An application of the reasoned action approach to clinical students' intention toward a career in geriatrics.

Guided by the reasoned action approach, this study examined select individual, information, and social factors that influence intention toward pursuing a career in geriatrics among 314 clinical medical and nursing students in Ghana. A Poisson regression showed attitude toward older persons was a significant influencing factor of intention to choose a career in geriatrics for medical students (B = 0.015, SE = 0.0048, p = 0.002) but not nursing students (B = 0.009, SE = 0.0145, p = 0.512). Personal interest was, however, a significant influencing factor for both medical and nursing students (B = 0.462, SE = 0.0592, p = 0.000) and (B = 0.015, SE = 0.0048, p = 0.002), respectively. Nursing students with moderate to strong interest were 1.6 times more likely to express an intention to specialize in geriatrics, and medical students were 1.5 times more likely to express an intention to specialize in geriatrics. The results show that the most important factor influencing geriatric career intention is students' personal interest in the field. Evidence-based interventions such as early educational and practice exposure to the field and interactions with older adults are recommended.

Associations between Cigarette Smoking and Health-Related Quality of Life in Adult Survivors of Adolescent and Young Adult Cancer.

This cross-sectional, secondary data analysis examines the association between cigarette smoking and self-reported health-related quality of life (HRQoL) in adult survivors of Adolescent and Young Adult Cancer. Pooled data for survivors of Adolescent and Young Adult Cancer (N = 1495) were drawn from the 2016 and 2017 Behavioral Risk Factor Surveillance Survey. Binary logistic regression models were utilized to examine independent associations between each of the four HRQoL domains (i.e., self-related general health, activity limitation days, poor physical, and mental health days) and cigarette smoking. Of the 1495 Adolescent and Young Adult Onset Cancer Survivors (AYAO-CS) in this study, approximately 30% reported currently smoking cigarettes. Relative to never smokers, the odds of reporting fair/poor general health were significantly higher for current and former smokers: (OR = 3.95, 95% CI: 2.08-7.50) and (OR = 2.51, 95% CI: 1.46-4.32), respectively. Likewise, current smokers were significantly more likely to report frequent days of poor physical health (OR = 2.79, 95% CI: 1.38-5.65). The study findings suggest a significant cross-sectional association between cigarette smoking and poor health-related quality of life in adult survivors of adolescent and young adult cancer. These findings, although cross-sectional, underscore the need for prospective studies to examine the longitudinal association between HRQoL and cigarette smoking among cancer survivors. Findings also help establish both the need for smoking cessation programs and the importance of effective strategies for addressing HRQoL issues among cancer survivors.

Resilience as a Mediator between Adverse Childhood Experiences and Prescription Opioid Misuse among U.S. Adults.

BACKGROUND:: Studies have shown some linkage between adverse childhood experiences (ACEs) and prescription opioid misuse. While preventable, once an individual is exposed to ACEs, they can have irreparable health impacts. Resilience could have protective effects on preventing those with ACEs from adulthood health-risk behaviors. Objectives: To examine how resilience mediates the association between ACEs and adulthood prescription opioid misuse among U.S. adults. Methods: Adult respondents (n = 33,613) from the National Epidemiologic Survey on Alcohol and Related Conditions-III (2012-2013) were included. A count of ten types of ACEs constituted the ACE score (range: 0-10). A latent variable was created to measure resilience based on the Connor-Davidson Resilience Scale. Generalized structural equation modeling (GSEM) was utilized to conduct the mediation analysis. The Problem Behavior Theory was used to guide covariate selection. Results: The GSEM measurement model estimated the latent variable resilience and determined that tolerance of negative effects, self-control, acceptance of change, and spiritual influence were all associated with resilience, holding personal competence constrained for estimation purposes. Respondents with a higher ACE score were more likely to misuse prescription opioids in the past year (OR = 1.08; p < 0.01), where 40.8% of the association was mediated by resilience (indirect effect OR = 1.06). Conclusion: Reducing prescription opioid misuse is an essential step in alleviating the current opioid epidemic. Findings suggested that resilience mediated the relationship between ACEs and adulthood prescription opioid misuse. To prevent adults with ACEs from misusing prescription opioids, interventions designed to address ACEs' impact should include behavioral and educational components for enhancing the priority dimensions of resilience.

Medical students perspectives and consideration of geriatrics for future practice. An exploratory study of a public medical school in Ghana.

Ghana has one of the fastest growing aging populations in sub-Sahara Africa, but little is known about the geriatric workforce. A sample of 12 medical students in one Ghanaian public university participated in an exploratory qualitative study to share their perspectives on specialty choices in Ghana, interest in working with older patients, and their consideration of geriatrics for future practice. The findings revealed limited knowledge of geriatrics as well as low interest in its selection as a specialty for future practice. These were attributable to multi-faceted factors, including the lack of both exposure to geriatric medicine and geriatrics-focused training for students in this institution. It is critical that geriatric education be prioritized and incorporated in medical schools to nurture students' interest and future consideration of the specialty. This will help bolster the number of geriatric-oriented physicians and secure specialized care for the aging population.

A Salient Belief Elicitation Examining Adolescents' Meditation Beliefs Using the Reasoned Action Approach.

The purpose of this study was to identify adolescents' consequence, referent, and circumstance beliefs about trying to meditate at least twice in the next week in order to inform subsequent meditation intervention design. A survey based on reasoned action approach (RAA) constructs was developed and pilot-tested. Thereafter, adolescents (N = 129), recruited from a northeastern U.S. high school, responded to open-ended survey questions eliciting beliefs underlying intention to try meditating. Thematic analysis was executed to examine beliefs and frequencies of beliefs. Five types of salient meditation beliefs were identified: advantages (e.g., reduces stress, increases relaxation, improves focus), disadvantages (e.g., slows everything down), supporters and disapprovers (e.g., family and friends), and facilitating circumstances (e.g., more time, fewer distractions). Adolescents recognize meditation as having health benefits but as also taking time. They further viewed meditation as socially acceptable but need sufficient time and a conducive environment to try it. To be effective, interventions designed to promote adolescents' self-regulation through meditation should address identified salient beliefs.

Physical activity and fitness among pediatric cancer survivors: a meta-analysis of observational studies.

PURPOSE: The number of pediatric cancer survivors has increased dramatically over recent decades. Prior studies involving pediatric cancer survivors have reported reduced physical activity and fitness levels. Thus, the aim of this meta-analysis was to synthesize previous findings on physical activity and fitness levels of pediatric cancer survivors, who had completed cancer treatment and are in complete remission compared with age-matched, non-athletic healthy controls with no history of cancer diagnosis. METHODS: Three electronic databases (PubMed, Web of Science, and EBSCO) were searched using a combination of 24 terms. Observational studies examining the post-treatment physical activity and/or fitness levels of pediatric cancer survivors compared with that of non-cancer controls and published in peer-reviewed, English-language journals before August 22, 2018 were eligible. Random-effect models were used in Comprehensive Meta-Analysis software for effect-size estimations of eight studies for physical activity and eight for fitness. RESULTS: The studies included a total sample of 2628; 1413 pediatric cancer survivors and 1215 non-cancer controls. Both physical activity and fitness were significantly lower in childhood cancer survivors than in non-cancer controls (g = - 0.889; 95% confidence interval [CI] = - 1.648 - 0.130; p = 0.022) and (g = - 1.435; 95% CI = - 2.615 - 0.225; p = 0.017), respectively, with high heterogeneity. CONCLUSIONS: Pediatric cancer sequelae and its treatment may limit participation in physical activity and fitness activities by survivors of pediatric cancer. Accentuating the need to incorporate physical activity and fitness into treatment protocols and post-treatment recommendations may improve pediatric cancer survivors' health and well-being.

Addressing Challenges to the Reliable, Large-Scale Implementation of Effective School Health Education.

The long-held priority of teaching young people the knowledge and skills needed for healthy living has recently been diminished in many preK-12 schools. Driven by federal and state priorities, laws, and policies associated with high-stakes testing, instruction in untested subjects has been reduced or eliminated in most schools in order to devote more attention to tested subjects, like reading, math, writing, and science. This article proposes a pathway to ensure that all children are able to learn what society knows about health. To that end, four challenges to the reliable, large-scale implementation of effective school health education are identified: (1) establishing school health education as an undeniable social and cultural priority through improved advocacy; (2) strengthening educational institutions' capacities to reliably deliver large-scale, high-quality, school-based health education; (3) collaboratively coordinating efforts of health-promoting governmental and nongovernmental organizations that generate thought leadership for school health education; and (4) creating multidisciplinary research capacities for solving problems associated with the implementation of reliable, large-scale, effective school health education. By implementing specific strategies associated with each challenge, health educators can promote the social and system-level conditions required to support, elevate, and ensure delivery of effective health education to every student in every school every year.

Quality Assurance in Teaching K-12 Health Education: Paving a New Path Forward.

To be effective, school health instruction should be taught by health educators who have graduated from accredited health education teacher education programs and are certified in health education. Unfortunately, the nation has failed to ensure that all those who teach health in schools are well prepared. States vary in the required coursework for health teachers in terms of initial licensure and continuing education for licensure renewal; most elementary teachers are not required to receive preparation in health education; health education and physical education are often viewed as synonymous disciplines; support for in-service education of health teachers is often lacking; and more research is needed in professional preparation and development of school health educators. This article provides a call to action in five areas to strengthen both the professional preparation and professional development of school health educators. Given that education is a social determinant of health, public health educators must become stronger allies in supporting school health to promote health equity. Public health practitioners can advocate to state and community school decision makers for comprehensive school health education taught by teachers with appropriate professional preparation and certification in health education. Public health faculty can educate their students about the Whole School, Whole Community, Whole Child framework and effective strategies for its implementation, and seek rigorous professional preparation and certification and accreditation standards for their school teacher preparation programs. National health and education organizations can call for new leadership and investments in health education teacher preparation and development for a brighter future.

Perceived factors influencing hospital-based primary care clinic referrals to community health medical nutrition therapy: An exploratory study.

Primary care clinics provide an array of diagnostic and clinical services that assist patients in preventing the onset or managing acute and chronic conditions. Some chronic conditions such as high blood pressure, high cholesterol, and type 2 diabetes require primary care professionals to seek additional medical intervention from registered dieticians. This study explored beliefs, attitudes, and practices of medical and administrative professionals in primary care clinics encountering patients who are potential candidates for ongoing nutrition education or counselling. Five focus groups with primary care providers and clinical staff (n = 24) were conducted to identify perceived intra-organisational factors influencing initiation of community health medical nutrition therapy (MNT) referrals. Lack of clarity regarding community health dieticians' role in chronic disease management was the primary finding for the absence of MNT referrals. Insurance-imposed constraints, perceived patient readiness to change, and service inaccessibility were revealed as barriers that influence referrals to both community health and specialty care dieticians. This study underscores the importance of identifying organisational and interpersonal barriers that influence the initiation of community health MNT referrals. Understanding these barriers can create stronger interprofessional collaboration between primary care providers and community health dieticians.

Exercise in Young Adulthood with Simultaneous and Future Changes in Fruit and Vegetable Intake.

OBJECTIVES: Regarding weight management, changes in exercise behavior can also influence nutrition behavior by application of self-regulatory psychological resources across behaviors (transfer effect). This study aimed to determine: (1) if changes in exercise frequency in young adulthood predict simultaneous changes in fruit/vegetable intake (transfer as co-occurrence); and (2) if exercise frequency affects future fruit/vegetable intake (transfer as carry-over). METHODS: 6244 respondents of the National Longitudinal Survey of Youth 1997 were followed at ages 18-22 (Time-1), 23-27 (Time-2), and 27-31 (Time-3). Repeated measures analysis of variance and hierarchical multiple regression determined if the change in exercise frequency between Time-1 and Time-2 was associated with simultaneous and sequential changes in fruit/vegetable intake frequency, controlling for sex, race/ethnicity, education, income, body mass index, and baseline fruit/vegetable intake. RESULTS: Only 9% continued exercising for 30 minutes more than 5 days/week, while 15% transitioned to adequate exercise and another 15% transitioned to inadequate exercise; for both fruits and vegetables, intake of once per day or more increased with age. Males were more likely to exercise adequately and females to consume fruits/vegetables adequately. Exercise frequency transition was linearly associated with concurrent fruit/vegetable intake during Time-1 and Time-2. The highest increase in mean fruit/vegetable intake occurred for participants who transitioned from inadequate to adequate exercise. A significant Time-2 exercise frequency effect on Time-3 fruit/vegetable intake emerged, after accounting for baseline intake. Increase in Time-2 exercise by one day/week resulted in increased Time-3 fruit and vegetable intakes by 0.17 and 0.13 times/week, respectively. CONCLUSION: Transfer effects, although usually discussed in interventions, may also be applicable to voluntary behavior change processes. Newly engaging in and continuing exercise behavior over time may establish exercise habits that facilitate improved fruit/vegetable consumption. Interventions that facilitate transferring resources across behaviors likely will enhance this effect.

Weight perception and dietary intake among Chinese youth, 2004-2009.

BACKGROUND: Little is known on the extent of weight misperception and its relation with dietary intake among Chinese youth. PURPOSE: The study aimed to investigate extent and correlates of weight misperception and its relation with dietary intake among Chinese youth. METHOD: Data pertaining to Chinese youth, 6-17 years of age, from the 2004-2009 China Health and Nutrition Survey (N = 3,923) were analyzed using STATA version 12.1. The heights and weights of the participants were measured by well-trained health workers at the participants' homes or a local clinic following the reference protocol recommended by the World Health Organization. The dietary intake data of the participants were collected on three consecutive days at both the household and individual levels. RESULTS: Of the children 6-11 years of age, 18.9% were underweight and 15.3% were overweight. Among the children 12-17 years of age, 18.3% were underweight and 8.1% were overweight. Less than 60 % of Chinese youth accurately estimated their weight status. Nutrition knowledge was positively related to a perception of being overweight (adjusted odds ratio [AOR] = 1.98, p = .007) among children 12-17 years of age. A perception of being overweight was positively associated with fat and protein intake among children 6-11 years of age (p < .05). CONCLUSIONS: A discrepancy exists between the actual and perceived weight status of Chinese youth. Efforts are needed in China to promote accurate weight perception, healthy weight, and eating behaviors.

Coping with Community Violence: Perspectives of African American Young Adult Men and Hispanic/Latino Young Adult Men.

Further study is needed regarding the intersection of community violence exposure, coping strategies, and health behaviors among young adult African American men and Hispanic/Latino men. This study did so in Lake County, Indiana, which contains multiple areas with disproportionate prevalence of violence relative to population size. Approximately 22 miles from Chicago, Lake County includes noteworthy mid-sized cities such as Gary, Hammond, and East Chicago. This study explored the perceptions of African American men and Hispanic/Latino men ages 18 to 25 regarding coping strategies and both healthy and health risk behaviors after directly witnessing or indirectly experiencing a violent act or event. We used aspects of social cognitive theory to design this community-based participatory research study. Thirteen males who self-identified as African American, Hispanic/Latino, or both, completed 34- to 80-minute, audio-recorded phone interviews. Audio recordings were transcribed, and NVivo 12 Windows was used by the research team (primary researchers and two coders) to complete transcript analysis. Findings from this study provided insight around African American men and Hispanic/Latino men regarding (a) witnessing violence directly or indirectly experiencing violence; (b) changes in everyday life experiences; (c) coping strategies that involved socio-emotional health, spiritual health, social health, and risky health behaviors; (d) rationales for not asking for help; (e) observations of significant others' coping; (f) what to do differently in the future; (g) beliefs about mentors; and (h) beliefs about mental health providers. Delving into participants' experiences revealed that African American men and Hispanic/Latino men in Lake County, Indiana chose to adopt a range of health risk and health positive strategies after directly witnessing or indirectly experiencing violence. Becoming knowledgeable about African American men's and Hispanic/Latino men's diverse coping strategies and health behaviors may help inform the community about how best to cocreate spaces that aim to alleviate the traumatic experience of having directly or indirectly experienced community violence.

Correlates of moderate-to-vigorous physical activity participation in adults with intellectual disabilities.

Adults with intellectual disabilities (ID) have low levels of physical activity and higher than average rates of related chronic health conditions. Understanding correlates of their physical activity participation may improve health promoting interventions. Forty-two adults with ID participated in a physical activity study. Physical activity knowledge and skills, awareness of recommendations and demographic characteristics were analyzed for their association with moderate-to-vigorous physical activity (MVPA) participation measured by accelerometers. Five variables were significantly correlated with MVPA. Body mass index was inversely correlated with MVPA, and gender, job location, job tasks, and place of residence were all significantly associated with MVPA. Understanding correlates of physical activity in this population will help inform disability service and health promotion professionals in future research and health intervention design.

Upper-air observation indicators predict outbreaks of asthma exacerbations among elementary school children: integration of daily environmental and school health surveillance systems in Pennsylvania.

OBJECTIVE: To determine whether a relationship exists between asthma exacerbations among elementary school children and daily upper-air observations (temperature, relative humidity, dew point, and mixing ratio) and, if so, to derive a mathematical model that predicts asthma exacerbations among children. METHODS: Using an ecological study design, school health records of 168,825 elementary school students enrolled in the Health eTools for Schools program within 49 Pennsylvania counties were analyzed. Data representing asthma exacerbations were originally recorded by school nurses as the type of treatment given to a student during a clinic visit on a particular day. Daily upper-air measurements from ground level to the 850 mb pressure level, covering a radius of 800 km around Pittsburgh, PA, were obtained. The Wilcoxon two-sample test was used to identify associations. A generalized estimating equation model was used to predict the occurrence of more than 48 asthma exacerbations, the daily mean for 2008-2010. RESULTS: Surveillance of asthma among school children in Pennsylvania increased over 3 years. The greatest occurrence was in the fall, followed by summer, spring, and winter. Annual averages of upper-air observations were significantly different between seasons (p < .02). Upper-air temperature, dew point, and mixing ratio above their 3-year mean values and upper-air relative humidity ≥ 50% were significantly associated with occurrence of asthma exacerbations (p < .011). CONCLUSIONS: Monitoring of upper-air observation data over time can be a reliable means for predicting increases of asthma exacerbations among elementary school children. Such predictions could help parents and school nurses implement effective precautionary measures.

Air pollution indicators predict outbreaks of asthma exacerbations among elementary school children: integration of daily environmental and school health surveillance systems in Pennsylvania.

Objectives of this study are to determine if a relationship exists between asthma exacerbations among elementary school children in industrialized countries (with climatic seasons) and exposure to daily air pollution with particulate matter, sulfur dioxide, nitrogen dioxide, nitrogen oxides, carbon monoxide, and ozone, when controlled for potential confounders; and, if so, to derive a statistical model that predicts variation of asthma exacerbations among elementary school children. Using an ecological study design, health records of 168,25 students from elementary schools in 49 Pennsylvania counties employing "Health eTools for Schools" were analyzed. Asthma exacerbations were recorded by nurses as treatment given during clinic visits each day. Daily air pollution measurements were obtained from the EPA's air quality monitoring sites. The distribution of asthmatic grouping for pollen and calendar seasons was developed. A Poisson regression model was used to predict the number of asthma exacerbations. The greatest occurrence of asthma exacerbations was in autumn, followed by summer, spring and winter. If the number of asthma exacerbations on a day is N and the daily mean of asthma exacerbations for the three-year period is 48, the probabilities of N > 48 in tree pollen and grass pollen seasons were 56.5% and 40.8%, respectively (p < 0.001). According to the Poisson regression, the week number and prior day CO, SO2, NO2, NOx, PM2.5, and O3 had significant effects on asthma exacerbations among students. Monitoring of air pollutants over time could be a reliable new means for predicting asthma exacerbations among elementary school children. Such predictions could help parents and school nurses implement effective precautionary measures.

Developing a physical activity education curriculum for adults with intellectual disabilities.

Adults with intellectual disabilities have high rates of physical inactivity and related chronic diseases. Researchers have called for an increase in the development and evaluation of health education programs adapted to the unique needs of this population. Formative and process evaluation strategies were applied to develop a physical activity education program. The first phase of formative evaluation included a comprehensive literature review to select educational strategies and curriculum content. The theory of planned behavior was selected as a guiding framework, and meetings with stakeholders were held to assess feasibility. The second phase of formative evaluation included an assessment of materials by an expert panel and the priority population, and pilot testing. Next, field testing was implemented, followed by process evaluation and an assessment of implementation fidelity. The final curriculum was developed as a result of the completion of the aforementioned steps and led to a successful physical activity intervention.

Frequent Social Media Use and Its Prospective Association With Mental Health Problems in a Representative Panel Sample of US Adolescents.

PURPOSE: This study examined the relationship between frequent social media use and subsequent mental health in a representative sample of US adolescents. Also investigated were sex differences in multiyear growth trajectories of mental health problem internalization relative to social media use. METHODS: Four waves (2013-2018) of nationally representative, longitudinal Population Assessment of Tobacco and Health data were analyzed. A total of 5,114 US adolescents aged 12-14 years at baseline had repeated data across all waves. Statistical analysis involved testing a series of sequential-weighted single-group and multi-group latent growth curve models using R version 3.6.2. RESULTS: Of the 5,114 respondents, 2,491 were girls (48.7%). The percentage of frequent social media use was 26.4% at Wave 1 and 69.1% at Wave 4 for boys compared to 38.3% and 80.6% for girls (p < .001). Boys showed an improving (-0.218, p = .005) but girls showed a deteriorating linear trend (0.229, p = .028) for mental health at the full multigroup latent growth curve model. Social media use accounted for mental health conditions across Waves 1-3 for boys (ps<.01) but only at Wave 1 for girls (p = .035). With the addition of the social media use variable alone, model fit dramatically improved, and residual variances in growth patterns (i.e., random effect) became nonsignificant for boys. Substantial sex differences existed in baseline status, directionality, and shape of mental health growth trajectories as well as interplay of social media use with other factors. DISCUSSION: Findings of the study suggest that frequent social media use is associated with poorer subsequent mental health for adolescents.

Air pollutants and attention deficit hyperactivity disorder medication administration in elementary schools.

Air pollution is considered a risk factor for several diseases, particularly respiratory and cardiovascular diseases. However, the effects of air pollution on neurobehavioral disorders have not been confirmed as of yet. Thus, the aim of this study was to determine whether there was an association between seven air pollutants and ADHD medication administration (ADHD-MA) in Pennsylvania-located elementary schools over a 3-year period. An ecological study design involving records of 168,825 children from elementary schools in 49 Pennsylvania counties was used. The number of children with ADHD-MA was extracted from an online software specifically designed for allowing nurses to record health conditions in schools. Daily measurements of air pollutants were obtained from the U.S Environmental Protection Agency. The differences in the number of ADHD-MA among the four seasons, for all years, were statistically significant (P<0.001). Three air pollutants (SO2, CO, and PM2.5) were significantly associated with ADHD-MA; no interactions among air pollutants were significant. Air pollution was thus likely associated with ADHD-MA. Prospective epidemiological and biomedical studies should next examine the molecular relationship between air pollution and ADHD symptoms.

The role of family conflict in mediating impulsivity to early substance exposure among preteens.

OBJECTIVES: Preadolescence substance exposure, which increases the risk of regular substance use, has been a public health concern. Although studies found that impulsivity is a predisposing factor of early substance exposure, the pathways through which impulsivity is associated with early substance exposure remain unclear. This study examined how family conflict mediates this association among U.S. preteens as family environment plays an essential role in pre-adolescent development. METHODS: Respondents (N = 11,800, 9-10 years old) from the Adolescent Brain Cognitive Development (ABCD) Study Release 2.01 (July 2019) were included in this study. Generalized structural equation modeling was performed to investigate the mediation effects of family conflict on the associations between childhood impulsivity and early exposure to alcohol and tobacco use, controlling for covariates based on the Problem Behavior Theory. RESULTS: Pre-adolescents with high impulsivity levels (≥90th percentile) were more likely to report early alcohol and tobacco exposure (total effect: ORs = 1.49 and 1.70, respectively), where 4.13% and 12.41% of the associations, respectively, were meditated by family conflict (indirect effect: ORs = 1.02 and 1.07; Sobel test ps = 0.022 and 0.005, respectively). CONCLUSIONS: Family conflict mediates the associations between childhood impulsivity and early substance exposure among preteens, with higher impulsivity leading to more severe family conflicts that are, in turn, associated with a higher likelihood of early substance exposure. To prevent preteens with high impulsivity level from early use of substances, interventions may focus on reducing family conflicts such as parenting counseling that guides parents to strengthen conflict-resolution skills and create a stable home environment for preteens.

Elementary School Personnel and Cultural Factors Affecting Health Education Implementation in the High-Stakes Testing Era.

BACKGROUND: Despite proven health and learning benefits, health education implementation in elementary schools is not optimal. This study investigated learning environment, leadership, and training factors that may influence elementary-level health education implementation in the current standardized testing-saturated environment. METHODS: Survey data were collected from principals of 8 Michigan elementary schools and, via focus groups, 30 teachers in their schools. Teacher groups were separated into 2 categories based on principals' understanding of state health education policies. Grounded theory analysis was used. RESULTS: Despite all 30 teachers' positive attitudes toward health education, numerous consistent implementation barriers were identified; competition for instructional time with tested subjects was most critical. Teachers with principals who indicated a greater understanding of state policies reported more: consistent instruction; availability of resources, and encouragement to teach select topics, especially mental health. CONCLUSION: That these findings were produced in a state with strong CSHE polices, proven curricula, and expansive support systems are disheartening and accentuate the profound impact of standardized testing on elementary-level health education implementation. More promising, principals' understanding of applicable state-level policies appeared to generate stronger health education implementation. Future research should focus on the possible impact of time devoted to health instruction on standardized test scores.