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Knowledge and Perceptions About Back Education Among Elementary School Students, Teachers, and Parents in Belgium Greet Cardon, llse De Bourdeaudhuij, Dirk De Clercq

ABSTRACT: A back education program for Belgian elementary school children was evaluated using self-reported questionnaires before intervention and at three follow-up points during one year. Most children found the program interesting, important, and amusing. Intervention children (n = 347) showed better back care knowledge than control children (n = 359), and knowledge gained was retained over a period of one year. Back education did not result in increased fear-avoidance beliefs about physical activity, and intervention children reported more checking of their book bag weight than controls at all test moments. Self-reported behavior in rehtion posture-related and back care related segeficacy were affected only minimally by the pmgram, possibly due to pwr serf- judgment. Involvement. fear-avoidance belief, and back care knowledge of teachers and parents of the intervention children showed low correlation with the children’s perceptions and knowledge. Suficient promise exists to justib fitrther development and evaluation of early back education. (J Sch Health. 2002;72(3):100-106)

onsidering the social costs and disability secondary to C back pain, it is important to encourage back pain prevention programs, Prevention efforts are mainly directed at adults, but the results have been questioned,’3 so several authors advocate implementation of back education in elementary schools.” Other reasons for implementing early back education include the high back pain prevalence rates in children and adolescent^,'-'^ school-related risk factors of back pain such as book bag weight6.” and prolonged ~itting,’~ and predictive value of adolescent back pain on back pain as an Moreover, prevention h u g h the school system makes it possible to reach a large percentage of the population.

The need for early back education is expressed by many authors, but specific guidelines do not exist and little is known about effects of such a In the sparse literature on this topic, improved back care knowledge and practice of back care principles was found in elementary school children, shortly after completing a back education program.‘8 1Y-z2 Chometon et a12’ found improved self- reported behavior in relation to back care up to two years following back education. Based on the theory of planned beha~io?~ knowledge, attitudes, self-efficacy, and social support can be considered important predictors for health behavior. However, literature on these factors in relation to back education in children is limited. Making use of a practical test, efficacy of a back education program influenced use of back care principles up to one year after program completion.2-’ In this simultaneous study, determinants of the effects are examined, making use of questionnaires in extended samples.

In contrast to positive outcomes from early back education, Burtonz6 reported in a study on low back pain in chil-

Gnsl Cordon, PhD, ([email protected]); the De Bounhudh@, PhD, ([email protected]); and Dirk Dc Clercq, PhD, (dirk.declercq8rug.ac.be); Ghent University, Dept. of Movement and Sports Sciences, Watersportfaan 2, 9wo Ghent, Belgium. This articie was submitted March 2, 2001, and revised and accepted for publication October i, 2001.

dren and adolescents little evidence that giving ergonomic advice would be beneficial in adolescents with back pain, and it is arguable that such advice might be unduly alarmist. Conversely, Burton et alZ7 found in a study on adult back pain patients that back education resulted in improved fear-avoidance beliefs about physical activity. Fear-avoidance beliefs about physical activity may be involved at a very early point in the development of pain and associated activity problems in people with back pain.’* However, no study could be located that evaluated the influence of back education in elementary school children on their fear-avoidance beliefs about physical activity.

This study investigated effects of a six-week back education program in children 9 to 11 years of age. Researchers hypothesized that knowledge, fear-avoidance beliefs, self- efficacy, and self-reported behavior in relation to back care are better in children who followed a back education program than in controls within one week after the program, three months after the program, and one year after the program. A previous studys and the literatures found that the teacher of the children may play an important role in efficacy of back education. According to the literature,M parents also play a vital role as primary influences on children’s health choices. However, no studies were found on involvement of parents in back education given to children. A second aim of this study was to evaluate commitment, social support, knowledge, and fear-avoidance beliefs of parents and teachers whose children or pupils followed back education, and to study the correlation for these variables between the children and their teachers and parents. Researchers hypothesized that a positive correlation (> 0.5) exists between children and their teachers and parents for the evaluated variables.

METHODS Child data were collected at school, during regular class

periods, under the supervision of an independent tester within one week before the start of the intervention (pretest); within one week after the intervention (posttest

100 Journal of School Health March 2002, Vol. 72, No. 3

1); three months after the intervention (* 10 days) (posttest 2); and one year (A 1 month) after the intervention (posttest 3). At posttest 1, parent and teacher questionnaires were completed at home and collected at school. Data were obtained from April 1999 to December 2000.

Sample Respondents included fourth- and fifth-grade pupils

(Table 1) from Belgian public elementary schools with similar curricula, the intervention pupils’ parents and their class, and the physical education (PE) teacher, Classes (n = 16) of pupils (n = 347) were selected by simple randomiza- tion from all classes (n = 36), participating in the back education program between April and November 1999. Classes (n = 16) of controls (n = 359) were randomly selected from five comparable schools not participating in the program. Children younger than 9 or older than 12 years at pretest were excluded.

Because the parent and teacher questionnaires were linked directly to the program, they were only given to parents (one parent for each child, n = 347) and teachers (16 class teachers and 13 PE teachers) of intervention children. Three classes of the intervention group had no physical education teacher because physical education classes were given by the class teacher. A limited sample (n = 198) of the intervention group, evaluated with a practical test in the scope of a different simultaneous study,” was used to evaluate the correlation between self-reported and observed behavior after following back education. The pupil questionnaire was considered part of the psychological, medical, and social counseling provided by the school for which parents signed a consent form. The study protocol was approved by the Ethics Committee of the Institution.

Intervention The back education program, also used in previous stud-

ies,ZI,29.31 was organized and sponsored by a health insurance company and the local government. The program was developed and carried out by a team of practitioners, independent of the testers. The long-term goal of the program was to attain good body mechanics and correct posture while performing various tasks based on good understand- ing of basic back care principles. Every six weeks, exclud- ing holidays, the program started in fourth- and fifth-grade classes of other schools.

The program, begun in January 1999, consisted of six sessions of 60 minutes at one-week intervals. It was taught by a physical therapist through guided discovery and active hands-on methods to one class group at a time (maximum

Table 1 Number, Gender, and Average Age

of Respondents in the Intenrention and Control Groups

Inbtwntlon Group Control Group

Number 347 359

BoydGirls (%) 16511 82 (47.662.4) 236/123 (65.7134.3)

Avoraga Ago (SD) 10.0 years (* 0.6) 10.1 years (kO.7)

26 pupils). All games, movements, and exercises were based on children’s daily activities, like getting out of bed, brushing teeth, sitting at a table, and canying a book bag. Back care principles were “translated,” made easy to understand and attractive for the children, through use of cartoons, games, and lots of materials. Pupils were taught basic anatomy and pathology of the back and basic principles of correct posture while standing, sitting, lying, lifting, carrying, pushing, and bending.

To optimize integration of back care principles into the daily classroom routine, the teacher was present during all sessions. The program was created making use of 10 guidelines on how ”to make your discs happy:” 1) always keep the natural curves of your back, 2) be active and join in sports, 3) place your book or homework on a ring binder or inclined desk, 4) when you relax lie down on your back with your legs raised, 5 ) bend your knees and not your back, 6) to lift, stand as close as possible to the object, 7) ask for help in lifting a heavy object, 8) carry an object as close as possible to your body, 9) carry your book bag on your back, and 10) your book bag should not weigh more than one-tenth of your body weight.

In every school, an information session was organized for parents and teachers, consisting of a two-hour lecture on back care principles with guidelines on how to enhance back care at home and in the classroom. Parents and teachers received a back care brochure. Every teacher received a manual with a thorough description of all lessons and extra exercises.

Instruments . Different questionnaires, based on a previous study and

the liter~~,9.I1.1920.32 were used for the children, parents, and teachers (Table 2). In a pilot study, 150 children, 20 parents, and 10 teachers not participating in this study, completed the questionnaire to identify unclear questions, which then were modified. Information about social support was obtained directly through the parents and teachers. Questions abut back pain prevalence and physical activity also were included, but reporting of these results is beyond the scope of this study.

Data were analyzed using SPSS for Windows (9.0). To evaluate test-retest stability, 85 pupils not participating in this study, completed the questionnaire twice with a one- week interval. Stability estimates ranged from 0.42 to 0.82. The lowest estimate was found for self-reported posture while carrying a load. In cases where scales were used, Cronbach’s Alpha reliability coefficients were established to check internal consistency of the items (Table 2). Independent-sample T tests were conducted to detect significant between-group differences. To study the correlation between observed and self-reported behavior and between scores of parents, teachers, and pupils, Pearson’s correlations were determined. Statistical significance was set at P c 0.05.

RESULTS Pupil Questionnaire

A dropout of 8% (n = 56) was found from pretest to posttest 3 (interval 13-14 months), due to transfers to other schools or being absent on the day of the survey. Within one week after program completion, mean score for attitude toward the program among intervention children was

Journal of School Health March 2002, Vol. 72, No. 3 101

14.3/15 (range 3-15, SD IS), with a maximum score in 72.1% of the children. At baseline no significant group differences were found except for a significantly higher score for self-reported book bag weight checking in the intervention group.

The intervention had a clear effect on general and specific back care knowledge at the three follow-up points. Improvement in general back care knowledge from pretest to posttest 3 was 33% in the intervention group and 12% in the control group. For knowledge more specifically related

to the program, the improvement was 21% in intervention children and 6% in controls. The intervention children demonstrated better fear-avoidance beliefs than comparison pupils at posttest 1 and 3. For self-efficacy, no statistical group differences were found, except for keeping good posture at posttest 1 and 2. For self-reported checking of book bag weight, intervention pupils scored higher than controls at baseline and at all posttests. Self-reported posture while taking off shoes was significantly higher in intervention pupils at posttest 2, while scores for lifting and

Table 2 Information on the Questionnaire for Pupils, Parents, and Teachers

Conmct Qurrtlonnaim for the Pupils

# of ltems Sample Item Response Format a

When lifting a heavy box off the floor you should a) keep your feet as far apart as possible, b) do most of the work with your back, c) bend your knees, General back care

knowledge 12 d) keep the box on one side of the body Multiple choice

To carry a heavy load far away from your body 3-point scale (Yes, no or Specific knowledge 10 is healthy not sure)

5-point scale (definitely yes Fear-avoidance beliefs 5 When your back hurts, it is dangerous to swim to definitely no)

Attitude towards the program* 3 The back education program was interesting agree to I strongly disagree)

5-point scale (I strongly

How do you perceive checking your Self -efficacy 3 book bag weight?

4-point scale (very difficult to very easy)

5-point scale (definitely yes Self-reported behavior 4 Do you check the weight of your book bag? to definitely no)

Quectionnaim for the Parents Specific knowledge See pupils Fear-avoidance beliefs See pupils

Program commitment 5 Did you join the information session? 2-point scale (no-yes)

5-point scale (definitely yes Social support 3 Do you check your child's book bag weight? to definitely no)

5-point scale (definitely yes Do you think your child is able to keep good posture? to definitely no) Perceived behavior 2

NA

NA

0.70"

0.71b

NA

NA

O.7Ob

NA

NA

NA

Questionnaire for the T m c k (class + Pf) Specific knowledge See pupils

Fear-avoidance beliefs See pupils Class: 0.82 PE: 0.70b

Program commitment 10 Do you think the manual is useable for your lessons? 2-point scale Qes-no) NA

': Reliability coefficients were calculated using baseline data. b: Reliability coefflcients were calculated using posttest 1 data (no pretest data available). NA = not applicable (not one-dimensional items)

only obtained from the intervention children at posttest 1


Table 3 Estimates and T-values of Between-Group

Dlfferences for Knowledge and Fear-Avoidance Beliefs in the Intervention and Control Groups

at Pretest, Posttest 1,2, and 3

Intervention Control Group Group N=347 N=359

Variable Mean (SD) Mean (SD) T

0.IWHII back care knOWlCtdfp

(range-12- +12)

Sprciflc back care -@ale (range-10- +lo)

Fearavoidance beliefs (range 5-25)

wf+rncacy (range 1-4)

doing sports daily

* posture

book bag load

Self-reported behavior (range 1-5) book bag

weight

* posture while taking off shoes

posture while lifting

carrying close to the body

Pre Post 1 Post 2 Post 3










0.7 (3.1) 5.1 (3.1) 5.3 (3.1) 4.7 (3.0)

5.1 (2.1) 7.1 (2.3) 7.2 (2.2) 7.2 (2.3)

12.9 (4.2) 14.0 (5.2) 14.0 (5.9) 13.9 (5.3)

3.1 (0.6) 3.2 (0.8) 3.2 (0.6) 3.1 (0.7)

2.7 (0.8) 2.8 (0.8) 2.8 (0.8) 2.6 (0.7)

3.0 (0.9) 2.8 (0.9) 2.8 (0.9) 2.6 (0.9)

2.5 (1.2) 3.2 (1.9) 3.1 (1.1) 2.9 (1.1)

3.9 (1 .l) 4.2 (1.2) 4.3 (1 .O) 4.3 (1 .O)

3.5 (1.2) 4.2 (1.2) 4.2 (1 .l) 4.2 (1.1)

4.0 (1,l) 4.6 (1 .O) 4.4 (1.2) 4.4 (1 -1)

0.4 (3.0) 0.8 (2.9) 1.2 (2.7) 1.9 (2.9)

5.1 (2.0) 5.2 (2.1) 5.0 (2.3) 5.7 (2.2)

13.1 (4.2) 12.7 (4.2) 13.8 (4.6) 12.8 (4.8)

3.1 (0.7) 3.2 (0.7) 3.1 (0.8) 3.1 (0.7)

2.7 (0.9) 2.7 (0.9) 2.6 (0.9) 2.5 (0.8)

3.0 (0.9) 2.8 (0.9) 2.7 (1 .O) 2.6 (0.9)

2.0 (1.1) 2.2 (1 .l) 2.2 (1.2) 2.2 (1 .l)

4.1 (1.0)

4.1 (1.2) 4.4 (0.8)

3.6 (1.2)

3.8 (1.3)

4.3 (0.9)

3.9 (1 .l)

4.1 (1.0)

4.1 (1.1) 4.2 (1.0) 4.0 (1.3) 4.4 (0.8)

1.2 18.8- 18.1- 11.6-

0.2 10.8- 12.4- 8.5-

0.4 3.5- 0.4 2.6-

0.5 0.2 0.2 0.2

0.2 2.3* 2 . F 1.3

0.1 0.3 0.7 0.5

5.4- 11.6- 10.9"" 7.3-

1.9 2.0 3 . P 1.2

1 .o 1.9, 3.9"" 1.1

0.8 4.5- 3.9"" 0.4

p c 0.05, ** p < 0.01, - p 0.001

carrying posture were higher at posttest 1 and 2. Correlations between self-reported and observed behavior for posture while lifting, carrying a load, and taking off shoes, evaluated with a practical test in a limited intervention group sample in the scope of a different study," ranged from 0.01 to 0.28 (Table 3).

Parent Questionnaire Parents' response rate on the post-program questionnaire

was 94% (n = 327); 75% of questionnaires were completed by the mother, 25% by the father. The mean score was 8.7110 (SD 1.6) for the knowledge test and 15.7/25 (SD: 4.1) for the absence of fear-avoidance beliefs. Some 358 of parents reported they followed the information session, 52% read the brochure completely, and 3 1.3% partly, and 62% reported implementation of guidelines from the brochure. Checking of their child's posture was reported by 75% of parents, checking of book bag weight by 468, and doing exercises with their child by 12%. Some 89% of parents reported that their child could keep a good posture, and 68% that their child can keep book bag weight down.

Teacher Questionnaire At posttest 1, all class teachers (n = 16) and 1 1 PE

teachers completed the questionnaire. The knowledge score of the class teachers was 9 3 1 0 (SD: 0.9); for PE teachers the knowledge score was 9.2110 (SD: 1.1). Absence of fear- avoidance beliefs was 17-5/25 (SD: 3.2) in PE teachers and 16325 (SD: 3.7) in the class teachers. Some 15 class teachers and seven PE teachers followed the information session. The brochure was read by 14 class teachers and nine PE teachers, and all found it interesting. The brochure was kept by 14 class teachers and nine PE teachers. Some 11 class teachers read the manual and found it interesting, useable, and clear. All teachers indicated they implemented guidelines in their lessons. Eight PE teachers read the manual and found it interesting and clear. All class teachers but only one PE teacher found the manual useable for their lessons.

Correlation Between Children and Their Parents and Teachers

A low but significant correlation was found between pupils' knowledge scores and commitment of the class teachers (r = 0.24: p < 0.05). the PE teachers (r = 0.13; p < 0.05). and the parents (r = 0.14: p < 0.05). Correlations between commitment of the teachers and parents and the self-efficacy and self-reported behavior scores of the pupils were not significant, except for commitment of the class teacher and self-reported book bag weight checking (r = 0.18; p < 0.05). No significant correlation was found between back care koowledge of the children and the class teachers (r = 0.10), the PE teachers (r = 0.03), and the parents (r = 0.11). A low but significant correlation (r = 0.15; p < 0.05) was found between fear-avoidance beliefs about physical activity of parents and those of children. Correlation of fear-avoidance beliefs between teachers and pupils was not significant (class teachers: r = -0.07; PE teachers: r = 0.11).

For checking book bag weight and keeping a good posture, no significant correlation was found between the pupils' self-reported behavior and the behavior perceived by parents (posture r = -0.02; book bag r = 0.06).

Journal of School Health March 2002, Vol. 72, No. 3 103

lntervention pupils whose parent joined the information session scored significantly higher than intervention pupils whose parent did not follow the information session on general back care knowledge and on fear-avoidance beliefs at all three posttests. Specific knowledge, self-efficacy, and self-reported behavior produced no significant differences, between both intervention groups (Table 4).

DISCUSSION In a simultaneous study= with smaller samples, a practi-

cal test showed improved use of back care principles up to one year after completing a back education program. This study evaluated pupils’ knowledge and perceptions after following back education, making use of questionnaires in extended samples. Children who followed the program were enthusiastic. Almost three-quarters found the program interesting, important, and amusing. A positive attitude toward a health promotion program can exert a positive influence on behavioral change. As hypothesized, and in line with previous findings21J1 and the literature,” intervention children gained knowledge and retained it over one year. In contrast to the assertion by Burtonx that early back education could possibly result in increased feat-avoidance beliefs about physical activity, pupils in this study who followed back education did not have higher fear-avoidance beliefs than controls at all three posttests. However, results may be different in a program aimed only at children with back pain.

In this study, at all test moments, most intervention and control children reported they retained good posture while lifting, canying, and taking off shoes. Lack of improvement following back education might be due to a ceiling effect of baseline scores. However, for these items, low correlations were found between self-reported behavior and actual behavior, observed with a practical test in a limited intervention sample in the context of a different study.2’ Moreover, in the literatureLga and in a previous study:1 poor body mechanics was found in children of this age who did not follow back education.

Perhaps 9- to 12-year-old children have poor awareness of their posture during activities. It may prove useful to help children increase body awareness to help them recog- nize correct and incorrect postures. For book bag weight, intervention children already reported more checking before the start of the program. This finding may be caused by the fact that pupils were aware they would be participating in a back education program. They may have started to check their book bag weight of their own accord since this is a well-known topic of back education. It is a positive study outcome that higher reports of book bag weight checking in the intervention children were retained over the three follow-up points. However, information was only obtained from self-reporting, and book bags were not weighed.

The literature suggests self-efficacy affects both the initiation and continuance of behavior.” Most children in the intervention and control groups perceived back care behavior as “easy” before the start of the program. In contrast to the study hypothesis, intervention pupils did not improve their self-efficacy toward back care behavior except for keeping a good posture at posttests 2 and 3. As for self-reported behavior, and based on high baseline scores, lack of improvement in self-efficacy may be due to

poor judgment of behavior in relation to back care. Alternatively, it could suggest that the program does not implement modeling, feedback, and reattribution suffi- ciently, since these factors are important to improve self- efficacy in health-related behavior.”

These study findings should be interpreted with caution, because a quasi-experimental design and self-reporting questionnaires were used. Moreover, based on low correlations between self-reported and observed behavior, validity of the questionnaire could be questioned. However, this study indicated satisfactory to good test-retest stability, and according to Sallis et al,” self- reported questionnaires can be used with children from about 10 years of age, if results are interpreted with caution.

Only one-third of parents of the intervention children reported they followed the information session organized at school. The brochure, which parents could read at home, attracted more interest. Asking parents to come to school appears to be a barrier. However, an information session is valuable because pupils whose parents followed the information session, better scores were found for general back care knowledge and fear-avoidance beliefs. Parents’ knowledge scores were found to be high, possibly because the brochure was used or remembered while filling out the questionnaire.

According to these study findings, three of four parents check the posture of their child, while for book bag weight, less than one-half of parents do so. A possible explanation may be that parents identify poor posture as a back pain risk factor rather than overweight book bags, or parents may consider book bag weight more the responsibility of

Table 4 Estimates and T-values for Knowledge

and Fear-Avoidance Beliefs in the Intetvention Pupils Whose Parents Did Follow the Information

Session (intervention 1) and in the lnterventlon Pupils Whose Pa& Did Not Follow the Information

Session (intenrention 2) at Pretest, Posltest 1,2, and 3

Variable

Intervention 1 Intervention 2 N-115 N-212 Mean (SD) Mean (SD) t

General Pre back cam Post 1

(range-12- +12) Post 3 w* Post 2

sw* Pre back cam Post 1 howww Post 2 (range-10- +lo) Post 3

Pre Fear-avoidance Post 1 beliefs Post 2 (range 5-25) Post 3

1.3 (3.0) 6.0 (3.1) 6.1 (2.8) 5.7 (2.3)

5.4 (2.0) 7.4 (2.2) 7.4 (2.2) 7.4 (2.2)

13.7 (4.3) 14.7 (4.8) 14.7 (4.9) 15.1 (6.8)

0.8 (3.1) 5.2 (3.0) 5.1 (3.1) 4.5 (2.9)

5.1 (2.1) 7.1 (2.2) 7.3 (2.1) 7.2 (2.2)

12.7 (4.2) 13.5 (4.8) 13.3 (5.7) 13.0 (4.4)

1.5 2 . 2 2.7” 3 . F

1.4 0.7 0.4 0.6

1.8 2.2” 2.0, 2 . F


teachers. Parents should be informed about the risk of over- loaded book bags. For posture and book bag weight checking, most parents believe their child can perform this behavior. In contrast to the study hypothesis, pupils’ self- reported behavior differed from their parents’ perceptions of this behavior.

As also found in the literature,J.19 most teachers seemed receptive to the program. In contrast to parents, most teachers attended the information session, perhaps influenced by the school principal. Practical relevance of the manual seemed higher for class teachers than for PE teachers. The class teacher spends more hours with the children, so it seems logical that content of the manual is directed more to activities of the class teacher. However, findings on the teachers need to be interpreted with caution because the sample size was small. Moreover, to accurately evaluate correlations between the children and their parents and teachers, the questionnaires were not completed anony- mously, possibly resulting in social desirability influencing the answers.

In contrast to the study, correlations between the answers of parents and their children, and between teachers and the children in their classes, were low for back care knowledge and fear-avoidance beliefs. For parents this result may be explained by the fact that most parents did not attend the information session. Teachers, especially the class teachers, demonstrated more commitment to the program. As found in a previous study,” more specific guidelines may optimize the complementary role of the teacher and program efficacy. In line with these findings, children of the parents who reported more support for certain back care principles did not report more implementation of these principles in this study. Efforts should be encouraged to optimize the parents’ role as program rein- forcers. In this study, correlations were evaluated immedi- ately after the program. Perhaps involvement of the parents and teachers has more impact on the children’s results after several months. Moreover, in this study teachers’ and parents’ questionnaires were only used in the intervention group, so program effects on parents and teachers could not be evaluated.

CONCLUSION Back pain prevalence rates in children and adolescents

are high,”-” and adolescent back pain has a predictive value on back pain as an so preventing back pain at young age is an important topic. School-related risk factors for back pain in children and adole~cents~~”“ favor prevention of back pain in children through the school system as a part of a healthful school environment. Back education through the elementary school is a fairly new concept. This study and previous study findings indicate that early back education can favor healthy behavior in relation to back care.

Because changes in knowledge, attitude, and skills may ultimately yield substantial public health benefits, sufficient promise exists to justify further development and evaluation of early back education. The possible role of early back education in primary back pain prevention requires further attention. To evaluate and optimize the role of parents and teachers within early back education, a randomized controlled study is recommended. It also would be useful to compare outcomes of this general back education program

and special pull-out programs aimed only at children with back pain.

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A S H A P A R T N E R S

These institutions and corporations have expressed their commitment to and support of coordinated school health programs by joining with the American School Health Association as an ASHAPmer.

The contributions of ASHA Partners enable ASHA to continue to shape standards of practice for school nurses, physicians, health educators, and mental and social health professionals, to maintain high-quality education programs, and to conduct and report research on the cutting-edge.

Nurse Achievement Award, School Health Educator of the Year, and sponsorship of the John P. McGovern Annual Lectureship in School Health. We thank ASHA Partners for their support.

Programs supported by ASHA Partner contributions include: sponsorship of the Outstanding School

President's Diamond Endowment Partner + + McGovern Fund for the Behavioral Sciences, 221 1 NorfoIk, Suite 900, Houston, TX 77098-4044 ETRAssociates, P.O. Box 1830, Santa Cruz, CA 95061-1830

Gold Endowment Partner + +

Navajo Comprehensive School Health Initiative, P.O. Box 160, Shiprock, NM 87401 Tampax Health Education, 1500 Front St., Yorktown Heights, NY 10598

Silver Endowment Partner + + + + + + +

Bayer Consumer Care Division, 37 Elmwood Terrace, Wayne, NJ 07470 College of Health and Social Services, New Mexico State University. MSC: 3446, Educational Services Center, Las Cruces, NM 88003-8001 Dept. of Applied Health Science, Indiana University, Bloomington, IN 47405 Dept. of Health Science Education, College of Health and Human Performance, University of Florida, P.O. Box 1 182 10, Gainesville, FL 3261 1-82 10 Division of Health and Safety, Texas A&M University, College Station, TX 77843-4243 Phyllis J , Lewis, RN, BSN, MSN. Indianapolis, IN 46214 William V. MacGillk Co., 1000 Lombard Road, Lombard. IL 60148

Sustaining Partner + + +

Center for School Mental Health Assistance (CSMHA), University of Maryland School of Medicine, Baltimore, MD 21201-1570 National Association of State School Nurse Consultants, Inc., P.O. Box 708, Kent, OH 44240 Schoolcare, Inc., 37276 Six Mile Road, Suite 200, Livonia. Mi 48152

A M E R I C A N S C H O O L H E A L T H A S S O C I A T I O N 7263 State Route 43 + P.O. Box 708 + Kent, OH 44240 + 330/678-1601 + www.ashaweb.org

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