CDC’s Healthy Schools program funded 16 state education agencies (SEAs) in 2018 to build and promote healthier school environments over 5 years. Funded states delivered PD and TA to districts and schools to support improvements in school nutrition, physical education and activity, and management of chronic conditions among students. In 2020, the CDC awarded $6.9 million in COVID-19 supplemental funding to existing awardees of CDC’s Healthy Schools Initiative to support dissemination and implementation of CDC’s COVID-19 guidance for K-12 schools. States used the supplemental funds to deliver COVID-19-related PD and TA through in-person and virtual self-paced and real-time formats. During the 2020–2021 school year, funded states delivered 1220 PD events and 1796 TA events on topics related to preventing COVID-19 in schools. Each state determined the specific topics, audiences, and formats of PD and TA delivered based on their state’s needs, priorities, and political landscape. States engaged training cadres and national and state organizations to deliver PD and TA.

The sampling approach used among the 9 participating states varied by state and was largely driven by state preferences. In 4 states, the survey was sent to a stratified, random sample of 30% of all districts and schools in the state drawn by the national evaluation team. Two states opted to administer the survey to all districts and schools in their respective states. Three states selected their own sample of districts and schools to receive the survey.

The district and school surveys measured the implementation of 10 strategies to prevent COVID-19 (Table 1) aligned with the CDC’s operational guidance for school settings in effect as of October 29, 2020.⁴ For each item, respondents were asked to indicate the extent to which the prevention activity was implemented during the 2020–2021 school year from 4 choices: not in place, planning, partially in place, or in place. Using a binary checklist, the surveys also asked respondents to indicate if they or others in their district/school received any PD and/or one-on-one TA on each of 12 topics to support implementation of COVID-19 prevention strategies, such as “procedures for isolating sick individuals safely,” “maintaining appropriate social distance during meals,” and “addressing the social, emotional, and mental health needs of students during and after school closures” (see Table 3 for a full list of measured PD and TA topics). The survey did not measure the quantity or quality of the PD or TA received.

The web-based survey was administered to selected district and school personnel between March and June 2021. Survey invitations were emailed to district superintendents and school principals requesting them to forward the invitation with a link to the survey to the district or school staff member primarily responsible for leading and/or coordinating COVID-19 response efforts for the district or school. Some states opted to send the invitations to contacts directly from SEA personnel for increased recognition of the sender. Other states preferred that a member of the national evaluation team send the invitations to districts and schools in their state.

In total, the surveys were sent to 1313 districts and 5988 schools across the 9 participating states. Responses were received from 310 districts and 931 K-12 schools, yielding 24% and 16% response rates, respectively. The average survey response time was 19.5 minutes for both districts and schools.

Responses to each of the 10 prevention strategies identified by CDC were recoded into 10 dichotomous variables. Districts and schools that reported a strategy as “in place” were coded as 1, and districts and schools that reported the strategy as “not in place,” “planning,” or “partially in place” were coded as 0; missing responses were excluded. COVID-19 prevention implementation scores were computed as the sum of the 10 dichotomous variables, ranging from 0 to 10.

Dichotomous variables were created for PD received on any 1 or more of 12 topics (yes/no), TA received on any 1 or more of 12 topics (yes/no), PD received on each of 12 individual PD topics (yes/no), and TA received on each of 12 individual TA topics (yes/no) for each survey respondent.

Frequencies, means, and standard deviations were computed for each variable. The percentages of districts and schools that reported implementing each of the 10 prevention strategies were examined, as well as the mean implementation scores for districts and schools. Percentages of districts and schools receiving PD and TA on any topic and on each of the 12 specific topics were also examined.

Independent t tests were conducted to examine whether districts and schools that received PD or TA on any topic or PD or TA on specific topics demonstrated different COVID-19 prevention implementation scores than districts and schools that did not receive PD or TA on any topic or on specific topics; P values <.05 were considered statistically significant.

Individual prevention strategies were implemented by 35% to 95% of districts and 38% to 96% of schools (Table 1). On average, districts reported implementing 7.11 of the 10 prevention strategies and schools reported implementing 7.30 of the prevention strategies (Table 2). For both districts and schools, the use of standard protocols for cleaning and disinfecting frequently touched surfaces was the most frequently implemented prevention strategy (95% of districts and 96% of schools). Teaching and reinforcing hand hygiene and hand washing were also implemented frequently by districts (95%) and schools (92%). Operating an enhanced ventilation system was the least frequently implemented strategy by 35% of districts and 38% of schools.

About two thirds of districts (66%) and schools (69%) reported receiving PD on at least 1 of 12 COVID-19-related topics during the 2020–2021 school year, whereas about one third of districts (33%) and schools (29%) reported receiving TA on at least 1 topic during the same period (Table 3).

PD on 12 individual topics was received by 32% to 54% of districts and 36% to 57% of schools during the 2020–2021 school year. TA on each of the 12 individual topics was received by 11% to 22% of districts and 10% to 17% of schools.

An independent samples t test revealed that schools that reported receiving PD on at least 1 topic had higher COVID-19 implementation scores on average than schools that did not receive any PD (t = 7.40; P < .001) (Table 4). Similarly, districts that reported receiving PD on at least 1 topic also had higher COVID-19 implementation scores than districts that did not receive any PD; however, for districts, the finding was not statistically significant (t = 1.92; P = .06).

In the case of TA received (Supplemental Digital Content 1, Table, available at http://links.lww.com/JPHMP/B356), schools receiving TA on at least 1 topic had higher COVID-19 implementation scores than schools that did not receive any TA (t = 2.21, p = .03). A similar relationship was not found for districts.

Regarding PD on individual topics, schools that reported receiving PD on 5 distinct individual topics had higher COVID-19 implementation scores than schools that did not receive PD on those same topics: offering physical education and physical activity in school while social distancing (t = 2.82; P = .01); continuing physical education and physical activity during school closures (t = 2.45; P = .02); addressing the needs of students with chronic health conditions and special health care needs during COVID-19 (t = 3.45; P < .001); managing students with chronic conditions while social distancing (t = 2.39; P = .02); and supporting vulnerable individuals at higher risk for COVID-19 (t = 2.11; P = .04). No significant differences in COVID-19 implementation scores were found between districts that received PD and did not receive PD on individual topics (Table 4).

Significant differences in COVID-19 implementation scores were found between schools that did and did not receive TA for all 12 of the individual TA topics (Supplemental Digital Content 1, Table, available at http://links.lww.com/JPHMP/B356). Among districts, differences in COVID-19 implementation scores were observed among districts for each of 10 topics (Supplemental Digital Content 1, Table, available at http://links.lww.com/JPHMP/B356). The only 2 TA topics received by districts that were not related to higher implementation scores among districts were CDC’s school-based COVID-19 guidance (t = 1.39; P = .17) and maintaining appropriate social distance during meals (t = 1.71; p = .09).

Evaluation data did not control for a priori differences among districts and schools before PD and TA were received; therefore, we are not able to conclude that the observed differences in implementation of COVID-19 prevention strategies among districts and schools were a direct result of PD and TA received. Furthermore, the sample is limited to states funded by CDC to support school health infrastructure and thus are not representative of states that do not receive such funding. The use of varied sampling strategies across states could result in differences in how districts and schools are represented across states. The overall response rate was low, particularly among schools. States, districts, and schools also varied in their participation due to the overwhelming demands of the pandemic. In addition to the limitations of the sample, the PD and TA topics measured by the survey were not designed to align one-to-one with the recommended COVID-19 prevention strategies. Implementation measures of COVID-19 prevention strategies did not account for changes in CDC’s operational guidance after October 2020. Self-reported measures of implementation and PD and TA received did not assess fidelity, quality of implementation, intensity, or the modality of the PD and TA received. The evaluation did not examine implementation of COVID-19 prevention strategies in relation to school or community-level case counts during the program period.

Evaluation findings lend preliminary support for the use of PD and TA as tools to promote the implementation of CDC guidance to prevent the spread of COVID-19 in schools. The results contribute to a body of evidence to support PD and TA as promising tools for managing the spread of infectious diseases and advancing public health aims in school settings. However, more questions remain regarding the impacts of PD and TA in effectively supporting strategies to prevent and manage acute infectious diseases like COVID-19. Empirical studies are needed to verify these findings and to better understand how the quality and duration of PD and TA and other factors may affect implementation and impacts of a broader range of prevention and health promotion strategies in schools.