"Spend the money on what the fight was about!" In 2000, Mississippi Attorney General Mike Moore urged attendees at the American School Health Association National Conference to insist that their state governments spend funds from the Master Settlement Agreement (MSA) with major tobacco companies on public health priorities (1). Despite a difficult economy, the state of Hawaii has preserved a portion of its tobacco settlement funds to create and support the Healthy Hawaii Initiative (HHI) to promote health and reduce the burden of chronic disease.

In 1999, the Hawaii legislature enacted legislation that distributed a total of $14,444,758 in MSA funds in the following way:

The DOH Health and Wellness Advisory Group, representing leading community agencies and coalitions, and the Centers for Disease Control and Prevention (CDC), collaborated to develop HHI. A major goal of HHI is to promote the healthy development of youth relative to 3 critical risk factors: poor nutrition, physical inactivity, and tobacco use. HHI efforts include school-based programs, community programs, public and professional education, and program evaluation.

In 2000, DOH entered a 3-year agreement with the Hawaii Department of Education (DOE) to provide HHI support for school health programs. This article describes progress, challenges, and insights from the first 3 years of the Partnership.

Hawaii is a culturally diverse state, described as a rainbow of cultures and ethnicities — though blended, each maintains its unique characteristics and strengths. Hawaii's people live on 7 islands, each known for its distinct geographical and cultural features. For example, the Big Island of Hawaii has active volcanoes that draw visitors from all over the world. The densely populated island of Oahu is known as "the gathering place." Visitors must obtain permission to go to the tiny island of Niihau, inhabited primarily by Native Hawaiians. Hawaii recognizes English and Hawaiian as official languages of the state.

The state of Hawaii has one centralized DOE and one Board of Education. The Hawaii DOE encompasses 280 public schools, 182,798 students, and 13,000 teachers. DOE operates 7 geographical school districts, but decision making occurs at the state level. Hawaii's one statewide school system implements new directives and initiatives, such as the revision of the Hawaii Content and Performance Standards (HCPSII) in 1999 (3).

DOE added health education as a curriculum component — distinct from physical education — as part of the 1999 HCPS revision (HCPS II). Advocates used data from the CDC-funded Hawaii Youth Risk Behavior Survey (YRBS) of middle and high school students, and the Hawaii School Health Education Profile (SHEP) of secondary school health programs, to support the need for school health education. YRBS data provide information on the status of adolescent health-risk behaviors in these 6 priority categories: 1) behaviors that contribute to unintentional and intentional injuries; 2) tobacco use; 3) alcohol and other drug use; 4) sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases; 5) unhealthy dietary behaviors; and 6) physical inactivity. SHEP data provide information on the status of school-based programs and policies designed to address priority health-risk behaviors among youth. The SHEP questionnaires are designed to be answered by principals and lead health education teachers.

Although Hawaii youth generally demonstrated lower levels of health-risk behaviors than their counterparts across the United States — for example, 44.6% of Hawaii high school students used alcohol during the past month in 1999, compared to 50.0% nationally — YRBS data showed that Hawaii's young people engage in behaviors that put them at risk for serious health problems (4). Only 5.0% of lead health education teachers were licensed in health education; 52.8% of lead health education teachers were licensed in health and physical education (5).

The prospect of implementing standards-based health education was challenging for Hawaii's schools. The University of Hawaii at Manoa (UHM) had discontinued its Bachelor of Education emphasis in health education for secondary majors during a period of faculty and resource shortfalls. Undergraduate students majoring in elementary education received no preparation in health education. In 1999, school health education largely was taught by a few licensed health educators who functioned with little professional support and by teachers from other fields who were assigned health education classes to fill their teaching schedules. The national state-of-the-art in health education was far from the state-of-the-practice in Hawaii.

With health education clearly designated as part of the Hawaii curriculum, supporters at last had a viable vehicle for promoting school health throughout the state. The American Cancer Society, Hawaii Pacific, Inc. (ACS) convened the first meeting of a statewide Comprehensive School Health Education (CSHE) committee in summer 1999. Participants included representatives from ACS, DOE, DOH, College of Education (UHM), Hawaii Board of Education, Hawaii Parent-Teacher-Student Association, Area Health Education Center (AHEC), John A. Burns School of Medicine (UHM), DOE School Food Service, and corporate sponsors Meadow Gold Dairy, Bank of Hawaii, and the 3 Hawaii electric companies, HECO, HELCO, and MECO (6).

In fall 1999, the Partnership began efforts to educate school and community members about standards-based health education. This new approach to health education focused on building personal and social skills in the context of priority health-risk behaviors identified by the CDC (7). The 7 Hawaii Health Education Standards, based on the National Health Education Standards, required schools to help students learn the following skills: acquiring core health education concepts; accessing information, products, and services; practicing self-management; analyzing influences; demonstrating communication; modeling decision making and goal setting; and advocating for health (8). The following 7 health-risk areas were designated as context for learning and practicing health skills: 1) injury and violence prevention; 2) alcohol and other drug use prevention; 3) sexual health and responsibility; 4) tobacco use prevention; 5) nutrition and physical activity; 6) mental and emotional health; and 7) personal and consumer health.

The ACS Cancer Control Director appealed to community partners to assist DOE with the cost of district-level teacher workshops on Oahu and neighboring islands. The resulting public-private collaboration continues today. Meadow Gold Dairy and the Hawaii electric companies provided funding for conference rooms and meals throughout the state. DOH, UHM, and ACS provided additional fiscal, logistical, and professional support.

The Partnership asked UHM to develop new graduate-level summer institute courses in health education. COE faculty members pooled their expertise to create courses in areas such as school violence prevention, healthy sexuality education, and K-12 school health methods across health-risk areas. The Partnership also made plans for a first statewide Health Celebration Conference for teachers, counselors, and administrators during fall 2000. The summer institutes and state conference were funded largely through DOE grants from the CDC, the U.S. Department of Education, and local corporate sponsorship. Meadow Gold Dairy launched a corresponding statewide Got Health? campaign that featured the new Hawaii Health Education Standards on the side panels of 300,000 milk cartons.

Teachers responded positively to the first year's professional development opportunities, provided on Oahu, Maui, Kauai, and the Big Island of Hawaii. For example, teachers provided this type of feedback: "Knowing how to eliminate work that isn't standards-based, I think I will be more comfortable with implementing activity-based curricula as well as teaching to the standards with success" (9). To attend these initial workshops and conference sessions, however, teachers had to ask their schools to pay for substitute teachers. Because the health education standards were new, many schools did not yet consider health education as a professional development priority. Some schools were not willing or able to allocate funds toward substitutes, and as a result, some teachers were unable to attend the initial workshops and conference sessions.

Despite those challenges, the 2000-2001 academic year brought exciting news. With more focus placed on health education, DOH made the decision to allocate HHI funds directly to DOE for implementing and promoting health education programs at the school level.

Through the HHI 3-year agreement and other federal financial support, DOE and DOH have been able to provide funding for:

Broad assessment measures of progress over time include the YRBS and SHEP. Professional development for Hawaii educators in standards-based school health education began in 1999. The Partnership will track the status of youth risk behaviors over time as implementation of standards-based school health education increases.

The 2002 Hawaii SHEP data showed strong school progress in teaching to meet the Hawaii Health Education Standards and providing healthy school environments. Almost all secondary schools (97%) reported teaching a required health education course with the state standards. More than three fourths of lead health education teachers sought to increase student knowledge of health-risk behaviors. More than 90% of teachers sought to increase student standards-based health skills and used a range of interactive teaching and learning strategies. Approximately 50% of teachers received professional development about health-risk areas and teaching skills for behavior change. More than 70% received professional development in interactive teaching methods for health education. Most teachers expressed interest in future professional development in health education (11).

Partnership efforts have resulted in the continued building of school health education infrastructure. At the university level, COE developed a new health education methods course, which is now required for all elementary education majors. In addition, the HHI-funded summer institutes led to the development of a Health Education Specialization in the Master of Education program. To support these efforts, AHEC allocated 5 years of funding to support a new tenure-line faculty position for school health in COE.

With increasing need for support in health education, DOH allocated additional HHI funds to create a new DOE education specialist position to oversee HHI school-based activities. Health education now holds equal footing with the other 9 content areas in the Hawaii Content and Performance Standards.

Hawaii's school health education efforts received another boost with the announcement of a 2003 Coordinated School Health Program Infrastructure Cooperative Agreement between DOE and the CDC, with DOH serving as an essential partner. This new funding will support continued CSHP efforts in the state, with a focus on implementing CSHP throughout entire school complexes. This funding adds to Hawaii's school health infrastructure by providing new education specialist and state resource teacher positions for CSHP, as well as school-level funding.

The Partnership has produced several publications (6, 9, 11) and developed a teaching guide: Healthy Keiki, Healthy Hawaii: Teaching with the Hawaii Health Education Standards — A Handbook for K-12 Educators (12). More than 2,000 copies of the handbook have been distributed to Hawaii educators.

Support for Hawaii's school health programs has grown through the steadfast dedication and action of a group of committed partners in health and education. They believe that school health programs can make a positive difference in the lives of children, families, and communities. The rate of progress and growth has been exciting. However, the institutionalization of school health education is under constant threat from state budgetary shortfalls and academic priorities mandated by federal legislation. In particular, the tobacco settlement funds are the target of many special interest groups during each legislative session. The federal education focus on standardized testing often results in schools focusing their attention on reading and mathematics and excluding other areas. The Partnership tackles these issues by continuing to invest time and resources in teacher education and professional development efforts. Another objective is to convince administrators of the importance of skills-based health education. With 13,000 teachers in the state, professional development needs remain great.

The importance of promoting the health of school-age youth receives spoken support from decision makers. Hawaii's cultural values make child and family health education a good fit with state priorities. However, Partnership members recognize that DOE funding alone is inadequate to support school health programs. Partners must continue to seek funding from other community, state, federal, and private sources to keep programs viable.

Hawaii educators have welcomed the support they have received for improving their health curricula and teaching skills. Educators routinely ask when and where the next workshops, summer courses, and state conferences will be held, and they report changing their teaching to reflect what they learn through participation in the program. School and district administrators have been more difficult to reach than teachers, primarily because their positions encompass a vast scope of work. Demonstrating to administrators how school health efforts can improve academic achievement is a primary focus for the Partnership.

Hawaii's experience may reflect more accurately how local school districts operate, rather than how state education agencies operate. As mentioned earlier, Hawaii has only 7 geographical school districts, and decision making occurs at the state level. The 7 districts in Hawaii make up Hawaii's one statewide school system. Hundreds of independent school districts may be located within a single state elsewhere in the United States, and they may not be able to work so closely with their state education agency. The Partnership has been diligent about publicizing accomplishments across the state and the nation, in the belief that decision makers tend to support efforts that enhance their own goals for the health of children.

Collaboration among the Partnership members overall has been smooth. Supporters of child and adolescent health have stepped forward readily to be involved in this work. Partners seem to have naturally found the things that they do best (e.g., writing, organizing, teaching, contacting schools, seeking funding), rather than competing to do the same things. The ACS CSHE committee provides the "glue" that holds the Partnership together. Perhaps Hawaii's most important lesson is simply to find, connect, and coordinate the individuals and groups who share common goals for improving the health of children and who are willing to work together to achieve them. Within the Partnership, a small group of core individuals who represent K-12 education, health, and UHM meet monthly to coordinate efforts of the larger membership.

In the midst of pressures to improve math and reading test scores to meet the demands of federal legislation, supporting school health programs can refocus attention on guiding and nurturing children rather than teaching subject matter alone. The Council of Chief State School Officers (13) and the Association of State and Territorial Health Officials (14) describe the importance of supporting both health and education for young people by stating that "healthy students make better learners, and better learners make better communities." Hawaii's school health slogan, "Healthy Keiki, Healthy Hawaii," reflects a continued focus on doing what matters for the well-being of children and doing it well.