccine, 20 vacuum, 58 vaginal, 6 validation, 23, 112, 226 validity, 103, 146, 151, 198, 211, 212 values, 54, 66, 67, 81, 82, 84, 87, 91, 122, 210, 243, 246, 250 variability, 218 variable, 199, 202, 203, 204, 205, 206, 222 variables, vii, 1, 35, 123, 146, 199, 201, 202, 203, 204, 205, 206, 207, 208, 209, 211, 243 variance, 17, 204, 205, 206, 207, 208, 210, 225 variation, 37, 38, 51, 205, 206, 243 vasectomy, 15 vehicles, 167 vein, 81 video, 98, 100 village, 71 viral, 102, 110, 141 viral infection, 141 Virginia, viii, 105, 106 virus, 2, 8, 13, 15, 20, 21 visible, 84, 135 vision, 42, 130, 135, 136, 141, 142, 143, 144, 146, 153, 155, 156, 158, 159, 161, 164, 165, 166, 167, 173, 176, 177, 180, 241, 246 visual, 88, 116, 122, 136, 137, 138, 141, 144, 146, 149, 150, 157, 158, 159, 160, 161, 162, 163, 165, 168, 172, 173, 175, 177, 179, 180, 181, 182, 183, 184, 217, 218, 219, 220, 224, 225 visual acuity, 159 visual attention, 173

Index visual field, 159 visual images, 219, 220 visual memory, 224 visual skills, 165 visualization, 237 vitamin A, 106, 113 vocabulary, 158, 218 vocational, 40, 152, 171 vocational training, 40 voice, 141, 166 vomiting, 87, 89, 90 voters, 55, 57 vulnerability, 80 vulnerable people, 84

W waiting times, 96 Wales, 241, 255 walking, 136, 137, 138, 141, 150, 151, 175, 176 warrants, 33, 34, 36, 37, 38, 39, 41, 42, 44, 45, 47, 48, 51, 56, 58 Washington, 103, 106, 182, 183, 184, 227 waste, 59 water, 99, 120 Watson, 131, 180 weakness, 35 wealth, 37, 39, 40, 41, 43, 44, 67, 153 wear, 5, 22, 139, 158, 168 web, 184, 220, 244 websites, 100 weight loss, 106 welfare, 112

277

well-being, 95, 125 wellness, 8, 121, 122, 154, 170, 171 West Africa, 108, 110 Western societies, 38 wheelchair, 166, 169 White, 130, 131, 132, 133, 134, 135, 185 wildfire, 16 wind, 167 windows, 213, 224 winter, x, 229 wisdom, 48, 82 wives, 17 women, 2, 5, 9, 10, 13, 15, 16, 19, 20, 21, 22, 23, 24, 26, 27, 29, 71, 72, 73, 76, 77, 87, 88, 89, 91 word recognition, 218, 226 work, 116, 117, 128, 130, 131, 133, 134, 153, 162, 166, 171 work environment, 74 workers, 43, 84, 90, 98, 101, 107, 161 workforce, 37, 38, 43, 74, 76 working population, 87 workplace, 62, 67, 71, 72, 74, 75, 160, 230 World Health Organisation (WHO), 80, 87, 103 worldview, 110 worry, 45, 183 writing, 55, 65, 130, 134, 217, 218, 219, 225, 235, 247 writing process, 235

Y yellow fever, 110 yield, 38, 50, 144