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Factors that influence dissemination and adoption of a web-based health education curriculum

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Title:
Factors that influence dissemination and adoption of a web-based health education curriculum
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Young, Walter F
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Denver, CO
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University of Colorado Denver
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xv, 217 leaves : ; 28 cm

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Consider this ( lcsh )
Web-based instruction ( lcsh )
Children -- Tobacco use -- Prevention -- Study and teaching ( lcsh )
Youth -- Tobacco use -- Prevention -- Study and teaching -- United States ( lcsh )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Includes bibliographical references (leaves 208-217).
Thesis:
Health and behavioral sciences
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Department of Health and Behavioral Sciences
Statement of Responsibility:
by Walter F. Young.

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Full Text
FACTORS THAT INFLUENCE
DISSEMINATION AND ADOPTION OF A
WEB-BASED HEALTH EDUCATION CURRICULUM
by
Walter F. Young
B.S., University of Akron, 1969
M.A. University of Northern Colorado, 1977
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
Health and Behavioral Sciences


This thesis for the Doctor of Philosophy
degree by
Walter F. Young
has been approved
by
Erv Bettinghaus
Rod Muth


Young, Walter F. (Ph.D., Health and Behavioral Sciences)
Factors that Influence Dissemination and Adoption of a Web-based Health
Education Curriculum
Thesis directed by Associate Professor Kitty Corbett
ABSTRACT
The goals of this research project were to describe the factors associated with
adoption of the Consider This middle school tobacco education curriculum and to
characterize the diffusion process for this Internet-based health education curriculum.
The specific aims of this study were to:
1) Describe the Diffusion of Innovations characteristics (relative advantage,
compatibility, etc.) that contributed to adoption of the CT curriculum;
2) Identify the PRECEDE model factors (predisposing, enabling and reinforcing
factors) associated with adoption of CT; and
3) Describe emergent and non-theoretically-based factors that influenced
adoption of CT.
The research question answered in this study was, Is the extent to which teachers
identify individual adoptive behaviors or characteristics, environmental factors
conducive to adoption, and CT characteristics associated with the DOI and
PRECEDE models associated with adoption of the CT curriculum?
This follow-up study used quantitative and qualitative methods to gather information
from Colorado educators who were trained to use CT in 2002. All educators
who were trained (n= 147) were mailed a questionnaire that assessed the factors
that associated with dissemination and adoption of the curriculum. The returned
questionnaires (n=87) also identified study participants and their personal contact
information who were willing to be interviewed by the investigator (n=27).
Twenty-three face-to-face and telephone interviews with educators from around the
state of Colorado helped enrich the data that was collected via the survey. Interviews
were recorded on audio tape and transcripts entered into a text analysis software
package to facilitate coding and analysis of data.


Some of the factors shown to positively influence dissemination of this curriculum
included: computer availability and accessibility; teacher knowledge of and skill
with computer technology; teacher access to peer networks; teacher motivation /
determination; and information technology support. Some of the barriers to diffusion
and adoption included: attrition (turnover) of teachers; discontinued training program
for CT; too few computers; poor access to the computers in schools (scheduling and
restricted use); apathy toward classroom change; and frustration with and lack of IT
support on technical problems.
This abstract accurately represents the content of the candidates thesis. I recommend
its publication.
IV


DEDICATION
This research is dedicated to my family that has so patiently tolerated my weekend
absences over the past year and especially to mv wife Susan whose encouragement
kept me working when times were tough. This is also dedicated to my parents
Florence Young and the late, Walter J. Young, who always encouraged and supported
continued education.


ACKNOWLEDGEMENTS
The author would like to thank the many health education teachers, school nurses,
counselors and administrators who responded to my survey and who agreed to be
interviewed for this research. I would also like to thank Dr. Kitty Corbett for her
guidance throughout the planning, conduct and writing of this dissertation and to my
dissertation committee members who read and edited earlier versions of this work. .
A special thanks goes to Dr. David Buller, Vice President, Health Communications
Division of the Cooper Institute for his support, patience and tolerance of an
employee who was often preoccupied with his dissertation work.


CONTENTS
Figures.....................................................xii
Tables......................................................xiii
CHAPTER
1. INTRODUCTION..............................................1
Specific Aims and Hypotheses...........................3
Background.............................................4
Overview of Research Design and Methods...............10
2. TECHNOLOGY IN EDUCATION AND YOUTH TOBACCO USE.11
Factors Associated with Diffusion of Computer-based
Educational Technology...........................................12
Applications of the PRECEDE Model in Public Health...............20
Tobacco Use Among Youth..........................................21
Health Effects and Risks of Tobacco Use..........................22
Prevalence of Youth Tobacco Use..................................23
Incidence of Initiation..........................................24
School-based Tobacco Use Prevention..............................26
Project TNT...................................................28
Life Skills Training..........................................29
Not On Tobacco (NOT)..........................................31
Project Alert.................................................31
Consider This.................................................32
Internet Use Among Youth.........................................37
Computers and Internet Access in Colorado Schools................40
VII


3. THEORETICAL APPROACHES.........................................42
Diffusion of Innovations....................................42
Elements of the Diffusion Process...........................44
Innovation Traits........................................44
Communication Channels...................................46
Time.....................................................47
Social Systems..............................................48
Other Human Elements of the Diffusion Process ..............51
Summary of Diffusion of Innovations Constructs..............51
Criticisms of Diffusion Research.........................52
Related Diffusion Research...............................53
Relevance of Diffusion of Innovations....................58
PRECEDE-PROCEED Planning Model..............................59
Interface of Diffusion of Innovations and PRECEDE Theories..62
4. SURVEY OF CONSIDER THIS TRAINING SEMINAR ATTENDEES
(QUANTITATIVE STUDY)...........................................64
Survey Background and Purposes..............................64
Survey Methods..............................................65
Research Design..........................................65
Survey Sample............................................66
Questionnaire Design.....................................67
Survey Administration....................................72
Data Processing..........................................72
Analysis Methods.........................................73
Statistical Tests........................................74
viii


Findings.........................................................74
Study Participant Characteristics............................74
Frequency of Teacher Use of Consider This....................79
Dissemination................................................81
DOI-Related Findings by Construct............................85
Characteristics of Participants Who Agreed to be Interviewed.88
Factors Associated with Teacher Adoption of Consider This....91
Discussion...................................................91
5. INTERMEWS WITH CONSIDER THIS TRAINING SEMINAR
ATTENDEES (QUALITATIVE STUDY)
Introduction.....................................................93
Background.......................................................93
Context of Wave I Face-to-Face Interviews DCSD.............93
Context of Wave II Telephone Interviews with
Non-DCSD Participants........................................95
Sample...........................................................95
Methods..........................................................97
Interview Guide Development..................................98
Interview Process and Disposition of the Interviews..........99
Limitations of Telephone Interviews.........................102
Data Transcription, Coding and Analysis.....................103
Classroom Observation.......................................106
Findings........................................................107
DCSD School and Community Environments......................107
Classroom Observations......................................108


Diffusion of Innovations. CT Adoption Characteristics......... Ill
Relative Advantages....................................... 111
Relative Advantages for Students (Teacher Perspectives)...116
Compatibility............................................. 117
Complexity................................................119
Trialability...............................................123
Observability..............................................123
Social System Member Characteristics.......................124
Communication Channels / Diffusion Networks................123
PRECEDE Adoption Characteristics...............................126
Predisposing Factors ......................................127
Enabling Factors...........................................130
Reinforcing Factors........................................137
Non-DOI or PRECEDE Model Diffusion Factors.................142
Barriers...................................................142
Attitudes..................................................131
Critical Mass..............................................133
Summary of Qualitative Findings...................................134
Classroom Observation..........................................134
Participant Interviews.........................................134
Relative Advantages........................................134
Compatibility Factors......................................133
Complexity Factors.........................................153
Observability..............................................156
x


I
Social System Member Characteristics.....................156
Predisposing Factors.....................................157
Enabling Factors.........................................157
Reinforcing Factors......................................157
Barriers.................................................158
Attitudes................................................158
Conclusion......................................................159
6. DISCUSSION.........................................................160
Diffusion of Innovations Adoption Characteristics...............163
Relative Advantages.........................................163
Compatibility Factors.......................................163
Complexity Factors..........................................164
Trialability Factors........................................165
Observability Factors.......................................166
Communication Networks......................................167
Critical Mass...............................................168
Innovation Development......................................168
Dissemination...............................................169
Adoption....................................................169
Implementation..............................................170
Maintenance.................................................170
PRECEDE Adoption Characterisatics..............................171
Predisposing Factors.......................................171
Enabling Factors............................................172
XI


Reinforcing Factors.............................172
Emergent Adoption Characteristics...............173
Synthesis of Findings.............................176
Hypothesis Test...................................179
7. CONCLUSIONS..........................................182
Recommendations for Policy Change.................183
Future Research...................................183
APPENDIX................................................188
A. CONSIDER THIS FOLLOW-UP EVALUATION.............188
B CONSIDER THIS INTERVIEW GUIDE...................194
C. EMPLOYEE CONSENT...............................202
D. INTERNET USE FROM ANY LOCATION BY .............203
INDIVIDUALS AGE THREE AND OLDER
ENDNOTES................................................207
REFERENCES..............................................208


FIGURES
Figure
1.1 Process of Quantitative and Qualitative Study on Dissemination.......7
of Consider This, an Internet-Based Tobacco Education Curriculum.
2.1 Stages of Concerns-Based and Diffusion of Innovations Models.........17
2.2 Age at First Use and First Daily Use of Cigarettes..................26
3.1 Percent Distribution of Adopters Over Time...........................50
3.2 Interface of Diffusion of Innovations and PRECEDE /
PROCEED Models......................................................63
4.1 A Model of Stages in the Decision Process............................69


TABLES
Table
2.1 Conditions that Facilitate Implementation of Educational
Technology Innovations....................................................15
2.2 Consider This Program Module Activities and Prevention Principles........33
3.1 Key Diffusion of Innovations Theory Constructs.............................51
3.2 Adoption Categories for Information Technology Groups......................54
4.1 Factors that Influenced Registration and Attendance at CT
Training Seminars by Select DOI Adoption Characteristics.................70
4.2 Demographic Characteristics and Self-reported 30-day Smoking
Status for Consider This Survey Participants (n=82).......................75
4.3 Advanced Education and Computer Training for Consider This
Survey Participants (n=82)................................................76
4.4 Frequency and (Row Percent) of School District and Participant
Adopter Classifications and Comfort Level with Computer Technology.......77
4.5 Frequency of Consider This Use by Adopter Group (n=57)...................80
4.6 Frequency and (Percentages) of Classroom Use by How Teachers
Heard About Consider This (n=57)..........................................83
4.7 Frequency of Classroom Use by Single Source of How Teachers
Heard About Consider This.................................................85
4.8 Frequency of Classroom Use by Adoption Characteristics that
Influenced Attendance at CT Training Seminars Among Survey
Participants (n=57).................................................86
4.9 Frequency and (Percent) of Interviewed and Non-Interviewed
Participants by Characteristics...........................................89
5.1 Demographic Characteristics, Self-reported Smoking Status,
Education, IT Training, Frequency of CT Use, Comfort with
Computers and School District and Personal Adoption Characteristics
of Interview Participants (n=24)..........................................96
XIV


5.2 Disposition of Study Participants (n=147).............................101
5.3 Codebook for Coding Text Data from Interviews with Colorado
School Personnel Who Were Trained to Use Consider This, 2003........ 104
5.4 Douglas County School District: Profile of Demographic, Geographic
and Economic Indicators...............................................107
5.5 Relative Advantages to Using the Consider This Tobacco Prevention
Curriculum............................................................112
5.6 Gardner's Multiple Intelligence Types.................................114
5.7 Compatibility Factors Associated with Use of the Consider This
Tobacco Prevention Curriculum........................................ 117
5.8 Complexity Factors Associated with Use of the Consider This
Tobacco Prevention Curriculum.........................................120
5.9 Predisposing Factors Associated with Adoption of the Consider This
Tobacco Prevention Curriculum.........................................127
5.10 Teacher Certification Standard Seven: Knowledge of Technology........129
5.11 Enabling Factors Associated with Use of the Consider This Tobacco
Prevention Curriculum.................................................131
5.12 Reinforcing Factors Associated with Use of the Consider This Tobacco
Prevention Curriculum.................................................137
5.13 Barriers to Adoption of the Consider This Tobacco Prevention
Curriculum............................................................143
6.1 Factors that Contribute to Adoption, Implementation and Maintenance
of the Consider This Curriculum.......................................176
xv


CHAPTER 1
INTRODUCTION
"Despite the fact that the number of computers in teachers
classrooms has increased dramatically in the last 20 years,
researchers and educators alike report that integrating technology
into the classroom curricula is not easily accomplished.
(Ertmer, Addison, Lane. Ross, & Woods, 1999)
Computer-based curricula, if adopted broadly by teachers for classroom
use, have great promise for enhancing educational outcomes. Computer-related
tools, when used regularly in the classroom, have been shown to have positive
effects on student cognitive and attitudinal outcomes (Cotton. 1997; Godfrey,
2001; Handel, 1997; Newhouse, 1998). However, dissemination of computer-
based curricula into classrooms is a challenge, and not well understood. Research-
based dissemination strategies are needed to overcome teacher-related and system
or structural barriers to use of computers and computer-based curricula in the
classroom. Better understanding of barriers to the adoption and use of computer-
based curricula should contribute to greater success in teaching that employs new
technologies. Understanding of the factors that promote and inhibit dissemination
and ultimately adoption of web-based curricula should inform the design of effective
dissemination strategies. This project draws on theoretical approaches that have
been useful for understanding how technological innovations are diffused (Rogers
1


Diffusion of Innovations theory, referred to as DOI) and how projects are planned and
implemented (PRECEDE-PROCEED Model). This project employs constructs from
these theories to determine the processes and factors that influenced the dissemination
and adoption of a web-based tobacco education curriculum. Consider This (CT), that
was designed for middle school students in Colorado.
Internet-based curricula will likely play an increasingly significant role
in health education for school children in the next decade. Computer-based
instructional tools hold great potential to provide health information and influence
health behavior. Cancer, heart disease and diabetes are among the leading causes of
death in the United States and each of these diseases has behavioral risk factors that
can be influenced through education and behavioral interventions (CDC, 2000). As
computer technology advances and new online instructional software are developed
and disseminated, schools will have an increasing opportunity to adopt Internet-based
educational curricula that have potential to influence health behaviors. The rate and
extent of the diffusion of these technology-based innovations depend on numerous
and complex individual and environmental factors. Understanding these factors and
their influence on dissemination and adoption processes will help advance the efficacy
of Internet instructional technology.
This project draws on theory to elucidate successes and failures with the
dissemination and adoption of a web-based tobacco education curriculum. Consider
This (CT). for middle school students. The goals of this research project were to
describe factors associated with dissemination and adoption of CT, an online tobacco
prevention program, and to characterize the diffusion process for this Internet-based
health education curriculum.
2


Specific Aims and Hypotheses
The specific aims of this study were to:
1) Describe the DOI characteristics (relative advantage, compatibility, etc.)
that contributed to adoption of the CT curriculum;
2) Identify the PRECEDE factors (predisposing, enabling and reinforcing
factors) associated with adoption of CT; and
3) Describe emergent factors that influenced adoption of CT.
Identifying the factors and processes associated with adoption and use of CT
will help inform educators and school policymakers how to better plan, develop, and/
or adopt Internet-based health education curriculum.
This study answered the following research question: What is the relevance of
teacher characteristics (i.e., knowledge, attitudes, and experiences related to adopting
the curriculum) and school environments (i.e., hardware environment, staffing
factors), to adoption of an online health curriculum? Study hypotheses proposed that
teachers who adopt CT are more likely:
to self-identify as early adopters of technological innovations;
to have heard about CT through social networks;
to have registered for the training seminars because of the incentive
factors offered;
to have greater comfort level with computer technology;
to have had formal training in use of computers or Internet;
to have received his or her undergraduate degree later;
to have an advanced degree;
to be younger;
3


to have received more formal training in use of computers or the Internet;
to be nonsmokers;
to participate in social systems that demonstrate leadership in their school
or profession.
Background
An education futurist envisioned that technology was empowering an
evolution in educational infrastructure for learning and that advanced information
technology was essential to success (Dede. 1990). At the time of this publication
computer technology was a part of teacher activity, from the most remote rural
schools to schools in the inner city. This paper reported that teachers used computers
to prepare lessons, record grades, create handouts, and communicate with each other,
school administrators, and parents. But do they use computers in the classroom? If
computers are not used, why not? If they are used, what factors facilitated use?
Less than 10% of faculty at Stanford University were using computer
technology in the classroom in 1999 (Cuban, 1999). While classroom utilization
may have improved since the Stanford report, use of technology in the classroom
depends on the teachers' ability to integrate it (Dalton, 1989; Kent & McNergney,
1999), material factors (e.g., scarcity of equipment), and social factors. Dalton also
determined that when teachers lack confidence to integrate technology, they ignore
it. A review of existing studies on teacher attitudes disclosed that a teachers own
confidence level in their ability to use computer technology had a strong effect on
its use (Hardy, 1998). In 1999, only 10% of public school teachers reported feeling
very well prepared, and 23% reported feeling well prepared to use computers
4


t
or the Internet for instruction. The majority (53%) reported feeling somewhat
prepared, and 13% reported feeling not at all prepared (USDOE, 1999).
While there appears to be support for use of computers in the classroom, not
all educators agree. At least one author contends that there is early and excessive
concern about computer literacy, too often at the cost of basic literacy and that
schools systems are unable to maintain equipment or train teachers once the hardware
is in place (Oppenheimer. 2003). He contends that "computer infatuation has not only
drained billions of dollars from more urgent educational needs, but that its misuse
actually damages students, turning out a generation of kids with inferior learning and
thinking skills (Newsweek, 2003). Despite his contentions, computer technology
has become an important educational resource in schools and it will not likely become
less so. Therefore, identifying ways to more effectively use this educational resource
remains an important effort.
The Internet-based curriculum on which this investigation focuses is
Consider This (CT). a tobacco use prevention and cessation curriculum designed for
middle-school students (grades 6 through 9) by researchers at the Center for Health
Communications of The Cooper Institute, Denver office.
CT is an online curriculum (http://www.considerthisusa.net) that employs
interactive Web technology with high-quality audio and video features that actively
engage students in lessons about tobacco use and its health effects. It tailors
information and provides individualized feedback based on the knowledge, attitudes,
behaviors and behavioral intentions of student users. A downloadable teachers
manual is available. The curriculum aims to influence attitudes and behaviors about
tobacco use through an interactive multimedia smoking prevention and cessation
program. CT was offered to all Colorado schools in the fall of 2001.
5
I


The Douglas County School District (DCSD) in Colorado was initially
selected as the sole site for this investigation. However, after eight interviews with
DCSD employees and multiple attempts to contact middle-school principals it became
apparent that DCSD would not provide sufficient participants from whom to gather
information. The study was expanded to include all teachers and administrators who
were trained in late 2001 and early 2002 to use CT.
Figure 1.1 illustrates the process and timing of this study. The narrative that
follows describes each step of the process.
During the school year 2001-2002, with funding from the Colorado
Department of Public Health and Environment, I directed a project that offered the
CT program to all Colorado schools with middle school aged students (ages 12-14).
As part of this offering, training seminars were made available to all middle-school
health teachers, school nurses, counselors, principals, school district administrators,
and both district-level and school-level information technology staff.
Promotional materials (posters and brochures), were designed, printed and
distributed to all public and private schools in Colorado for the dissemination phase.
Packets of promotional materials describing the Consider This program and inviting
them to attend a training seminar in their area were mailed to all school district
administrators, principals, Safe and Drug-free education coordinators', and Colorado
Department of Education (CDE) health education contacts who work with students
grades 6-9. Seminars were offered free-of-charge in each of the eight CDE Regional
Service Areas during the 2001-02 school year. Interested persons called project
offices on a toll-free number to register or registered online.
6


Figure 1.1: Process of Quantitative and Qualitative Study on Dissemination of
Consider This, an Internet-Based Tobacco Education Curriculum.
Development of
Consider This
^t^^en99S-2doo.:4^i^i
Innovation
Dissemination
Teacher Training on
Consider This
i >^^i^wjnter,200C20p2:4>
Classroom
Implementation
Study Initiation
Spring 2003
Wave I: DCSD
Interviews (n=8)
|^fc^tebma^jWarcfi;2003f^iK
Survey of Teacher
Trainees (n=147)
Wave II: Non-DCSD
Teacher Interviews
v*July-August 2b03^^rJ(i
Analysis and Writing
Survey and Interview Data
7


A total of 147 school personnel were trained during the months of November
2001 through January 2002. At these one-day, all-expense-paid training sessions,
school personnel learned how to implement the CT program. Teachers were shown
how the CT program fits within the Center for Disease Control's Best Practices
for Comprehensive Tobacco Control (USDHHS, 1999) and the state of Colorado's
tobacco control objectives. They learned the tobacco prevention principles that form
the scientific basis of the online activities included in the CT program. Each feature
and educational module of the Internet-based program was introduced, reviewed, and
demonstrated, with special emphasis on those features that ensured confidentiality of
student responses. Teachers learned the administrative tools in the CT program that
enabled them to help students enroll and use it. They were informed about telephone
and email technical assistance services provided by the CT project staff, and
received a teacher's manual containing information designed to support successful
implementation of the program in their classrooms.
Wave I of the interviews conducted for this study occurred in the Douglas
County School District (DCSD) because an administrator there was particularly
interested in using this curriculum and strongly encouraged the initiation of the
program. Ten DCSD teachers, two administrators, and one information technology
staff person attended one of the eight training seminars. The Wave I interviews
informed development of the questionnaire that was used in the survey of all trainees.
The survey identified additional interview participants from throughout the state of
Colorado for a total of 23 interviews. (Study process details are described in Chapters
3 and 4.)
8


Despite the availability of this free program and the no-cost training to
facilitate implementation, not all school districts were represented at the training
seminars and not all of those who were trained ended up implementing the curriculum
in their classrooms. Investigating the reasons for this variable use of CT will help
inform future dissemination efforts related to Internet-based school health curricula.
This investigation used two theories to structure the inquiry: 1) Diffusion of
Innovations and 2) PRECEDE / PROCEED. Diffusion of Innovations offers
a theoretical framework that explains the process by which an innovation is
communicated through certain channels over time among the members of a social
system" (Rogers, 1995, p. 10). PRECEDE theoretical constructs (predisposing,
reinforcing and enabling factors) are based on the premise that diagnosis of an
educational problem precedes an intervention plan and that there are specific
predisposing, enabling and reinforcing factors that contribute to the accomplishment
of that plan (Green and Krueter, 1991). Because this investigation was limited to the
process stages that led to teacher adoption and use of CT in the classroom, constructs
of the PROCEED stage of this theory ( Implementation and Evaluation) were not
used here. (Process, impact and outcome measures are currently under investigation
in a separate study being conducted by investigators at The Cooper Institute, Denver
office.)
In summary, the outcomes of this investigation were achieved through a
research design that combined elements of the Diffusion of Innovations (DOI)
theory, a theory central to communications research, and elements of a public health
community (environmental) behavior change planning model, PRECEDE. The DOI
model focuses primarily on innovation characteristics and social system processes,
9


while PRECEDE is more ecologically or social systems focused. PRECEDE was
designed to assess social system factors that influence public health outcomes for
more effective health planning. For this investigation, combining these two models
provides a broader perspective on the adoption characteristics than either could have
provided alone.
Overview of Research Design and Methods
Quantitative and qualitative methods were used to achieve the specific aims
of this investigation. A non-probability, purposive sample was used for the survey
research (Backstrom CH, Hursh-Cesar G, 1981). The population surveyed was
the population of educators who attended one of the eight CT training seminars
provided in Colorado during the school year 2001-2002. A structured questionnaire
was developed and mailed to each training seminar attendee. Specifically, survey
questionnaires were mailed to 147 teachers, administrators, counselors, school nurses,
school information technology staff, and public health agency tobacco control staff
who attended a CT training seminar. Of the 87 returned surveys, 24 respondents
consented to be interviewed.
In-depth, semi-structured interviews were conducted using open-ended
questions with the 24 participants who consented to be interviewed. Purposive
sampling allowed me to interpret or test the DOI and PRECEDE theories.
Quantitative and qualitative results of this multi-method investigation were
combined for an enriched understanding of the factors that influenced dissemination
and adoption of CT.
10


CHAPTER 2
TECHNOLOGY IN EDUCATION AND
YOUTH TOBACCO USE
This chapter reviews the literature on diffusion of technology in education,
tobacco use among youth, health effects and risks of tobacco use, prevalence of youth
tobacco use, incidence of initiation, school-based tobacco prevention programs,
diffusion of technology in education, Internet use among youth, computers and
Internet access in Colorado schools.
The literature in this area of research focuses on factors that impede or
promote adoption of computer technology in the classroom. Since these factors can
be categorized using many theoretical approaches, this literature review identified
and collapsed them into 5 groups: factors in the individual domain; factors in the
organizational domain; material factors; perceived attributes of the innovation; and
social factors. While an effort was made to segregate and label these factors into the
above groups, many of the factors identified did not fit into a single category and were
labeled accordingly.
The predominant diffusion model referenced by the research discussed here
was Rogers' Diffusion of Innovations (1995). In general, the authors of the papers
reviewed here based much of their work on the DOI model. It was also apparent from
this review that the study of diffusion of computer-based technology in education is
still quite young and therefore rich in diverse opinions and perspectives.
11


Factors Associated with Diffusion of
Computer-Based Educational Technology
An extensive literature review identified the following factors that prevent
teachers from using technology (Mumtaz, 2000).
Lack of teaching experience with information and communications
technology (ICT) (individual factor);
Lack of onsite support for teachers using technology (organizational
factor);
Lack of help supervising children when using computers (organizational
factor);
Lack of ICT specialist teachers to teach students computer skills
(individual / organizational factor);
Lack of computer availability (material factor);
Lack of time required to successfully integrate technology into the
curriculum (individual / organizational factor); and
Lack of financial support (organizational factor).
Mumtaz's review identified factors in four of the five groups discussed in
this review.
Three styles of computer use among teachers were identified as: avoidance,
integration and technical specialization (Evans-Andris, 1995). Avoidance was
reported as the dominant style of computer use in this study. Those teachers
distanced themselves from computers and reduced the amount of time they spent
attending to computer related activities. Those teachers who engaged in integration
embraced computers, integrating them into their teaching methods and curriculum.
12


The technical specialization" teachers embraced computers and promoted their use
in school, but also viewed them as a challenge.
Teachers resistance to computer use was divided into several broad-based
themes (Robertson, Calder, Fung, Jones, OShea, & Lambrechts, 1996). Those
themes were:
Resistance to organizational change (individual / organizational factor);
Resistance to outside intervention (individual factor);
Time management problems (individual / organizational factor);
Lack of support from administration (organizational factor);
Teachers perceptions (perceived innovation attributes); and
Personal and psychological factors (individual factor).
Social factors that influence diffusion of technology in the classroom must be
incorporated in the instructional development process (Scurry and Farquhar, 1996).
After a discussion of social factors identified by Rogers (1995), the authors reviewed
a model developed by Stockdill and Morehouse (1992). This model identifies
five categories of social factors that influence innovation diffusion: 1) educational
need (social and organizational factors); 2) user characteristics (individual factors);
3) content characteristics (perceived attributes of the innovation); 4) technology
considerations (materials factors); and 5) organizational capacity (organizational
factors). Scurry and Farqhuar concluded with recommendations that they hope
will advance the evolution of technology-based instructional development. These
recommendations were:
Instructional developers should consider adoption and diffusion as
strongly as they consider instructional effectiveness (social factors).
13


Instructional developers should understand that adoption is the result of
purposeful planning and does not automatically follow the development of
instructional or technically superior products (organization and individual
factors).
Instructional designers should modify their design and development
models to incorporate tools discussed in their paper. (Two of these tools
are: Environmental Analysisa process that identifies the physical
environment and support system factors in place at the adoption site(s) and
Adoption Analysisa process that identifies key factors likely to influence
the adoption of their product.)
Scurry and Farquhar concluded that social factors must be incorporated into
the instructional development process in order to increase adoption.
In a review of the literature on the impact of computer based technologies
in schools Lai (2002) identified the following factors that influenced technology
uptake and integration in the classroom. Those factors were: ease of Internet access
(material factor): involvement of the whole school community (social factor); support
of the school principal and commitment of teachers to professional development in
the technology area (individual / organizational factor); collaborative professional
development projects and staged implementations (social factors); rallying schools
around a technology goal (organizational factor), and; a good interpersonal
relationship between the teacher and the technology administrator (social factor).
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Table 2.1: Conditions that Facilitate Implementation of Educational
Technology Innovations
Condition Description Linked to...
Dissatisfaction with the status quo (individual/organizational factor) Feeling a need to change Leadership
Expertise (individual factor) Access to the knowledge and skills required by the user Resources, rewards & incentives, leadership and commitment
Resources (organizational factor) Things needed to make it work funding, hardware software, tech support, infrastructure, etc. Commitment, leadership, rewards & incentives
Time (individual/organizational factor) Prioritize allocation of time to make it work Participation, commitment, leadership, rewards & incentives
Rewards and incentives (organizational factor) Internal and external motivators preceding and following adoption Participation, resources, time and dissatisfaction with status quo
Participation (individual/social factor) Shared decision-making,; full communi- cation; good representation of interests Time, expertise, rewards & incentives
Commitment (organizational factor) Firm and visible evidence of continuing endorsement and support Leadership, time, resources and rewards & incentives
Leadership (individual/organizational factor) Competent supportive leaders of project and larger organization Participation, commitment, time resources, and rewards & incentives
In a review of conditions that facilitated the implementation of educational
technology innovations Wilson et al. developed the above table (Table 2.1) to
summarize their findings. (The parenthetical phrases in the conditions column are the
investigators categorization of the facilitating conditions.)
The Wilson et al. article was a departure from other articles reviewed in that it
cited features common to failed innovations. The factors that they cited were:
15


Practitioners become disenchanted and disillusioned because the
innovation is more difficult than expected, causing too much disruption
and taking too much time, (perceived innovation attribute factor)
Innovation supporters leave or are not available, (individual/social/
organizational factor)
People lack training and lose enthusiasm, (individual factor)
Funding runs out. (organizational factor)
There is inadequate supervision and support from management,
(organizational factor)
The program lacks accountability, (organizational factor)
There is a take-it-or-leave-it attitude on behalf of the promoters, (social/
organizational factor)
This article was important to this investigation in that it documented some
factors on the negative side to the diffusion of innovations equation, in an effort to
remind practitioners to learn from the mistakes of others. This approach to learning
has been largely neglected in the literature, and therefore motivated me to identify
barriers to diffusion in this investigation.
A simple model of diffusion, Concerns Theory, was reviewed by Dooley
(1999). This stage-based theory was developed by Hall and Hord (1987), and is
based exclusively on the concerns of the user as they unfold in the change process.
Its basic premise of this theory is that change is a process not an event. The authors
contend change should be examined by the various motivations, perceptions,
attitudes, and feelings experienced by the individual.
16


At the beginning of the change process the typical non-user has concerns
that that are relatively high regarding Awareness, Information and Personal (self
concerns). These non- or low-users are concerned about gaining information about
the innovation and how it will affect them. As new users become more comfortable
with the new technology they develop more concerns about the management of
the innovation (task concerns). These two concerns decrease in intensity as the
user becomes more skilled with use of the innovation and the impact concerns
(Consequence, Collaboration, Refocusing) become more intense.
Dooley loosely associates this model to Rogers stages in the innovation-
decision process. Figure 2.1 below illustrates how these models compare.
Figure 2.1: Stages of Concerns-Based and Diffusion of Innovations Models
Concerns-Based Adoption Model
Stages in the Innovation-Decision Process
There is a school of thought that contends that the primary reason for low-
uptake of computer technology in the classroom is related to the lack of supporting
knowledge, beliefs and attitudes about computers among teachers. The concept of
17


barriers to implementation pre-dominates this school of thought. Handal (2001) cites
a quotation that captures this paradigm, The knowledge, attitudes and beliefs that
teachers have... shape what they choose to do in their classrooms and explain the
core instructional practices that have endured over time (Cuban, 1993, p. 256).
While the DOI model is a conceptual focus of this dissertation, findings that
encourage teachers to use technology will also be discussed in Chapters 4 and 5 using
constructs from the PRECEDE model. The following literature review lends support
to the use of the PRECEDE model when categorizing factors associated with teacher
use of computer technology. While not categorized using PRECEDE constructs, the
following studies identified factors that encourage use. All of these findings could
be categorized using these PRECEDE constructs.
One study of 72 computer using teachers with a mean age of 42 years found
that it was most important to their personal work and to their teaching and that they
planned to extend their use of computers in the future (Cox, Presto & Cox, 1999).
This study further found the following factors to be most important to sustained use
in teaching: making lessons more interesting; easier; more fun for them (teachers) and
their pupils; more diverse; more motivating for the pupils and more enjoyable.
A second study of four teachers from a Dutch secondary school who were
observed and interviewed, disclosed a few significant findings (Veen, 1993). First,
while school factors (principal support, 20 hours per week of IT support) played
an important role in how these teachers used their computers, personal factors
outweighed the school factors. These teacher-level or personal factors were divided
into beliefs and skills. The beliefs included: teachers beliefs about what should
be in the curricula (content); and the way in which subjects should be taught. The
18


skills that influenced their use of computers included: skills related to a teachers'
competence in managing classroom activities (enabling factor); pedagogical skills
(enabling factor); and to a lesser degree, computer-handling technical skills (enabling
factor). The most important finding from this study was that if the software matched
the teachers' pedagogy (reinforcing factor) they used it. The outcomes of this study
must however, be viewed with some reservation, since it was conducted with a very
small sample and in an artificially constructed research environment, where 20 hours
per week of IT support was provided in a single school to four teachers.
Several studies used survey methods to identify factors that teachers
integrated computers into their teaching practices (Mumtaz, 2000). One nationwide
study of fourth through twelve grade teachers conducted in the United States found
three factors associated with accomplished teachers who integrated computers in
their teaching (Sheinhold and Hadley, 1990). These factors were:
teacher motivation and commitment to their students learning and to
their own development as teachers (predisposing factor);
the support they experienced in their schools (predisposing factor); and
access to sufficient quantities of technology (enabling factor).
These teachers also worked in schools where hardware and access to
resources were twice the average (enabling factor), were comfortable with technology
(enabling factor) and used computers for many purposes (predisposing, enabling and
reinforcing factor).
A more recent study in constructivist classrooms on professional engagement
and teaching practice, including computer use, found that teachers who regularly
engage in professional interactions and activities beyond the classroom teach in
19


different ways than teachers who have minimal contact with their peers (Becker
& Riel, 2000). (Constructivist classrooms are where students are guided to teach
themselves by gathering information and making their own observations and
conclusions. The constructivist teacher sets up problems and monitors student
exploration, guides the direction of student inquiry and promotes new patterns of
thinking (SEDL, 2004)). The more that teachers were involved with professional
activities (informal interaction with peers, workshops, leadership activities,
mentoring, presentations at conferences), the more likely they were to use computers
in exemplary ways. This finding suggests that professional interactions and activities
may be predisposing and reinforcing factors for adoption of technology. This finding
is also consistent with Rogers (1995) observation that innovators or early adopters
tend to be more cosmopolite than laggards.
Applications of PRECEDE Model in Public Health
PRECEDE stands for predisposing, reinforcing, and enabling constructs
in educational/'ecological diagnosis and evaluation. The model recognizes that
institutional and environmental factors influence knowledge uptake and behavior
change.
This model appealed to me since it represents a planning process that leads to
implementation of changes needed for improvement of health and social conditions.
While it was designed expressly for application in the community public health
area, it was easily adapted to the school environment. In this study the PRECEDE
model was not implemented in a stepwise fashion as the model suggests, but was
adapted so it could serve as a tool for planning and implementing change in the
20


school environment. This model provided a conceptual framework or structure for
an evidenced-based investigation into the dissemination and adoption of the CT
health education curricula. The core constructs were borrowed for this study since
they are likely easily understood by policy makers/school administrators who will be
responsible for the application of the findings.
Tobacco Use Among Youth
Tobacco use is the single-greatest cause of preventable death and disability
in the United States. Among young people, the short-term health consequences of
smoking include respiratory and non-respiratory effects, addiction to nicotine, and the
associated risk of other drug use. Long-term health consequences of youth smoking
are reinforced by the fact that most young people who smoke regularly continue to
smoke throughout adulthood. (USDHHS, 1994)
Tobacco use causes more than 400,000 premature deaths each year in the U.S.
(one in every five deaths) and results in an annual cost of more than $50 billion in
direct medical costs. This death toll is greater than the number of deaths from AIDS,
alcohol, drug abuse, car crashes, murders, suicides, and firescombined (IOM,
1994, p. 3). The Colorado Department of Public Health and Environment (CDPHE)
estimates that with a $15 million annual investment from the tobacco settlement
there is the opportunity to save $930 million a year and over 4,000 lives in Colorado
(CDPHE, 2001).
Tobacco use most often begins with addiction to nicotine in childhood and
adolescence. Each year 20,000 Colorado youth under age 18 become daily smokers.
At this rate, 86,000 Colorado youth alive today will die an early preventable death
21


because of a decision made as a childthe decision to smoke cigarettes. Tobacco
caused disease is also associated with use of smokeless or spit tobacco. Colorado
has one of the highest rates of spit tobacco use among boys in the country (CDPHE,
2000).
Health Effects and Risks of Tobacco Use
Cigarette smokers have a lower level of lung function than those persons who
have never smoked. Smoking is particularly deleterious to the health of young people
since it reduces the rate of lung growth. Smoking hurts young people's physical
fitness in terms of both performance and enduranceeven among young people
trained in competitive running.
In adults, cigarette smoking causes heart disease and stroke. Studies have
shown that early signs of these diseases can be found in adolescents who smoke
(USDHHS, 1994). On average, someone who smokes a pack or more of cigarettes
each day lives 7 years less than someone who never smoked (Kuller, Garfinkel,
Correa, Haley, Hoffmann, Preston-Martin, 1986).
The Surgeon General's 1994 report also reported that the resting heart rates
of young adult smokers are two to three beats per minute faster than nonsmokers and
that smoking at an early age increases the risk of lung cancer. For most smoking-
related cancers, the risk for cancer increases as the individual continues to smoke.
Teenage smokers suffer from shortness of breath almost three times as often
as teens who dont smoke, and produce phlegm more than twice as often as teens who
don't smoke (Arday, Giovino, Schulman, Nelson, Mowery, & Samet, 1995). These
22


researchers also reported that teenage smokers are more likely to have seen a doctor
or other health professionals for an emotional or psychological complaint.
Teens who smoke are three times more likely than nonsmokers to use alcohol,
eight times more likely to use marijuana, and 22 times more likely to use cocaine.
Smoking is also associated with a host of other risky behaviors, such as fighting and
engaging in unprotected sex (USDHHS, 2002).
Prevalence of Youth Tobacco Use
28.5 percent of high school students currently smoke cigarettes, down
from 36.4 percent in 1997 and 34.8 percent in 1999. Current smoking is
defined as having smoked on one or more days of the 30 days preceding
the survey.
If teen smoking prevalence continues to decline at the current rate, the
United States could achieve the 2010 national health objective of reducing
current smoking rates among high school students to 16 percent.
Lifetime cigarette use among high school students is 63.9 percent, down
from 70.4 percent in 1999.
Current frequent smoking, defined as smoking on at least 20 of the 30 days
preceding the survey, decreased from 16.8 percent in 1999 to 13.8 percent
in 2001.
In 2001, as in previous years, white and Hispanic students were
significantly more likely than black students to report current smoking
(USDHHS, 2002).
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Incidence of Initiation
The onset of tobacco use occurs primarily in early adolescence, a
developmental stage that is several decades removed from the death and disability
that are associated with smoking and smokeless tobacco use in adulthood. Currently,
very few people begin to use tobacco as adults; almost all first use has occurred by the
time people graduate from high school. Ninety percent of smokers started smoking
before the age of 19 years and 609f before 16 years of age. The earlier young people
begin using tobacco, the more heavily they are likely to use it as adults, and the
longer potential time they have to be users. Both the duration and the amount of
tobacco use are related to eventual chronic health problems. The processes of nicotine
addiction further ensure that many of todays adolescent smokers will regularly use
tobacco when they are adults (USDHHS, 1994).
A retrospective study of regular smokers found that each day an alarming
number of young people join the ranks of regular smokers. This study (Substance
Abuse and Mental Health Services Administration's 1994-1997 National Household
Surveys on Drug Abuse) estimated that more than 6,000 persons under the age of
18 years try their first cigarette each day. The study also found that more than 3,000
persons under the age of 18 years become daily smokers every day (USDHHS, 1998).
Other findings from this study on uptake or initiation of cigarette smoking are:
In 1996, more than 1.851 million Americans became daily smokers, of
which an estimated 1.226 million (66.2 percent) were under the age of
18 years.
The number of adolescents who become daily smokers before the age
of 18 years increased by 73 percent from 1988 (708,000) to 1996 (1.226
24


million) rising from nearly 2,000 to more than 3,000 persons under
the age of 18 years who become daily smokers each day. If the rate of
smoking initiation among young people had held constant since 1988, then
1.492 million fewer persons under the age of 18 years would have become
daily smokers by 1996.
In the 1960s and 1970s, the rate of first-daily smoking was highest for
persons aged 18-25 years. Since the late 1980s, however, the rate of first-
daily smoking was similar for adolescents aged 12-17 years and young
adults aged 18-25 years.
Among persons aged 12-17 years, the incidence of first use of cigarettes
per 1,000 potential new users has been rising continuously during the
1990s and has been steadily higher than for persons aged 18-25 years
since the early 1970s.
Figure 2.2 illustrates that, for example, there are only two years between the
age that a 16-year old person first tries a cigarette and the age at which daily smoking
begins. This figure also illustrates that if a child has not started smoking by the time
they graduate from high school (age 18) it is likely he/she will never start smoking.
Ten percent or less of those surveyed in this study started smoking after age 19.
A recent Colorado survey of high school students shows that 39.4 percent of
Colorados sixth- to eighth-graders report having used tobacco products, compared to
33.5 percent nationally; one in four of these students had experimented with cigarettes
before the age of 11 (CDPHE, 2001). This is particularly troublesome since, the
younger a person is when they first start smoking the higher his or her chance of
becoming a regular smoker, the less likely he or she is to quit successfully and the
more likely he or she is to contract lung cancer (Khuder, Dayal, & Mutgi, 1999).
25


Figure 2.2: Age at First Use and First Daily Use of Cigarettes*
Source: National Household Survey on Drug Abuse
*Among Persons 30-39 Years Old Who Have Ever Smoked Daily
Age
Smoking among adolescents is on the rise with an estimated 3,000 youth
becoming regular smokers everyday (Gilpin, Choi, Berry & Pierce, 1999). Tobacco
use begins in early adolescence with 12 years of age being the average age a child
smokes his/her first cigarette. Approximately one-third of these children will
eventually die of smoking related illnesses (CDPHE, 2000).
School-based Tobacco Use Prevention
Evidence of the intractable nature of the tobacco use problem in schools was
found by the Youth Risk Behavior Survey (NCI, 2001). This assessment found that
26


during the 30 days that preceded the survey, 14.6 percent of high school students
reported smoking on school property.
Much of the responsibility for educating youth about the tobacco problem
and providing them with the tools to resist tobacco use has fallen on schools.
Consequently, Colorado middle and junior high schools, and schools around the
nation, have searched for effective tobacco use prevention curricula and policy
strategies that are relevant to their students and can be implemented efficiently.
Intervening to prevent tobacco use in these early, formative years is an important
strategy to reduce the human and economic toll of tobacco use. School-based
smoking prevention programs based on a model of identifying social influences
on smoking and providing skills to resist those influences, have demonstrated
consistent and significant reductions in adolescent smoking (USDHHS, 1994, p.
274). This Surgeon General's Report goes on to say, The effectiveness of school-
based smoking-prevention programs appears to be enhanced and sustained by
comprehensive health education and community-wide programs that involve parents,
mass media, community organizations, or other elements of the adolescent's social
environment (USDHHS, 1994, p.275). Despite these conclusions, implementation
of sustained school-based interventions has proven difficult.
Only a few school-based educational efforts have been found to be effective in
preventing tobacco use among youth and young adults. Since schools are a focal point
for educational efforts to prevent youth tobacco use, these curricula and others in the
process of being tested or developed hold promise to reduce tobacco use among young
people. Among the few school-based programs that were found to be effective are
Project TNT, Life Skills Training, Project Alert, and Not On Tobacco, described below.
27


Project TNT
Researchers with CDC (Wang, Crossett, Lowry, Sussman & Dent, 2001)
concluded that Project TNT (Towards No Tobacco), a classroom intervention, was
highly cost-effective compared with other widely accepted preventive interventions,
and that school-based prevention programs of this type warranted careful
consideration by policy makers and program planners.
Project TNT. a ten-lesson curriculum designed to counteract the social and
physical consequences influences of tobacco use, was delivered by trained health
educators to 7th-grade students in eight junior high schools. A cohort of 1,234
students participated in the program and was presented with a 2-day booster session
in the second year. The effectiveness evaluation was based on a cohort of 770 9th-
grade students who participated in this two-year follow-up study. When the uptake
rate for the comparison group was compared to the rate in the intervention cohort,
TNT prevented an estimated 34.9 students from becoming established smokers, at an
intervention cost of $16,403. Savings estimates were calculated at $13,316 per life
year (LY) saved and $8482 per quality-adjusted life year (QALY) saved. These results
demonstrate that TNT had cost savings over a range of model parameter estimates.
A one-year follow-up study of a school-based tobacco use prevention project
disclosed that Project TNT was significantly more effective in decreasing both initial
and weekly use of cigarettes than any of its individual components alone ($ussman,
Dent. Stacy, Sun, Craig, & Simon, 1993). This randomized experiment of four
different curricula, one for each of three social influence components (refusal skills,
awareness of social misperceptions about tobacco use, and misconceptions about
physical consequences) and a curriculum that combined all components, involved 48
junior high schools.
28


Each curriculum, except for the curriculum in which refusal skills were taught,
was effective in decreasing the initial and weekly use of use of cigarettes. Only the
combined curriculum showed an effect on the weekly use of smokeless tobacco.
The combined intervention (TNT) was the most effective overall in reducing the
initial and weekly use of cigarettes and smokeless tobacco. The authors concluded
that this suggests that different reasons for use exist and need to be counteracted
simultaneously.
Life Skills Training
In 1980 Botvin, Eng and Williams published an evaluation of the Life Skills
Training (LST) program. This program, based on Bandura's Social Learning
Theory (1986), promotes opportunities for processing life experiences, structuring
experiences, and actively gaining experiences. LST creates opportunities for youth
to acquire skills that enable them to avoid manipulation by outside influences such
as peers and the media. It teaches social resistance skills and general personal and
social competence skills. In one study, rates of substance use behavior, attitudes,
knowledge, normative expectations, and related variables were examined among
students (N = 1090) from 20 schools. These schools were randomly assigned to
either receive the prevention program (9 schools, n = 426) or serve as a control group
(11 schools, n = 664). Data were analyzed at both the individual-level and school-
level. Individual-level analyses controlling for gender, race, and family structure
showed that intervention students reported less smoking in the past year, more
pronounced anti-drinking attitudes, increased substance use knowledge and skills-
related knowledge, fewer normative expectations for smoking and alcohol use, and
29


higher self-esteem at the posttest assessment, relative to control students (Botvin,
Griffin, Paul, & Macaulay, 2001). School-level analyses showed that the annual
prevalence rate was 61% lower for smoking and 25% lower for alcohol use at the
posttest assessment in schools that received the prevention program when compared
with control schools. In addition, mean self-esteem scores were higher in intervention
schools at the posttest assessment relative to control schools. Findings indicate that a
school-based substance abuse prevention approach previously found to be effective
among middle-school students is also effective for elementary school students.
In another study, the authors evaluated the substance initiation effects of
the LST curriculum that combines family and school-based competency-training
(Life Skills) intervention components. (Spoth, Redmond, Trudeau, & Shin, 2000)
Thirty-six rural schools were randomly assigned to one of three conditions: (a) the
classroom-based Life Skills Training LST) and the Strengthening Families Program:
For Parents and Children 10-14, (b) LST only, or (c) a control condition. Outcomes
were examined one year after the intervention posttest, using a substance initiation
index (SII) measuring lifetime use of alcohol, cigarettes, and marijuana and by
rates of each individual substance. Planned intervention-control contrasts showed
significant effects for both the combined and LST-only interventions on the SII and
on marijuana initiation.
A long-term follow-up study of 447 individuals who were contacted after the
end of the 12th grade, six-and-a-half years after the initial pre-test of the Life Skills
Training program, found that students who received the LST program during junior
high school reported less use of illicit drugs than controls (Botvin et ah, 2002). These
results also support the hypothesis that illicit drug use can be prevented by targeting
the use of gateway drugs such as tobacco and alcohol.
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Not On Tobacco (NOT)
N-O-T is a teen stop smoking program of the American Lung Association.
It is a 10-session, gender-specific program with booster sessions that incorporates
life management skills to help teens deal with stress, decision-making, and peer and
family relationships. It recognizes that males and females have different reasons for
starting to smoke, for quitting, and relapsing. It also addresses alcohol use and illicit
dug use, as well as exercise and nutrition. A preliminary post program evaluation
shows a 22.4% quit rate among teenaged cigarette smokers. Of those who continued
to smoke, 65.4 percent reduced the number of cigarettes smoked during the weekdays
and 75 percent reduced the number they smoked on the weekends. These results were
bio-chemically validated (ALA, 2002).
Project Alert
Project Alert is a drug prevention curriculum for middle-school students
(11-14 years old) which has been proven to reduce the onset of substance abuse
and regular substance use. It is a two-year program delivered to 6th, 7th, or 8th
grade students, which focuses on the substances that adolescents are most likely to
use: alcohol, tobacco, marijuana and inhalants. It has 14 lessons 11 core lessons
delivered the first year and three booster lessons the second year. The Rand Outcome
study of Project Alert conducted in 30 California and Oregon schools found that
students receiving Project Alert reduced initiation of marijuana use by 30 percent;
decreased current marijuana use by 60 percent; reduced past month cigarette use
by 20 to 25 percent; decreased regular and heavy cigarette use by 33 to 55 percent;
demonstrated substantially reduced pro-drug attitudes and beliefs (Ellickson, Bell, &
Harrison, 1993).
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A recent study of the revised Project Alert curriculum was conducted in 55
South Dakota middle schools. The revised Project Alert curriculum curbed cigarette
and marijuana use initiation, current and regular cigarette use, and alcohol misuse.
Reductions ranged from 19% to 39% (Ellickson, McCaffrey, Ghosh-Dastidar, &
Longshore, 2003). The Project Alert curriculum motivates adolescents not to use
drugs and by teaching them skills to translate that motivation into effective resistance.
The lessons focus on norms, beliefs about drugs, and intentions to help motivate
adolescents not to use, and stress skills on how to identify and resist pressures
stemming from the availability of drugs and from pressures to use (Rand, 2004).
Consider This
The Cooper Institute researchers and researchers from the University of New
Mexico, the University of Arizona, and the Anti-Cancer Council of Victoria, Australia
developed the Consider This interactive Web site (http://www.considerthisusa.net)
using multimedia and database software and innovative communication strategies
to reduce smoking among adolescents aged 11-15 (grades 6-9) with funds from the
National Cancer Institute.
The CT curriculum program tailors information, discussions about tobacco
use, and social skill-building to personal smoking experiences of adolescents (non-
users, experimenters and regular users). The Web curriculum features six, 50-minute
modules, designed specifically for the middle-school student. The content is designed
to counter social pressures to smoke, debunk myths surrounding smoking, correct
norms regarding youth smoking, model social skills, teach stress management
techniques, promote decision-making strategies that affect childrens smoking, and
32


clarify personal values. Table 2.2 describes the curriculum activities and prevention
principles related to each module.) These prevention principles have all proven to be
successful in randomized trials on youth tobacco prevention.
Table 2.2: Consider This Program Module Activities and Prevention Principles
Module Activities Prevention Principles
Introduction to Web site Preview Ground rules On-line smoking survey Appeal for continued abstinence from smoking or to stop smoking
Media Museum Introduction Radio studio Movie theater Models activity TV wall animation Pop culture Create an ad Increase media literacy De-glamorizes smoking Reveal tobacco industry manipulation strategies Reveal power of media persuasion Debunk realism of media depictions of pop culture
Relationships What kind of person are you? Communication skills Advice column Peer pressure in the mall Statistics on friends Increase social skills to improve communication and relationships Teach peer pressure resistance skills Correct social norms related to smoking
Mind / Body Effects of smoking on the human body Substances in cigarettes Aspects of addiction / dependence Perfect world Stressful situations Learn harmful effects of cigarette smoke on the body Provide personalized / tailored feedback on growing addiction to nicotine Model and practice stress management techniques
Decision-making and Values You pick it, you get it Virtual interviews Values Model and practice decision-making skills Hear testimonials of teen smokers who quit Clarify personal values and explore mismatch of smoking and personal values
Influences Exposing memos Smoking situations Top 10 ways to say no Reveal tobacco industry plans to target teens Learn to recognize smoking situations Model and practice skills for avoiding and resisting pressures to smoke
For example, Botvin (2000) demonstrated in the Life Skills Training program
that by teaching students to recognize factors like the influence of mass media,
33


tobacco industry manipulation strategies and the power of media persuasion, students
could debunk the realism of media depictions of pop culture and increase their capacity
to think critically. The Media Museum module of the CT curriculum demonstrates
the influence of the media by engaging online users in interactive learning experiences.
Additionally, like Life Skills Training, CT delivers stress management activities,
although these are provided in an interactive computer program.
Social norms theory provides a model for understanding human behavior
that has important implications for health promotion and prevention. It states that
behavior is influenced by incorrect perceptions of how other members of our social
groups think and act (Berkowitz, 2002). In the case of tobacco use, correcting
misperceptions that the majority of youth use cigarettes or other tobacco products
is key to prevention activities. This is done in the Relations module of the CT
curriculum. The above described activities, and others that are part of proven
effective tobacco control curricula, are included in the Consider This curriculum.
The Consider This curriculum user interface is guided by a virtual host, a
teenage female of uncertain racial or ethnic heritage, who leads students through
activities with audio instructions and feedback. The feedback is guided by user
responses to smoking history questions. These questions are asked during the course
of user navigation through the curriculum modules. User responses to the smoking
history questions create a user profile that is the basis of the virtual host's interaction
with the user (e.g., The last time you were on this Web site, you told me that you
were experimenting with cigarettes. Are you still experimenting?). This tailoring
aspect and the audio track provided by a peer (the virtual hostess) personalizes the
Web site for the user and provides researchers with user smoking history data.
34


The effectiveness of CT is being tested in two National Cancer Institute
funded, group randomized pretest-posttest controlled trials, one each in the United
States and Australia. Preliminary analyses were conducted on 977 students (62%
intervention and 28% control) who had completed a pretest and posttest questionnaire
in 2001-02 in the U.S. trial.4 All responses were measured using a Likert scale. Since
the probability of future tobacco use can be predicted from behavioral intent and
susceptibility (Pierce, 1996; Norman, 1999; O'Callaghan, 1999), for the preliminary
analysis, the main outcome of interest was the subjects' response to the statement
I will not smoke in the future. Intervention subjects showed a significant positive
change (p<0.001) from pretest to posttest while the controls showed no change.
When the difference between pretest and posttest scores was compared across
treatment groups, a significant difference was detected (p<0.05). To visualize the
impact of CT more clearly, the changes over time among intervention group children
were compared with the control group changes. In the intervention group, 35.4%
of the children were positively moved in their pre to post responses compared to
only 17.3% of the control group. Thus, the intervention was able to have an impact
on the responses in over two times as many children in the intervention group
compared to the control group. Further, the percentage of children who reportedly
shifted from disagreeing with the statement that they would not smoke in the future
to agreeing with the statement, was differential amongst the children who did shift
categories: 65.6% of the intervention students who did show a changed response
to this question switched from disagreeing to agreeing compared to only 41.9%
of the control students. Using McNemars test for the direction of the change, the
intervention group moved to a more favorable status (pcO.OOl) compared to the
35


Control group that did not move. Thus, the authors feel that CT may have potential
to provide inoculation against future smoking, if by nothing more than allowing the
children to express that this is an option. Similar positive changes (p<0.05) were
detected for intervention subjects but not control subjects in their responses to items
assessing self-efficacy to refuse a cigarette offered by a friend and knowledge of the
addictiveness of cigarettes and smokeless tobacco (i.e., Smoking is as addictive as
other drugs such as heroin or cocaine).
In summary, this interactive, Internet-based curriculum tailors information
and discussions about tobacco use. and presents social skill-building activities based
on the personal smoking experiences of adolescents (non-users, experimenters
and regular users). Student smoking status is assessed throughout the program
and responsive audio messages to the student user are made by the virtual host to
reinforce nonsmoking behavior, encourage self-examination of smoking behavior
and attitudes, and discourage smoking. Since CT has not been fully tested, this may
influence its adoption.
All of the above curricula are based on scientifically demonstrated prevention
principles and have been or are being tested in the classroom. Despite positive
findings and the subsequent availability of effective tobacco use prevention
curricula, there remains a significant problem with tobacco use among young people.
Identifying the predisposing, enabling and reinforcing factors related to adoption of
tobacco prevention curricula could help mitigate this seemingly intractable problem.
When exploring the school context of tobacco use and tobacco use curriculum and
policies within Colorado schools, a recently completed focus group study of Colorado
school principals (Rocky Mountain Center, 2002) disclosed the following themes:
36


!
CSAP (Colorado Student Assessment Program) has a strong influence
on all school decisions (This is a state required testing program that imposes
perform ancestandardsoneveryColoradoschool,with tiestofundingifstandardsare
not met.);
Tobacco is not the highest priority for schools;
Every school is different;
Limited resources affect ability of schools to incorporate
new programs; and
Cultural norms of the community / parents (might) accept tobacco
as okay."
These findings helped better inform me regarding the context of this research.
Internet Use Among Youth
While the identification of effective intervention strategies to prevent youth
tobacco use is an important research step, successful implementation of effective
strategies is ultimately dependent on effective diffusion of interventions to schools
and communities.
One promising strategy for dissemination is delivery of tobacco prevention
learning experiences via the World Wide Web or the Internet. The Internet is fast
becoming a universally available tool that teens use regularly for their schoohvork.
It also holds great potential since access to this tool is not confined to the school
classroom and it has potential to reach teens where they live and play. Identification
of the barriers to implementation of Web-based curricula should be of value to our
schools and public health.
I
37


The Internet has become an important learning tool for teens and recognized
as a valuable learning resource by parents. A Pew Research Center survey of 754
youths ages 12-17, conducted in the closing months of 2000, found the following:
98% of American public schools have some kind of Internet access for
students and 77% of instructional classrooms have Internet connections
[This percentage drops to 60% for schools with the highest concentrations
of poverty (Cattagni, 2001);
Only 73% of the youths surveyed use the Internet, despite the fact that the
Internet is available to virtually all teens at their school;
94% of online youth use the Internet for school research and
78% say they believe the Internet helps them with schoolwork;
87% of parents of online youth believe that it helps students with their
schoolwork and 93% believe that it helps students learn new things;
55% of parents of online youth believe that it is essential for todays
children to learn how to use the Internet and another 40% believe it is
important (Lenhart, 2002).
The PEW researchers working on this study reported that there was a
substantial disconnect between how students use the Internet for school and how
students use the Internet during the school day and under teacher direction. They
found that students educational use of the Internet occurs outside of the school day,
outside of the school building, and outside of the direction of their teachers. A few of
the factors students attributed to this disconnect were:
The quality of student Internet-based assignments was poor
and uninspiring;
38


School administrators set the tone for Internet use at school. Policy
choicesby those vvhorunschoolsystemshaveresultedindifferentschoolshaving
differentlevelsofaccesstothelntemet.dilferentrequirementsforstudenttechnology
literacy skills, and different restrictions on student Internet access;
The single greatest barrier to Internet use at school is the quality of access
(connection speed and reliability ) to the Internet;
Because not every student has access to the Internet outside of school, the
vast majority of students report that their teachers do not make homework
assignments that require the use of the Internet;
Students repeatedly told researchers that the quality of their Internet-based
assignments was poor and uninspiring (Lenhart, 2002).
These barriers, while significant now, if not addressed soon will become even
more pronounced as broadband connections become more commonplace and more
students become online users. Teachers will need to become better prepared to use
and/or design instructional lessons that are available on the Internet. Internet-based
assignments will need to be compelling and inspire student learning. Administrators
will need to become better informed about the technical and administrative barriers
to effective use of the Web in schools. Change agents will need to know how to
effectively deliver and disseminate Web-based tools to schools and school districts.
Other research findings indicate that use of Web technology in the educational
environment can be effective in changing health practices. In a study of a Web-based
computer-tailored, nutrition education program, changes in student determinants of
behavior were found (Oenema, 2001). If the Internet is to become an effective
1
39


teaching tool for classroom teachers, then research needs to expand so that knowledge
of effective dissemination and instructional strategies continues to develop.
Use of the Internet, like other communication media, has both benefits
and liabilities. Its primary benefit for adolescents who are seeking health-related
information may be the anonymity that is afforded by an interactive computer
environment. One study of adolescents seeking health care found that they frequently
need and want to talk with their primary care providers about health risks but often
do not (Klein & Wilson. 2000). The adolescents in this study most frequently
discussed healthy dietary habits (49%), weight (43%), and exercise (41%) with their
clinicians, but most frequently wanted to but did not discuss drugs (65%), smoking
(59%). and healthy dietary habits (57%). Overall, 70.9 percent of their study sample
reported at least one of eight potential health risks, but 63 percent of these adolescents
had not spoken to their doctor about any of these risks. While not tested in this
study, disclosing health behaviors, especially those that are known to be socially
undesirable, in an interactive computer environment, like that provided by CT, may
be easier for some adolescents than talking wfith health care providers or parents.
Computers and Internet Access in Colorado Schools
A national market research study conducted during school year 1998-99
found that the computer-to-student ratio for Colorado schools was only slightly above
the national average. There was one computer for every 5.3 students in Colorado
and the national average was 5.7. These ratios compare favorably to California
schools, where the ratio was little more than one computer for every 8 students, but
unfavorably to Wyoming schools, where the ratio was one computer to 3.5 students.
40


There was one Internet computer for every 12.9 students in Colorado and one for
every 13.6 nationally, and 95% of Colorado schools have Internet access compared to
90% nationwide (The Denver Post, 1999).
In conclusion, with this literature review as the knowledge and conceptual
bases for this research, I pursued the identification of factors that promoted and
impeded adoption, implementation and maintenance of the Web-based tobacco
education and prevention curriculum entitled Consider This.
41


CHAPTER 3
THEORETICAL APPROACHES
This chapter discusses the primary theories (DOI and PRECEDE) that
guided the inquiry and helped to shape interpretations of the data.
Identification of the determinants of Internet program usage in the classroom
was done in the context of theoretical approaches to communications and behavior
change. DOI identified the communications context for dissemination and adoption
of CT. The PRECEDE health promotion planning and intervention model defined
behavioral and environmental factors.
More specifically, this chapter describes the theoretical context within which
diffusion of CT took place among study participants during the 2001/2002 school
year. The teacher curriculum adoption process is described using DOI constructs
(relative advantage, compatibility, complexity, trialability, observability, adoption,
dissemination, and maintenance). Individual and environmental behavioral factors
associated with adoption of Consider This are described with constructs from the
PRECEDE model (predisposing, enabling, and reinforcing factors).
Diffusion of Innovations
Given that an innovation exists, communication
must take place if the innovation is to spread.
Everett M. Rogers, (Rogers, 1995, p.17)
42


New ideas or innovations are adopted through a process that Rogers calls the
innovation-decision process, the process through which an individual or decision-
making unit passes from first knowledge of an innovation to forming an attitude
toward the innovation, to a decision to adopt or reject, to implementation and use of
a new idea, to confirmation of this decision (Rogers, 1995, p. 161). Understanding
and influencing the decision-making process can help expedite adoption and influence
the survival of an innovation.
New ideas or innovations often do not survive because financial support for
the idea is not sustained sufficiently for the innovation to be accepted within a social
system. Understanding the diffusion process, its barriers, and how it is enabled is
especially important if the innovation is to be accepted and this acceptance sustained.
Understanding the factors that influence diffusion of Consider This (e.g., change
agents, complexity, trialability, etc.), and being able to control or manipulate those
factors is vital to the viability of the program as a tool to inhibit tobacco use.
Diffusion of Innovations theory provides a framework for identifying effective
approaches for disseminating the Consider This program. DOI holds that several
characteristics of an innovation affect its adoption (Buller, 2001).
Rogers (1995. p. 5) defines diffusion as the process by which innovation
is communicated through certain channels over time among members of a social
system. He defines communication as a process in which participants create
and share information with one another in order to reach a mutual understanding
(Rogers, 1995, p. 17). Rogers contends that diffusion is a special type of
communication in that the messages are concerned with new ideas. It is the newness
or uncertainty of the idea that makes diffusion a unique type of communication.
43


Elements of the Diffusion Process
There are four elements that characterize the diffusion process:
1) Innovation Traits The idea, practice, or object that is perceived as new
by an individual or other unit of adoption;
2) Communication Channels The means by which messages about the
innovation get from one individual to another;
3) Time -The length of time it takes an innovation to be adopted or rejected
by an individual or system (the innovation-decision period);
4) Social Systems A set of interrelated units (individuals, informal groups,
organizations, and/or subsystems) that are engaged in joint problem-
solving to accomplish a common goal.
The following discussion of these elements in the context of the innovation
that is the focus of this research helped inform the study design and instrumentation
used to gather data.
Innovation Traits
Rogers contends that if the idea seems new to the individual, then it is
an innovation. Newness of an idea may be expressed in terms of knowledge,
persuasion, or a decision to adopt. The perceived traits of an innovation or idea thus
influences how quickly a new idea is tried and adopted.
Rogers makes a distinction between hardware and software innovations, two
broad innovation traits. Hardware innovations are equipment or tools, and software
innovations are the information base for the tool. In the case of the Consider This
project, the innovation is quite literally a software innovation that is accessed using
44


computers (hardware / equipment) available in Colorado schools. Schools have been
using personal computers for approximately 20 years, and some school personnel
had access to computers long before personal computers were introduced. In the
strictest sense of Rogers definition of hardware (a tool that contains the technology as
a material or physical object), we could also define the Internet as the hardware that
embodies the Consider This software. Without the availability of computer hardware,
diffusion of this innovation would not be possible. Therefore, the most important trait
of this innovation is that it is dependent on the availability of and access to personal
computers.
Much of Rogers research has been in the domain of technology. An
important observation of his that is relevant to this study is included:
A technological innovation usually has some degree of benefit for its
potential adopters. This advantage is not always very clear-cut, at least not to the
intended adopters. They are seldom certain that an innovation represents a superior
alternative to the previous practice that it might replace. (1995, p. 13).
In the case of the CT innovation, teachers and other school personnel, as the
potential adopters, may be uncertain about the benefit that an Internet-based tobacco
education curriculum might provide over a traditional document-based, classroom
curriculum.
In the strictest sense of the term, the only potential adopters of the CT
curriculum are teachers. They are the only subgroup of school employees who have
routine access to the classroom (the environment where it is implemented) and to the
students who are the ultimate beneficiaries of the innovation.
i
45


Rogers contends that perceived attributes of an innovation help explain the
rate of adoption of an innovation (1995, p. 206). Those attributes are described here:
1. Relative Advantage The degree to which an innovation is perceived as
better than the idea it supercedes;
2. Compatibility The degree to which an innovation is perceived as
being consistent with existing values, past experiences, and the needs of
potential adopters;
3. Complexity The degree to which an innovation is perceived as difficult
to understand and use;
4. Trialability The degree to which an innovation may be experimented
with on a limited basis; and
5. Observability The degree to which the results of an innovation are
visible to others.
Innovations that have the above five qualities more relative advantage, a
high degree of compatibility, trialability, observability, and less complexity are more
likely to have higher rates of adoption.
Specific innovation attributes of the CT curriculum as perceived by the teacher
participants in this study are described in the qualitative portion of this dissertation.
Communication Channels
Communication channels, another element of the diffusion process, are
the means by which messages about an innovation get from one person to another.
Mass media and interpersonal communications are the two principal means by
which information is transmitted. Mass media channels involve radio, television,
46


newspapers, mass mailings, etc. Interpersonal channels involve face-to-face
interactions between two or more persons.
The quality and effectiveness of communications transmitted through these
two channels are influenced by the principle of homophily, i.e., the degree to which
two individuals are similar in certain attributes such as education, beliefs, and social
interests. Homophilous individuals share personal and social characteristics, attribute
similar meanings to things and ideas, and share a mutual subcultural language. In
contrast, persons who are heterophilous do not share these characteristics.
Time
The innovation-decision process is one that is measured in part by time. Time
represents a) the period between an individuals initial knowledge of an innovation
to the moment of adoption or rejection, b) the relative earliness or lateness of an
innovation being adopted, and c) the rate of adoption of an innovation in a social
system.
The innovation-decision process consists of five steps: a) knowledge when
an individual or decision-making unit learns of an innovation; b) persuasion when
individual or unit forms a favorable or unfavorable opinion on the innovation; c)
decision when an individual engages in activities that lead to adoption or rejection
of the innovation; d) implementation when the individual puts the innovation into
practice; and e) confirmation when the individual realizes reinforcement of an
innovation-decision.
Time is an important dimension explaining the innovation-decision process.
Broad steps or markers of the CT curriculum adoption process were identified in both
47


the survey and interview portions of this investigation to help characterize the rate
of adoption.
Social Systems
A social system is a set of inter-related units that
are engaged in joint problem-solving to accomplish
a common goal."
Rogers (1995, p. 23)
The social system is an environment within which change or adoption of
innovations occurs. Characteristics of social systems therefore affect diffusion.
More specifically, within a social system the roles of opinion leaders and change
agents, social norms that relate to, enable or constrain adoption of an innovation,
and the types and consequences of an innovation all affect diffusion. Formal and
informal social systems within schools and school districts affect the rate and
breadth of diffusion. The formal systems are those that are created by management
and administration of a school district or school. The informal systems are those
that are established through inter-personal communications. The communication
structure (patterned communication flow) within and among schools and between
school and district administrators determines who interacts with whom and under
what circumstances. Understanding the dynamics of the social system and its
communication structure helps define the diffusion process and its predisposing,
enabling, and reinforcing factors.
Norms, or social standards, are cultural models shared by individuals in a
social system which communicate to individuals what behaviors are expected and
|
48


desired. Norms therefore are often powerful factors in the diffusion process.
Personal innovativeness or adopter categories help classify members of a social
system according to their willingness or tendency to adopt new ideas (Rogers, 1995).
The adopter categories are as follows:
Innovators Persons or decision-making bodies who are venturesome.
Their interest in new ideas tends to lead them outside of their peer
networks and into a more cosmopolitan circle. They serve a gatekeeper
role in the flow of new ideas into a system.
Early adopters Persons who are respected and are more integrated or
active within their local social system. They have the greatest degree of
opinion leadership within the social system. Ideally change agents would
seek them out to help promote acceptance of a new idea or innovation.
Early majority Persons who adopt new ideas just before the average
member of a system. They interact frequently with their peers and
represent approximately one-third of the social system (Rogers, 1995).
Late majority Persons who adopt new ideas just after the average person
in a social system. Economic necessity and/or peer pressure usually
motivates adoption for this group, which is about another one-third of the
social system.
Laggards Persons who are last in a social system to adopt an idea. They
are near isolates within the social networks of their system and tend to be
suspicious of new ideas or innovations.
49


Figure 3.1 below illustrates the adopter categories that will be used in the analysis of
the quantitative and qualitative data collected during this investigation.
Figure 3.1: Percent Distribution of Adopters Over Time
Innovators those who are adventurous, who have financial resources
and like to play with new tools (5%)
Early Adopters those who see strategic advantage in adopting an innovation (10%)
Early Majority followers who make a deliberate choice to adopt (35%)
Late Majority those who are skeptical and who adopt when it is less risky (35%)
Laggards those who adopt an "over my dead body" attitude (15%)
The adoption of innovation social change process began before this research
project began. The CT innovation development stage (the first step in the social
change process) took place in 1998 at The Cooper Institute.5 At this time the CT
curriculum was developed for a research project testing the effectiveness of the
Internet-based tobacco education curriculum described here.


Other Human Elements of the Diffusion Process
The following two human roles are key catalysts in the diffusion process.
Opinion Leaders Individuals who are able to influence informally, in a
desired way and with relative frequency, other individuals attitudes and
behaviors.
Change Agents Individuals who influence clients innovation-decisions
in a direction deemed desirable by the agency they represent. (Note:
Change agents usually use opinion leaders as their lieutenants or
champions in diffusion campaigns.)
Summary of Diffusion of Innovations Constructs
Table 3.1 summarizes the principal constructs and terminology relevant to the
Diffusion of Innovations theory (Rogers, 1995).
Table 3.1: Key Diffusion of Innovations Theory Constructs
Stages of Diffusion/ Social Change Process Elements of the Diffusion Process Rate of Adoption Characteristics Social System Member Classifications
Innovation development Dissemination Adoption Implementation Maintenance Innovation traits Time Channels Social System Relative advantage Compatibility Complexity Trialability Observability Innovators Early Adopters Early Majority Late Majority Laggards Change Agents Opinion Leaders
51


Criticisms of Diffusion Research
There are four major criticisms of diffusion research: 1) its pro-innovation
bias; 2) the individual-blame bias; 3) the recall problem; and 4) the issue of equality
(Rogers, 1995, p. 99).
Pro-innovation bias implies that the innovation should be diffused and
adopted by all members of a social system, that it should be diffused more
rapidly, and that it should not be re-invented or rejected.
Individual blame bias holds that an individual is responsible for his or her
problems, rather than the social system of which he or she is a part.
Recall problem bias is a bi-product of the research process itself and
results when individuals are asked to remember the time when they
adopted a new idea or innovation.
Issue of equality bias is concerned with the consequences of an innovation
and how the benefits of that innovation distribute within a social system.
I observed all of these biases. For example, during the course of teacher
interviews in this study, I noted the tendency of teachers to offer only positive
remarks about their experiences with the adoption of the CT curriculum. In other
words, they tended to share only their successes with implementation of this
innovation. They seemed more reluctant to offer descriptions of the problems they
encountered unless they were prompted. This is an example of pro-innovation bias or
social desirability bias.
Teachers also tended to accept blame for not having successfully implemented
CT in their classes. Some would make self-effacing comments about their limited
experience with or knowledge of computer technology, when, in fact, the limitations


of their Internet connections may have precluded successful implementation. These
self-effacing comments were sometimes made despite their knowledge of the Internet
connection limitation.
Rogers (1995) suggests alternative research approaches (e.g., held studies
while the innovation is being disseminated rather than post-diffusion studies) that
were used on a limited basis to help explain some of the bias inherent in innovation
research. One of those approaches, classroom observations, was used to help provide
an objective perspective on the diffusion/adoption process.
Recall bias will need to be accounted for by inquiries that explore the
continued dissemination of CT during the 2002-2003 school year.
Another criticism of diffusion research is that the predominant focus of
diffusion studies has been on successful diffusion events and that events where
diffusion was unsuccessful have not been studied (Henrich, 2000). This study
effectively addressed this criticism when the design was expanded to include
participants from school districts where CT may not have been implemented at all.
(See Chapter 4 for a detailed discussion.)
Related Diffusion Research
Similar to Roger's theoretical perspective is one that focuses on the
transformation processes that move organizations towards change or adoption of new
instructional innovations (Kershaw, 1996). This three-step process is centered on
individual behaviors. First, individuals must recognize that there is an urgent need for
change in the organization. Second, individuals must come to understand that they
themselves must change. Finally, they must realize that they need to change the way
they perform their roles in the organization.
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A more simplified model applied to faculty of educational institutions,
(Geoghegan, 1995) envisions two groups of adopters: early adopters and mainstream
faculty. This model characterizes early adopters as techies' who experiment with
every new technology that comes along. Mainstream faculty tends to focus more on
problems, processes, and tasks at hand than on the tools that might be used to address
them, and they prefer incremental change. Table 3.2 describes and contrasts the
characteristics of these two information technology adopter groups.
The Geoghegan model suggests that early adopters are often poor change
agents due to their lack of focus on process. Their success in using technology to
bring about qualitative improvements in teaching and learning, and the visibility that
can accompany such success, can have an alienating effect on others. It can foster a
belief that most faculty members should be using technology and that greater access
to technology and training is a prerequisite to success (Geoghegan, 1995).
Table 3.2: Adoption Categories for Information Technology Groups
Early Adopters Mainstream Adopters
Favor revolutionary change Favor evolutionary change
Visionary Pragmatic or conservative
Strong technology focus Strong problem and process focus
Risk-takers Risk adverse
Experimenters Want proven applications of compelling value
Largely self-sufficient May need significant support
Horizontally networked Vertically networked
54


Another diffusion model that is a management information systems model,
based on the Theory of Reasoned Action (Glanz, 1997), is the Technology Acceptance
Model (TAM), (Dillon and Morris, 1996). TAM predicts that user acceptance of any
technology is determined by:
1) Perceived usefulness The degree to which a person believes that the use
of the new technology will enhance his or her performance; and
2) Perceived ease of use The degree to which a person believes the new
technology will be free of effort.
Perceived usefulness is comparable to Rogers' construct of relative advantage,
and the perceived ease of use is comparable to his idea of complexity. This very
simplified two-dimensional model does not acknowledge the complexities of adoption
behavior, whereas DOI includes a broader range of constructs such as compatibility,
observability, and trialability as adoption characteristics.
In contrast to the TAM model, Reeves (1997) describes a more complex
model that seeks to explain significant pedagogical dimensions of computer-based
learning. This model describes fourteen pedagogical dimensions of computer-
based education (CBE) in an effort to provide improved criteria for understanding,
describing and evaluating CBE. While these dimensions were identified as evaluative
factors, they are suggestive of factors that may contribute to diffusion of CBE. These
factors are in the philosophical, teacher, student and technical domains.
epistemology;
pedagogical philosophy;
underlying philosophy;
goal orientation;
55


experiential value;
teacher role;
program flexibility;
value of errors;
motivation;
accommodation of individual differences;
learner control;
user activity;
cooperative learning; and
cultural sensitivity.
Some of these dimensions or factors and their definitions validated adoption
factors identified in the analysis of the observation and interview data collected
in this study. For example, learner control was a factor that students and teachers
liked about CT. Students liked that they could direct their choices from various CT
learning modules with the click of a mouse. Teachers liked that their students could
move through the program at their own pace.
A study of the introduction of integrated learning systems (1LS) into schools
suggests five stages of teacher participation in the implementation of ILS (Clariana,
1992). These are:
Novice, non-participatory, where a teacher drops off a class at the ILS
(computer) laboratory;
Novice participatory, where the teacher attends the classes but does not
know ILS;
Practitioner, where the teacher uses ILS progress reports to help pupils by
remediation or re-teaching;
56


Integrator, who manipulates the ILS sequence so that it better matches the
classroom instruction; and
Extender, who has fully integrated the ILS into classroom curricula.
This teacher classification system suggests that teachers be extenders because
they are required to be in the classroom when students were logged onto CT and to
integrate it into their broader health-education curricula.
One on-line discussion of the diffusion of technology in K-12 education
focused on cost and instructional strategies (Recesso. 2001). Using Rogers' DOI
model and a cost analysis model, the discussants concluded that the widespread
use of interface technology would result in low per student costs. To accomplish
widespread use of technology it identified that teacher effectiveness is an integral
issue related to the development and implementation of a technology-based interface.
One discussant stated that The drive to create this tool (a technology-based
interface) makes the assumption that teachers are also technologists ... we should
discriminate between content expertise, designing and developing the content for
presentation, and facilitating the learning experience (Recesso, 2001). This quote
and the surrounding discussion provide some perspective on the complexity of
the technology/user interface with which teachers are confronted. While the CT
curriculum does not require that teachers be designers or developers of technology, it
does require that they, to some extent, be content experts and, to a greater extent, that
they be facilitators of the learning experience.
This online discussion concluded that successful classroom use of a
technology-based learner interface would have to overcome barriers presented by
teacher training, costs, and providing a system conducive to facilitating effective
57


instruction. Because training was provided to teachers who were participants in this
study, the effectiveness of that training was examined in this investigation.
Relevance of Diffusion of Innovations
School tobacco education programs like CT are an important component
of a comprehensive tobacco control program (CDC, 1999). However, knowledge
of effective school-based strategies to influence adolescents on important health
topics, such as tobacco use, will have little or no impact if they are not effectively
disseminated to teachers and school officials. Computer-assisted instruction has been
used in schools for several years now. However, use of programs delivered over the
Internet is still novel (Buller, 2001). Thus, in DOI terms, teachers who are currently
using the Internet as an instructional tool are likely to be either early adopters or
early majority users of computer-based instructional tools. The DOI model postulates
that early users are apt to be attuned to communications from individuals and groups
outside of their informal social environment (e.g., national and local education and
health leaders) typically via mass media (non-localized channels) when making
adoption decisions. It is reasonable to expect then that direct marketing of the CT
program and its computer based attributes by outside entities such as the developers
of CT would reach early adopting schools and teachers and induce them to learn
more about and use the CT program. New adopters look to earlier adopters for
evidence that an Internet-based program is feasible and effective in the classroom.
These adopters depend on teachers who are opinion leaders for information about
the Consider This program. Identification and understanding of the diffusion or
communication constructs that promote use of new or innovative instructional tools
58


within and among schools and school districts will help facilitate adoption of new
tools such as the Consider This, Internet-based curriculum.
PRECEDE-PROCEED Planning Model
This diagnostic model was established to guide public health professionals as
they apply theories of health behaviors in the community setting (Green and Krueter,
1984). It provides a structure for applying theories, in order that the most appropriate
intervention strategies can be identified and implemented. PRECEDE-PROCEED
can be thought of as a road map, and theories as the routes to a destination (Glanz,
1997). The PRECEDE acronym stands for Predisposing Reinforcing and Enabling
Constructs in Educational. Diagnosis and Evaluation. The PRECEDE portion of the
model addresses planning variables including: individual behavior, environmental,
organizational, administrative and policy factors. This model is based on the
premise that a diagnosis of the educational environment is needed before an effective
intervention can be implemented. Glanz explains that this model is not a theory
per se, since it does not attempt to explain or predict the relationship among factors
thought to be associated with an outcome of interest. It is however, a structure within
which various theoretical approaches can be applied. This aspect of the PRECEDE
model had particular appeal to the investigator, since he was interested in explaining
not only the social system processes from the perspective of Diffusion of Innovations
theory, but also those individual and environmental factors that influence utilization
of health education curriculum in schools.
59


While there are nine phases to the entire PRECEDE (planning) PROCEDE
(implementation) model. Green and Krueter (1991) describe the PRECEDE portion
as having five phases of investigation or diagnosis:
Phase I Social diagnosis;
Phase II Epidemiological diagnosis;
Phase III Behavioral and environmental diagnosis;
Phase IV Educational and organizational diagnosis; and
Phase V Administrative and policy diagnosis.
The PROCEED portion of this model has four phases;
Phase VI Implementation
Phase VII Process evaluation
Phase VIII Impact evaluation
Phase IV Outcome evaluation
The PRECEDE model enables practitioners to incorporate constructs from
individual, interpersonal, communications, and organizational behavior change
theories in their work. Because impact and outcome evaluations of the Consider
This curriculum were not within the domain of this investigation and the PROCEED
portion of the model represents implementation and evaluation phases, this research
project will use only constructs from the PRECEDE portion of the model and
more specifically, constructs associated with Phase 4 of this model, the educational
diagnosis phase. This phase of the PRECEDE model assesses the causes of health
behaviors identified in previous phases of the model. Three kinds of causes are
identified predisposing factors, enabling factors, and reinforcing factors. Enabling,
reinforcing and barrier factors (PRECEDE constructs) will be identified for each of
the stages of the Diffusion of Innovations theory.
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Predisposing factors are the antecedents that provide the rationale or
motivation for a behavior. They include knowledge, attitudes, beliefs, personal
preferences, existing skills, and self-efficacy beliefs. In other words, predisposing
factors include any characteristics of a person or population that motivate behavior
prior to the occurrence of that behavior.
Enabling factors are those precursors that allow motivation to be realized,
directly or indirectly, through an environmental factor. Enabling factors include
programs, services, resources, or skills necessary for behavioral or environmental
outcomes to be realized. They facilitate action and any skill or resource required to
attain a specific behavior. Examples of enabling factors include accessibility to a
resource, availability of that resource, and skills necessary to access or use a resource.
Reinforcing factors are those elements that appear subsequent to behavior and that
provide continuing reward or incentive for the behavior to become persistent. These
factors include social support, peer influence, significant others, and vicarious
reinforcement. Simply put, these factors are rewards or punishments following or
anticipated as a consequence of a behavior. They serve to strengthen the motivation
for behavior.
The most significant value is using the PRECEDE model was the
identification of factors that, if modified, would most likely result in behavior
change. The identification process included determining and sorting these factors
into PRECEDE categories / constructs (e.g., enabling, predisposing or reinforcing).
For this study the factors that impeded or obstructed diffusion were categorized as
barriers and are be reported separately, outside of the DOI or PRECEDE findings.
Prioritizing these factors within each of the PRECEDE construct categories was the
61


concluding step in the research process. Prioritization of factors was based on the
weight of research evidence or relative importance and changeability.
Interface of Diffusion of Innovations and PRECEDE Theories
Factors or constructs of the PRECEDE model are used to describe aspects
in each of the stages of the Diffusion of Innovations model. This investigation
combined constructs from the Diffusion of Innovations (the social systems approach)
and PRECEDE models (individual behavioral and environmental approaches)
to better understand the factors that contribute to diffusion of the Consider This,
Internet-based tobacco education curriculum.
Using the Diffusion of Innovations model and constructs from the PRECEDE
model, this study described social change and diffusion processes and identified
predisposing, enabling and reinforcing factors that influenced diffusion of the
Consider This online curriculum. Each of these models defines its constructs on the
assets side of the diffusion equation. Therefore, in addition to DOI and PRECEDE-
related factors, barrier factors (the liabilities side of the diffusion equation) were
defined separately.
Figure 3.2 illustrates how the Diffusion of Innovations (DOI) and PRECEDE
models interface. Both models are stage-based models that describe processes
leading up to program or innovation implementation. The Diffusion of Innovations
model represents a social process that study participants went through to disseminate,
adopt, and implement the Consider This curriculum. While participants did not
actually develop this innovation (the first step in the Diffusion of Innovations model),
they did engage in activities to develop capacity for implementation (e.g., attended
training). Cl researchers developed the innovation.
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Figure 3.2: Interface of Diffusion of Innovations and PRECEDE / PROCEED Models
Plannning Model Stages: PRECEDE/PROCEED
Social Epi Behavioral/ Educational & Administrative &
Dx Dx Environmental Organizational Policy
Dx Dx Dx
Implementation Process-Impact-Outcome
Evaluation
Innovation-Dissemination-Adoption
Implementation
I. B I
Maintenance
Stages of Diffusion/lnnovation: Diffusion of Innovations
A = Pre-implementation activities B = Implementation C = Post-implementation activities
The PRECEDE/ PROCEED Model is a diagnostic health education, program
planning model that "is based on the premise that just as medical diagnosis precedes a
treatment plan, so should educational diagnosis precede an intervention plan (Glanz,
1997). While the PRECEDE model represents a conscious administrative planning
process, participants (teachers and administrators) may have unconsciously used a
model similar to this one to diagnose tobacco use in their schools and to plan their
response to identified problems.
The parallel social and individual behavior change processes represented by
DOI and PRECEDE occurred simultaneously yet in different domains. The common
point of interface for these models is the point of implementation or adoption.
Interview and observational data collected during this investigation were fitted to
this two-dimensional theoretical framework. The time period and contexts under
investigation are represented by the stages that are italicized in Figure 3.2. The
independent and interactive factors specific to each theoretical stage will be discussed
in this research.
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CHAPTER 4
SURVEY OF CONSIDER THIS TRAINING SEMINAR
ATTENDEES (QUANTITATIVE STUDY)
Survey Background and Purposes
The survey portion of the study was conducted with the cooperation of
administrators, principals, teachers, counselors, school nurses, and information
technology staff who attended one of the eight Consider This training seminars that
were offered during the 2001-2002 school year. While the overall study w'as initially
conceived and designed to be contained within a single school district (Douglas
County Schools [DCSD]), using only qualitative methods, many of the intended
interviews with DCSD administrators and school principals did not take place because
of difficulties scheduling and keeping appointments w'ith the study population.
A brief telephone conversation with a principal who called me on the
telephone to cancel an appointment, made it clear that middle school principals
and school district administrators in this school district were very busy people who
would not likely make time in their schedule for the interview. This brief telephone
conversation also suggested that decisions regarding health education curricula
selection were most often made by teachers a suggestion that w;as later verified
through this study. Hence, a focused, DCSD district-wide study using interviews as
the exclusive source of information was cancelled after interview's had already been
conducted with seven DCSD teachers and one administrator.
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I expanded the scope of the study to include all of the educators who were
trained to use CT during the 2001-2002 school year. An unforeseen benefit of this
change in study design was that it enabled the collection of data front school district
employees throughout Colorado whose district had not made a prior commitment to
broadly implement CT, like DCSD had made. By expanding the study to include a
broader population of study subjects, data became available from participants w'here
the adoption of CT was not as widespread as it appeared to be in DCSD. Making
this change in the study design addressed the criticism that diffusion research had
predominantly focused on successful diffusion events, and that events w'here diffusion
was unsuccessful had not been studied.
A cross-sectional, self-administered questionnaire that was mailed to all 147
CT trainees at the school where they were employed was selected as the method
of choice, since it enabled efficient, low-cost contact with each of the CT trainees.
Email addresses were not available for all potential participants so that method of
distribution w'as dismissed. The primary purposes of this survey were to: 1) collect
quantitative data that w'as more readily collected using survey methods than interview
methods; and 2) expand the pool of study subjects who would be interviewed in the
qualitative portion of the study. This survey w;as not a part of the training seminar
evaluation, but was conducted as a separate, special study.
Survey Methods
Research Design
Three components of survey design were considered when this research was
undertaken. These components were described as total survey design (Fowler, 1993).
65


They were a. sampling, b. question design and c. survey administration. Backstrom
and Hursh-Cesars (1981) Characteristics of Survey Research were used as guidelines
to help assure that the survey data would be free of bias and reliable for decision
making. These guiding characteristics define survey research as: 1. systematic-
follows a set of orderly rules of operation; 2. impartial selects units of the
population without prejudice; 3. representative includes representative units of the
population; 4. theory-based operations are guided by principles of human behavior
and mathematical laws: 5. quantitative assigns numerical values to non-numerical
characteristics to permit uniform interpretation; 6. self-monitoring procedures are
designed to avoid unwanted biases; 7. contemporary it is current fact-finding;
and 8. replicable other researchers using the same methods can get essentially the
same results.
Survey Sample
A census of the entire population of participants who attended CT training
seminars (n= 147) was determined to be an efficient, comprehensive and feasible
sampling strategy that would provide a response that would be representative of
the entire study population. This approach was possible since each of the study
participants had signed consent releases (at the training session they attended)
to allow follow-up studies by project researchers. It was also possible since the
estimated cost of its administration was within the budget that I allowed for this
data collection. Since I was still employed by the Principal Investigator of the CT
research project, I was able to obtain training session attendance rosters with subject
identifying and contact information for purposes of this research. The survey sample
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included all of the school district and local health related personnel who attended one
of the eight CT training seminars offered in December of 2001 or January of 2002.
Questionnaire Design
Diffusion of Innovations theory and PRECEDE model constructs guided
development of the survey questionnaire. Questions were derived to answer
theoretically sound inquiries that would address the specific aims of the study. (The
survey questionnaire can be found in Appendix A.)
The procedures used to develop the mailed questionnaire were procedures that
I have used in previous studies. These procedures are those generally recommended
by Dillman (1976), the Total Design Method for surveys, (Aday (1996) and Czar and
Blair (1996). A questionnaire was drafted to answer the principal research questions
using DOI and PRECEDE constructs as guides to content development. The steps
employed were: 1) determine the kind of information sought; 2) structure a question;
and 3) choose the words carefully. Attitudes, beliefs, behaviors and attributes were
the general types of information sought (Dillman, 1976).
Field testing of the questionnaire on a subset of the study population would
have biased their responses to the final questionnaire, so this method of pre-testing
the instrument w'as not used. The draft survey instrument was reviewed for clarity
and contextual language by a school administrator (personal friend) who was not a
potential participant in the survey. Changes were made in accordance with feedback
provided by this third party.
The logic employed in determining the content and structure of questions
is described in the following paragraphs. Detailing the structure and content of the
67


questions helped identify the data processing requirements.
To assure that survey respondents were eligible for the study the first
question on the survey instrument asked respondents if they attended one of the CT
training seminars. (As mentioned above, all but one of 83 respondents answered
affirmatively.)
Since there were two principal groups of seminars trainees, teaching and non-
teaching school district staff, and the ability to implement the CT curriculum in the
classroom was limited to the teaching group, a question was developed to determine
the position held by each participant (question #2).
The innovation-decision process is the process through which an individual
(or decision-making unit) passes (1) from first knowledge of an innovation, (2) to
forming at attitude toward an innovation (persuasion), (3) to a decision to adopt or
reject. (4) to implementation of a new idea, and (5) to confirmation of this decision
(Rogers, 1995, p. 161). Therefore, determining how teaching and non-teaching
staff first heard about CT (knowledge) is a critical step in the dissemination research
process. Figure 4.1, A Mode! of Stages in the Decision-making Process describes all
of the steps in this theoretical process.
This figure and the model it represents drove development of the survey
questionnaire. It also provided a guide to the analysis of the survey and interview
data. Question 3 was developed to answer the question as to how knowledge of
the innovation came about. The discrete responses for this question were informed
by the seven interviews conducted with DCSD employees in the early stage of
this investigation and with his knowledge of Consider This promotional activity
that occurred prior to the training seminars. The possible responses to question 3
acknowledged that adopters would likely hear about this innovation through the
68


promotional activities (the primary source) of the change agent (CT project staff) and
secondary sources (their social networks).
Figure 4.1: A Model of Stages in the Decision Process
A Model of Stages in the Decision Process
CT dissemination activities included incentives for school personnel to attend
training seminars (e.g., school reimbursement for substitute teachers). Question 4,
What factors influenced your registration and attendance at this training seminar?
enabled me to identify specific factors that encouraged participants to investigate
CT as a curriculum they might adopt. It was developed to address the persuasion
69


stage illustrated in Figure 4.1. Here once again, the DCSD interviews conducted in
the early stages of this investigation helped inform the response choices that were
offered. Each of the response categories added was associated with at least one
of three of Rogers' rate of adoption characteristics for an innovation (i.e., relative
advantage, trialability, compatibility). For example, substitute teacher expenses
were reimbursed, a response choice, was categorized as a factor that made it easier
for teachers to try CT (trialability). Table 4.1 contains an index of how each response
was categorized by DOI adoption characteristics.
Table 4.1: Factors that Influenced Registration and Attendance at CT Training
Seminars by Select DOI Adoption Characteristics
Trialability factors Compatibility factors Relative Advantage factors
Substitute teacher expenses Our school needed a new or CT is a student-
were reimbursed supplemental tobacco education directed, tailored,
Travel expense (mileage) curriculum interactive
was reimbursed CT is a student-directed, tailored, curriculum
The training session was interactive curriculum Online instructional
relatively close to my home Online instructional aspect of curriculum aspect of
or school was appealing curriculum was
Lunch was provided at the 1 was required to go by a supervisor or appealing
seminar administrator CT is free for
CT is free for schools to use CT is compatible with national education schools to use
Continuing education credits standards
were offered Continuing education credits were offered
Since the training seminar was the first significant exposure to CT that the
participants experienced, a question (question 5) assessing the perceived helpfulness
of the seminar was asked. The perceived quality or value of the seminar could have
contributed to the adoption or rejection of CT.
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The next series of questions (questions 6 through 10), asked of teachers
exclusively, assesses their experience implementing CT in the classroom. (Non-
teachers skipped to question 11.) These questions enabled the collection of data on
frequency of classroom use, the school year that it was used, satisfaction with the
CT program, and if teachers did not use CT, reasons for non-use. In summary, these
questions provide a measure of the extent to which CT was adopted by teachers.
The next two questions (question 11 and 12) assessed teaching and non-teaching
participant perceptions of their school district's and their own rate of adoption of new
or innovative ideas / technology. This data was used to determine the relationship
between these self-reported adopter categories and their use of CT.
Following the rate of adoption questions, all respondents w ere asked to
indicate their comfort level with computer technology and whether or not they had
had formal training in the use of computers and/or use of the Internet (questions 13
and 14). Comfort with and training related to computer technology are enabling
factors that allow participant motivations to be realized.
The closing questions were used to record respondent demographic
descriptors (when they received their bachelors degree, if they had an advanced
degree and the type of degree, gender, age and race) and smoking behavior (use of
cigarettes in the past 30 days).
The final question of the survey asked the respondent if he or she was "willing
to help the investigator with this research by being interviewed on the telephone.
This question enabled the identification of respondents who would become
participants in the qualitative portion of the study.
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Survey Administration
The survey instrument was reviewed by the statistician at Abacus Statistical
Consultants prior to being mailed, to assure that the data could be processed and
analyzed with relative ease. Training seminar registrant address information was
extracted from CT project files, mailing labels were printed, and letters, including
the survey instrument, were mailed to all 147 seminar attendees. A cover letter
explaining the purpose of the study and asking potential participants to complete the
enclosed survey questionnaire was mailed in late February of 2003 to all persons on
the CT training seminar attendee list. Two follow-up reminder postcards were mailed
to non-respondents at two-week intervals following the initial mailing. All responses
were received by early April of 2003.
Eighty-three of the seminar attendees responded to the survey, for a 56%
response rate. One person returned the survey and indicated that they had not
attended any one of the CT training seminars and was therefore deemed ineligible for
the study. Therefore, there w'ere 82 eligible respondents who were included in the
analysis of the survey data. At this point in time, the completed survey questionnaires
were forwarded to Abacus Statistical Consultants for data entry into an Excel
database.
Data Processing
As questionnaires were returned they were logged-in and separated into two
piles. One pile contained those questionnaires whose respondents declined to be
interviewed and the other included those who agreed. Email messages were sent
to those participants who agreed to be interviewed to schedule a date and time for
72


a telephone interview. If there was no reply to the email message, approximately
two weeks from the logged-in date of the returned survey, phone calls were made to
schedule the interviews. After the telephone interviews were scheduled, the survey
data were entered into an Excel data file by a data entry operator affiliated with
Abacus and frequency distributions for each question and the data file returned to the
investigator. The receipt of this data signaled the initiation of the analysis activity.
Analysis Methods
Completed questionnaires were reviewed for completeness and clarity
of responses before they were forwarded for data entry. Extraneous marks were
removed from the completed questionnaires and responses verified by range checks.
Frequency tables of questionnaire variables were provided by Abacus and cross
tabulations produced after review of the preliminary tables. Confidence intervals or
the Fisher Exact Test was used to test statistical associations between variables.
Adoption of CT was limited to the teacher group, since this is the subgroup
of study participants that has routine access to students and works regularly in the
classroom, the intended implementation environment for CT. It was important
therefore to examine the adoption behaviors of this group separately from the
non-teachers. (It was assumed that non-teachers do not routinely plan lessons or
implement curricula in the classroom, two requirements for successful use of CT.)
Teacher responses were grouped according to their reported CT adoption behavior
and DOI and PRECEDE factors associated with each group described.
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Statistical Tests
Chi-square tests of significance were used in testing tables where the expected
number of cases in each cell was 5 or greater. Since there were relatively few
respondents to the survey in this study (n=82), the Fisher Exact test was used to test
significance for those tables where expected cell values were <5.
Findings
Study Participant Characteristics
A total of 82 persons responded to the survey of CT training seminar
attendees. Study participants who identified themselves as having positions as
administrators (n=4). information technology staff (n=4), counselors (n=5), school
nurses (n=5). other non-teaching positions (n=4), in their school district, and local
public health agency staff (n=2) as of spring of 2002 were categorized as non-teachers
in the analyses. All others (n=58) were teachers. Table 4.2 contains the frequency
and percentages for demographic and smoking status descriptors for the study
participants.
Seventy-five percent of the respondents were female (one person did not
respond to the gender question). Seventy-one percent of the teacher participants and
87% of the non-teacher participants were female. The average age of all of study
participants was 42.1 years; the median was 43 years and the mode was 44 years.
The average ages for teachers and non-teachers were 41.6 years and 44.1 years
respectively.
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Table 4.2: Demographic Characteristics and Self-reported 30-day Smoking Status
for Consider This Survey Participants, n=82
Gender Teachers Non-teachers Total
Male 17(29.3) 3(13.0) 20 (24.7)
Female 41 (70.7) 20 (87.0) 61 (75.3)
Total 58 23 81 (100)
Age (in years) Teachers Non-teachers Total
20-29 7(12.3) 1 (5.0) 8 (9.8)
30-39 14 (24.6) 6 (30.0) 20 (24.4)
40-49 26 (45.6) 7 (35.0) 33 (40.2)
50-59 9(15.8) 4 (20.0) 13(15.9)
60-69 1 (1.7) 2(10.0) 3 (3.7)
Total 57 20 77 (100)
Race / ethnicity Teachers Non-teachers Total
White 56 (96.6) 22(100) 78 (97.5)
Black 0 0 0
Asian/Pac. Islander 0 0 0
Am. Indian/Alaska Native 1 (2.2) 0 1 (1.2)
Hispanic 1 (2.2) 0 1 (1.2)
Total 58 22 80(100)
Days smoking in last 30 days Teachers Non-teachers Total
Zero 55 (94.8) 21 (95.4) 76 (92.7)
1 or 2 0 0 0
3 to 5 1 (1.7) 0 1
30 2 (3.5) 1 3
Total 58 22 80(100)
Ninety-eight percent (n=78) were white, one study participant each indicated
that they were American Indian/Alaskan Native and Hispanic. Only 7 percent (n=4)
indicated that they had smoked cigarettes in the past 30 days. The smokers were
proportionately distributed among the position categories with three smokers being
teachers.
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A greater proportion of the non-teachers had advanced degrees with nearly
70% of the non-teachers having advanced degrees, compared to nearly half of
the teacher group. Overall, more than half of the respondents (43 ) had advanced
degrees, with all but one of those being a Master's degree and that one was a
Doctoral degree. As can be seen in Table 4.3, the difference between the groups on
training in computers and/or Internet use was not as great as it was for advanced
degrees. Eighty-seven percent of the non-teachers compared to 78% of the teachers
had this training. Overall, 80% indicated that they had had training in computers
and/or Internet use. See Table 4.3 above for the frequency and percent of advanced
education and training.
Table 4.3: Advanced Education and Computer Training for Consider This Survey
Participants, n=82
Advanced degree Teachers Non-teachers Total
Yes 28 15 43*
(48.3) (68.2) (53.8)
No 30 7 37
(51.7) (31.8) (46.2)
Total 58 22 80
Training in computer and/or Internet use Teachers Non-teachers Total
Yes 45 20 65
(77.6) (87.0) (80.2)
No 13 3 16
(22.4) (13.0) (19.8)
Total 58 23 81
* Includes 42 Masters degrees and one PhD
Table 4.4 shows that 44.4% of the respondents classified their school district
in the early adopter category (among the first to try ) and 40.3% classified their district
76


as in the early majority group (after a few others have tried). Fourteen percent
(14.2%) indicated that their district tends to adopt new ideas or innovations after most
others or long after most others try it.
Table 4.4: Frequency and (Row Percent) of School District and Participant Adopter
Classifications and Comfort Level with Computer Technology
When does your Among first After a few After mnct Long
district adopt to try it others try it others try it (late majority) after most
new / innovative (early (early others try it Total
ideas? adopter) majority) (laggards)
Teachers 27 21 4 4 56
(48.2) (37.5) (7.1) (7.1) (100.0)
Non-teachers 5 8 2 1 16
(31.2) (50.0) (12.5) (6.2) (100.0)
Total 32 29 6 5 72
(44.4) (40.3) (8.3) (6.9) (100.0)
When do you adopt a new/ innovative idea? Among first to try it (early adopter) After a few others try it (early majority) After most others try it (late majority) Long after most others try it (laggards) Total
Teachers 20 32 5 0 57
(35.1) (56.1) (8.8) (100.0)
Non-teachers 7 12 2 1 22
(31.8) (54.6) (9.1) (4.5) (100.0)
Total 27 44 7 1 79
(34.2) (55.7) (8.9) (1.2) (100.0)
Comfort level with computer technology? Very comfortable Somewhat comfortable Somewhat Very Total
Teachers 16 32 7 3 58
(27.6) (55.2) (12.0) (5.2) (100.0)
Non-teachers 11 12 0 0 23
(47.8) (52.2) (100.0)
Total 27 44 7 3 81
(33.3) (54.3) (8.7) (3.7) (100.0)
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Teachers rated the average time for adoption of innovations by their school
district as earlier than non-teachers. Forty-eight percent of teachers and only 31 % of
non-teachers rated their district as an early adopter. This finding may be influenced
by the inclusion of information technology staff in the non-teacher group. IT staff
may see themselves as early adopters and the organizations that they work for as later
adopters, thus reflecting a likely bias towards adoption of technology innovations.
They were also likely biased toward adoption of innovations. This difference
seems to diminish somewhat when the early adopter and early majority categories
are combined. Eighty-eight percent of the teachers and 81 % of the non-teachers
indicated that their school district was either an early adopter or early majority
adopter. Nearly one teacher in six (15.2%) identified their school district as either a
late majority adopter or laggard.
Self-reported personal innovation adoption practices or behaviors were
classified using the same DOI adopter classifications as that for the school districts.
One-third (33.3%) of the respondents indicated that they (personally) were among
the first to try new innovations (early adopters) or ideas and over half (54.3%) adopt
new ideas or innovations after most others try them (late majority). Ten respondents
(12.4%) self-described their adoption behavior as adopting after most others try or
long after most others try. While the percentage of participants that were personally
categorized as being on the early adopter side of the normal curve (early adopters
and early majority) was slightly greater than that for their school districts behavior
(89.9% versus 84.7%), it is interesting to note that 10% fewer respondents (34.2%
versus 44.4%) felt that they were among the first to try a new idea compared to the
perceived adoption rate for school districts. This suggests that some respondents felt
that their school district was more innovative than themselves.
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The adoption of innovations characteristics for both school district and
personal adoption behaviors are skewed positively or to the right, with many more
early and early majority adopters than normally expected. If adopter behavior for
school districts and school personnel were normally distributed, it would be expected
that approximately 50% would be in the early or early majority categories. Nearly
90% of the study participants were either early or early majority adopters. With
greater than three quarters of the participants self-classifying in these categories, this
suggests that self-reporting of adopter classification is significantly favorably biased.
As Rogers suggests (1995. p.269), this bias may be the result of the high educational
level of the study participants.
Table 4.4 also includes data on participant comfort level with computer
technology (an enabling factor). One-third of all respondents indicated that they
were very comfortable with computer technology (33.3%), over half were somewhat
comfortable (54.3%), and 12.4% were either somewhat uncomfortable or very
uncomfortable. A surprising finding was that 17.2% of teachers indicated that they
were either somewhat or very uncomfortable while none of the non-teachers were
uncomfortable with computer technology.
Frequency of Teacher Use of Consider This
The frequency of use of the Consider This curriculum in the classroom is the
strongest indicator of its dissemination among study participants who were trained
in 2001-2002. Among the entire study group, teachers were the only subgroup that
could implement CT in the classroom. The non-teacher respondents (counselors,
nurses, IT personnel, administrators, non-school district personnel) do not routinely
79


I
have instructional responsibilities in the classroom. Of the 82 school personnel
who responded to the survey, 59 indicated that they were teachers and 57 of those
responded to the frequency of use question. Therefore, the following analyses on use
of CT are limited to the teacher subgroup.
Of the teachers who responded to the survey, 40.2% indicated that they never
used CT after they were trained (Never users): 21.0% tried it briefly for one or a few
class periods ancfdid not use it again (Trial users): 21.0% used it for multiple class
periods for one or two class groups (Temporary users): and 17.5% used it for three or
more class groups (Adopters). Table 4.5 below summarizes the frequency of teacher
use of CT in the classroom.
Table 4.5: Frequency of Consider This Use by Adopter Group (n=57)
Group Name Frequency of CT classrooom use N (%)
Never users Never used it 23 (40.4)
Trial users Tried it for one class period and did not use it again 2(3.5)
Tried it for a few class periods and did not use it again 10(17.5)
Temporary users Used it for multiple class periods with one class group 8(14.0)
Used it for multiple class periods with two class groups 4 (7.0)
Adopters Used it for three or more class groups 10(17.5)
Total 57 (100)
Grouping teachers by reported frequency of CT usage in Table 4.5 disclosed
that 40% never used CT and therefore could be classified as never users. This group
failed to move past the decision stage to the implementation stage. (See Figure 4.1.)
The remaining sixty-percent of teachers (34/57 or 60%), those who adopted CT for
one or more classes, moved to the implementation stage. This group included the trial
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and temporary users and the adopters. Among this group, the temporary users and
adopters (12 + 10 / 57 or 48.6%), was the group that moved to the implementation
stage. Those who used CT for three or more class groups (10/57 or 18%), the
adopters, are those teachers who implemented CT and took actions to maintain or
confirm its use. None of the teacher groups were immune from discontinued use or
later adoption. So it is important to recognize that this cross-sectional review of CT
use does not imply that eighteen percent of the teachers who responded to the survey
surveyed (the adoption group) continued to use CT after this survey was conducted
or that they were even using it at the time of the survey. As Figure 4.1 in this chapter
illustrates, discontinuance by those who had adopted CT (later adoption) can occur
after the implementation and confirmation stages, thus changing the size of the
adoption group. Later adoption by those who had rejected CT is also possible. These
adoption dynamics influence cross-sectional analyses of adoption rates.
Dissemination
The dissemination stage, the second stage (following innovation development)
in the diffusion process model was the first stage to be assessed in this survey. For
purposes of this study, those persons who were eligible to be classified in this stage
were all of the participants who attended one of the CT training seminars. Those
who returned a survey, a subset of this group, were those who were classified as
having reached this dissemination stage for the analysis. How teachers initially heard
about CT and the offering of CT training seminars (first knowledge of CT) may be
an important determinant of the most effective means for promoting or disseminating
CT. Survey respondents checked all of the methods by which they had heard about
81


the CT curriculum and specified the means by which they heard about CT that were
not listed by describing them on the other category response line. The means by
which teachers heard about CT were grouped for this analysis into the following three
groups. See Table 4.6 for this data.
Promotional actions brochure or poster received in the mail or CT
project staff contacted them directly.
In-school network (i.e., word of mouth) principal told me; another
teacher in my school told me; a district administrator told me; school nurse
told me; heard at a health curriculum meeting; and previous person in my
position told me.
Out-of-school network (write-in responses) a teacher in another school;
health education consulting organization; and local tobacco control
coalition.
Did the means by which teachers heard about the CT curriculum influence use
in the classroom? Since CT had not previously been promoted in Colorado schools
prior to the CDPHE-funded dissemination project, the brochure and poster packet
mailing to Colorado middle, junior and senior high schools was likely the only way
that school personnel could have heard about CT. In Table 4.6. columns 1.2 and 3
represent the in-school responses to the question How did you first hear about CT?
(Participants w'ere permitted to check all responses that applied.) Column 3 is the
total of columns 2 and 3, and column 5 is the total of columns 4 and 2.
Over all groups of adoption types, the data in Table 4.6 suggest that the in-
school network / information channel was the most important channel by which
teachers initially heard about CT and the CT training seminars. Over half of the
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survey respondents (56.1%) heard about CT through in-school network channels
alone or in combination with other sources. (See Table 4.6, columns 1 and 2 totaled.)
One-third (33.3%) heard about CT through promotional actions alone.
Table 4.6: Frequency and (Percentages) of Classroom Use by How Teachers Heard
About Consider This (n=57)
(1) (2) (3) (4) (5)
Frequency (Column %) (Row %) In-school network only ln-school network & promotion actions Promotion actions only Out-school network only Unknown source Total
Never tried 9 (33.3) (39.1) 2 (40.0) (8.7) 9 (47.4) (39.1) 1 (33.3) (4.3) 2 (66.7) (8.7) 23 (40.4) (100.0)
Tried briefly 8 (29.6) (66.7) 0 2 (10.5) (16.6) 1 (33.3) (8.3) 1 (33.3) (8.3) 12 (21.0) (100.0)
Tried multiple periods for 1-2 groups 6 (22.2) (50.0) 0 5 (26.3) (41.7) 1 (33.3) (8.3) 0 12 (21.0) (100.0)
Used > 3 or more classes 4 (14.8) (40.0) 3 (60.0) (30.0) 3 (15.7) (30.0) 0 0 10 (17.6) (100.0)
Total 27 (100.0) (47.4) 5 (100.0) (8.8) 19 (100.0) (33.3) 3 (100.0) (5.3) 3 (100.0) (5.3) 57 (100)
Out-of-school communication networks were largely ineffective in
disseminating information about CT, with only 5.3% indicating that as the source
through which they heard about CT. On face value, it could be concluded that the
most important method for communicating with teachers about CT was the in-school
network. However, that conclusion does not take into account the time dimension or
sequence of events that led to teacher knowledge of CT. The promotional materials
83


and other dissemination actions (phone calls by CT project staff) that were employed
created knowledge of CT and activated in-school communication networks, thereby
initiating the diffusion process.
Channels of communication outside of the in-school network (column 4, Table
4.6) were the least important channels of communication, with only 5 percent of the
teachers reporting that they heard about CT from outside sources. Only 8.8% of the
teachers indicated that they both saw the promotional materials and heard about CT
through the in-school network.
The numbers in each cell of Table 4.6 are too small to reliably draw statistical
conclusions about the relationship between how teachers heard about CT and their
decision to adopt, but they suggest that the in-school network is as important a means
for information dissemination about CT as the promotional materials.
Did promotional actions or in-school communication channels have a greater
influence on eventual adoption of this curriculum? Adoption, implementation and
maintenance of an innovation were the desired outcomes of the diffusion process, so
it was important to test the influence of these two dissemination methods on those
outcomes. Because of small numbers, the Chi-Square statistic could not be used to
test differences in usage of CT between the teachers represented in columns 1 and 4
of Table 4.6. Instead, confidence intervals were computed around the proportions in
columns 1 and 4 which are independent groups. The confidence intervals were very
wide and overlapped, supporting that there is no difference. (See Table 4.7.)
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Table 4.7: Frequency of Classroom Use by Single Source of How Teachers Heard
About Consider This
* Percent of all teachers
In-school network only Promotion actions only
# %* 95% Confidence Interval # %* 95% Confidence Interval
Never tried 9 33.3 (17.2-54.0) 9 47.4 (25.2-70.5)
Tried briefly 8 29.6 (14.5-50.3) 2 10.5 (1.8-34.5)
Tried multiple class periods for 1-2 groups 6 22.2 (9.4-42.7) 5 26.3 (10.1 -51.4)
Used > 3 or more classes 4 14.8 (4.9 34.6) 3 15.7 (4.2-40.5)
Total 27 100.0 19 100.0
DOI-Related Findings bv Construct
The DOI theory postulates that there are innovation factors or characteristics
that influence the diffusion process. Those factors are: trialability, compatibility,
complexity, relative advantage, and observability. The results of using CT. in this
case were related to student tobacco use outcomes, which were not readily visible
to teachers. Observability is therefore obscured just by the nature of the teacher -
student relationship and a teacher's proximity to observe student smoking behavior
and initiation of smoking. Therefore, observability as a diffusion factor was excluded
from this analysis.
Complexity was also excluded since it could not be determined for
questionnaire development how teachers would define CT complexity in their
own terms. (Complexity is discussed in Chapter 5 of this study as it is described
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Full Text

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FACTORS THAT INFLUENCE DISSEMINATION AND ADOPTION OF A WEB-BASED HEALTH EDUCATION CURRICULUM by Walter F. Young B.S., University of Akron, 1969 M.A. University of Northern Colorado, J 977 A thesis submitted to the University of Colorado at Denver in partial fulfillment of the requirements for the degree of Doctor of Philosophy Health and Behavioral Sciences 2005

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This the sis for the Doctor of Philosophy degree by Walter F. Young has been ap proved by Erv B ettinghaus Rod Muth

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Young, Walter F. (Ph.D., Hea lth and Behavior a l Sciences) Factors that Influ e nce Di ssem ination and Adoption of a Web-based H ea lth Education Curriculum The sis directed by Assoc i ate Pro fessor Kitty Corbett ABSTRACT The goals of thi s rese a rch project were t o describe the factors associated with a dopti o n of the C o nsider This middle schoo l tobacco education c urri c ulum and to characterize the diffu s ion process for this Internet-based health education c urriculum The spec ific aims of this st ud y were to: 1) Describe the Di ff usion of Inno va tion s characterist ics (re lative adva nta ge, com p atib ility etc.) that contributed t o adoptio n of t he CT curriculum; 2) Identif y the PRECEDE mod e l factors (predisposing, enablin g and reinforcing fac tor s) assoc i a t ed with adopt ion of CT; and 3) Describe emergent a nd n on -th eoretical l y-based factors tha t influenced adoption of CT. The re searc h question answere d in thi s study was, Is the exte nt to which teachers identify individual adoptive behaviors or characteristics, e n vironmenta l factors conducive to adoption, and CT characteristics associated with the DOI and PRECEDE mode ls assoc i ated with ado pti o n of the CT curriculum?" Thi s follow-up study u sed quantitative and qualitative met hod s to gather inform a tion from Color ado educators who were trained to use CT in 2002. All educators who were trained (n=l47) were mailed a questionnaire that assessed the factors that associated with dissemination a nd adoption of the curriculum. The returned questionnaire s (n=87) also identified s tud y participants and their perso nal contact information who were willing to be interviewed by the inve st igator (n=27). Twenty-three face-to-face and telephone interview s with educators from around the state of Colorado helped enrich the data that was collected via the survey. Interviews were recorded on audio tape and transcripts entered into a t ex t analysis software package to facilitate coding and analysis of data. iii

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Some of the factors show n to positively influence dissemination of this curricu lum included: computer availabi lity and accessibility; teacher knowledge of and skill with computer technology; teacher access to peer networks ; teacher motivation I determination; and information technology s upport. Some of the barriers to diff u sion and adoption included: attrition (turnover ) of teachers; discontinued training program for CT; too few computers; poor access to the computers in schools (scheduling and restricted use); apathy toward classroom change; and frustration with and l ac k of IT support on technical problems. This abstract accurately represents the content of the candidate's thesis. I recommend it s publication. Signed: Kitty Corbett iv

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DEDICATION This research is dedicated to my family th at has so patiently tolerated my weekend absences over the past year a nd espec i ally to my w i fe Susan w h ose encourageme nt kept me working when times were tough. This i s a l so dedicated to my parents Florence Young and the late, Walter J. Young, who a lways encouraged a n d s upport ed continued education.

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ACKNOWLEDGEMENTS The author wo uld lik e to thank the many health education t eachers, sc ho ol nurses, counselors and administrators who responded to my survey and who agreed to be interviewed for this research. I would a l so like to thank Dr. Kitty Corbett for her guidance throughout the planning conduct and writing of this dissertation and to my dissertation committee members who read and edited earlier vers i ons of this work .. A special thanks goes to Dr. David Buller, Vice President Health Communications Division of the Cooper Institute for his suppot1, patience and tolerance of an employee who was often preoccupied with his dissertation work.

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CONTENTS Figures .. ....... ....................................... ............... .............. ... ... ........................ xii Tables .... ........ ..................... ... ... .... ..................... ....... ... ....... ............ .............. x i i i CHAPTER 1. INTRODUCTION .... . ...... ..... .................................................... ...... . ........ 1 Specific Aims and H y pothe ses ........ ..... .... .............................. .......... ..... 3 Background .... ............................. ............ ............ ............... ........ ... ......... 4 Overview of Re s earch Design and Methods . ... .... . ......... . .................. 10 2. TECHNOLOGY IN EDUCATIO AND YOUTH TOBACCO USE ...... 11 Factors Associated with Diffu s ion of Computer-based Educational Technology .... .................. ...... ........................... ............ ... 12 Applications of the PRECEDE Model in Public Health ......... ............. 20 T obacco Use Among Youth .... ............. ... ..... ... .............. ... ................ 21 Health Effects a nd Risks of Tobacco Use .................... ... ............ ... ...... 22 Prevalence of Youth Tobacco U se ....... .... ..... ... ............ ............. ....... ... 23 Inc i dence of Initiation ...... . .................... .................. ....... ...... .... .... ..... 24 School-based Tobac co Use Prev en tion .... ......... ...... .... . ..... ............... 26 Project TNT ... ... ............. .................................... .... ............ ............. 28 Life Skills Training ........ .............. ..... ................ ....... .... ................. 29 Not On Tob acco (NOT) ....... ................... ........... ... .................... ... 31 Project A l ert ..................... ... ..... ... ........................ ......................... 3 1 Consider This ... ........................ ..... ...................... ........................ . 32 Int ernet Use Among Youth ............................................................. ...... 37 Computers and Int ernet Access in Colorado Schoo l s ................ ... ... .... 40 vii

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3. THEOR E TICAL APPROACHES . ............... . ......... ...... ......... .................. 42 Diffusion of Innovations ...... ........ ...... .... ..... .......... ... ........ ................. 42 Elements of the Diffusion Proce ss ... ....................... ...................... ...... 44 Innov at ion Traits .... ..... ..... ............................ ..... . ...... ............. ..... 44 Communication Channe l s ... ....... .................................................... 46 Time .................... . ......... ..... .......................... ... ..... .... .................... 47 Soci a l S ys tems .............. ............ . ....... ....... .......... .............. ....... .... ... 48 Other Human Elements of t he Diffu s ion Process ... ...................... ...... 51 Summary of Diffu s ion of Innovation s Constructs ................................ 51 Critici s m s of Diffusion Re earch ........ ...... ..... ...... ........................... 52 Re l a t ed D i ffusion Research ..................... ............. ................ ....... 53 Relevance of Diffusion of I nnovations ............... .......... ............... 58 PRECEDE-PROCEED Planning Model .............................................. 5 9 Int e r face of Diffusion of Innovations and PR ECEDE Theorie s ........... 62 4. SURVEY OF CONS I D E R THIS TRAINING SEMINAR ATTE DEES (QUA TITATIVE STUDY) ..................... ............................ . ................. 64 Survey Background and Purposes ................... .................................... 64 Survey Method s ........................................... ......... ...................... ....... 65 Research Design . ............................................................................ 65 Survey Sample ................. .... ......... .......... ... . .............. ..... ..... . . .... 66 Questionnaire Desig n .................. ............... ... ............ ................. .... 67 Survey Administration ........... ................ ..... ............... .... ..... ...... .... 72 Data Process i ng .................................. ...... . ....... ........................ ... 72 Ana l ysis Methods . ........ ... ... ............ .... .... ... . ........................... ...... 73 Statistica l Tests . ...... ..... . ................... ... ................... ........ ..... ........ 74 viii

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Findings ..... ........... ....... ...... ...................... ........ .......... .... .... . . .............. 74 Stud y P ar ticip a nt Ch a r ac teri stics .................................................... 74 F req u ency of Te ac her U e of Consider Thi s ....... . .......................... 79 Di ssen1i n at ion ...................... .... ........ . ... ...... ... . ...... ..... ....... ............ 8 1 DOl-Related Fin din gs by Construct .................... .......................... 85 Characterist i cs of P rtic ipant s Who Ag reed t o be Int erv iewed ...... 88 Factors Associated with Teacher Adopt io n of Consider This ...... ... 9 1 Di scussio n ..... ........... .... . ............................................ ...... .............. 91 5 INTERVIEWS WITH CONSIDER THIS T R AI ING SEMI TAR ATTE D EES (QUALITATIVE STUDY) Intr oduction .................................................................... ..... ....... ... ...... 93 B ackgro und ... . ... ... . . .................... . . .... .......................... .... ........... ..... 93 C ontext of Wave I Facet o-Face Inter v iews DCSD .................... 93 Context of Wave II Telephone Inte rviews with o n -DCS D Participants ... ... .......... ..... ................ ..... ........... ........... 95 Sample ............ ......... .... ....... ............................. .... ... ............................ 95 M e tho ds .... ......... . ............... ..... .................................. . ..... ... .................. 97 Inter v iew Guide Deve lopm e nt ........................................................ 98 Interview P rocess and Di s position of the In terv iews ...... ............... 99 Limitations of T e leph o n e Interviews ......... ............. .................... I 02 D ata Tra n scr iption Coding a nd Analysis ................. . . . .......... .... 103 Classroom Observat ion . ...... .................. ............. ... . . ................ I 06 Findings ... ........................... . ..... ......... ..... ...................... .... . ............. 1 07 DCSD School a nd Community Environments . ..... ......... .......... . I 07 C l assroom Observatio n s ..................... ...... .......... ..................... .... I 08 ix

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Diffu s ion of Innova tion s CT Adopti on Charac teristic s ............... 111 R e l a tiv e Advantages .... ... ....................... ... ...... ......................... 111 Rel ative Advantages for Students ( Teacher Perspectives) ..... 116 Compatibility . ............ . ........ ..... ... ...... ...... . ........ ..... .......... ... 117 Complexity ................................................. .............. ... ...... ... 119 Tri a labilit y .......... .............. ....... ............ ... ........ ...... ................. l2. 3 Observability ........... ........ ............................................ ......... 123 Social System Member Characteristics ... ................ ........... . 124 Communication Channels I Diffusion Networks .................... 1 25 PRECEDE Adopti o n Characteri tics ......................................... ... 126 Predisposing Factors ................. ... ... ....... ............. ......... ... ..... 1 27 Enabling Factors ........... ........................ . ........ . .................... 130 Reinforcing Factors ...... ......... ....... ........ .............. ............ ..... 1 37 Non-DOI or PRECEDE Mode l Di ffusion Factors ........ ...... . .... ... 14 2 BaJTiers .......................... ..... ................ ...... ... ... ...... ... ... .... ..... 142 Attitudes ...... . ... ....................... ..... . ..... ....... . ... ................. ..... 151 Critical Mass ........... . . ....... ..... ............ ... .... . ... .... ................... 1 53 Summary of Qu ali t at i ve Findings ... ........... .......................... ..... ... ..... 1 54 Cl assroo m Observation ... ... ............................... ... ....... ... .... .... .... 1 54 Parti cipan t Interviews .......... .... .... ...... ... ....... ........ ...................... 154 R e l a tive Advantages ......... ......... .......... ... ... ...... . ... .... .............. 154 C o mp a tibility F ac tor s .... .... ..... .................... ................ ......... ... 155 Complex it y Factors .......... .... . ........... . .............................. ... 155 Obse rvabilit y ........................ .... .............. ............... ... ......... ..... 156 X

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Social System Member Characteristics ...... ...... ...... .............. 156 Predisposing Facto r s . .................................................... ......... 1 57 Enabling Factors .................... ...................... ............... ...... ..... 157 Reinforcing Factors ............... ................... . .................. ..... ... 157 Barriers ........ . ............................ ....... ...................... .... ......... 158 Attitudes .......... .......... . ..... ........ ... ........................................ 158 Conclusion .... ....... ............................................ ................. ................ 159 6. DISCUSSIO ............................................ . ......................... ...... ........... 160 Diffu s ion of Inno vat ions Adoption Character i stics .. ..... ..................... 1 63 R elative Adva nt ages ............... . .................................. .... ............ 1 63 Compatibility Factors .... .................. ...... ......... ........... ........ ... .... 1 63 Complexity F ac t o r s .............. ........................... ... ... ..... ................. 1 64 Trialability Factors ......... ....... ... ....... ..... ... ....... ..... ....................... 1 65 Observ ability Factors .......................................... ...................... . 166 Communication Networks .......... ...... .......... .... ....... ...................... 1 67 Critical Mass . . .... .... ........................................................... ....... 1 68 Innov atio n Development... ... . ... ...... ................. .... .............. ......... 1 68 Di ssemina tion ....................................... ... ................................. .. 169 Adoption ..... ........... ................................. ...... ... ............... .... ... ..... 169 I mplementation .............................................. ................. .... ...... ... 170 Maintena nce ...................... .... .... ........... ...................................... 1 70 PRECEDE Adoptio n Characteri sat ics ........... ... ............ ... ............... . 171 Predi sposing Factors .................................... .... ... ...... ............. ..... 171 Enabling Factors . .... .......................... . ........................... ............ 172 xi

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Reinforcin g Factors ...... ..... ....... ..... .............. ........ ........... .... . ...... 172 Emergent Adoption Characteri s tics ........................ ................. ... 173 Synthesi s of Findin gs ... . ........... .... ............... ... ............... ......... .... . .... 176 H ypothes i s T est ..... .... ... .................... ... .......... .... .......... ...... ................ 179 7. CO CLUSJONS . . .... ....... .......... ... ...... ... .......... ... .............. ........... ....... ... 1 82 R eco mm enda tion s for P o l icy Change ................. . ..... ........................ 1 83 Futur e Re earc h ....... .... ......... ............ .... ................... ... ........... ...... .... 185 APPENDIX .... ... ....... ........ ..... . ......... .... ........... ..................... ... .......... .......... 1 88 A. CONSIDER THIS FOLLOW-UP EVALUATION .................. . ... 1 88 B CO SIDER THIS INTERVIEW GUIDE ................... . ......... .... 1 94 C. EMPLOYEE CONSE T ..... ... ....... . . ........... ............. ..... ............ 202 D INTERNET SE FROM A Y LOCAT IO N BY ........ .... ........ ... 205 INDI V IDU AL S AGE THREE AND OLDER END OTES .......... ....................... ...... ... ..... ........ ... . ......... ..... .... ................... 207 REFERE CES . ........... ........... . .... .... .... ........ ............ ... ............................ ..... 208 xii

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FIGURES Figure 1 1 Process of Qu a ntitati v e a nd Qualitative Study on Di sse mination ...... ........ .... 7 o f Consider This, a n Intemet -Based Tob acco Education Curricul um 2. 1 St ages of Concern -Base d an d Di ff u s ion of Innovation s Model s ..... ..... ... ... J 7 2.2 Age a t First Use a nd Fir s t D aily se of Ci gare tte s .................. ........ . ............. 26 3 1 P e rcent Di st r i bution of Adopters O ve r Tim e ................ . ... ........ ... ... ........... 5 0 3.2 In terface of Di ff u s i on of Inno vat i o n s and PRECEDE I PROCEED Mode l s .... . ............................... .... ........... .......... ....... ................ ... 63 4.1 A Mode l of Sta ges in the Deci s ion Proces s ...... .... .... ....... ...... . ..................... 69 xiii

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TABLES T ab l e 2. I Conditio n s that Facilitate Implementat i o n of Ed ucatio n a l Technology Inn ovations ........................................................ ....... .................. 15 2.2 Con side r Thi s Pro gram Module Ac tivitie s and Prevention Principle s ..... . . 33 3. I Key Diffu s i on of I nnovation s Theory Con s tru c t s ....................................... ... 5 1 3.2 Adopt i on Categori es fo r In formation Te ch nology Groups ... ... ..................... 54 4. 1 Factors th a t Influ enced Regi tration a n d Attendance at CT Training Se mi nars by e l ect DOT Adoption Characteristi cs ... ..... ... . ............ 70 4 .2 Demographic Characteristic s and Se l f -r eported 30-day Smoking Statu s for Con s id er Thi s Survey Panicipant ( n = 82) ................... ............... 75 4.3 Advanced Education a nd Computer Tra ini ng for Consider Thi s Survey Particip a nt ( n= 82) ............................ .... ... ...... .......... ....................... 76 4.4 Frequency and (Row P ercent) of School Di s trict and Participant Adopter C l assificatio n s a n d Comfort Level with Computer Technolo gy ...... 77 4.5 Freq u ency of C onside r Thi s Use b y Adopter Group (n=57) ............. .... ....... 80 4 6 Frequency a nd ( Percentage ) of C l assroom Use by How Tea c hers H eard About Consid e r Thi s (n = 57) ...... ... ... ........ . ...... .......... .... .......... ....... 83 4.7 Frequency of Cl assroo m Use by Sing l e Sou rce of How Te ac hers H eard Abo ut Consider This ............ ................. ........ ......... ........ ........ ........... 85 4.8 Frequency of Classroo m Use by Adoption Characteristics that Influ enced Attendance a t CT Training Seminars A m ong Survey P articipa nt s ( n=5 7) ......... ....... ................................................... ... ..... ........... . 86 4.9 Frequency and (Percen t ) of In terviewed a nd Non-Int erv iewed Particip a nt s by Ch arac t erist ic s ................... ... ...... ..................... ..... ............. 89 5. 1 Demographic Characteristic s, S e l f-re p orted Smok in g Status, Edu cat ion, IT Traini n g, Freq u e nc y of CT Use, Comfort w i th C omputers a n d School Di s tri c t and P e r so n a l Ado pti o n Characteristics of In terview Particip a nt s ( n=24 ) .............. . .......... ....... ... ....... ... .................. 96 xiv

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5.2 Disposition of Study Participants (n=147) ............ .... ... ... ... ......................... 101 5.3 Codebook for Coding Text Data from Interview s with Colorado S c hool Perso nnel Who Were Trained to Use Consider This, 2003 ........... ... 104 5.4 Douglas County School Di s trict: Profile of Demogra phic Geogra phic and Economic Indicators ......... ... ......... .... ................ ....... ..... ... ........... ..... .... 107 5.5 R e lativ e Advantages to Using the C o n s id e r Thi s Tob acco Prev e ntion Curriculun1 . .............. . .... ........ ...................... ....... ..... .... .............. .......... ..... I 12 5.6 G ard ner 's Multiple Int e lligen ce Typ es ....... ..... ....... ................. .... ........ . ... .. 114 5.7 Compatibility Factors Associated with se of the Con s id e r This Tob acco Prevention Curriculum ... ..... ............ ...... ....... ..... ......... .............. .. 117 5.8 Compl exity Factors Associated wit h Use of the Consider Thi s T obacco Pre ve nti o n Curr iculum ........ ......................... . .... .... ..................... I 20 5.9 Predisposing Factors Associated with Adoption of t he Con s id e r Thi s Tob acco Prevention Curriculum ........ ...... .... .... . ....................... .......... . ..... 1 27 5.10 T eacher Certification Standard Seven: Knowl edge of T ec hn o logy ........... . 129 5.11 Enablin g Fac t ors Associated wit h Use of the Consider This T obacco Pre ventio n C u rric ulum ................ ... ................. ........ ............. . ........ .... ......... 131 5.12 R ei nfor ci n g Factors Associated with Use of the Consid e r Thi s T obacco Prevention Curriculun1 ................ ... ............................. .... .......................... 137 5.13 Barrier s to Adoption of the Consider This Tob acco Prev e ntion Curri c ulun1 ... ............ .............................. . . ... . . .... ........ ........ ... .......... .... 143 6.1 F actors th at Contribute t o Adoption, Impl e ment at i o n a nd M a int e n a nce of th e Consid e r Thi s Curric ulum ........... .... ... ...... .... . .... ... ..... . .... ... ...... .... 176 XV

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CHAPTER 1 I NTRODUCTION D es pit e t h e fac t th a t the number of compute r s in t eac h e rs' c l assroom h as increased d r a m at ically in t h e l as t 20 years r esearchers a n d ed u cators a l i k e report that integra tin g techn o l ogy int o the classroo m curri cu l a is no t easi l y accomplis h ed." (E t t m er, Addiso n L ane, R oss, & Wood s, 1 999) C o mput er-based cu r r i cula, i f adopte d b road l y by t eac h e r s f or c l ass r oo m u se, h ave g reat p romi se fo r e n h a n cing ed ucatio n a l o u tco m es. C o mput e r r e l a t e d tool s, wh e n u sed regularly in th e c l assroo m h ave bee n s h own t o h ave p os iti ve effect s o n s tud e nt cogni t ive a nd attit u d i na l ou tco m es ( C o tt o n. 1 997; Godfr ey, 2 00 I ; H a nd e l J 99 7 ; Newh o u se, J 998). H owever d i ssemina tion of computerb ase d c u rricula int o cia sroo m s i s a challen ge, a n d no t well u nders t ood. R esearc h b ased dissem i natio n strategies are needed t o overco m e t eacher re l a t e d a nd sys t e m or s tru ct u ra l barriers to u se of com pu t ers an d compu ter -b ased c urri cula i n the c l ass room. B et t e r und e r s t a ndin g o f b a rri e r s t o the a d o pt i on a n d u s e o f comput e r b ase d curri cula s h ould contribut e t o g reat e r s u ccess in t eac hin g th a t empl oys new t e chno l og i es. nd e r s t a ndin g of th e facto r s tha t p ro m o t e a nd inhibit d i sse min atio n a nd u l tim a t e l y a d o pti o n of we b-b ase d curr i c u l a s h o uld info rm the de s i g n of effecti v e disse min atio n s tr ateg i es. Thi s pro ject dr aw on theoretic a l a ppr oac he s th a t h ave b ee n useful fo r und e r s t a ndin g how t echno l ogica l innovatio n s are di ff u se d ( R oge rs'

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Diffusion of Innovation s theory, referred to as DOI) and ho w projects are planned a nd implemented (PRECEDE-PROCEED Model). Thi s project employs constructs from these theories to determin e the proc esses a nd factor th at influenced the dissemination and adoption of a web-based tob acco ed ucati on curricu lum Consider This (CT), that was designed for middle schoo l students in Colorado. Internet-based curricu l a will likely play an increasingly significant role in health education for schoo l children in the next decade. Computer-based instructional tools hold great potential to provide health information and influence health behavior. Cancer. heart disease and diabetes are among th e l eading causes of death in the United States a nd each of these diseases has behavioral risk factors that can be influenced throu gh education and behavioral int erventions (CDC, 2000) As computer technology advances and new online instructional oftware are developed and dis eminated, school will have an increasing opportunity to adopt Int ernet-based educational curri c ula that have potential to influence health behaviors. The rate and exte nt o f the diffusion of these techn o l ogyba sed innovations depend on numerous and complex individual and environmental factors. Understanding these factors and their influence on dis eminati o n and adopt ion processes will help adva nce the efficacy of Internet instructional techno l ogy. This project draws on theory to elucidate successes and failures with the dissemination and adoption of a web-ba ed tobacco educat i on curricu lum Consider This (CT) for middle schoo l st ud ents. The goal s of this research project were to describe factors associated with dissemination and adopt ion of CT, a n online tobacco prevention program, and to characterize the diffusion process for this Internet-based he a lth education curriculum. 2

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Specific Aims and Hypotheses The s pecific aims of this study were to : 1 ) D esc ribe the DOl c h a r acteristics (re l a tive advantage, comp a tibility, etc.) th a t co ntri buted to adoptio n of the CT curric ulum ; 2) Id e ntify th e PRECEDE factors ( pr edispo ing, enabling a n d reinforcing fac t o r s) assoc i ated w ith adoptio n of CT; and 3) Describe emergent factors that influ enced adopt i on of CT. Identi fy in g th e factors a nd processes associ ted w ith adopt ion a nd use of CT will h e lp infor m educ ators and school polic y m ake r how t o better pla n develop, and / or a dopt Int ernetba sed hea lth education curr i c ulum This st ud y answered the followi n g r esearch question: What i s th e relevance of t eac her c h aracter i stics (i. e knowledge, a tti tudes, a nd experiences re l ated to adop tin g the cuniculum) and schoo l e n v ironment s (i.e., h ardware environment s t affing fac t ors), to ado ption of an o nlin e health curriculum? S tud y hypotheses proposed th at teachers who ado pt CT are more l ikely: t o se l f-identify as early adop t e r s of t ec hnol og i ca l innovations; to have he ard a b o ut CT through soc i a l network s; t o hav e regi s tered for th e tra inin g sem i nars becau se of the incentive factors offered; t o ha ve greater comfort l eve l w ith computer techn o l ogy; to hav e h ad for m a l tra i ning in u se of co mputer s or Int e rnet ; t o h ave received his or her under g radu ate de g ree l a t er; to h ave a n adva n ced de gree; to be younger; 3

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to have received more formal training in u se of computers o r the Int ernet; to be non s moker s; to particip a te in socia l sys tem s that d e mon s trate le aders hip in their sc hool or profe ss ion B ackgro un d An ed u catio n fut uri st env i sio n ed that t ec hn ology was empoweri ng a n evo luti o n i n ed uc at i ona l infrastructure for l earning and that adva nc ed infor m a tion technology was esse n t i a l t o s ucc ess ( D ede. 1 990). At the time of this publication computer t echno l ogy wa a part of teac her act ivity, from the most remote rural sc hool s t o schoo l s in th e inner city. This p a p er reported th a t teachers u sed computers to prep are le sso n s, record gra de s, create h a nd o ut s, a nd communicate w ith eac h other, schoo l adm ini stra t ors, and parents. But do they use computers in th e c l assroo m ? I f computers are not u sed, w h y not ? I f th ey are used, w h a t factors fac ilit ated u se? Less th a n I 0 % of faculty a t Stanford U n ive r sity were u si n g computer t ec hn o l ogy in the classroo m in 1 999 (Cu b a n 1 999). While classroom util izat ion may h ave improv ed s ince the Stanford report, u se of technology in th e c l assroo m depend s on th e teachers' ab ilit y t o integrate it ( D alto n 1 989; K ent & McNergney, 199 9), material fac t or (e.g., scarci t y of eq uipm e nt ), a nd soc i a l fac t ors. D a lton a l so d e termin ed that when t eac hers l ac k confidence t o int egra te t ec hnolo gy, they i g nor e it. A review of existing s tudie s on teacher att itud es disclosed that a teacher's own confidence l evel in th e ir a bility to u se computer technolo gy h a d a stro n g effect on its use ( Hardy, 1 998). In 1999 only I 0% of public sc hool teacher s reported feelin g "very well prep ared," and 23% reported fee lin g "well prepared to use computer s 4

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or the Int ernet for instruction. The majority (53%) reported feeling" omewhat prepared, and 13% reported feeling "not at all prepared" (USDOE, 1999). While there appears to be support for use of computers in the c l assroom, not all educator agree. At lea tone author contends that there is early and excessive concern about 'computer literacy," too often at the cost of basic literacy and that schools systems are unable to maint a in equipment or train teachers once the hardware is in place (Oppenheimer. 2003). He contends that computer infatuation has not only drained billion s of dollars from mo re urgent educational need s but that its misuse actually damages s tudents. turning out a genera tion of kid s with inferior learning and thinking skills" ( ewsweek, 2003). Despi te hi s contentions, computer technology has become an important educational re source in schoo l s and it will not lik ely become le ss so. Therefore identifying ways to more effective l y use this educationa l resource remam an important effort. The Int ernet-based curricu lum on which this in vestigation focu ses is Consider Thi s (CT). a tobacco u se prevention and cessation curriculum designed for middle-school students (grades 6 through 9) by researchers at the Center for He a lth Communications of The Cooper In s titute, Denver office. CT is an online curriculum (http:/ / www.considerthisusa.net) that emplo ys interactive Web technology with high-quality audio and video feature that active l y engage students in le sso ns about tobacco use and its health effects. It tailors information and provides individualized feedback based on the knowledge attit ude s, behaviors and behavioral intentions of st ud ent users. A downloadable teacher 's manual is available. The c urriculum aims to influence attitudes a nd behaviors about tob acco use through an interactive multimedia smoking prevention and cessation program. CT was offered to all Colorado school s in the fall of 200 l. 5

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The Douglas County School Di s trict (DCSD) in Colora d o wa s initially se lect ed as the so l e s ite for this investigation. However after eight interviews with DCSD empl oyees and multiple attempts to contact middle-school princip a l s it became apparent th a t DCSD would not provid e s ufficient participants from whom to ga ther inform at i on. Th e s tud y was expa nded t o includ e all te ac h ers a nd ad mini s tr a tor s who were tr ained in l a t e 200 l a nd early 2002 to u se CT. Figure 1.1 illustrates the proce s a n d timin g of thi s study Th e narr at i ve th a t fo llow s describ es each step of th e pro cess D u ring the school year 2 00 l-2002, w ith f undin g from the Colorad o Depart me nt of Publi c Health and Environment, I directed a projec t that offered the CT pro gram t o all Col orado sc ho o l s with middl e schoo l aged stude nt s (ages 12-14 ) As part of this offeri n g tr aining seminars were m ade availab l e to all mid d l ec hool h ea lth teachers, sc hool nu r es, cou n se l ors, prin cipals, sc h oo l distri c t administr a tor s, and both distr i ct-leve l and schoo l-level inform ation technology staff. P romot ion a l materials ( po s ter s a nd brochur e ), were designed, print ed and distrib uted t o all public a nd privat e sc hool s in Colorado for the dissemination phase. Packet s of promotion a l m aterials d e cribin g th e Consid e r Thi s pro g r a m a nd inviting the m to a tt end a trainin g se min a r in their area were m aile d t o all sc hool di stric t adm ini s tr ators, prin c ip a l s, S afe and Drug-free educ a tion coordinators1 and Colorado D e partm e nt of Edu catio n (CDE) health education contacts w h o work with st udent s grades 6-9. Semin ars were offered free-of-charge in each of th e eight CDE Re g ion a l Service Areas during the 200 l -02 sc ho o l year. Intere s ted perso n s called project offices on a toll-free number to re g i s t e r or regi s tered on lin e. 6

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Fi g ur e 1.1: Proc ess of Quan ti t a t ive a n d Qu al i tative Stud y o n D issemina tio n o f Consider This, an Interne t -Based Tobacco Education Curricu l um. Development of Consider This I nnovation Dissemination Study Initiation Spring 2003 Survey ofTeacher Trainees (n=147) 7

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A total of 147 sc hool personnel were trained during the m onths of November 2001 through January 2002. At these one-day all-expense-paid training sess i ons, schoo l personnel learned how to implement the CT program. Teachers were shown how the CT program fits within the Center for Disease Control 's B est Pra c tices for Compr e hensive Tobacco Control (USDHHS, 1999) and the state of Colorado's tobacco contro l objectives. They l earned the tobacco prevention principles that form the scientific ba s i s of the o nline ac tivitie s incl uded in the CT program. Each feature and educational module of the Internet-ba sed program was introduced, reviewed and demonstr ated, with specia l emphasis on tho se features that ensured confidentia lit y of student responses. Teacher s l earned the administrative tool s in the CT program that enab led them to help students enroll and use it. They were informed about telephone and email t ec hnical assistance services provided by the CT project staff, and received a teacher's manual containing information de ign ed to s upport successful implementation of the program in their c l assrooms. W ave I of t he interviews conducted for this tu dy occurred in the Douglas County School Di s u ict (DCSD) becau se an administrat o r there was particularly interested in u s ing this curriculum and s trongly encouraged the initiation of the program Ten DCSD te ac hers. two ad ministrator s, and one information techno l ogy s taff perso n attended one of the eight training seminars. The Wave I int erv i ews informed deve l opment of the questionnaire that was used in the survey of all trainees. The survey identified additiona l interview participants from throughout the state of Colorado for a total of 23 int erviews. (Study process details are de cribed in Chapters 3 and 4.) 8

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D es pite the availa bility of thi s f ree pro g r a m a nd the n o-cos t tr a inin g to f ac ilit a t e implem e nt atio n not all school di s trict s w e r e represent e d a t the tr a inin g s emin a r s a nd n o t all of those w h o were tr ai n e d e nd e d up impl e m e ntin g the c u rr i c ulum in th e i r cl assrooms. In vest igatin g th e reaso n s fo r this variable use of CT w ill h e lp in form f utur e disse min atio n effo rt s re l a t ed to In te rn e t b ase d schoo l health c urri cula Thi s investiga tion u se d t wo theo r ie s to s t r u cture th e i nquiry: 1 ) Diff u sio n of Innovatio n s a nd 2) PRE C E D E I P R OCEED Diffu s i on of Innovat i o n s offers a theoretical fra m ework t ha t explai n s "the p r o ces s by whic h a n innovatio n i s co mmunicat ed t hrou gh cert ai n c h a nn e l ov e r tim among t he m e mb e r of a soc i a l sys t e m ( R oge r s 1 995, p J 0 ) PR E C E D E t heoretical co n struc t s ( p red i spos in g, rein forc in g a n d e n a blin g f ac t ors) are b ased on th e pr e mi s e t h a t d i ag n os i s of a n e du cat i o n a l pr o b l e m prece de s a n int e r ve nt io n pla n a n d tha t th ere are s p ec i fic p re di s p osing, e n ab l ing a n d reinforci n g factor s t ha t co ntr ibute t o t he accomplis hm e nt of t h a t pla n ( G reen a n d K r u e t er, 1 99 1 ) Because this inv e t igatio n was l i mit e d t o th e p rocess s t ages t h a t l ed to teach e r a d optio n a n d u se of C T i n th e cl ass r oo m con s truct s of th e PROCEED s t age o f thi s th eory ( Impl e m e nt atio n a n d Evaluat i o n ) were not u se d h e r e ( Pro cess, i m p ac t a n d o utcom e m eas u res a re c ur re ntl y unde r in vestigation in a sep ara t e study b eing con d u c t e d by i nvestiga t ors at The Cooper In st itu te, D e n ver office.) In s umm a ry, th e out c om es of thi s in vest igatio n wer e ac hieved throu g h a re searc h des i g n th at co mbin e d e l e m e nt s of the Di ffus i o n of Innovatio n s (DOl) theory, a th eo r y c e nt ra l t o communicatio n s rese arc h a nd e l e m e nt s o f a publi c he a lth c ommunity (e nvir o nm e nt a l ) b e h av i o r c h a nge pla nnin g mod e l PRECEDE. The DOl mod e l foc u s e s prim arily o n inno va tion ch arac teri stics a nd s o c i a l sys t e m process e s, 9

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while PRECEDE is more ecologically or socia l systems focused. PRECEDE was designed to assess socia l system factors that influence public health outcomes for more effective health planning. For this investigation, combining these two models provides a broader per pective on the adoption characteristics than either cou ld have provided a lon e. Ove r view of Des ign and Methods Quantit a tive and qualitative method s were used to achieve the specific aims of this investig a tion. A non-probability purposive sample was used for the survey research (Backstrom CH, Hursh-Cesar G, 1981 ). The population surveyed was the population o f educators who attended one of the e i ght CT training seminars provided in Col orado during the school year 200 l-2002. A structured questionnaire was developed and mai led to each training seminar attendee. Specifically, survey questionnaires were mail e d to 147 teachers administrators, counsel ors, schoo l nurses, school information technology staff, and public health a gency tobacco control staff who attended aCT training seminar. Of the 87 returned surveys, 24 respondents consented to be in terv iewed. In-depth, semi-structured intervi e ws were conducted using open-ended questions with the 24 participants who consented to be interviewed. Purposive samplin g a llo wed me to interpret or test the DOl and PRECEDE theories. Quantitative and qualitative results of this multi-method investigation were combined for an enriched understanding of the factors that influenced dissemination and adoption of CT. 10

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CHAPTER 2 TECHNOLOGY IN EDUCATIO AND YOUTH TOBACCO USE This chapter reviews the literature on diffusion of technology in education, tobacco u se among youth. health effects and risks of tobacco use, prevalence of youth tobacco use, incidence of initiation, school-based tobacco prevention programs, diffusion of technology in education, Internet use among youth, computers and Internet access in Colorado schools. The literature in this area of research focuses on factors that impede or promote adoption of computer technology in the classroom. Since these factors can be categorized using many theoretical approaches, this literature review identified and collapsed them into 5 groups: factors in the individual domain; factors in the organizational domain: material factors; perceived attributes of the innovation; and social factors. While an effmi was made to segregate and label these factors into the above groups, many of the factors identified did not fit into a single category and were labeled accordingly. The predominant diffusion model referenced by the research discussed here was Rogers' Diffusion oflnnovations (1995). In general, the authors of the papers reviewed here based much of their work on the DOl model. It was al o apparent from this review that the study of diffusion of computer-based technology in education is still quite young and therefore rich in diverse opinions and perspectives. 11

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Factors Associated with Diffu s ion of Computer-Based Educational Technology An extensive liter at ure review identified the following factors that prevent teachers from using technology (Mumtaz, 2000). L ack of teaching experience with information and communications technology (ICT) (individua l factor); Lack of onsite support for teachers using technology (organizationa l factor); Lack of help superv isin g children when u sing computers (organizat ional factor); Lack of ICT specialist teachers to teach students computer skills ( indi v idual I organizational factor); Lack of computer availability (ma teri a l factor); Lack of time required to successfully integrate technology into the curriculum (individual I organizational factor); and Lack of financial s upport (organiza tional factor) Mumtaz's review identified factors in fo ur of the five groups discussed in this review. Three sty l es of computer use among teachers were identified as: avoidance, integration and technical speciali::.ation (Eva n s -Andri s, 1995). Avoidance was reported as the dominant s tyle of computer u se in thi s study. Those teachers distanced them se l ves from computers and reduced the amount of time they spe nt attending to computer related activities. Those teachers who engaged in "integration" embraced computers, integrating them into their teaching methods and cuniculum. 12

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The "technica l specializat ion te achers embraced computers and promoted their use in school, but a l so viewed them as a challenge. Teachers' resi s t a nce to computer u se was divided into severa l broad-based themes ( Robertson. Ca l der, Fung, Jones O'Shea & Lambrechts 1996). Those themes were: Resi sta nce to organizationa l change (individual I organizational factor); Re s istance to outside inte r ve nti o n ( individu a l factor); Time management problems ( ind ivid ual I organizational fac tor ); Lack of suppor t from administration (organizational factor); Te acher's perceptions ( percei ved innovation a ttribut es); and Perso nal and psychological fa c tors ( individual factor) Socia l factors that influence diffu s ion of technology in the classroom must be incorpor a ted in the ins tructional development process (Sc urry and Farquhar, 1996). After a d i sc us s ion of soc ial factors identified by Roger s (1995), the authors reviewed a model deve l oped by Stockdi ll and Morehou e ( 1 992). This mode l identifies five categories of social factors that influence inn ova tion diffusion: I ) educationa l n eed (socia l and organizat i onal factors); 2) user cha r acteristics (individual factors); 3) content c h aracteristics ( perceived a ttribute s of the innovation); 4) technology considerations (materia l s factors); and 5) organizationa l capacity (organizationa l factors). Scurry and Farqhuar concluded with recommendations that they hope will advance the evolution of technology-based instructional deve l opment. These recommendations were: In s tru ct ion a l developers s h ould consider adoption a nd diffusion as stro n g l y as they cons ider ins tructional effectiveness (socia l factors) 13

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Instructional developers should understand that adoption is the result of purposeful planning and does not automatical l y follow the development of instructional or technically superior products (organization and individual factors). Instructional designers shou ld modify their design and development models to incorporate tools discussed in their paper. (Two of these tools are: Em ironmental Analysis-a process that identifies th e phy s ical environment and support syste m factors in place at the adoption site(s) and Adoprion Ana ly sis-a proce ss tha t identifies key factors likely to influence the adoption of their product.) Scurry and Farquhar concluded that social factors must be incorporated into the instructional development process in order to increase adoption. In a revi ew of the litera ture on the impact of computer based technologies in schools Lal (2002) identified the following factors that influenced technology uptake and integration in the clas sroom. Those factors were: ease of Int ernet access (material factor); involvement of the\ hole school community (socia l factor); support of the school principal and commitment of teachers to professional development in the technology area ( individual I organizational factor); collaborative professional development project and staged implementations (socia l factors); rallying schools around a technology goal (organizational factor), and; a good interpersonal relationship between the teacher and the technology administrator (social factor). 14

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Table 2.1 : Condit i o n s that Fac i l i tate Impl ementation of Educational Technology Innovations Condition Description Linked to ... Dissatisfaction with the status Feeling a need t o change Leadership quo (individual/organizational factor) Expertise Access to the knowledge and skills required Resources, rewards & (individual factor) by the user incentives, leadership and commitment Resources Things needed to make it work-funding, Commitment, leadership, (organizational factor) hardware software, tech support, rewards & incentives infrastructure, etc. Time Prioritize allocation of time to make it work Participation, commitment, (individual/organizational leadership, rewards & factor) incentives Rewards and incentives Internal and external motivators preceding Participation, resources, time (organizational factor) and following adoption and dissatisfaction with status quo Participation Shared decision-making, ; full communi-Time, expertise, rewards & (individual/social factor) cation; good representation of interest s incentives Commitment Firm and visible evidence of continuing Leadership, time, resources (organizational factor) endorsement and support and rewards & incentives Leadershi p Competent supportive leaders of project Participation, commitment, (individual/organizational and larger organization time resources, and rewards & factor) incentives In a review of conditions that facilitated the implement a tion of educationa l t ec hnology inno va tions Wi I son et al. deve l oped the above tab l e ( Tab l e 2 1 ) to summarize their finding s (The parenthet i ca l phra ses in the conditio n s col umn are th e investigator 's categorization of t h e faci l itating cond i t i ons.) The Wi lson et al. article was a de p art u re fro m o ther artic les rev iewed in tha t it cited feat u re comm o n to failed i n n ovat i o ns. T h e factors t h at they c i ted were: 15

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Practitioners become disenchanted and disillusioned because the innovation is more difficult than expected, causing too much disruption and taking too much time. (perceived innovation attribute factor) Innovation supporters leave or are not available. (individual/social/ organizational factor) People lack training and lose enthusiasm. (individual factor) Funding runs out. (organizational factor) There is inadequate supervision and support from management. (organizational factor) The program lacks accountability. (organizational factor) There is a "take-it-or-leave-it" attitude on behalf of the promoters. (social/ organizational factor) This article was important to this investigation in that it documented some factors on the negative side to the diffusion of innovations equation, in an effort to remind practitioners to learn from the mistakes of others. This approach to learning has been largely neglected in the literature. and therefore motivated me to identify barriers to diffusion in this investigation. A simple model of diffusion, Concerns Theory, was reviewed by Dooley (1999). This stage-based theory was developed by Hall and Hord (1987), and is based exclusively on the concerns of the user as they unfold in the change process. Its basic premise of this theory is that change is a process not an event. The authors contend change should be examined by the various motivations, perceptions, attitudes, and feelings experienced by the individual. 16

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At the beginning of the change process the typical non-u se r ha s concerns that that are relatively high regarding Awareness, I nformation and P ersona l (self concerns) These nonor l ow -u sers are concerned about gaining inform at ion abou t the inno va tion and how it will affect them As new u sers become more comf01table with the new technology they develop more concerns about the management of the innov at ion (task conce rns ) These two concerns decrease in inten s ity as the user becomes more ski lled with use of the innovation and the impact concerns (Consequence, Collaboration, R efocusing) become more inten se Dooley loo se l y associates this model to Rogers' stages in th e innov ationdecision process. Figure 2.1 below illustrates h ow these models compare. Figure 2.1 : Stages of Concerns-Based and Diffusion of Innovation s Model s Concerns-Based Adoption Model Self I I Task ., Impact __ .. ____ co_ n c e _rn_ s __ __ c o _n_c e _rn_ s __ __ Stages in the Innovation-Decision Process There i s a schoo l of thought that co nt ends th at the primary reason for low upt ake of computer techno l ogy in the c l assroo m i s r e l ated to the l ack of s upportin g knowledge, beliefs and att itude s abo ut computers a m ong teachers. The concept of 17

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barriers to implementation pre-dominates this school of thought. Handa! (200 I) cites a quotation that capture s this paradigm, "The knowledge, attitudes and beliefs that teachers have ... shape what they choose to do in their classrooms and explain the core instructional practices that h ave endured over time" (Cu ban, J 993, p. 256). While the DOl model is a conceptual focus of this dissertation, findings that encourage teachers to use technolog y will also be discu ssed in Chapters 4 and 5 using constructs from the PRECEDE mod el. The following lit e r ature review lends support to the u se of the PRECEDE model when categorizing factors associated with teacher use of computer technology. While not categorized u s ing PRECEDE constructs, the followin g studies identified factors that "encourage" use. All of the se findings could be categorized using these PRECEDE constructs. One study of 72 computer u si ng teachers w ith a mean age of 42 years found that it was most imp orta nt to their personal work and to their teaching and that they planned to extend their u se of computers in the future (Cox, Presto & Cox, 1999). This study further found the following factors to be most important to sustained u se in teaching: making lesson s more interesting; easier; more fun for them ( teachers ) and their pupils; more diverse; more motivating for the pupil s and more enjoyable. A second study of four teachers from a Dutch seco ndary school who were observed and interviewed, disclo ed a few significant findings (Veen, 1993). First, while school factors (principal support, 20 hours per week of IT support) played an important role in how these teachers u sed their computers, personal factors outweighed the school factors. These teacher-level or personal factors were divided into beliefs and skills. The beliefs included: teachers' beliefs abou t what sho uld be in the CUlTicul a (content); and the way in which subjects shou ld be taught. The 18

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skills that influ enced their use of computers included: skills related to a te ac hers competence in managing classroom activ ities (enabling factor); pedagogical skills (enabl in g factor); and to a lesser degree, computer-handling technical skills (enabling factor). The most important finding from this study wa that if the software matched the teachers' pedagogy (reinforcing factor) they used it. The outcomes of this study must however be viewed with some reservation, since it was conducted wi th a very small sample and in an artificially con str ucted research environment, where 20 hour s per week of IT support was provided in a single school to four teachers. Several studies used s urvey methods to identif y factors that teachers integrated computers into their teaching practice s (Mumtaz. 2000). One nationwide study of fourth through twelve grade teachers conducted in the United States found three factors associated with "accomplished" teacher s who integrated computers in their teaching (Sheinhold and Hadley, 1990). These factors were: teacher motivation and commitm ent to th eir students' l earning and to their own deve lopment as teachers ( predisposi ng factor); the support they experienced in their schools (p redisposing factor); and access to sufficient quantities of t echno l ogy (e nabling factor). These te achers a l so worked in sc hools where hardware and access to resources were twice the average (e nabling factor), were comfortable with technology (enab lin g factor) and used computers for many purposes ( predisposing, enabling and reinforcing factor). A more recent stud y in constructiv ist classrooms on professional engagement and teaching practice including computer u se, found th a t teachers who regu larly engage in professional int eractions and activit i es beyond the classroom teach in 19 ------------------------------------------

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different ways th a n teachers w ho h ave minim a l contact with their peers (Becker & Rie l 2000). (Cons t r ucti v i s t classrooms a re where s tuden ts are g uide d to teach the m se lves by gathering inform at i o n a nd making their own observations a nd conclusions. The constructivist t eac her se t s up problems a nd monitor s st udent exploration, guides the directi o n of s tud ent inquir y and promotes new patterns of thinkin g (SEDL, 2004)). Th e more that teachers were invo l ved w ith pro fessio n a l activ iti es (informal interaction wit h peers works h ops, l eaders hip activities, mentorin g, presentations at conferences), th more likely they were t o use computers in exemplary ways. This finding suggests that profe ss i ona l interaction s and ac tiviti es ma y be pr e di s posing and rein forcing factors for adopt i on of technology. Thi s finding i s a l so consistent with Rogers (1995) observation tha t innovator s or earl y adop t e r s tend to b e more cos m opo lit e th a n l aggards. Applications of PRECEDE Model in Public Health PRECEDE s tands for predisposing r einforcing, a nd enabling con s t r u c t s in educational/ecological diag no sis a nd evaluation. The model rec ognizes that institution a l a nd environmental factors influ e nc e knowledge upt a k e a nd behavior change. This model ap p ea led to me s ince it r epresents a planning process th a t l eads t o impl e ment a tion of changes needed for improvement of health a nd soc i a l conditions. Whil e it was de s igned expressly fo r application in th e co mmunity public h ea lth area it was eas ily adap t e d to the sc hool e nvironment. In this s tud y the PRECEDE model was not implemented in a stepwise fa s hion as the model s u gges t s, but was adapted so it could serve as a tool for planning and implementin g change in the 20

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school environment. Thi s mo de l provided a conceptual framework or st ructure for an evidenced-based inve s ti ga tion into the dissemination and adoption of the CT he a lth education curri c ula. The core constructs were borro we d for this s tudy since they are like ly easily understood b y polic y maker s / sc hool ad mini s tr a tor s who will b e responsible for the app lic at ion of the findings. Tobacco Use Among Youth Tob acco u se is the single-greates t cause of preventable deat h and disability in the United States. Amon g young peopl e, th e sho rt-t e rm health con se quences of s moking include respiratory and non-respiratory effects, a ddi ctio n to nicotine, and the associated ris k of other drug u se L o n gterm health con seque nc es of youth s mokin g are r e inf orce d by the fact tha t mo s t young people w h o smoke regularly continue to smoke throughout adu lth ood. (US DHHS 1 994) T o bacco use cau ses mo re than 400,000 prematur e deaths each year in the U.S. (o ne in every five death s) a nd r es ult s in a n a nnu a l cos t of more than $ 50 billion in dire c t medic a l costs. Thi s death t oll i s g re ater th a n th e number of d eat h s from AIDS, alcohol, drug abuse, car crashes, murd e r s, s uicide s, and fires---combined (IOM, 1 994 p. 3). The C olora do D e partm e nt of Publi c Health and Envi ro nm e nt (CDPHE) estimates th a t with a $15 million an nu a l in ves tment from th e tob acco sett lement there i s th e opportunity to save $930 million a year and over 4,000 lives in Colorado (CDPHE, 2001 ). Tobacco u se most often be gins with addiction to nicotine in childhood and ado l escence. Each year 20,000 Colorado youth under age J 8 become daily smokers. At this rate, 86,000 Colorado youth alive toda y will die an early preventable death 21

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because of a decision made as a child-the deci sio n to s moke cigarettes. Tobacco caused disease is also associated with use of s mokele ss or spit tobacco. Colorado ha s one of the high es t rates of spit tob acco use among boy s i n the country (CDPHE, 2000). Health Effects an d Ri sks of Tob acco Use Cigar e tt e smokers h ave a l ower l evel of lun g f uncti o n than tho se persons w ho have never s moked. Smoki n g i s particularly deleterious to th e health of young people since it reduces the rate of lun g growth. Smoki n g hurts young people s physical fitness in terms of both performance and e nduran ce-even among young people train ed in competitive running. In ad u lts, cigarette s moking causes heart disease and stroke. Studies h ave s hown that early sig n s of th ese diseases can be found in adolesce nt s w ho smoke (USDHHS, 1994). On a verage, someone who s m okes a pack or more of cigarettes each da y lives 7 years l ess than someo n e w ho ne ve r smoked ( Kuller Garfinkel, Correa H a l ey, Hoffm a nn Preston-Martin, 198 6). The Surg eo n G e n e ral' s 1994 report a lso r e port e d that the re s ting heart rates of young adu lt smokers a r e two to t h ree beats per minute faster than non s moker s and that smok ing at an earl y age increases the risk of lun g cancer. For mo s t s moking related cancers, the risk for cancer incre ases as the individual continues to s moke. Teenage smokers suffer from shortness of breat h a l most three time s as often as teen s who don t s moke, and produce ph legm more than twice as often as teens who don't smoke (Arday, Giovino Schulman, Nel s on, Mowery & Samet, 1995). These 22

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researchers a l so reported that teenage smokers are more l ike l y to h ave seen a doctor or other health professionals for an e motion a l or psychological complai nt. Teens who smoke are thr ee times mo re l ikely tha n nonsmokers to use alco hol eight times more likely to use marijuana, and 22 times more like l y to use cocaine. Smoking is a l so associated with a host of other risky behaviors, s u ch as fight in g a nd e n gaging in unprotected sex (USDHHS, 2002). Prevalence of Youth Tobacco Use 28.5 percent of high school students currently smoke cigarettes, dow n from 36.4 percent in 1997 and 34.8 percent in 1 999. Current smoki n g i s defined as h aving smoked on one or more days of the 30 days preceding the survey. If teen smoking preva lence continues to decli n e a t th e cun ent rate, the United States could achieve the 2010 nation a l h e a l th ob j ective of reducing current smoking rates among h i gh schoo l s tu dents to 16 percent. Lifetime cigarette use among high schoo l students is 63.9 percent, down from 70.4 percent in 1 999 Current freque nt s m o king, d efined as smoking on at l eas t 20 of the 30 days preceding the survey, decreased from 16.8 percent in 1 999 to 13.8 percent in 200 1 In 200 1 as in previous years, w hite and Hi spanic stude nt s were significant l y more lik e l y than black st ud ents to report curre nt smoking (USDHHS, 2002) 23

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Incidence of Initiation The onset of tobacco use occurs primarily in earl y adolescence, a developmental stage that is severa l decades removed from the death and disability that are associated with smoking and smokeless tobacco use in adu lth ood. Currently, very few people begin to use tobacco as adults; almost all first use has occurred by the time people graduate from high school. Ninety percent of smokers started smoking before the age of 19 ye ars and 60o/c before 16 years of age. The earlier young people begin using tobacco the more heavily they are likely to u s e it as adults, and the lon ger potential time they have to be users. Both the duration and the amount of tobacco use are related to eventual chronic health problems. The processes of nicotine addiction f urther ensure that many of today's adolescent smokers will regularly u se tobacco when th ey are adu l t s (USDHHS, 1 994). A retrospective study of regular smokers found th a t each d a y an alarming number of young people join the ranks of regular smokers. This study (Substa nc e Abuse and Mental Health Services Admin i strat ion's 1994-1997 National Household Surveys on Drug Abuse) estimated that more than 6.000 persons under the age of 18 year s try their first cigarette each day. The study also found that more than 3,000 persons under the age of 1 8 years become daily smokers every day (USDHHS, 1 998). Other findings from this study on uptake or initiation of c i garette smoking are: In 199 6. more tha n 1.851 million Americans became daily smokers, of which an estimated 1.2 26 million (66.2 percent) were under the age of 18 years. The number of adolescents who become daily smoker s before the age of 18 years increased by 73 percent from 1988 (708,000) to 1 996 ( 1.226 24

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million)-rising from nearly 2,000 to m ore tha n 3,000 persons under the age of 1 8 years who become daily smokers each day If the rate of smoki n g ini tiat i on among young people had held constant since 1988 th en 1.492 million fewer persons under the age of 1 8 years would h ave become daily smokers by 1 996. In the 1 960s and 1970 s, the r a t e of first-dai l y smoking was hi ghest for persons aged 1 8-25 years. Since the l ate 1980s, however, the rate of firstdaily s moking was similar for adolesce nt s aged 1 2-17 years and young adults aged 1 8-25 years. Among per so n s aged 12 1 7 years, the inc i dence of firs t u se of cigarettes per 1 ,000 potential new u sers ha s been ris ing continuously during the 1 990s and has been steadily higher than for persons aged 18-25 years since the early 1970s. Figure 2.2 illustrates that, for examp l e, there are only t wo years between the age that a 1 6 year old person first tries a c i garette and the age at which dai l y smoking begins. This figure also illustrate s that if a chi l d ha s n ot started s moking by the time they graduate from high school (age 1 8) it i s likely h e / s h e w ill never star t smoking. Ten percent or l ess of those surveyed in thi s study started s moking after age 19. A recent Colorado survey of high sc hool students shows that 39.4 percent of Colorado's sixt hto eig hthgraders report h aving u sed t obacco products compared to 33.5 percent n ationally; one in four of these st ud ents had experi m ented wit h c i garettes before the age of 11 (C DPHE, 200 1 ). This is particularly troublesome since, the younger a person i s when they first s tart s mokin g the hi gher his or her c h a nce of b eco min g a r egular s m oker, the l ess lik e l y h e or s h e i s to quit s u ccessfully and the mor e like l y h e or s h e is to contract lun g canc er (K hud er, Dayal, & Mutgi, 1999). 25

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Figure 2.2: Age at First Use and First Daily Use of Cigarettes Source: National Household Survey on Drug Abuse 100 80 ..., Among Persons 30-39 Years Old Who Have Ever Smoked Daily FirstT ried a Cigarette --... -60 Began Smoking Daily u ...
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during the 30 days th at preceded the survey, 14.6 percent of high school students reported smoking on school property. Much of the re s ponsibility for educating youth about the tobacco problem and providing them with the tool s to resist tobacco use has fallen on sc hools. Consequently Col orado middl e and junior high sc hool s and schools around the nation have searched for effective tob acco use prevention curricula and policy stra t eg ie s that are relevant t o thei r students a n d can be impl emented effic iently. Intervening to pre vent tobacco u se in these early, forma tiv e years i s a n import a nt strategy to r educe the human and economic t oll of tobacco us e. "School-based smoking pre ventio n programs based on a model of identi fying soc i a l influ e nce s on s mokin g and providing sk ills t o re s ist t ho se influence s, have d e mon s trated consistent a nd significant reductions in ado lescent s m ok i ng" (USDHHS, l 994, p. 274). This Surgeon General's Report goes on to say, "The effect ivene ss of school base d smoki ngrevention programs ap pear s to be enhanced a nd s u s tained by comprehensive he a lt h e ducation a nd community-wide progr ams that invol ve parents m ass media, community organizations, or other elements of the adolescent's social environment" (USDHHS, 1994, p.275). Des pite the se conclusions, implementation of sustained sc hool-b ased inter vent ions h as pro ve n difficult. Only a few sc hool-b ase d educational effmts have been found to be effective in preventing tobacco u se among youth and young adu lts. Since sc hools are a foca l point for educationa l efforts to prevent youth tobacco use the se curricula and others in the proces s of being te s ted or developed hold promise to reduce tobacco use among young people. Among the few schoo l-b ased programs that were found to be effective are Proj ec t TNT, Life Skills Training Proje c t Alert, and Not On Tobac co, described below. 27

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Project TNT Researchers with CDC (Wang, Crossett, Lowry, Sussman & Dent, 200 I) concluded that Project TNT (Towards No Tobacco), a classroom intervention, was highly cost-effective compared with other widely accepted preventive interventions, and that school-based prevention programs of thi s type warranted careful consideration by policy makers and program planners. Project T T. a ten-lesson curriculum designed to counteract the social and physical con s equence s influences of tobacco use was delivered by trained health educators to 7th-grade students in eight junior high school s A cohort of I ,234 students participated in the program and was presented with a 2-day booster session in the second year The effectiveness evaluation was based on a cohort of 770 9th grade students who participated in this two-year follow-up study. When the uptake rate for the compari s on group was compared to the rate in the intervention cohort, T T prevented an estimated 34.9 students from becoming established smokers at an intervention cost of 16,403. Savings estimates were ca l culated at $1 3,316 per life year (LY) saved and 8482 per quality-adju ted life year (QALY) saved. These results demonstrate that TNT had cost savings over a range of model parameter estimates. A one-year follow-up study of a school-ba ed tobacco use prevention project disclo ed that Project TNT was significantly more effective in decreasing both initial and weekly use of cigarettes than any of its individual components alone (Sussman, Dent, Stacy, Sun, Craig, & Simon, 1 993). This randomized experiment of four different curri cu l a, one for each of three socia l influence components (refusa l skil l s, awareness of socia l misperceptions abo ut t obacco use, and misconceptions abo ut physical consequences) and a curricu lum that combined all components, involved 48 junior high schoo ls. 28

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Each curriculum, except for the c u rriculum in which refusal skills were taught, was effective in decreasing the initial and weekly u se of use of cigarettes. Only the combined curricu l um showed an effec t o n the weekly use of smokeless tobacco. The combined intervention (T T) was the most effective overall in reducing the initial and week l y u se of cigare t tes and smokeless t obacco. The authors concluded that this s u ggests that different reasons for u se exist and need to be counteracted simultaneously. Life Skill s Training I n 1980 Botvin Eng and Williams pub l ished an evaluation of the Life Skills Training (LST) program. This program, based on B andura s Socia l Learning Theory (1986), promotes opportunit i es for processi n g life experiences, struct urin g experiences, and actively gaining experi ences. LST cre a tes opportunities for youth t o acquire skills that enab l e them to avoid manipulation by outside influences s u c h as peers and the media. It teaches soc i al resistance skills and ge n era l personal and socia l compete nce skills. In one study, rates of substance use behavior, attitudes, knowledge, normative expectations, and related var i ables were examined among students (N = 1090) from 20 schoo ls. These schoo l s were random l y assigned to either receive the prevention program (9 schools, n = 426) or serve as a contro l group (II sc h ools, n = 664). Data were analyzed at both the individual-level and schoollevel. Indi vid u a l-level ana l yses contro llin g for ge n der, race, and fami l y str u ct u re s h owed that int erve nti on stude n ts reported l ess smoking in the past year, more pronounced a nti-drinkin g attit ud es, increased s ubstan ce u se k nowl edge a nd sk ill s r e l ated knowledge, fewer normative expec t a tion s for s m oking a nd a l cohol u se, a nd 29

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higher self-esteem a t th e posttest assessme nt relative to control stude nt s (Botv in Griffin, Paul, & Macau l ay, 2001 ). School-level analyses showed that the annua l prevalence rate was 61% lower for smoking and 25 % lower for alcoho l use at the posttest assessment in schools that received the prevention program when compared wit h contro l sc ho ols. In add ition mean se l f-esteem scores were higher in intervention schools at the posttest as essment rel a tive to control schools. Findings indicate that a school-based substance abuse prevention approa c h previous l y found to be effective among middle-school studen t s is also effective fo r elementary school students. In another study the authors evalua ted the ubstance initiation effects of the LST curriculum that combi ne s family and school-based competency-training (L i fe Skills) intervention components. (Spath, Redmond, Trudeau, & Shin 2000) Thirty-six rural schools were randomly assigned to one of three condition : (a) the classroom-based Life Skills Training LST) and the Strengthening Families Program: For Parents and Children 10-14, (b) LST on ly. or (c) a control conditio n Outcomes were examined one year after the intervention postt e st. using a ub tance initiation index (SII) measuring lifetime u se of alcohol, cigarettes, and marijuana and by rates of each indi vid ual s ub stance. Planned intervention-control contrasts showed significant effects for both the combined and LST-only interventions on the SIJ and on marijuana initi ation. A l ong-term follow-up study of 447 indi vidua l s who were contacted after the e nd of the 12th grade six-and-ahalf years after the initial pre-test of the Life Skills Training program, found that students who received the LST program during junior high sc hool reported le ss u se of illi cit drugs than contro l s (Botvin et al., 2002). These resu lt s a l o s upport the hypothesis that illicit drug use can be prevented by targeting the u se of gateway drugs s uch as tob acco and alcohol. 30

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Not On Tobacco ( OT) N-0Tis a teen stop smoking program of the American Lung Association. It is a 1 0-session, gender-specific program with booster sessions that incorporates life management skills to help teens deal with stress, decision-making, and peer and family relationships. It recognizes that males and females have different reasons for starting to smoke, for quitting. and relapsing It also addresses alcohol use and illicit dug use a s well as e xerc ise a nd nutrition A pre liminary post program evaluation shows a 22.4 % quit rate among teen a ged ciga r ette smokers. Of those who continued to smoke 65.4 percen reduced the number of cigarettes smoked during the weekdays and 75 percent reduced the number they smoked on the weekends. These results were bio-chemically validated (ALA, 2002). Project Alert Proj ect Alert i s a drug prevention curriculum for middle-school students ( 1 1-14 year s old ) whi c h has been proven to reduce the onset of substance abuse and regular substance u s e. It is a two-year program delivered to 6th, 7th, or 8th grade students, which focuses on the substances that adolescents are most likely to use: alcohol, tobacco, marijua n a and inhalants It has 14 lessonsI I core lessons delivered the first year and three booster lessons the second year. The Rand Outcome study of Project Alert conducted in 30 California and Oregon schools found that students receiving Project Alert reduced initiation of marijuana use by 30 percent; decreased current marijuana use by 60 percent; reduced past month c i garette use by 20 to 25 percent; decreased regular and heavy cigarette use by 33 to 55 percent; demonstrated substantially reduced pro-drug attitudes and beliefs (Ellickson, Be ll, & Harrison, 1993). 31

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A recent s tud y of the revised Proj ect Alert c urriculum was conducted in 55 South D ako t a mid d l e schoo l s The rev i sed Proj ec t Alert curric ulum curb ed c igar e tte a nd mari j u ana u se initi at ion current a nd regu lar c igar e tte u se, a nd a lcohol misuse. R ed u ctio n s ranged from 1 9 % to 39 % (E ili ckson, M cCaffrey, Ghosh-Dastidar, & L o n gs h ore, 2003). The Proj ect A l ert c urri c ulum m ot iv ates ado le scents n o t t o u se drugs a nd by t eachi n g them sk ill s t o tr a n s lat e th at motivation int o effect i ve resistance. Th e l essons foc u s on nor m s belief s abo ut drugs. and int entions to help motivate adolescent s n ot to u se, and stress sk ills on how to identify and resist pressures ste mmin g from th e avai l abi lit y of dru gs and from pressures to u se ( R and, 2004). C o n sider This The Cooper In stit ut e re searc h e r s a nd r esearchers from the Univers ity of New Mexico t h e niver s ity of Arizo n a, and the Anti-Cancer Council of Victoria, Australia developed the Consider Thi s int erac tiv e Web site ( http ://www.co n siderthi susa .n et) u sing multimedia a n d database software a nd inn ovative communic atio n stra tegie s to reduce smoking amon g adolescents aged 11-15 ( grades 6-9) w ith funds fro m the Nation a l Cancer In sti tute Th e CT c urri cu lum program tailor infor m a tion disc u ss ion s abo ut tobacco u se, and soc i a l skill-buildin g to p ersona l s m oking experiences of ado l e cen t s ( non u se rs, experim e nt ers a nd regu l ar u se rs). Th e Web c urri c ulum features s i x, 50-minute modul es, designed spec ific ally for the middl e sc hool tudent. The cont e nt i s designed to counter soc i a l pressures to s moke debunk myth s s urrounding s mokin g, correct norm s regarding yo uth s moking, mod e l soc ial skills, teach s tre ss m a n age ment t ec hnique s, promote decision-making s tr ateg ie s that affec t children's s mokin g, a nd 32

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c l arify personal values. Table 2.2 describes the cuniculum activities and prevention pri nciples re l ated to each modu l e.) These prevention principles have all proven to be s u ccessful in randomized tr i a l s on youth tobacco prevention. Table 2.2: Consider Thi s Program Module Activities and Prevention Principles Module Activities Prevention Principles Introduction to Preview Appeal for continued abstinence from Web site Ground rules smoking or to stop smoking On-line smoking survey Media Museum Introduction Increase media literacy Radio studio De-glamorizes smoking Movie theater Reveal tobacco industry manipulation Models activity strategies TV wall animation Reveal power of media persuasion Pop culture Debunk realism of media depictions of Create an ad pop culture Relationships What kind of person are Increase social skills to improve you? communication and relationships Communication skills Teach peer pressure resistance skills Advice column Correct social norms related to smoking Peer pressure in the mall Statistics on friends Mind I Body Effects of smoking on the Learn harmful effects of cigarette smoke human body on the body Substances in cigarettes Provide personalized I tailored feedback Aspects of addiction I on growing addiction to nicotine dependence Model and practice stress management Perfect world techniques Stressful situations Decision-making You pick it, you get it Model and practice decision-making skills and Values Virtual interviews Hear testimonials of teen smokers who quit Values Clarify personal values and explore mismatch of smoking and personal values Influences Exposing memos Reveal tobacco industry plans to target teens Smoking situations Learn to recognize smoking situations Top 10 ways to say no Model and practice skills for avoiding and resisting pressures to smoke For examp l e, Botvin (2000) demo n strated i n t h e L i fe Skills Training p r ogram t hat by teac h i n g students t o recognize factors like the influence of mass media, 33

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tobacco industry manipulation strategies and the power of media persuasion, students could debunk the realism of media depictions of pop culture and increase their capacity to think critically. The 'Media Museum" module of the CT curTicu lum demonstrates the influence of the media by engaging online users in interactive learning experiences. Additionally, like Life Skills Training CT delivers stress management activities, a lth ough these are provided in an interactive computer program. Social norm theory provides a model for understanding human behavior that has impoltant implications for health promotion and prevention. lt states that behavior is influenced by incorrect perceptions of how other members of our social groups think and act (Berkowitz 2002). In the case of tobacco u s e, correcting misperceptions that the majority of youth use cigarettes or other tobacco products is key to prevention activities. This is done in the "Rel ations" module of the CT curriculum. The above described activities, and others that are palt of proven effec t ive tob acco contro l curricu l a, are included in the Con s ider This curriculum. The Consider This curriculum user interface is guided by a virtual host, a teenage fema l e of uncertain racial or ethnic heritage, who leads students through activities w ith audio instructions a nd feedback. The feedback is guided by u ser responses to smoking history questions. These questions are asked during the course of user navigation through the curricu lum modules User responses to the smoking history questions create a user profile that is the basis of the virtual host's interaction with the user (e.g., "The l ast time you were on this Web site, you told me that you were experi mentin g wit h cigarettes. Are you still experimenting?"). This tai loring aspect and the audio track provided by a peer ( th e virtual ho stess) persona l izes the Web s ite for the u ser and provides researchers wit h user smoking history data. 34

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The effectiveness of CT is being tested in two Nationa l Cancer In s titute funded, group randomized pretest-posttest cont rolled trials, one each in the United States and Australia. Preliminary a n a l yses wer e con ducted on 977 stude nt s (62 % intervention and 28 % cont rol) who had completed a pretest and posttest questionnaire in 2001-02 in t h e U.S. All responses were measured using a Likert sca l e. Since t he pr obability of future to b acco u s e can be predicted from behavioral intent and susceptibility (Pierce, 199 6; Norman, 1999 ; O'Callag han 1999 ) for the pre limin ary analys i s the main outcome of intere s t was the s ubjects' response to the stateme n t I will not smoke in the future." Intervention subjects showed a significant positive change (p
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Control group th at did not move. Thus, the authors feel that CT may have potential to provide inoculation against future smoking, if by nothing more than allowing the children to express that this is an option. Similar positive changes (p<0.05) were detected for intervention subjects but not control subjects in their responses to items assessing se lfefficacy to refuse a cigarette offered by a friend and knowledge of the addictiveness of cigarettes and smokel ess tobacco (i.e "Smoking is as addictive as other drugs such a s heroin or cocaine"). In summary. this interactive, Internet-based curriculum tailors information and discussions about tobacco use, and presents social skill-building activities based on the personal smoking experiences of adolescents (non-users, experimenters and regular users). Student smoking status i s assessed throughout the program and responsive audio messages to the student u er are made by the virtua l host to reinforce non making behavior, encourage self-examination of smoking behavior and attitudes, and discourage smoking. Since CT has not been fully tested, this may influence its adoption All of the above curricula are based on scientifically demonstrated prevention principles and h ave been or are being tested in the c ia sroom. Despite positive findings and the sub equent avai l ability of effective tobacco use prevention curricula, there remains a significant problem with tobacco use among young people. Id entifying the predisposing, enabling and reinforcing factors related to adoption of tobacco prevention curri cu l a could help mitigate this seemingly intr actab l e problem. When exploring th e schoo l context of tobacco use and tob acco u se curri cu lum and policies within Colorado schools, a recently completed focus gro up s tudy of Colorado school principals ( Ro cky Mountain Center, 2002) disclosed the following themes: 36

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CSAP (Co lorado Student Assessment Program ) h as a strong influence on all sc hool decision s (This is a state required testing pro gra m that impo ses peiforrn a nce standar dsoneveryCo l oradoschool,withtiestofundingifstandardsare not met.); Tobacco i s not the highest priority for schoo ls; Every sc hool i s di ffere nt ; Limited resources affect ability of schoo l s to incorporate new programs; a nd Cultural norms of the community I parents (might) accept tob acco as 'okay: These findings helped better inform me regarding the context of this research Intern et Use Among Youth While the identi ficat ion of effective intervention tr a tegie s to prevent youth tobacco use is an import a nt research step. uccessful implementation of effective strategies is ultimatel y dependent on effective diffusion of intervention s to schools and communities. One promi si ng st r ategy for dis se min a tion i s delivery of tobacco prevention learning experiences via the World Wide Web or the Internet. The Internet i s fast becoming a universally avai l able tool that teens u se regularly for their schoo lwork It a l so holds great potent ial since access to this too l is not confined to the sc hoo l c l assroom and it ha s potent ial to reach teens where they l ive and p lay. I dentification of the barriers to implementation of Web-based curricu l a shou l d be of value to our schoo l s and pub l ic hea l th. 37

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The Int e rn e t h as b eco m e a n import a nt learning tool for teen s a nd recog nized as a valuable learnin g resource by parents. A Pew R esearc h C e nter s ur vey of 754 youths ages 1 217 conducted in the closing months of 2000, found the fo llo wing: 98 % of American public schoo l s have so me kind of Int erne t access for s tud e nt s and 77 % of instructional classrooms have Int ernet conn ect ion s [Thi s percent age dro p s to 60% for sc h oo l s with the hig h es t concentrations of poverty (Cattag ni 200 l ); Only 73 % of the youths su r veyed use the Int ernet, despite th e fact t h at the Int e rn et i s avai l a ble to virtually all teens at their sc h ool; 94 % of online youth u se the Internet fo r sc h oo l research and 78 % say they b elieve th e Intern e t help s the m with sc hoolwork ; 87 % of p are nt s of o nlin e yo uth believe th a t it h e lp s s tud ents with th e ir sc h oo l\ ork a nd 93 % believe that it helps st u dents l earn new things; 55 % of p are nt s of online youth beli eve that i t is esse nt ia l for today's children to learn how t o u e th e Int erne t a nd another 40% believe it i s import a nt ( L e nhart 2002). The PEW researchers working on thi s s tudy reported th a t there was a s ub s t a nti a l disco nne ct between how stude nt use the Int ernet for schoo l a nd ho w s tud e nt s u se th e Internet during the sc h oo l day a nd under teacher direction. They found th a t st ud e nts' ed uc a tional u se of the Intern e t occurs ou t s id e of th e sc hool d ay, outside of the sc ho o l buildin g, a nd outside of th e direction of their teachers. A few of the factors students attr ibuted to thi s disconnect were: The qu a lity of s tudent Internet-b ase d assignments was poor and unin s piring ; 38

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School administrators set the tone for Internet use at school. Policy choicesbythosewhorun choolsystemshaveresultedindifferentschoolshaving differentlevelsofaccesstotheinternet,differentrequirementsfor tudenttechnology liter acy skills, and different re triction s on st udent Internet access; The single greatest barrier to Internet u eat sc hool i s the quality of access (connection speed and reli abi lity) to the Internet; Because not every student access to the Internet out ide of schoo l the vast majority of students report that their teachers do not make homework assignments that require the use of the Internet: Students repeatedly t old researchers that the quality of their Intemet-based assignment was poor and unin spir ing (Lenhart, 2002) These barriers while significant now if not addressed soon will become even more pronounced as broadband connections become more commonplace and more students become o nlin e u sers. Teacher s will need to become better prepared to use and/or design ins tructional lessons that are available on the Internet. Internet-based assignments will need to be compelling and inspire s tudent le a rning. Administrators will need to become better informed about the tec hnical and administrative barriers to effective u se of the Web in schoo ls. Change agents will need to know how to effectively deliver and disseminate Web-based tools to schoo l s and chool districts. Other research findings indicate that use of Web technology in the educational environment can be effective in changing health practices. In a study of a Web-based computer-tailored, nutrition education program changes in student determinants of behavior were found (Oenema, 2001 ). If the Internet is to become an effective 39

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teaching tool for cl assroo m tea c her s, then research need s t o expand so that knowledge of effective di sse min at ion a nd inst ructional strategies continues to develop. Use of the Int e rn et, li ke other communication media ha s b o th b e nefit s and lia bilities. It s prim ary b e n efi t for adolescents who are seek ing he a lth-related information may be th e ano nymit y tha t i s afforded by a n int eractive co mputer e n v ironm e nt. One study of adolescents seek in g he a lth care fou nd that they freq u e ntl y ne ed and want to ta l k with t he i r prim ary care provider s about health risks but oft e n d o n o t (K lein & Wilson 200 0) The ado le scents i n thi s st udy most frequently disc u ssed hea lth y dietary habits (49 % ), weight (43 % ), and exe r c i se (41%) w ith th e ir clini cia n s, but most frequent l y wanted to but did not discuss drugs (6 5 %) s moking (59 % ). and health y dietary h abits (57 %). Ove rall, 70.9 p ercen t of their st ud y sa mple reported at least one of e i g ht p otentia l h e alth ri sks, but 63 p e rc e nt of the se adolescents h ad n o t spoken to t h e ir doctor a bout any of the se risks. While not tes t e d in thi s st ud y disclos ing he a lth b ehav i ors, es p ec i a lly those that are known to be soc ially unde sirable, in an interactive computer environment like that p rov ided by CT, may be easier for so me ado l esce nt s than talking with health c are providers or p a rents. Computers a n d Int ernet Access in Colorado Schools A nation a l m arke t r esearch study conducted durin g sc hool year 199 8 -99 found th a t the computer-to-student ratio for Colorado sc ho o l s was only s lightly above the nation a l average. There was one computer for every 5 .3 s tudent s in Colorado and the n a tional average was 5.7. These r a tio s compare favorably to California schools, where the ratio was little more than one computer for every 8 s tudents but unfavorably to W yo ming schoo l s, where the ratio was one computer to 3 5 s tudents. 40

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There was one Internet computer for every 12.9 st udents in Colorado and one for every 13.6 nationally, and 95 % of Colorado schools have Internet access compared to 90 % nationwide (The Denver Post 1999). In conclusion, with this liter at ure review as the knowledge and conceptual bases for this research I pursued the identification of factors that promoted and impeded adoption, implementation a nd maintenance of the Web-based tobacco education and prevention curriculum en titl ed C o nsider This. 41

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CHAPTER 3 THEORETICAL APPROACHES This chapter discus ses th e prim ary the ories (DOl and PRECEDE) th at g uid ed the inquiry and helped to shape interpretations of the data. Identification of the det e rmin a nt s of Internet program u sage in the classroom was done in t h e conte x t of theoretical approaches to communications a nd behav i o r cha ng e. DOI identifi e d t h e communica t io n s context f or di s seminatio n and adopt i o n of CT. The PRECEDE health p r omotion pl a nnin g and interventio n model defined behavioral and environm e ntal factors. More s p ecifically, thi s chapter de scr ibe s the theore t ica l con t e xt within w hi c h diffusion of CT took place a mong s tudy p artic ip a nt dur i n g the 200 1 / 2002 sc hool year. The teache r curricul um adoption proc ess i s descr ibed u sing DOl construc t s ( relative advantage, co mpatib i l i ty, complexity, tria/ability, obse r va bility, adoption, dissemination and main t e nanc e) Individu a l and e nvironmental b ehaviora l fac tors assoc iat ed with adoption of C on s id er Thi s ar e d escribe d with co n str u c t s from the PRECEDE model (predisposing, enab ling, and reinforci n g factors). Diffu sio n of Inno vations Giv e n that a n innov a tion exists, communication must t ake place if th e inno va tion is to s pre ad." Everett M. Rog ers, ( Ro gers 1995, p.l7) 42

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New i deas or innovations are adopted thr o u gh a p rocess that R ogers calls th e inn ovation dec i sio n process, th e process through whic h an indi v idual or decisio n making unit passes from first knowledge of an i nnovation t o forming an attit ude t oward th e innovation, to a decision to a d opt or reject, t o imp l emen t at i o n and u se of a new idea, t o confirmatio n of this decis ion" (Rogers 19 95, p. 161). U nd ersta nding and influ e n ci n g the decisionm aking process can help expedite adoptio n and influen ce the s u rvival of an inn ovat i on New ideas or inn ovat i o n s often do n ot surYiv e be c a use financ ial s upport for the idea i s not s u stained suffic i e ntly for the innov atio n to be acce pted w ithin a soc ial sys tem. Understa ndi ng the diffusion process, its barriers, and how it i s enabled i s espec i ally impo rt ant if the innovation i s t o be accepte d and thi s accepta n ce s u stained. Understanding th e factors tha t influe nce diffusion of Co n sider This (e.g., chan ge age n ts, compl ex ity, trial a bility etc.), and being able to control or manipulate those facto r s i s vital to t h e viab ility of the progr a m as a tool t o inhibit tobacco u se. Diffusion of Inn ovat i ons theory provide s a framework for identifying effective approac h es for di ssemina ting the Consider Thi s prog ram. DOl h o ld s th at .seve ra l characteristics of a n inn ovat i o n affect its adoption (B ull er, 200 I). R ogers (1995 p. 5) defines d(ffus i on as ''the process by whic h inn ovatio n is co mmuni cated through certai n c h anne l s over time among m e mbers of a social system." H e defines comm unica tio n as "a proces s in which participants crea t e a nd share in for mation with one a no the r in order to reac h a mutu a l under s t a nding" ( Roger s, 1995 p 17) Roge r s contends th a t diffu s i o n i s a specia l t ype of communication in th at the m essages are concerned with new ideas It i s th e newne ss or uncert a int y of the idea that makes diffusion a unique typ e of communication. 43

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Elements of the Diffu s ion Process There are four elemen t s that character i ze the diffusion process: 1 ) I nnovat i o n Traits -The idea, practice, or object that is perceived as new by an individual or other unit of adoptio n ; 2 ) Communi c ation Chan n el s -The mea n s by which mes sages about the innovation get from one i ndividual t o another; 3) Time-The length of time it t a ke s a n innovati o n to b e adopted or rejected b y a n indivi d ual or s ystem ( the inno v ation deci s i o n period); 4 ) S ocial S yst e ms-A set o f int e rre l ated unit s (individuals informal gro up s organization s and / or sub s ystems) th a t are enga ged in joint problem s o lving to a c c ompl i s h a common go al. The following di s cu ss ion of these e l ement s in th e context of the innovation that i s th e focu s of thi s r es earch helped inform the study design and instrument a t i on u sed to ga the r d at a Inn ovation Traits Rogers contend s that if the ide a seems new t o t he indi v idua l then it is an innovation Newn es s of a n id e a may be expressed in terms of knowledge, per s u asion or a decision to adopt. The perceived tra it s of an innovation or idea thus influences how qu i ckly a new idea is t r i ed and adopted. Rogers m akes a disti nction between hard ware a nd software inno vations, two broad inn ovatio n traits. Hardware inn ova tion s are e quipm ent or t oo l s, and softw a re innovations are the information base for t h e t ool. In the case of the Consider This project the innovation is quite lit erally a so ft ware inno vation th a t i s accessed u sing 44

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computers (hardware I eq uipment ) availab l e in Colorado schools. Schools have been using personal computers for approxima t ely 20 years, a nd some schoo l personnel had access to computers l ong before personal computers were introduced. In the strictest sense of Rogers' definition of hardware (a too l that contains the techno l ogy as a material or physical object), we could also define the Internet as t h e hardware that embodies the Consider This software. Without the availability of computer hardware, diffusion of this innovation would not be possible. Therefore, the most important t rait of this innovation is that it is dependent on the availability of and access to persona l computers. Much of Rogers' research has been in the domain of technology. An important observation of his that is relevant to this study is included: "A techno l ogical innovation usual l y has some d eg r ee of benefit for i ts pote n tial adopters. This advantage is not a l ways very clear-cut, at l east not to t h e intended adopters They are seldom certain that an innovation represents a superior a lt ernat ive to the previous practice that it might rep l ace." (1995 p. 1 3). In the case of the CT innovation, teachers and other schoo l personnel, as the potential adopte r s, may be unc ertai n abo ut the benefit that an Int ernet-based t obacco education cuni cu lum might provide over a baditional document-based, classroom curr i cu lum. In the str i ctest sense of the term, the only potential adopters of the CT c urriculum are t eac h ers. They are the on l y subgroup of sc h oo l empl oyees who h ave routine access to the classroom (the e nvir o nm e nt where it is implemented) a nd to the s tud e nt s who are th e ultimate b e n efic i aries of the innovation. 45

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Rogers contends that perceived attributes of an innovation help explain the rate of adoptio n of an innovation (1995, p. 206). Those attributes are described here: 1. Relative Advantage-The degree to which an innovation is perceived as better than the idea it supercedes; 2. Compatibility-The degree to which an innovation is perceived as being con s istent with existing value s, past experiences, and the needs of pot e ntial adopters; 3. Complexit y -The degree to wh i ch an innovation i s perceived as difficult to understand and use; 4 Trial ability-The degree to which an innovation may be experimented with on a limited basis; and 5. Observability-The degree to wh i ch the resul t s of an innovation are vis ible to others. Innovations that have the above five qualities-more rela t ive advantage, a high degree of compatibility, trialability, observability, and les s comp lexity-are more likely to have higher rates of adoption. Specific innovation attributes of the CT curriculum as perceived by the teacher participants in this study are described in the qualitative portion of this dissertation. Communication Channels Communication channe l s, another element of the diffusion process, are the means by which messages about an innovation get from one person to another. Mass media and int erpersonal communications are the two principal means by which information i s transmitted. Mass media channe l s involve radio, television, 46

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newspapers, mass mailing s, etc. Interpersonal channels involve face-to-face interactions between two or more persons. The quality and effectiveness of communications transmitted through these two channels are influenced by the principle of homophil y, i.e., the degree to whic h two individua l s are similar in certain attributes s uch as education, beliefs and social interests. Homophilou s individual s sha r e per so nal and social characteristics, attribute similar meaning s to things and ide as, and share a mutual subcultural language In contrast, persons who are heterophilou s do not share these charac teri s tics. The innovation-decision process is one that is measured in part by time. Time represents a) the period between an individual's initial knowledge of an innovation to the moment of adoption or rejection b ) the relative earliness or lateness of an innovation bein g adopted and c) the rate of adoption of an inno va tion in a socia l system. The innovation-deci s i on proce s consists of five steps: a) knowledge-w h en an individual or decision-making unit learn s of an innovation; b) persuasion-when individual or unit forms a favorable or unfavorable opinion on the innovation; c) decision when an individual engages in activities that lead to adoption or rejection of the innovation; d) implementation-when the individual puts the innovation into practice; and e) confirmation-when the individual realizes reinforcement of an innovation-decision. Time i s an important dimension exp l aining the innovation-decision process. Broad steps or marker s of the CT curri culum adoptio n process were identified in both 47

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the survey and interview portions of this investigation to help characterize the rate of adoption. So c ial Svstems "A social sys tem is a se t of int er-re lated units that are engaged in joint problem-solving to accomplish a common g al.'' Roger s ( 19 95, p. 23) The social sy tern is an enviro nment within which change or adoptio n of innov at ions occurs. Character ist ic s of social systems therefore affect diffusion. More specifica lly within a social system the roles of opinion leader s a nd change agents, soc i a l norms that rel ate to, enable or constrain adoption of an innovation, and the types and consequences of an inn ovat ion all affect diffusion. Formal and inform a l social systems within schoo ls and schoo l districts affect the rate and breadth of diffusion. The formal systems are those that are created by management and administration of a school district or school. The informal systems are those that are established through inter-personal communications. The communication structure (patte rn ed communication flow) within and among schools and between school and district administrators determines who int erac ts with whom and under what circumstances. Understanding the dynamics of the social syste m and its communication structure helps define the diffusion process a nd its predisposing, enabling, and reinforcing factors. Norms, or social standards, are cultural models shared by individuals in a social system which communicate to individuals what behaviors are expected and 48

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desired. Norms therefore are often powerful facto r s in the diffusion pro cess. Personal inn ova tiven ess o r a dopter categories h elp cla ss ify members of a soc ial sys tem accord ing to their w illin g n ess or tendency t o adop t new ideas ( R ogers, 199 5). Th e adopter categories are as fo llo ws: Innovator s Per s ons or dec i s i on-making bodi es who are venturesome Th e ir inte rest in n ew id eas e nds to l ead t h em outside of the ir peer n etworks and into a more co s m o p o lit a n circ l e They serve a gatekee p e r role in the flow of n ew idea s into a system. Early adopters Per so n s w h o are respec t ed and are more int egrated or active w i thin their l ocal soc i a l syste m Th ey have the greatest degree of opinion l eaders hip within the soc ial system. I deal l y change age nt s would seek the m out to h e lp p ro m ote acceptance of a new idea or inn ova tion Early m ajor it y Persons who a d opt new ideas just before the average m ember of a sys t em. They int e ra ct freq u ently with their pe e r s and rep r ese nt a pp rox im ate l y one third of the soc i a l sys t em ( Roger s 1995). Late majorityPer so n s who adopt n ew ideas ju s t after the a verage person in a soc i a l sys t em. Economic n ecessity a n d / or peer pressure u s u a lly motivates adoption f or this gro up wh ich is a bout a noth e r o n e -thi rd of the soc i a l system. LaggardsP ersons who are l as t in a soc i a l sys tem to a dopt a n idea. They are near i so l ates w ithin the soc ial network s of the ir sys t e m and t e nd to be s u s pic i ou s of new idea s or innovation s 49

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Figure 3.1 below illu strates the adopter categories that will be used in the a n alys i s of th e quantit ative and qualitative data collec t ed during thi s investiga tion. Figure 3. 1 : Percent Distribution of Adopters Over Time ....... c QJ u "-OJ Cl.. Innovators-tho e who are adve ntur ous. who have financial r e ource s and like to play with new tool s (5%) Early Adoptersthose w h o see s trate g i c advantage in adopting a n i n n ovation ( I 0 % ) Early Majoritywho make a deliberate choice to adopt (35o/c) Late M ajority those who are skept i ca l and who adopt when it is less risky (35%) Laggards-those who adopt an "over my de a d body" attitude ( 15% ) The adoption of inn ovat ion soc i a l c h ange process began before thi researc h project began. Th e CT innovation development stage (t he fir t step in the socia l cha n ge process) took place in 19 98 at The Cooper Institute.5 At this time the CT curriculum was developed for a research project testing th e effectiveness of the Int e rnet-b ased tob acco education curriculum described h e r e 50

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Other Human Elements of the Diffus i on Process The following two hum a n ro l es a re key catal ys t s in th e diffus i o n process Opinion L eaders Individual s w h o are abl e to influence informally in a des i red way and w ith re l ative frequency, other individuals attitudes and behaviors. Change Agents-Individuals who influence clients' innovation-decisions in a direction deemed de si rable by th agency they represent. (Note: Change agents usually use opi nion er as th e i r lieutenant or champions in diffu ion campaigns.) Summary of Diffu s ion of Innovation s Constru cts Table 3. I summarizes the princip a l constru c t a n d terminol ogy re l evant to the Di ff u sion of I nnovations theory (Roger 19 95). Tab l e 3. J : Key Diffusio n of I nnovations Th eory Con tructs Stages of Diffusion/ Elements of the Rate of Adoption SocialS ystem Social Change Diffusion P rocess Characteristics Mem ber Process Classifi cations Innovation Innovation traits Relative advantage lnnovat ors development Time Compatibility Early A dopters Dissemination Channel s Complexity Early M ajority Adoption Social System Trialability Late Ma jority Implementation Observability Laggard s Maintenance Change Agents Opinion Leaders 51

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Critici s ms of Diffu sion R esea r ch There are four m ajor crit i c i s m s of diffu s ion research: I ) its pro-inn ovatio n bias; 2) the individual-blame bias; 3 ) the r ecall problem; and 4 ) the i ss ue of equa lit y ( R ogers, l 995, p. 99) Pro-inn ovatio n bias implies that the innovatio n hould be di ff u sed and ado pt e d by all m e mb ers of a soc i a l sys t e m t h at it s hould be diffused more rapid ly, and that it sho uld not be rein ve nt e d or r ejec ted. I ndividual b l ame hia s hold s that an individ ual i s re spo n s ibl e for his or her p ro blem s rather than th e soc i a l syste m of which he or s h e i s a part. R eca ll pro b l e m bi as i s a bi-prod uct of the re searc h proce ss it se l f a nd res u lts whe n individu a l s a re as ked t o remembe r th e time when th ey adop ted a ne w id ea or inno vatio n I ssue of equality bias i s concerned with the consequences of a n innov ation a n d how the benefits of that innov atio n d i s tribute within a social sys tem I observed all of these biases. For exampl e, dur in g the cour se of teacher interviews in thi s st u dy, I n oted the tendency of t eac h ers to offe r only positive remark s abo ut thei r experiences with the ado ption of the CT curr i c ulum In other wo rd s, they tended to s h are on l y their successes w i t h implement a tion of thi s inn ovation Th ey see m ed more re lu ctant t o offer d esc ription s of the probl e m s they encount ered unl ess they were prompted. Thi s i s an example of pro-innov a tion bia s or soc i a l desirab ilit y bias. T eac h ers a l so tended to accep t bl a m e for n ot h avi n g s uccessfully implement ed CT in their c l asses. Some would make se lfeffacing comments a bout th e ir lim i ted experience w ith or knowl e dge of computer technology when in fact, the limitation s 52

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of their Intern e t connections m ay have precluded s uccessful implementation. These se lf-eff ac in g comments were sometimes made despite their knowledge of the Internet connection limitation. Ro gers ( 1 995) suggests alternative re search approaches (e .g., field stud ies while the innovation is being disseminated r ather than post-diffusion s tudie s) that were u sed on a limit ed basi to h e lp explain some of the bia s inherent in innovation research. One of those approaches, classroom observations, was used to help provide an objective perspective on the diffusion / adoption process. R ecal l bias will need to be accounted fo r by inquiries that explore the continued dissemination of CT during the 2002-2003 school year. Another critici sm of diffusion research is that the predominant focus of diffusion studies h as been on s ucc essful diffusion events and that event where diffusion was unsucces ful h ave not been stud i ed (Henrich 2000) This study effectively addressed thi critici sm when the design wa expanded to include participants from sc hool districts where CT may not have been implemented a t a ll. (See Chapter 4 for a detai l ed discussion ) R e lated Diffusion Research Similar to Roger's theoreti ca l p erspect i ve i s one th at focuses on the transformation processes that move organizations towards change or adoption of new instructional innovations (Kers haw, 1 996). This three-step process i s centered on individual behaviors. First, individual s must recognize that there is an urgent need for change in the organization. Second individuals must come to under s tand that they themselve s mu s t change. Finally, they must realize that they need to change the way they perform their roles in the organization. 53

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A more simplified model applie d t o faculty of e duc a tion a l ins tituti o n s, ( G e o g hegan 1 99 5 ) e n v i i o n s two gro up s of adop t ers : early ado pt e r s and m a instr ea m faculty Thi s model character ize s earl y ado pt ers as techies' who experiment with every new t ech nolo gy that come s a l ong. Main tream fac ult y t e nd s to focus more on problem s processes, a nd tasks at h a nd than on the too l s that mig ht b e u ed to address them a n d they prefer incremental change. T able 3.2 describes and contra s ts the c haracteri stics of these two infor m ation t ec hn ology ado pte r grou ps. Th e Geoghegan mod e l s u ggests that early adop t e r s a re often poor chan ge age nt s due to th eir l ack of focus on process. Their success in u s in g t echno l ogy to bring a bout qualitative improvement in teachin g an d learnin g, and the v i s ibility th a t can accompany s u c h success can have a n a lien ating effect on ot hers. It can foste r a b elief that m os t faculty members sho uld be u si n g technology a nd tha t greater access t o technolo gy and tr a inin g i s a prereq ui s it t o s u ccess (Geoghegan, 1 995). T a ble 3.2: Adoption Categories for Info r mati o n Technology Groups Early Adopters Favor revolutionary change Visionary Mainstream Adopters Favor evolutionary change Pragmatic or conservative Strong technology focus Strong p roblem and process focus R isk-takers Risk adverse Experimenters Want proven applications of compelling value Largely self-sufficient May need significant support Horizontally networked Vertically networked 54

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Another diffusion model that is a management information systems model, based on the Theory of Reasoned Action (Glanz, J 997), is the Technology Acceptance Model (TAM), (Dillon and Morri s, J 996). TAM predicts that u ser acceptance of any technology is determined by: 1) P erce ived usefulness-The degree to which a per so n believes th a t the use of the new t ec hnolog y will enhance his or h e r performance; and 2) Perceiv e d ease of use-The degree to whic h a person believes the new technology will be free of effort. Perceived usefulness i s comparable to Rogers' construct of relative advantage, and the perceived ease of u se is comparable to hi s id ea of complexity. Thi s v ery simplified two-dimen ional mod e l doe not acknowledg th complexities of adoption behavior, whereas DOl include s a broader range of constructs uch a compati bility, observability, and tri a lability as adoption chmacteristics. In contrast to the TAM model Reeves ( J 997) describes a more complex model that seeks to explain s ignificant ped agogica l dimensions of computer-based l earning. Thi s model describes fourteen ped agogica l dimension of computerbased education (CBE) in a n effort to provide improved criteria for under s tanding describing and evaluating CBE. While these dim e n sio n s were identified as eval uative factors, they me s uggestive of factors that may con tribute to diffusion of CBE. These factors are in the philo so phical, te ac her, student and technical domain epi stemology; pedagogical philosophy; underlying philosophy; goal orientation; 55

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experiential value; teacher role; pro g ram fle x i b ility; va lue of errors; motivation: acco mm odat ion of individ u a l differences; Ieamer contro l : user activity; cooperati v e l earning; and cultural sensitiv it y Some of these dimension or factors and their definition s va lid a ted adop tion factors identi fied in the ana l ysis of the observation a nd interview data collected in thi s study. For exampl e, le arner con tr o l was a fac tor that st u de nts a nd te ac her s liked a bout CT. Stud en t s liked th at th ey cou l d direct th e ir choices from var i o u s CT l ea rnin g modul es with the cli c k of a mou e. Teachers liked that t heir students cou l d move through the progr a m a t their own p ace A s tudy of the intr od uction of integrated learnin g syste m s ( ILS) int o sc hoo l s s u gges t s five s t ages of teacher participation in the implement a tion of ILS ( Cl a riana, 1992). These are: ovice, n o n -par ticip a tor y where a te ac h e r drop s off a c l ass a t the ILS (co mputer ) l abo r a tory ; No v ice p a rticipator y where the te ac her attends th e clas ses but does not know ILS; Practitioner, where the t eac her use s ILS progress report s to h elp pupi l s by remedi a tion or re-teachin g; 56

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Integrator, who manipulates th e ILS seq uen ce so that it better matches the classroom instruction; and Extender, who has fully integrated the ILS into classroom curricula. This teacher clas s ification system suggests that teachers be extenders because they are required to be in the classroom when students were logged onto CT and to integrate it into their broader health-education curricula. One on-line discussion of the diffusion of technology inK-J 2 education focused on cost and instructiona l strategies (Reces s o. 200 l ). Using Rogers DOl model and a cost analysi model, the discussants concluded that the widespread use of interface technology would re s ult in low per student costs. To accomplish widespread use of technology it identified that teacher effectiveness is an integral issue related to the development and implementation of a technology-based interface. One discus ant tated that "The drive to create this tool (a t chno l ogy-based interface) makes the assumpt i on that teachers are also t chnologists ... we sho uld discriminate between content expertise, designing a nd developing the content for presentation, a nd facilitating the l earni n g experience" ( R ecesso. 2001 ) This quote and the surrounding discussion provide some perspective on the compl exity of the technology / user intetface with which teachers are confronted. While the CT curr i culum does not require that teachers be designers or developers of technology, it does require that they, to some extent, be co nt ent experts and, to a grea ter extent that they be facilitators of the learnin g experience. This onli n e discussion concluded that successful classroom u se of a technology-based Ieamer intetface wou ld ha ve to overco me barriers pre se nt ed by teacher training, costs, a nd providing a sys tem conducive to facilitating effective 57

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instruction Becau se training was provided to te ac her s who were p art icip a nt in this stu dy, th e effectiveness of that training was examined in thi s investigation. R e le va n ce of Diffu s ion of Innovations School tobacco edu cation programs like CT are an imp ortant component of a comprehensive tobacco control prog ram (CDC, 1 999) However, knowledge of effective sc ho o l-b ased strateg i es to influence adolescents on important health topics, such as tobacco use, will have little or no impact if they are not effectively disseminated to teachers and schoo l officia ls. Computer-as s isted in s tructi on h as been u ed in schoo l s for severa l years n ow. H owever, u se of programs delivered over th e Internet i s st ill novel ( Buller, 200 I). Thus, in DOl terms. teachers w ho are cunentl y using th e Internet as an instructional tool are likel y to be either ear l y adopt e rs or ear l y majority users of computer-b ased instruction a l tools. The DOl model postulates that early u ers are apt t o be attu n ed to communicatio n s from individu a l s and g roup s outside of their informal socia l environment (e.g., n ationa l and local education and health leaders) typically via mass media (no n-localized channels) when making adoption decisions. It is reasonable to expect then that direct marketing of the CT program a nd its comput r b ased attrib ut es by o ut side entities such as th e developers of CT would reach early adopting schoo l a nd teachers and induce them to learn more about and use the CT progr am. New adopter look to earlier ado pter s for evidence that an Internet-ba se d progr a m is feasible a nd effective in the classroom. These adopters depend on teacher s who are opinion leaders for information a bout the Con sider This program. Identific at ion and understanding of the diffu sio n or communication constructs that promote use of new or innov at ive instructional tools 58

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within and among schoo ls and school districts will help facilitate adoption of new too l s s uch as the Consider This, Internet-bas ed curriculum. PRECEDE-PROCEED Planning Model This diagnostic model was establis h ed to guide public health p rofess i o n a l s as they apply theories of health behaviors in the communit y setting (Gree n and Krueter, 1984). It provides a structure for apply in g theories, in order that the m ost appropria t e intervention strategies can b identified and imple mented. PRECEDE-PROCEED ca n b e thought of as a road map, and theories as the routes to a destinat i on (Gla n z, 1 997). The PRECEDE acronym stands for Eredi posing R e in forcing and Enabling .Construct in Educational. Diagnosis a nd Evaluation. The PRECEDE portion of the model addresses planning variab le s including: individual behavior, e n v ironmental organizational, ad m inistra ti ve a nd policy factor Thi model i s based on the premise th a t a diagnosis of the educational environment i s n eeded before an effec tive interven tio n ca n be implemented. Glanz explains that this mod e l is not a theory per se, since it doe s not attempt to explain or predict the relationship a mon g factors thought to b e associated with an outcome of int ere t. It is however a str u c tur e within which var iou s theoretical approaches can b e applied This aspec t of the PRECEDE model had particular appeal to the in ve tigator, si nce he was int erested in explaining not on l y the socia l system processes from the perspective of Diffusion of Innovations theory, but a l o tho se individual and env ironm ental factors that influence utilization of health education c urri c ulum in sc hools. 59

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While there are nine phases t o the ent ir e PRECEDE (planning)PROCEDE ( implementation) model Green and Krueter ( J 991) describe the PRECEDE portion as having five phases of inve s tig a tion or diagnosis: Pha se I Social diagnosis; Pha se II-Epidemiological diagnosis; Phase III Behavioral and environmental diag nosi s: Phase IV-Educational a n d organizational diagnosis: and Ph as V-Admini trative and policy diagnosis The PROCEED po rtion of thi s model has four phases: Ph a e VI -Implementation Pha se VII -Process evaluatio n Phase VIII -Impact evaluation Phase IV-Outcome evaluation The PRECEDE model enables practitioners to incorporate construct from individu al, interper s onal communications. and organizational behavior change theories in their work. Because impact and outcome evaluations of the Con s ider This curriculum were not within the domain of this inve s tigation and the PROCEED portion of the model represe n ts implementati o n and evaluation phases, this researc h project will use only constructs from the PRECEDE portion of the model and more specifically, constructs associated with Phase 4 of this model, the educat ion a l diagnosis phase. This phase of the PRECEDE model assesses the causes of health behaviors identified in previous phases of the model. Three kinds of causes are identified -predisposing factors, enabling factors, and reinforcing factors. Enabling, reinforcing and barrier factors (PRECEDE constructs) will be identified for each of the stages of the Diffusion of Inn ovations theory. 60

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Predisposing factors a re the antecedents that provide the r a tion a le or motivation for a behavior. They include knowledge, att itud es, beliefs, personal pr eferences, exi s tin g skills. a nd e l f efficacy beliefs. In other words, predisposing factors include any character i s t ic of a perso n or popu l at i on that motivate behavior prior to the occ u rrence of that behavior. Enabling factor s are those precursors that allow motivation to be realized, directly or indirectly. through an environmental factor. Enabling factors include program s service s r e sources or skills nece s sary for behavioral or environmenta l outcomes to be realized. They facilitate action and any skill or resource required to attain a specific behavior. Exampl es of enab lin g factors include accessibility to a re o u rce availab ili ty of that re ource. and skills necessary to access or use a resource. Reinforcin g factors are those e l ements that appear subsequent to behavior and that provide continuing reward or i ncentive for the behavior to become persistent. These factors include soc i a l support, peer influence, significant others, and v i carious reinforcement. S i mp l y p ut these factor s are rewards or punishments following or ant icip ated as a conseque nce of a behavior. They serve to strengthe n th e motivation for behavior. The mo s t s i gn i fica nt value i s using the PRECEDE model was the iden tifi cat i o n of factors that, i f m odified, would most lik e l y r es ult in behavior change. The ide nti ficat i o n process included d etermining and sorting these facto r s into PRECEDE categories I con structs (e g enabling, predisposing or r einforcing). For thi s study the factors that imp eded or obstructed diffusion were categorized as bar ri ers and are be reported separate ly, outside of the DOI or PRECEDE findin gs Prioritizin g these factors w ithin each of the PRECEDE con struc t cat egories was the 61

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concluding step in the research proce ss. Prioritiz at ion of factors was based on the weight of research evidence or rel at i ve importance and c h angeab ility. Intetface of Diffu sion of Innovation c and PRECEDE Theories Factor or con truct of the PRECEDE model are used to describe a pects in each of the stages of the Diffusion of Innovations model. This investigation combined constructs from the Diffusion of Innovations (the social systems approach) and PRECEDE model (individual behavioral and environmental ap pr oaches) to better understand the factors that contribute to diffu ion of the Consider This, Internet-based tobacco education cunicu lum Using the Diffu ion of Innovations model and constructs from the PRECEDE model, this study described soc i a l change and diffusion processes and identified pred i sposing, enabling and reinforcing factors that influenced diffusion of the Consider Thi s online curricu lum Each of these models defines its constructs on the assets side of the diffusion equation. Therefore, in addit ion to DOl and PRECEDE related factors, barrier factors (the liabilities side of the diffusion equation) were defined se par ate! y. Figure 3.2 illu st r ates how the Diffu s ion of Innovations (DOl) and PRECEDE model s int erface. Both mode l s are stage-based models that describe processes leading up to program or innovation implementation. The Diffusion of Innovations model represents a socia l proces s that st udy parti cipa nt s went through to disseminate, adopt, and implement the Consider This c u rr i culum. While participants did not actually develop thi s innovation (the first step in the Diffu s i on of Innovations model), they did engage in activities to develop capacity for implement at ion (e g., atte nded training). CI researchers developed the innovation. 62

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F i gure 3.2: Interface of Diffusion of Innovation s and PRECEDE I PROCEED Models Plannning Model Stages: PRECEDE/PROCEED Socia l Ox Epi Behavioral / Educational & Ox Environmental Organizational Ox Ox Administrative & Policy Ox Innovation-Disseminati on-Adoption B Implementation Implem en t ation B Process-Impact-Outcome Evaluation Maintenance Stages of Diffusion/Innovation: Diffusion of Innovations A= Pre-implementation activities B =Implementat ion C =Post-implementation activities The PRECEDE/ PROCEED Model is a diagnostic health education program planning model that i s based on the premise th at just as medical diagnosis precedes a treatm ent plan. so shou l d educational diagnosis precede an inte r vention plan" (Glanz, 1997). While the PRECEDE model represents a co nsciou s admi nistr at ive planning proce ss, participants (teachers and ad mini s trator s) m ay hav e unconsciously u ed a model s imilar to thi s one to diagnose tobacco u se in their sc hool s and to plan their response to identified problems. The parallel socia l and individual behavior change processes represented by DOl and PRECEDE occurred simultaneo u s ly yet in different domains. Th e common point of interf ace for the e models i s the point of implementation or adoption. Interview and observationa l data collected during thi inve s tig atio n were fitted to this two-dimensional theoretical framework The time period a nd contexts under investig a tion a re repre se nted by the stages that are italicized in Figure 3.2. The independ e nt and interactive factors spec ific to each theoretical stage will be discussed in this research. 63

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CHAPTER 4 SURVEY OF CONSIDER THI S TRAINlNG SEMINAR ATTENDEES (QUANT ITATIVE STUDY) Survev Background and Purposes Th e su r vey portion of the tudy \'-'aS conducted with the cooperation of ad mini stra tor s, principal teach ers. counse l o r s, chool nurs s a nd information tech n ology staff w ho atte nded one of the eigh t Consider This training seminars tha t were offered during the 200 1 -2002 schoo l y ear. While the oYerall st udy was initi ally co n ceived and designed t o be containe d wit hin a sing l e school distri c t ( D oug l as County Schoo l s [DCSD]), u s ing only qual itative methods, m a n y of th e intended int erviews w ith DCSD adminis trat ors and sch ol pr i nc i pa l s d id not t ake place because of difficulties sc h eduling a n d keeping appoi ntment wit h the st udy population. A br ief t e lephone conversat i on wi t h a pri nc ipal who called m e on the t e l e phone to cancel a n appointment, m ade it c lear th a t middle schoo l principals and sc h oo l district admin i strators in thi sc ho o l district were very bu sy people who wo uld not like l y mak e t im e in their sched ule for the inter v iew. This brief telephone conver sat i o n a lso s u ggested that decisions regarding health education c u rricu la se l ection were m os t often m a de by teac hers-a sugges tion that was l a ter verifie d through this s tudy. H ence a foc used DCSD district-wide st udy using int erv iews as the exclusive sour ce of information was can celled afte r int erviews h ad a l ready been conducted w ith seve n DCSD te achers a nd one adm ini s trat or. 64

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I expand ed the scope of the st ud y to include all of the educators who were trained to use CT during the 2001-2002 school year. An unforeseen benefit of this cha n ge in tudy design was that it enabled the coll ection of data from school distr i ct employees throughout Colorado whose di s trict had not made a prior commitment to broadly implement CT, like DCSD had made. By expanding the study to include a broader population of study s ubject s, data became avai l a ble from participant s where the adoption of CT was not as widespread as it appeared to be in DCSD. Making this change in the st u dy design addressed the crit i cism that diffusion re searc h had predominantly focu ed on s u cces s ful diffusion events, and th a t events where diffusion was unsuccessful had not been studied. A crossectional, self-admin i stered que s tionnaire that was mailed t o all J 4 7 CT trainees at the sc hool where the y were employed was selected as the method of choice, since it enabled efficient, low-cost contact with each of the CT trainees. Emai l addre ses were no t available for all potential participant s so that method of di tribution was di s mi ssed. The primary purposes of this survey were to: J) collect quantitative data that was more readily collected using s ur vey methods than interview methods; and 2) expand the pool of tudy subjects who would be inter viewed in the qualitative portion of the s tudy This urvey was not a part of the training seminar evaluation, but wa conducted as a separate, special study Survev Methods Re earch Design Three components of s ur vey des i g n were conside red when thi s research was undertaken. These compon ents were described as total su r vey design (Fow l er, J 993). 65

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They were a. samplin g, b. question design and c. su rvey administration. Backstrom and Hursh-Cesar's (1981 ) Charact e ristics of Sur vey R esea r c h were used as guide line s to h elp assure that the survey data wou ld be free of bias and reliable for decision making. These g uidin g characteristics define survey research a : 1. systematicfollows a set of orderly rules of operat ion ; 2. impa.I1ialselects units of the population witho ut prejudice; 3. representative-includes repre se ntative unit s of the population ; 4 theory-based-operations are guided by principles of human behavior and mathematical l aws: 5. quantitative-assigns numerical values to non-numerical characteristics to permit uniform interpretation; 6 se lf monitoring-procedures are designed to avoid unwanted biases ; 7. contemporary-it is curren t fact -finding ; and 8. replicable-other researcher s using the same methods can get essentially the sa me results. Survev Sampl e A census of the entire population of participants who atte nd ed CT training semina r s (n=l47) was determined to be a n efficient, comprehens ive and feasible sa mpling s tr a t egy that would provide a response that wou l d be representative of the entire st udy population. This approac h was possible s inc e each of the study participants had sig n ed con ent releases (a t th e training sess i on they a tt ended) to allow follow-up stud ie s by project re earc hers. It was also possible since the estimated cost of i ts admini s tration was within the budget that I a llowed for this data collection. Since I was st ill employed by the Principal In ves tigator of the CT re earch project, I was a ble to obtain training session attendance ro s t e rs with s ubject identifyin g a nd contact information for purposes of thi s research. The s ur vey sampl e 66

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included all of the sc h oo l dis trict and lo ca l health related personnel who atte nded o ne of the eight CT tr a inin g se min ars offered in December of 200 1 or J a nu ary of 2002. Questionnaire D esign D iffus i o n of Innovations th eory a nd PRECEDE model constru cts guided development of th e s ur ey ques t ionnaire. Question s were derived to answer theoretically sou n d inquiries th at would addre s the specific aims of th e study. (The s urve y questionnaire can be found in Appen dix A.) The procedures used to deve l op the mailed questionnaire were procedures that I have used in prev i ous s tudies. The e procedures are those generally recommended by Dillm an ( 1 976), the Total Design Method for urvey s (Aday (J 996) and Czar a nd Blair ( 1 996). A qu estionnaire was drafted to answer the principal re s earch questio n s using DOl and PRECEDE construct as g uid e s to conten t develop m e nt. The s t eps emplo yed were: I ) de t ermine th e kind of informa tion sought; 2) structu r e a question; and 3) c hoo e the words carefully. A ttitu des, belie fs behavior s and a ttribut es were the ge neral types of information soug ht ( Dillm an, 197 6). Field t es tin g of the questionnaire o n a subse t of the study population wo uld h ave biased their responses to the fina l questionnai re, so this method of pre-testing th e in strument was not used. The draft s u rvey instrument was reviewed for c l arity a n d contextual l a nguage by a sc h oo l admi ni strator (personal friend) w h o was not a potential participant in the s urv ey. Changes were made in accorda nce w ith feed b ack pr ovided by this third patty. The logic e mployed in determining the content a nd stru ct ur e of qu est ion s i s de scr ib ed in the following p aragrap h s Det a ilin g the str u cture a nd co nt en t of the 67

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questi o n s helped id e ntify the data pro cess ing requirements. To assure that s ur vey r es p nd e nt s were eligible for th e study the first question o n th e s urvey instrument asked respondents if th ey atte n ded one of the CT tr a inin g s eminars. (A mentioned above, all but o n e of 83 respondents answered affi rm ati vel y.) Since there were two p rincipal groups of se minars t rainees, teaching a nd non teachin g c hool d i strict staff, and the ability to imp lement the CT c urri cu lum in the c l ass room was limit ed to the te ac hin g group. a ques t io n was devel oped t o determine th e positio n h e ld by each participant (q u estio n #2). "The innovario n-decision pro cess is the process thr ough whic h a n ind i v idu a l (or decision-making unit ) pa ses ( 1 ) from firs t knowledge of a n innovation, (2) to forming a t attitude toward a n innovation ( persuasion), (3) to a decision to adop t or r eject. (4) to implem e ntation of a new id ea, a n d ( 5) to o f thi s decision" ( Ro gers, 1 995, p 161 ). T h erefore, determining how teachin g a nd non-teac hing staff fir s t heard abo u t CT (know ledge) i s a critic a l s tep in th e dissem ination research pro cess Figure 4.1, A Model of Stages in the Decision-makin g Pro cess de cri be s all of the s t e p s in thi s theoretical proc ess. This figure a n d the model it re p rese nt s drove development of th e s ur vey questionnaire. It a lso provided a guide t o the anal ysis of th e s u rvey a nd int erv iew data. Questio n 3 was developed to answer the question as t o how k nowl edge of th e inno va tion came abo ut. The discrete r e p o n se for thi s question were info rm e d by the seven interviews conducted with DCSD employees in the early stage of this investigation a nd with his knowledge of Consider Thi s promotion a l activity that occurred prior to the tr a ining semin a r s. The possib l e re spo n ses to question 3 acknowledged that adopters wou l d likel y hear about thi s inn ovation throu g h the 68

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promoti o n a l ac tivitie s (t he primar y so urce) of the change agent (CT proj ec t s taff) a nd seco n dary s ources ( their soc i a l ne tworks). Figure 4.1: A Model of Stages in the Decision Proc ess A Model of Stages in the Decision Process Prior Conditions P revio u s practices Felt need s/ problem s lnnovativeness Social system norms Communication Channels r---------r---------r---------r--------, I I I I Decision-Making Un i t Characteristics Socioeconomic characteristics Per sonality variables Communication behavior Perceived Innovation Characteristics Relative advantage Compat ib ility Comp l exi ty Trialability Observability I I I . t--+ Ado p tion )lo Continued adoption '_ Late r adopt i on ,, / '/ ,, / "' .._0_ "' 1scontmuance '---+ Reject ion )lo Continued rejection CT dissemination activ itie s included incentive s for sc h oo l per sonne l to a ttend tr aining sem inar s (e g., schoo l reimburse ment for s ub s titute t eac h e r s) Ques tion 4 "What f ac tor s influenced yo ur re g i s tration a nd atte nd a nce at thi s training se minar?" e n a bled me to ide nti fy specific factors that e n couraged p art i cipants to investigate CT as a c u rric ulum th ey mig ht adopt. It was developed to address the per s u as ion 69

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stage illu strated in Figure 4 .1. H ere once again, the DCSD int erviews conducted in th e early s t ages of this investigation he l ped inform the respon e choices that were offered. Each of th e re spo n se categories added wa as ociated with at lea t o n e of three of Rogers' rate of adoption characteristics for an innovation ( i .e., re l ative advan t age, trialability, compatibi lit y). For example 's ubstitute teacher expenses were reimbur se d," are ponse choice, wa categorized as a factor that made it easier for t eacher to try CT (tria lability). T a b l e 4.1 contains a n index of how each response was categori zed by DOI adoption character i stics. Tab l e 4.1: Factors that Influenced Registration and Attend nee at CT Training Seminars by Sel ect DOl Adoptio n Character i stics T rialability factors Compatibility factors Relative Advantage factors Substitute teacher expenses Our school needed a new or CT i s a student-were reimbursed supplemental tobacco education directed, tailored, Travel expense (mileage) curriculum interactive was reimbursed CT i s a student-directed, tailored, curriculum The training session was interactive curriculum Online instructional relatively close to my home Online instructional aspec of curriculum aspect of or school was appealing curriculum was Lunch was provided at the I was required to go by a supervisor or appealing seminar administrator CT is free for CT is free for schools to use CT is compatible with national education schools to use Continuing education credits standards were offered Continuing education credits were offered Since the training seminar was the first significa nt expo s ure to CT that the participants experienced a question (q u estion 5) assessing the perceived helpfulness of the seminar was asked. The p erceived qu a lit y or va lu e of the se min ar could h ave con tr ibu ted to t h e adopt ion o r rejectio n of CT. 70

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The next series of questions (questions 6 through I 0), asked of teachers exc lu sively, assesses their experience implementing CT in the classroom. ( o n teacher s skipped to question 11.) These question s enab l ed the collection of data o n freq u ency of classroom use, the schoo l year that it was used, sat isfaction with the CT program and if teachers did not use CT, reasons for non-use. In summary. these question s provide a measure of th extent to which CT was adopted by teachers The next t\ o question (quest ion II an d 12) assessed teaching and non-teaching particip a nt perception of their school district's and their own rate of adoption of new or innovative id eas I techno l ogy. Thi data was used t determine the relationship between these s e l frep orted adopter categories a nd their use of CT. Following the rate of adoption qu es tion s, all resp nd e nts were asked to indicate their comfort level with computer technology and whether or not th ey had had forma l trai nin g in the use of computers and /or use of the Internet (questions 1 3 and 14). Comfort with and training re l ated t o computer technolo gy are enabling factors that allow participant motivation s to be re a l ized. The clos ing qu es tion s were u sed to record respondent demographic descriptors (when they received their bachelor's degree, if they had an advanced degree and the type of degree. gender, age a n d race) and smoking behavior (use of cigarettes in the past 30 days). The fina l question of the survey asked th e respondent if he or s h e was "wi llin g to help the investigator wit h this research by being interviewed on the telephone." This question enab l ed the identification of re s pondents who wou ld become participants i n th e qualitative porti on of the study. 71

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Survey Admini stration The s urvey instrument was reviewed by the stat i st i cian at Abacus Statist i ca l Con su lt ants prior to being mailed, to ass ur e that the d a ta could be processed a n d ana l yzed with relative ease. Training seminar registrant address informati o n was extracted from CT projec t fil es, mailing l abe l s were printed, and letter s. including the survey instrument, were mailed to all 14 7 se minar attendees. A cover letter expla ining the purpose of the study and asking potentia l participants to compl ete the enclosed s urvey questionnaire was mailed in late February of 2003 t o a ll persons o n the CT training seminar attendee list. Two follo\v-up reminder postcards were mailed to nonresponde n ts at two-week intervals following the initial ma ilin g. All responses were recei ed by earl Apri l of 2003. Eighty -three of the semi nar a ttendees responded to the surv ey, for a 56 % response rate. One person ret urn ed the s u rvey and indicated that they had not attended any one of th e CT tr a ining sem inar and was therefore deemed ineligib l e for the study. Therefore, there were 82 el i gib l e re pon dents who were inc luded in the ana l ysis of the survey data. At this point in time, the completed s urvey questionnaires were forwarded to Abacus Stat istical Consultants for data entry into an Excel database. D ata Processing As questionnaires were returned they were logged-in and separated into two piles. One pile cont ained those que s tionnaires whose respondents d ec lined to b e int erv iewed and the other included those who agreed. Email message were se nt to tho se p articipa nt s who agree d to be interviewed to sc hedul e a date and time for 72

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a telephone interview. If there was n o reply to the emai l message, approximately two weeks from the logged-in date of the returned survey, phone calls were made to sc h edule the interviews. After the telephone interviews were sched u l ed, the s u rvey data were entered into an Excel data fil e by a data entry operator affiliated with Abac u and frequency di tribution s for each question and the data fil e returned to the investigator The receipt of this data ignaled the initiation of the ana l ysis activity. Analysi s Method s C o mpleted que s tionnaire s were reviewed for compl e tene s s and cla rity of responses befor e they were forwarded for data entry. Extraneous marks were r e moved from the completed que tionnaires and responses verified by range checks Frequency tab l es of questionnaire variab l es were provided by Abacus and cross tabu l ation produced after review of the preliminary tables. Confidence intervals or the Fi s her Exact Test was u ed to test statistical as ociati o n between variables. Adoption of CT wa l imited to the t eacher group, since thi i s the subgroup of study participants that has routine access to students and works regularly in the classroom, the intend e d implementation e n vironment for CT. It was important therefore to examine the adoption b e haviors of this group separate l y from the non-teachers. (It \vas assumed that non-teacher do not routinely plan l e sons or imp lement curri cula in the c l assroom, two requirements for successfu l use of CT.) Teacher responses were grouped according to their reported CT adopt i on behavior and DOl and PRECEDE factors assoc i ated with each gro up described. 73

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Statistical T es t s Chiquare te st of s i g nific a n ce were used in testing tables where the ex p ec t ed numb e r of ca es in each cell was 5 or grea ter. Since the re were relatively few r es pondent s to the s ur vey in thi s study (n = 82), the Fisher Exact test was u sed to t es t s i g nific a n ce for those tables where expected cell values were <5 F inding s Studv P a rticipant Characteri stics A total of 82 p e r on s r esponded to th e survey of CT tra inin g se min ar a ttend ees. Study p arti ipants who ide ntifi e d themselves as h aving po s ition s as adm i nistrator s ( n=4 ), informat ion technology s t aff ( n=4), counsel ors ( n=5), sc hool nu rses ( n=5 ), other n on-teac hin g po s ition s (n =4 ) in th e ir sc hool d i str ict and lo ca l public he a lth age ncy staff ( n=2) as of s pring of 2002 were categorized as n on-teac h ers in the a n a l yses. All others (n=5 8) were t eachers. Table 4.2 contains the freq u e n cy and percent ages for demographic an d smoking sta tu s descriptor s for the study participants. Seventy-five percent of th e res p ondents were fem a l e (one perso n did n o t respond t o the ge nder question). Se e nt y -one p erce nt of th e teacher p ar ticip a nt s a nd 87% of th e non-teacher p art icip a nt s were female. The average age of all of tudy participants was 42.1 years; the m edia n was 43 yea r s an d th e mode was 44 years The average ages for t eac h ers and non-teach ers were 41.6 years an d 44.1 years r es p ec tively. 74

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T a ble 4.2: Demograp hi c C h a r acterist i cs a n d Self-reported 30-day Smoking Status for Consid er This Survey Particip a nts, n=82 Gender Teachers Non-teachers Total Male 17 (29.3) 3 (13.0) 20 (24.7) Female 41 (70.7) 20 (87.0) 61 (75.3) Total 58 23 81 (100) Age (in years) Teachers Non-teachers Total 20-29 7 (12.3) 1 (5.0) 8 (9.8 ) 30-39 14 (24.6) 6 (30.0) 20 (24.4) 40-49 26 (45.6) 7 (35.0) 33 (40.2) 50-59 9 (15.8) 4 (20.0) 13 (15.9) 60-69 1 (1.7) 2 (10.0) 3 (3.7) Total 57 20 77 (100) Race I ethni city Teachers Non-teachers Total White 56 (96.6) 22 (100) 78 (97.5) Black 0 0 0 Asian I Pac. Islander 0 0 0 Am. Indian/Alaska Native 1 (2.2 ) 0 1 (1.2) Hispanic 1 (2.2) 0 1 (1.2) Total 58 22 80 (100) Days smoking in Teachers Non-teachers Total last 30 days Zero 55 (94. 8 ) 2 1 (95.4) 76 (92.7) 1 or 2 0 0 0 3 to 5 1 (1.7) 0 1 30 2 (3.5 ) 1 3 Total 58 22 80 (100) Ninety-eight percent ( n=7 8) we r e white one st udy participant each indicated that th ey were American Indi a n / Alaska n Native a nd His p a nic. On l y 7 p ercent ( n=4 ) ind i cated that they h ad smoked cigarettes in the past 30 days. The s mok ers were proportionate l y distributed amon g th e position categor ie s with three s m okers b eing teach ers. 75

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A greater proportion of the non-teachers had adva n ced degrees with near l y 70% of the non-t eacher having advanced degrees, compared to nearly half of t h e t eacher group. Overall, more than half of the respondents (43) had advanced degrees, with all but one of those being a Master's degree and that one was a Doctoral degree. As can be seen in Table 4.3, t he difference between the groups on training in comp ut ers and/or Internet use was not as great as it was for advanced degrees. Eighty-seven percent of the non-teachers compared to 78 % of the teachers had this training. Overall 80 % indicated th a t they had had training in computers and /or Internet u s e. See Table 4.3 above for the frequency and percent of advanced education and training. Tab l e 4.3: Advanced Educatio n and Computer Training for Consider This Survey Participant n=82 Advanced degree Teacher s Non-teachers Total Yes 28 15 43* (48.3) (68.2) (53.8) No 30 7 37 (51.7) (31.8) (46.2) Total 58 22 80 Training in computer T eacher s Non-teachers Total and/or Internet use Yes 45 20 65 (77. 6 ) (87.0) (80.2) No 13 3 16 (22.4) (13.0) (19. 8 ) Total 58 23 81 Include s 42 Mas ter s degrees a nd one PhD Table 4.4 shows that 44.4 % of the respondents classified the i r chool district in the early adopter category (among the first to try) a nd 40.3 % c l assified their district 76

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as in the earl y m aj o rity g r o up (aft e r a jew ot hers have tri e d). F ou r t e en perc e nt (14 .2%) i ndicat e d th a t t h e ir dis tri c t t ends t o a d o pt new id eas o r in novations afte r m os t oth e r s or l o n g a f t e r mos t ot h e r s tr y it. Ta ble 4.4: F re q ue n cy a nd ( R ow P erce nt ) of S c h oo l Di s t r i c t an d P a rti c ip a nt A d o pt e r Cl ass i fications and C o m fort Leve l w ith Computer T ec hn o l ogy When does your A m o n g first After a few After most Long district adopt t o try i t others try i t other s try it after most new/ innovative (earl y (early (late majority) others try it Total ideas? a dopter) majority) (laggards) T e achers 27 21 4 4 5 6 (48.2) (37.5 ) (7.1) ( 7.1) (100 0 ) Non-teache r s 5 8 2 1 16 (31.2) (50.0) (12.5 ) (6.2) (100.0 ) Total 32 2 9 6 5 72 (44.4) (40.3) ( 8 .3) (6.9) (100.0) When do you Amon g first After a few After most Long to try it others try i t after most adopt a new/ (early (early others try i t others try it Total innovative idea? adopter) majority) (late majority) (laggards) Teachers 20 3 2 5 0 57 (35.1) (56.1) (8.8 ) (100 0 ) Non-teachers 7 12 2 1 2 2 (31.8) (54.6) ( 9.1) ( 4 5 ) (100 0 ) Total 27 44 7 1 7 9 (34.2) (55.7) (8.9) ( 1 2 ) (100.0 ) Comfort level Very Somewhat with computer comfortable comfortable Somewhat Very Total technology? Teache r s 1 6 3 2 7 3 5 8 (27.6) (55.2) (12.0) ( 5 2 ) (100 0 ) Non-teachers 11 1 2 0 0 23 (47 8 ) (52. 2 ) (100 0 ) Tot a l 2 7 44 7 3 8 1 ( 3 3 .3) (54. 3 ) (8.7) (3.7) (100.0) 77

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Teachers ra t ed the average time for adoption of inno va tions by their sc hool di s trict as earlie r tha n non-t eachers. For t y-e i g ht percent of teachers a nd only 3 1 % of n o n-te ac h e r s rated their di str ict as a n e arly ado pter. Thi s finding may be influenced by th e inclusion of in for m atio n technology staff in the non-teacher gro up IT staff may see themselve s as earl y adopte r s and the organizati o n s th at they work for as l ater ado pter s, thus reflecting a l ike l y bias toward s adopt i on of technology inn ovations They were a lso lik e l y biased t oward adoption of innovat i on This d i fference see ms to dimin i s h somewhat when the early adop ter and e arly m a jority categories are combin ed. Eighty eight percent of the te ac her s a nd 8 19{of the n on-teachers indicat ed that their schoo l d i s t r i ct was e ither a n earl y adopter or earl y majorit y ado p ter. earl y o n e teacher in six ( 15.2
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The a doption of innovation c h arac t eris tic s for both sc ho o l distri c t a nd personal adopt i o n behavi ors a re skewed p os iti ve l y or t o th e right, w ith many mo re ea rly and early m a j ority adopters th a n norm ally expec t e d. If adopter behavior for sc hool distr i cts a nd schoo l personnel were normally d i s tribu ted it would be ex p ec t ed that approx im ate l y 5 0 % wo uld be in the early or earl y m ajority categori es. Neml y 90 % of the s tudy p articipants were e ither early or earl y majority ado pter s With grea ter than three quarter s of the p artici p an t se l f-class if ying in these categori es this s u gge t that selfr ep01ting of a dopter c l assificat i on is significant l y favorab l y bias ed A s R ogers s uggest s ( 1 995, p.269), this bia s m ay be the res ult of the hig h educational l eve l of the s tud y participant s T a ble 4.4 a l so includes data on pa11icipant comfort level wi th co m puter t ec hnol ogy (a n e nablin g fac t or). One-third of all respondents indicated that th ey were very comfort able w ith computer technology ), over ha l f were somewhat co mfo rtab l e ( 54. 3 %), and 12.4 % were ei ther somewhat uncomfortable or very uncomfortable. A s urp rising finding was th a t 17. 2 % of teachers indi cated th a t they were either so mewh a t or very uncomfort ab l e while none of the non-t eac h ers were uncom for t a ble w ith co mpu te r te chno l ogy. Frequency of T eac he r Use of Consid e r This The f requenc y of u e of the Consider This c urri c ulum in the classroom i the s tron ges t indi ca tor of i ts dissemination amon g s tudy p ar ticip an t s who were trained in 2001-2002. Among the entire s tud y group t eachers were the on l y s ub gro up that cou ld impl e m e nt CT in the c l assroom. The n o n-t eac her respondents (counse lor s, nurse s IT per s onnel, admin i st r a t ors, nonsc hool distr ict per so nnel ) do not routine l y 79

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have i nstructional responsibi l ities in the c l assroom. Of the 82 schoo l personne l who responded t o the urvey, 59 indic a ted that they were teachers a nd 57 of those responded t o the frequency of use question. Therefore the following a nal yses on use of CT are limited to the teacher subgroup. Of the teacher s who responded to the survey, 40.2% indicated that they never u sed CT after they were trained (Ne1er users); 21.0 % tried it briefly for one or a few class periods and did not use it again (Tria/users); 21.0% u edit for multiple class periods for one or two class g roups (Temporary users); and 17.5 % used it for thre e or more clas group (Adopters) Ta ble 4.5 below summarizes the freque nc y of teacher u se of CT in the c l assroom. T ab le 4.5: Frequency of Consider This Use by Adopter Group (n=57) Group Name F requency of C T classro oom u s e N (%) Never users Never use d it 23 (40.4) Trial users Tried i t for one class period and did not use it again 2 (3.5) Tried it for a few class periods and did not use it again 10 (17.5) Temporary users Used it for multiple class periods with one class group 8 (14.0) Used it for multiple class periods with two class groups 4 (7.0) Adopters Used it for three or more class groups 10 (17.5) Total 57 (100) Grouping teachers by reported freq uency of CT u sage in T ab l e 4.5 disclosed that 40 % never u sed CT and therefore cou l d be classified as never users. This group fai l ed to move past the decision stage to the implemen tation stage. (See Figure 4. 1 .) The remaining sixty-percent of teacher s (34/57 or 60 %) those who adopted CT for one or more c l asses, moved to the implementation s tage. Thi s gro up inc luded the tr i a l 80

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and temporary u sers and the adopters. Among this gro up the temporary users and adopters (12 + 10 I 57 or 48.6% ), was the group that moved to the impl emen tation stage. Those who used CT for three or more class groups (10/57 or 1 8 %), the adopters. are tho se teacher s who implemented CT and took action to maintain or confi r m it s u se. on of the teacher groups were immune from discontinued u e or later adoption. So it is important to recognize that thi s cross sectio nal review of CT u se does not impl y that eighteen p ercen t of the te ac her s who responded to the survey surveyed (the adoption group) continued to use CT afte r this survey was conducted or tha t they were even using it at the time of the survey A s Figure 4.1 in this chapter illu strates discontinuance by those who had adopted CT (later adopt ion ) can occur after the implementation and confirmation stages, thus changing the size of the adoption group. Later adoption by those who had rejected CT i s also possible. These adoption dynamics influence crosssec tional analyses of a doption rates. Dissemination The dissemination stage, the second stage (following innovation development) in the diffu s ion proces s model was the first stage to be assessed in this s ur vey. For purposes of thi s study, those person s who were eligible to be classified in this stage were all of the particip a nt s who attended one of the CT training seminars. Those who returned a s ur vey, a subset of thi group, were tho e who were classified as having reached this dissemination stage for the analys is. How teachers initi ally heard about CT a nd the offering of CT training se min ars (first knowl edge of CT) may be an important determinant of the most effective means fo r promoting or disseminating CT. Survey respondents checked all of the m ethods by which they had heard a bout 81

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the CT curric ulum and spec ified th e me a n s by w hi c h they he ard abou t CT tha t w e re not lis t ed by describin g them on the 'other' c a tegory response line. The mean s by wh i ch te ac her s heard abo ut CT were gro uped for this a n a l y s is into the following three gro ups. See T able 4 .6 for thi s data. Pro mo t ion a l ac tions-br ochure or p os t e r received in the mail or CT proj ec t s t aff co nt acte d th e m directly. Inschoo l n etwork (i.e., word of mouth ) princ i pal told m e: another teacher in m y s chool t o l d me; a d i st rict a dminis t rato r t o l d m e; sc h oo l nur se told m e; he a rd a t a h ealt h curricu lum me e tin g; and previous p erso n in my position t o l d me Out-ofsc h ool network (wri t e-in responses)-a teacher in a n o ther sc hool; health educ a tion con s ultin g orga niz atio n ; and local tobacco contro l coa lition Did the mean s by whic h teachers heard abo ut th e CT c u rr iculum influence u s e in the c l ass room? Since CT h a d not previo u s l y b ee n promoted in Colorado sc hool s prior to th e CDPHE-f unded disse minati o n proj ect, the brochur e and pos ter packet mailing t o Colorado middl e, junior a nd se nior h igh sc ho ols was lik e l y the only w ay tha t sc ho o l per so nnel could h av e heard a bout CT. In Table 4.6. columns 1 2 a nd 3 represent th e insc hool responses to the que s tion "How did yo u fir s t hear a b o ut CT?" (Par tic i p a nt s were permitted to c h eck all re s pon ses that applied.) Column 3 i s the t ota l of column s 2 and 3, and co l umn 5 i s the tot a l of column s 4 a nd 2 Over all g roups of a doption type s the data in T a ble 4.6 s u gges t that the in sc hool n etwork I i nformation channel was th e mos t import ant chan nel b y whic h teacher s initially he ard abo ut CT and the CT training se min ars. Over half of the 82

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survey respo n den t s (56. 1% ) heard about CT throu g h in-school network channels alone or in combination with other sources. (See Tab l e 4.6, columns 1 and 2 tota l ed.) One-third (33.3%) h eard abo ut CT through p romotiona l actions a lone. Table 4.6: Frequency and (Percentages) of Classroom Use by How Teachers H ea rd Abo ut Consider This (n = 57) (1) (2) (3) (4) (5) Frequency In-school In-school Promotion Out-school network & Unknown Total (Column%) network promotion actions network (Row%) only only only source actions Never tried 9 2 9 1 2 (66.7) 23 (33.3) (40.0) (47.4) (33.3) (40.4) (39.1) (8.7) (39.1) (4.3) (8.7) (100.0) Tried briefiy 8 2 1 1 (33.3) 12 (29.6) 0 (10.5) (33.3) (21.0) (66.7) (16.6) (8.3) (8.3) (100.0) Tried multiple 6 5 1 12 periods for 1-2 (22.2) 0 (26.3) (33.3) 0 (21.0) groups (50.0) (41.7) (8.3) (100.0) Used 3 or more 4 3 3 10 (14.8) (60.0) (15.7) 0 0 (17.6) classes (40.0) (30.0) (30.0) (100.0) Total 27 5 19 3 3 57 (100.0) (100. 0 ) (100.0) (100.0) (100.0) (100) (47.4) (8.8) (33.3) (5.3) (5.3) Outof-schoo l communication networks were largel y ineffective in disseminating information abo ut CT, wit h on l y 5.3 % indicatin g that as th e source through which they he ard abo ut CT. On face value, it could be co nclud ed that the most im porta nt method for communicating w i th teachers about CT was the in-schoo l network. However, that conclusion does not take into account the time dimens i o n or se quence of even t s t h at led to t eacher knowledge of CT. The promotiona l m ate rial s 83

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and other d isse min a tion ac tions (p hone calls b y CT p roject s t aff) tha t were empl o ye d created k nowl e d ge of CT a nd activated insc hool communic at i o n networ ks thereby initiatin g the di ff usion process. Ch a nnel s of communication o ut s id e of the insc ho o l network (column 4, T able 4.6) were the l east import a nt channels of communicati on, with on l y 5 perc en t of the teachers reportin g th at they heard about C T from outs ide sources Only 8.8 % of the teachers indi cated t hat t h ey both Sc w the promotional material s a n d h e ard abo ut CT thr o u g h the inchool network. The numbers in eac h cell of Table 4. 6 are too s mal l t o reliably draw stat i s tical conclusions a b o ut the relation s hip between ho w teacher h eard a bout CT and the ir decis i o n to do pt but they s u ggest th a t the inschoo l netw o rk is as imp o rt ant a mean s for inform atio n dissemination about CT as the promotion a l materia l s Did prom otiona l actions or in-school communicatio n c h a nn e l s have a greater influen ce o n event u a l a d op tion of thi s curric u l um ? Ado p tion, imp l e ment ation a nd mainten a n ce of a n i nnova tion were the des ir ed ou tcome s of the diffusion pro cess, s o it was import a n t to te s t t he influence of these two dissemination methods o n those outcomes. Becau se of small numbe rs, the Chi-Square statis tic cou l d not b e u sed to t es t differ ences in u sage of CT between th e teachers rep re se n ted in column s I and 4 of Tab l e 4.6. In s t ead, confide nce interval s were computed arou nd the p roportio n s i n co lumn s 1 a nd 4 which are indep e nd e nt groups. The confidence intervals were ve ry wide and overlapped, s upportin g th at ther e is no d iffe re nc e. (See T a ble 4.7 .) 84

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Table 4.7: Frequency of Cl ass room Use by Single Source of How Teacher s H eard About Con si d e r This Percent of all teachers In-school network only Promotion action s only # %* 95 % Confidence # %* 95% c onfidence Interval lnt erval Never tried 9 33. 3 ( 1 7 .254. 0 ) 9 47.4 (25.2 -70.5) Tried briefly 8 29. 6 (14.5 -50.3) 2 10.5 (1. 8 -34.5) Tried multip l e class periods for 1-2 6 22. 2 (9.4-42.7) 5 2 6.3 (1 0 1 -51.4) groups Used 3 or more 4 14. 8 (4.9-34. 6) 3 15.7 (4.2 40 .5) classes Total 27 100.0 19 100 0 DOl-Rel ated Findings by Con s truct The DOl t heory p o s tulate s that the re are i nnov at i on fac tor s or charact e ristics that influ ence the diffusion process. Th ose factors are: trial a bil ity, compatibility, compl exity, re l at ive advantaee. a nd observability. The re s ult s of u s ing CT. in thi s case wer e related to student t o b acco u se outcomes, which were n o t readil y v i s ible to teachers Observability i t he r efore obsc ur ed just by the n a tur e of the te acher-s tudent r e l a tion s hip and a t eacher's pro x imity to observe student smok in g beh av ior and ini t i a tion of smoking. Therefore obse rvabiliry as a diffusion factor was excluded from thi s a n a l ys is. Compl ex it y was a lso excl uded s ince it could no t be determined for questionn a ire development how t eachers wou l d define CT complexity in their ow n term s ( Complexity i s d i sc u ss ed in Chapter 5 of thi s study as it i s described 85

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by teachers.) Table 4.8 describes the remaining CT ado pti on charac t eristics tha t influence the rate of adoption u sing DOl construct Table 4.8: Freq u ency of Classroom Use by Adoption C h aracteristic that Influenced Attendance a t CT Training Seminars Among Survey Participant (n =5 7) (1) (2) (3) (4) (5) (6) Relative Compatibil ity / Tria lability/ Trialability/ Trialability Compati bility Relative Relative Advantage Advantage Advantage Compatibility Never users 22 (41.4) 13(35.1) 14 (36 .8) 10 (38.5) 13(39.4) 7 (35.0) Trial users 11 (20 8) 8 (21.6) 11 (28 .9) 5 (19.2) 8 (24. 2 ) 8 (40.0) Temporary 11 (20.8) 8 (21 .6) 8 (21.0) 7 (26.9 ) 7 (21.2) 2 (10 .0) U s e r s Adopters 9(17.0) 8 (21.6) 5 (13.2) 4(15.4) 5 (15.2) 3 (15.0) Total 53 (93.0) 37 (64.9) 38 ( 66 7 ) 26 (45.6) 33 (57.9) 20 (35.1) Teachers were asked t o select possible factors that may have influenced their regi s tration and attendance at one of the CT training seminars from a list of predetermined choices (q ue stio n4 of s urvey instrumen t). The incent ives that were offered by CT project s taff t o schoo l s for teacher s to attend the training seminar ( i .e try CT) were factors that created a framework for tria/ability. Those incentives as described in the survey ins trum e nt (and in Table 4. 1 ) were: th e uaining semi n ar was f r ee; sub titute t eacher ex p e n ses were r ei mbur sed; trave l expenses were reimbursed; training sess i on was close to home or school; lun c h was provided; CT free for sc ho o l s to use; a nd continuing e du catio n unit s were offered. 86

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Compatibility factors (factors that are compatible with the values and needs of teachers) included: our schoo l ne eded a new or s upplemental tobacco education cutTiculum; CT is a s tudent-dire cted, tailored, interactive cutTi ulum ; the on line ins truction a l aspect of the curriculum was a ppe a lin g; I was required to go by my s upervi sor; CT i s compatible with nationa l education standards; and continuing education credits were offered. Two factors that influe nced deci ions to attend the training se min ars (relat i ve advantaae factors) were: online instructiona l a pect of curriculum was appealing and CT is a st ud en t-directed tail ored, interact i ve cuniculum. (Other relative advantage fac tor s were later disclo ed through the interviews conducted in the qualitative portion of this study.) Factors listed on the questionnaire that were rel ated to combinations of adoption characteristics were: CT is a st udent-di rected, tailored, interacti ve curriculum (compaTib i li t y and relarive advantage): CT is free for schoo l s to u se (trialabiliry and relative admntage); and continuin g ed ucati on c redits were offered (compatibility and trialabili(\'). T ab l e 4.8 contains the distribution of the se adopt ion characteristics by te ac her frequency of CT classroom u se by teachers. This table answers the research question: "To what extent did the DOl factors that influenced training sem inar attendance and regi s tr at ion influence classroom u se of CTT In th e theoretical context this question enabled the determination of the relative importance of the DOl adoption characteristics on c l assroom use of CT, the decisive measure of diffusion. Based on the weight of respon ses, the tri a l abi lit y factors had the greatest influence on teacher registration and attendance at a training seminar. Ninety-two 87

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percent of the teachers selected these factors as motivating their attendance and registration. In other words, those factors that made it easy for teachers to attend a seminar (e.g., the seminar was free) had the greatest influence on their decision to attend. Factors that were associated with relative advantage (e.g., online instructional aspec t ) and compatibility (e.g., CT i s student-directed) followed respectively with 66.7% and 64.9 % of the re sp ondents se l cting t hose factors. (See total cells in columns I, 2 and 3 of Table 4.8.) Characte ristics of Participants Who Agreed to be Interviewed While this finding i s related to the qualitati ve portion of the study, it is reported here s i nce it was a finding from the survey The l as t question on the survey was, "Are you willing to help further w ith thi s research by being interviewed on the telephone for 15 to 20 minutes?'' Twenty-seven (33 o) of the 82 s ur vey re s pondents checked ''Yes." Seven of these participants wer e Douglas County School District employ ees who had been intervi ewed previously. Therefore, conducting the survey of all per so ns who attended one of the CT training seminars not only provided information from a broader group of teachers who were trained to use CT, but it expanded the pool of cand i dates elig i ble to be interviewed beyond the DCSD empl oyees by 20 persons. Survey records for those persons who agreed to be interviewed were analyzed to better understand the characteristics of this subgroup compared to those who had not agreed to be interviewed. T ab l e 4.9 describes the result of the most significant findings in that comparison. 88

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Those w ho agreed to be interviewed were more lik ely to be early adopters (p<.05), to have received their und ergradua t e degree in 1990 or after (p<.02) and be trial users or adopters of CT (p<.04 ). Interviewees also tended to think that the training session was very helpful vs. helpful (p<.02). Table 4.9: Frequency and ( Percent) o f Intervi ewe d and Non-Interviewed Participants by Char ac teri st ics Variable Category Interviewed Not Total Fisher inte rviewed Exact Early adopter 13 14 27 (54.2) (25.5) (34.2) Early majority 9 35 44 Adopter (37 5) (63 6 ) (55. 7) character i stic 2 6 8 p<0 05 Late majority (8.3) (10.9) (1 0.1) Total 24 55 79 (100.0) (100 0) (100 0) Befor e 1990 10 41 51 (43.5) (74.6) (65.4) Year Graduated 1990 or after 13 14 27 p<0.02 ( 56.5) (25.4) (34.5) Total 23 55 78 (100.0) ( 1 00.0) (100 0) Never I Temp. 6 29 35 User (37 5 ) (70.7) (61 .4) Frequency CT Trial User I 10 12 22 p<0.04 classroom use Adopter (62 5) (29 3) (38.6) Total 16 41 57 (100.0) (1 00 0) (100.0) Yes 12 15 27 (50 0) (25 9) (32.9) Close to home No 12 43 55 p<0 05 (50.0) (74.1) (67 .1) Total 24 58 82 (100 0) (100.0) (100.0) 89

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Table 4.9 (Continued ) Variable Category lnte rviewed Not Total F i sher interviewed Exact Yes 9 11 20 Used 2002( 81.8) (44.0) (55.6) 2003 School No 2 14 16 p
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Factors Associated with Teacher Adoptio n of Conside r This Due to the relatively small numbers of respondents to the survey, the freq uen cy of CT use categories were collapsed from those described in Table 4.4 above. Never users and trial users were collapsed into one group and temporary users and adopters in a nother for thi s ection of the a naly s i s The Fisher Exact Tes t was u sed s ince th e expected number of cases in a cell was, for some tables les s than 5. Teacher frequency of CT use data were compared to the following DOl-related constructs and demographic variables: how they heard about CT (p=NS); factors that influenced registration for a training seminar (p=NS); personal and schoo l district adoption characteristics (e .g., early adopter, late majori ty, etc) (p =NS) ; comfort level with computer technology (p=NS); formal training in use of computers or Internet ( p= S); year undergraduate degree was received (p =NS); advanced degree (p = S); gender (p=NS); and age (p=NS). None of these variables was statistically associated with adoption of CT. Not finding s ignificant association between DOl constructs and adopt i on practices of teach rs signified the importance of the qualitative portion of thi study. Discussion Rogers noted that pro -innomtion bias is .. the implication in diffu sio n research that an innovation shou ld be diffused and adopted by all members of a s oci a l sys tem, that it should be diffused more rapidly .. ( 1995 p. I 00). Rogers a l so ob se rves that, "The early adopter i s r espected by his or her peers, and is the embodiment of s ucc essfu l discrete use of new ideas" (1995 p. 264). These character i stics of the early adopter a re highly desirable and therefore very likely bias participant 91

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perception of their own behavior and the practices of their school district in the earl y adopter direction. Thi s natural t endency of i dentify in g oneself w ith earl y adoptio n be h avior, in combination wit h th e high educational level of all of the teachers probably accou nt ed for much of the positi ve skewing Thi s pro-innovation bias and there ultant l ack of adequa t e discrimination in the theor e tical classificat ion of participants m ay a l so have contributed t o the l ack of significant findings relating frequency of CT us e and DOl diffus i on constructs. 92

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CHAPTER 5 INTERVIEWS WITH CONSIDER THIS TRAINING SEMINAR ATTENDEES (QUALITATIVE STUDY) Introduction Semi-structured interviews with twent y fou r study participants who ag re ed to help with thi s tudy. Th e information the y pr ov ided through the interviews enrich ed the data colle cted with the survey. Thi s was particularly important since the quantitative find i ngs were in con c l usive regarding identification of factors that were associated with adoption of CT and beca u se the breadth of experiences of teachers and administ ra t o r s with u se of CT could n o t be captured alone using s ur vey methods. The int erviews a nd a clas sroom observation prov ided a rich so ur ce of t ext data and va luabl e e x periential data from v hich an en h a nced u n de rs tanding of the factors that influenced dissemination and adoption of CT wa o bt a ined. Background Context of Wave I Face-to-Face Interviews -DCSD Int erv iew s with DCSD participants were conducted face-to-face in the work pl ace (office or sc hool ) sett ing I arrived at inter v iew sites approximately J 5-20 minutes early to observe activity in each middle schoo l and schoo l administrative office. While thi s observational time in the school buildings was very brief it helped provide a context for understanding responses to interview questions. 93

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Most of the middle s chool buildings in DCSD were built in the past t e n t o fifteen years. They were all bright, spacious environments. All of the buildings visited had signs on their front doors stating, "Welcome to Our Tobacco-free School! .. These signs were indicative of the schoo l district 's effor t to compl y with a state law (CRS-25-1-1 01) and a schoo l district policy th a t requires th a t schoo l campuses be tobacco-free. With school security being very high in a post-Columbine and post9 11 environment, other door signs directed all visitors to "Check-in'' at the schoo l office. There were however, no obvio u s s ign s of i nc reased security. Con sider ing that the I had not visited these buildings prior to the intervi ews and was therefore an unfamiliar face, the school receptionists o r office secretaries were cordia l and helpful. They called the teachers who were appoin t ed to meet with m e after the clas s period that was in progress wa s over. I was escorted to the classroom where th e teacher was l ocated or t he te acher came to the office to meet the in vestigator. When clas s periods changed, the h alls were alive with adolescent energy and banter. Students caJTyi ng ba kpacks t a lked with and jost l ed one a no t her and talked comfortab l y wit h teacher in hallways. Parents visited school offices to take the ir chi ld t o doctors' appointments and other personal business. Office secretar i es provided assistance to students. teachers and visitors alike. Mi d dle schools in Douglas County are bustling environments w ith periods of relative quiet whi l e classes are in session and a river of ado l escent hallway activity between cia ses. Four of the eight DCSD int erviews were cond u c t ed during the school day, between study participant c l asses. The remaining fo ur int erviews were conducted respectively, two after schoo l h o u rs in an e mpt y c l assroo m one in a turn of the ce ntur y schoo l building con ve11ed for ad mini s tr a ti ve offices and in the home of one of the he a lth t eachers. 94

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Context of Wave II Telephone Interview s with Non-DCSD Participants Wave II interviews were conducted on the telephone since it was not practical to do face-to-face interviews with teachers who resided or worked in lo cations throughout the state of Colorado. Additionally, the timing of these interview s coincided with the summer reces s for Colorado choo l s For these rea so n s, it was necessary to conduct th e over the ph o ne. All but one of these interviews was conducted while the parti c ipant was in his or her home. That interview was conducted while the participant was working at a summer job. S a mple Six of the 24 participants (25 %) interviewed were males and 9 (including 8 teachers ) were employees of DCSD. Aside from the 9 DCSD part icipants who represented s uburban Denver, int erview subjects were from various regions of the state including the nmtheas t and east-central plains of Colorado ( Logan Morgan Weld, and Lincoln count i es), the mountain region including Fremont, Park, Routt, Hinsdale and Delta counties In one of the smaller rura l school districts the participant was also the schoo l district nurse. In another, the health teacher was also the special education teacher. Based on the survey data, 5 (31.25 % ) of the interview participants were n ever users; I (6.25 % ) was a trial user; 4 (25 % ) were temporary users and 6 (37.5 % ) were adopters. Sixtee n (66.7 % ) were females; 9 (37.5 % ) were l ess than 35 year s old, 8 (33.3%) between 35 and 40, and 7 (29.2 % ) were 45 years old or older; 2 (8.3 % ) were smokers; 1 participant was non-white ; 10 (4 1.7 % ) had advanced degrees; 13 (56.5% ) grad u ated from college in 1990 of after; 18 (75.0 % ) had some training in IT or u se 95

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Table 5.1: Demographic Characteristics S e lf-rep orted Smoking St a tus, Education, IT Training, Fr eq uency of CT Use, Com fort with Computers and Schoo l District and Perso nal Adoption Characteri sts of Inter v iew Participants ( n = 24) Variable Category N (%) Male 8 ( 33.3 ) Gender Female 16 (66. 7) <35 9 (3 7 5) Age 35-44 8 (33. 3) 45+ 7 (29.2) White 23 (95. 8) Race I ethnic i t y Non-white 1 (4. 2) Non-smoker 22 (91. 7) Smoking status Smo ker 2 (8.3) Before 1990 10 (43.5) Year of under-grad degree 1990 or after 13 ( 56.5) Yes 14 ( 58.3) Advanced degree No 10 (41.7) Yes 18 ( 75 0) Training on IT or Internet use No 6 ( 25 0) Never 5 ( 31.3) Trial 1 ( 6 2) Frequency of CT classroom use Temporary 4 (25.0) Adopter 6 (37 5) Very comfort 10(41.7) Somewhat comfort abl e 13 ( 54.2) Comfort with computer technology Som e what unc om fortable 1 (4. 2) Very uncomfortable 0 Early adopter 13 (59.1) School district characteristic Early majority 5 ( 22 7) Late majority 6 (13.6) Laggard 1 (4. 6) Early adopter 13 (54.2) Personal characteristic Early majority 9 (37.5) Late majori t y 1 ( 4 2) Laggard 1 (4.2) 96

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of the Internet: all but o ne was either very comfortable or comfortable with computer technolo gy; 18 (81. 8 %) identified their school distric t as either early or early majority adopters, and; 22 (91. 7 %) c l assified them se lve s as either early or early m ajor it y adopters. (See Table 5.1 for this de criptive data.) Although it was a s urvey finding mentioned in Chapter 4, those who agreed to be interviewed were more likely to be earl y adopters (p<.05), to have received their undergraduate degree in 1990 or aft r ( p<.02) and be trial users or adopters of CT (p<.04). Intervi ewees also tended to t hink that the training session was very helpful vs. h e lpful (p<.02). Methods This s tudy u sed a naturalistic inquiry design (Creswell, 1998 ) with interview s that were g uided by an interv iew guide developed to gather information on the experiences and perspectives of the participants. The interview guide questions encouraged particip ants to t ell s torie s about th eir p erspectives and experiences regarding dissemination and u se of CT, so I could capture real worl d s itu ations without the predetermined constraints or biases that are nearly unavoidable wit h using survey methods. Inter v iew s in Wave I were cond uct ed f ac e-to-face in schoo l se ttin gs in the Spring of 2002, while sc hool was in sessio n Interview s in Wave II were conduc t ed on the telephone during the summer of 2002 when it was neces sary to interview particip a nt s in their homes.

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Interview Guide Development To help assure that topi cs relevant to thi s investigation were addressed by study participants during the interviews, a semi-structured interview guide was developed that a llo wed study participants to freely describe their experience w ith CT within the cont ext of focused, open-ended questions that were theoretically based. The semi structured int ervi w format. the investigator 's introductory remarks, a nd consent process helped ass u re that participants would respond t o my questions in an open and detailed mann er. The particip a nts' familiarity w ith the CT product and their previous contact with staff of t he CT project also contributed to the ease w ith which the interviews were arranged and conducted. All of the s tud y participants immediately acknowledged their familiarity with CT when contacted to schedu l e a n interview. The questio n s inc luded in the Wave I and II interview guides were st ructured to take advantage of three method s of q u es t ioning: d e pth interviewing t o intensively plumb a particular t opic; o ral h iswries t o ge t in touch with per so nal experience of some even t : and critical incidenrs t ec hnique to allow se mis tru c tur ed exploration of defining moments (Crabtree and Miller, 1999). Depth inte rview ing was the predominant approach to the int erview wit h participant oral histories bein g freely re l ated to the investi ga tor. Pre-determined probes were inclu ded on the interview instrument to cue me about follow-up questions, should the participant p rovide a limited response. One open-en ded question (Quest ion 5 on Interview GuideAppendix B ) was designed specifically to e licit both po s iti ve and n ega tiv e crit i ca l incidents from st udy pat1 icipants. 98

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Interview Process and Disposition of the Interviews After obtaining signed informed consent from each participant to be interviewed and approval to record the interview (See Appendix C.), for both the face-to-face and the telephone interviews, a tape recording was made using a Sony Microcassette-Corder, M-560V. One tape was used for each interview. Completed interview recordings were secured in a locked file cabinet in the investigator's home There were two wa v es of interviews. Wave I of the interviews was conducted face-to-face with 9 employees of the DCSD. Wave II was conducted after the survey portion of this investigation ( Chapter 4) was completed with 15 non-DCSD employees who attended a CT training seminar. The Wave II interview guide was abbreviated, eliminating the Wave I quantitative questions that were included in the survey. (See Appendices C and D for the DCSD interview guide [Wave I] and the revised guide [Wave II] respectively.) A purposeful sampling strategy that included 1 47 Colorado educators who were trained to use CT, had returned surveys, and who agreed to be interviewed was used to select participants for interviews. All 1 3 of the DCSD employees who were trained to use CT consented to help with this study at the time of the CT training seminar. However, only 9 of the 13 potential participants (69 % ) agreed to schedu l e a time to meet for a face-to-face interview with the investigator. With one exception, the interviews were conducted at the schoo l or administration building where each DCSD employee worked. In that case, I met this teacher at his home, because it was more convenient for the participant. Th i s wave (Wave I ) of interviews produced 8 interv i ews with 9 DCSD employees (one paired interview) between March 10 and Apri l 1 7, 2003. 99

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Wave II intervi e ws ( n=15) with non-DCSD sc hool di s tri c t staff from arou nd the state, were scheduled and conducted over th e telephone a fter the close of the 20022003 sc hool year, be g inning July 3 and finishing Augu t 17, 2003. This wave of interviews was conducted during the summer month s with calls to st ud y participants at their hom es. Home phone number and email addresses were provided t o me on the return ed survey forms. At lea t 2 contacts ( t e l e ph o ne or emai l ) were made wi h each pa11icipant. Durin g the first contact, the int erview date a nd time was sc hedule d. Th e seco n d contact was a tel phon e call a nd the i n terview itse lf. The co nte x t for the Wave II t e l e ph o n e interview s wa hig hl y variable a nd the influen ce that variabi lit y m ay h ave had on p artic ip a nt oral histories was unknown W ave II int erv i e w di ffered fro m Wave I in the following ways. The t e leph o n e inter v iews we r e all conducted durin g the summer month s of 2003 whereas the face-to-face DCSD interviews were conducted th a t prin g whi l e s hoo l was still in session. One par ticipant was interviewed on the t e l ep hone in his h me, just a week a fter th e death of a close family memb er. In f act, the initially sched uled interview had to be re-chedul ed due t o th i s family l oss Another participant was interviewed in an office while working a summer job, where s he tended the telephone for a seaso nal family bu siness S h e wa a l so b a b ys itting h e r grand daughter while te ndin g the office phone and b e ing int erviewed. A third participant was a s ingl e person who h a d jus t awakened in the l a te morning after a l ate night of partying. Each of these exampl es suggest that these contexts of Wave II interview s differed from the class room or administrative offices where Wave I interviews were co nduct ed. It appears that the particip a nt s who were interviewed on the telephone during the summer month s of 2003 were gener ally more rel axed and a t -ease in their 100

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responses to the investigator's inquiries. B ased on their tone of vo i ce, they seem e d to have a more philosophica l perspec tive or l a issez faire a ttitud e a bou t th eir recent CT teachin g experi e nces than i f they were s till facing the day-to-day a c tivit ies of their j ob. The promptness of the parti c ipant responses suggested th a t t h not have diffic ulty recalling CT-re lated events. Hence, there were e participa nts did no discernabl e di s tinction s in the responses to the i nves tigator's questi o n s th a t cou l d be a ttributed to the tim e l ag between th e faceto-face inten iew s in the s p ri n g a n d t h e telephone interviews during th e su mmer. Table 5.2 displays the di s p os iti o n of th e interv iews from thi s purposeful sa mple Twent y -on e teachers, J school d i stric t ad mini s trat o r l sch ool nurse, a nd J local public health age nc y tobacco contr o l employee were intervi ewed for a total of 2 4 completed interv ie ws. T able 5.2: Di sposition of Study Participant s (n=l47) Participants and Interviews n Total school personne l trained to use CT and surveyed 147 n of participan ts who responded to survey 82 n of participants who agreed t o be interviewed 27 n of partic ipan ts lost to follow-up 3 n of Wave I interviews (DCSD participants) 9 n of Wave II i nterviews ( non-DCSD participants) 15 Total n of interviews (included 1 paired interview) 24 101

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Limitation s of Telephone Int erv i ews The telephone interview p rocess was a c o n ve nient and practical method for completing th e qu a lit a tive portion of thi s inve s tigation Howeve r it precluded observation of the sc hool environments where participa nt s worked. Not bein g able to gather observational field d ata that m ay h ave been va lu able t o the under s tanding e n v ir onmental influences on doption of CT was the s inglegreates t limi tation of the t e l e phone int erv i ews. For exampl e, n ot bein g ab l e to observe the technical capac it y of the middl e schools (e.g computer l abo r ator i es, age of comput ers, attractiveness of work enviro nm ents) where participants t a u gh t meant th at the investigation h ad to r e l y exclu iv ely on part i cipant reported data. It a l so pre cl u ded se rendipit o us e ncount ers wi th o the r sc hool staff per so ns who m ay have b een ab le to identify f ac tor s th at i nfluenced a dopti on of CT. One suc h encounter occ urr ed s ub se quent t o a n inter view w ith o n e of th e DCSD teacher p a rticipants Whi l e gett i ng a p a r t icip a nt-led t o ur o f the school where an inter v iew took pl ace, the tour wa interrupted by a chance h allway e n counter w ith the sc hool IT s taff pe rso n During thi s e ncounter a b arr ier t o u se of CT identified during the int erv iew w ith the t eac her participan t in tha t sc hool was di sc u ssed w ith the IT person and as a resu lt. more fully disclosed Th e teacher t o ld m e how s h e was unable t o download the plu g-i ns req ui red to opera te CT. Sh e re ported th a t s he tri ed for t wo hours to downl oad the plug-in s witho ut s ucce ss A s s u s pect ed b y the invest igator during thi s h allway con versat i on, the IT staff person mentioned that th e district h a d a firewall in place that restricts teachers and other s taff from down l oading fil es from the Internet th a t are not authorized a nd th a t IT staff assistance was ne eded t o download plug-ins. 102

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This chance encounter was particularly compellin g since it revealed three impmtant potential barriers to adoptio n I) limited teacher knowledge of the administrative barriers to computer network operations: 2) inflated teacher self-perceptions of their ability to work effectively within school computing environments; a nd 3) a possible communication gap between teachers and information technology staff as evidenced by this participant's unwillingness or eeming reluctance to reque t technical support for computer related problems. (These are di in the Social System Dynamics sect i on below.) It was not po sib l e to gather fiel d data when int erv iewing study participants on the te l ephone. on-verbal cues and m ssage other than those that were auditory were not possible to observe. Data Transcription. Coding. and Analvsis The recorded tapes of participant interviews were transcribed toMS-Word documents by a profe ional office support service. Printed copies of the transcripts were reviewed and edited by the investigator. When the transcribed t ext was not c lear (e.g., obvious wrong word or blank space), I corrected the te x t and in some instances listened to the tape to c l arify and repair the text in the transcribed interview document. The interview documents were then imported into ATLAS/ti ,. a software package for processing large bodies of textual. graphica l and audio data (At l as-ti, 2004). Each intervie w transcript was read thorou gh l y and pre-determined and emerg in g codes were assigned to phrases a nd t ext passages that described the perspectives and experiences of participants u sing the Atlas program. Emerging 103

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codes were added as the tex t was read after a few transcr i pts had b een read. T h e text was coded us i ng the ATLAS /ti drag a n d drop met h od of code assignment. At l as memos were created for text passages to r e-describe or assign a new meaning or observation tha t was made during the codi n g process. These memos facilitated t he analys i s of the text data once the analysis o r synthesis p h ase was formally underway. Creating memos represented the first step in making the transition from the coding phase to the analysis phase. T h e tex t data was analyzed to identify the principal or under l ying themes that influenced dissemination and adoption of thi s online tobacco education curricu l um Th i s approach was chosen because it le a d s to "practical understandings of meanings a n d actions" (Miles & Hube rma n 1994). Table 5.3: Codebook for Cod i ng Text Data from Interviews with Col orado School Personnel Who Were Trained to Use Consider This, 2003 Rel at i ve advantage Compatibility Diffusion of lnnnovations Codes Complex i ty Trialability Observ abil i t y P redisposing factors PRECEDE Codes Enabling fac t ors Reinforcing factors Capacity Adoption bar r iers A dopt ion process C hannel s Continuing educa t ion pol icie s Emerged Codes A doption reasons Non-adop t io n reasons Technical support Coding of t he data was d o n e using a codebook that was com pr i sed of const ru cts fro m t h e DOI a nd PRECEDE theori es. As I r ead and code d text passages, 104

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other codes emerged. This templat e organi-::Jng style (Crabtree and Miller, 1999) was adopted because it provided a readily constructed codebook for interpreting the text data. It was also flexibl e enough to allow the addition of new codes that explained phenomena outside of DOl and PRECEDE theoretical constructs. The initial codebook consisted of the codes / constructs described in Table 5.3. The codebook expanded as T enco unter ed th e data and other interpretive perspectives became apparent. Some of the other codes th a t were added include: capacity, adop tion barrier s, adoption process, channels, continuing education policies, adoption rea s ons, non-adoption rea s ons and technical s upport. In order to effective l y man ag e the br ead th of text d ata a nd develop analyzable categories code families were created. Code families were created by grouping codes tha t may have had over lapping or related m eani ngs. For example, when coding beg a n text chunks that related to relative adva nt age (both positive and negative) were coded a s Relad. As coding progre sed, the code Barriers was introduced as a distinct code that re flected the relative disadvantages or obstac l es to adoption of CT. Hence, it became important to separate rel ative advantages a nd barri ers into di st inct families when creating code families. The grouping of te x t into families did not however preclude a nalyses that pulled-apart families. To assure that the codes ass i gned were categorized int o appro priate families, a quality check was conducted before the analysis commenced. The text data in each code family was reviewed and selected quotations were extracted from the Atlas file s to create quality-controlled MS-Word fil es that were more homogeneous. These second generation or extracted families of Word files were the basis for the final ana ly sis and synt h esis of the data, created to facilitate a n other reading of transcript excerpts, and to facilitate fina l document preparation. 105

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Themes were established within each of the theor etical constructs by either inte rpreting the te xt on face va lue or b y figurati ve l y s trippin g away the events a nd n a rrative content l eav ing the meaning of what was intended. M ea nin g most often emerged after reading and re-reading inter v iew tr a n scripts but frequently a participant art i c ulated a th e m e very clearly throu g h a n explicit sta t e ment or throu g h emotion al, non-verbal expressions ( e .g., auditory s i ghs, ra i sed tone of voice, raised eye brow s, etc.). Cia sroom Obse rv ation One of the DCSD participant teac h e r s in vited m e t o obse r ve her classroom. This single ob se r vationa l event, while the st udent were u si n g CT, provided the most comple t e picture of the cont ext within whic h t eachers u sed CT in the classroom. This particular teacher. w h o was a l so the IT instr u c t o r a t thi s middle sc ho o l a nd was recruited to teach health after the sc h ool health teacher (a person w ho was tr a ined to use CT) l eft her po ition at th e close of the prev i ous sc ho ol year. Sin ce th e new teacher's classroom was one of th e s choo l computer l abs, it was a n at ural extension of her t eac hin g assig nm ent to us e CT. (This t eac he r was n o t tr ai n e d by Cooper In s titute staff to u se CT. In thi s cas e, chance played a p art in ado ption of CT.) A brief account of that cl assroo m observation f ollows in the Fin dings sec tion of thi s chapter. 106

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Findings DCSD School and Community Environments It was appare nt from the observations during the school visits that DCSD was a predominately white, affluent s uburban school district. Very fe\v non-white stude nt s were observed in hallway s or The data in T able 5.4 confirm this observation. U.S Census data for 2000 reve a l that n e arly 90 % of Dougl as County residents were w hit e and the medi an household income for 2000 was ne arly $83,000. Another indicator of the affluence of this county-wide s chool distr ict was that bond i ss ue s for DCSD were passed by voters in J 997 and 2000. a time period when sc hool bonds in m any other Colorado counties were not approved. Table 5.4: Douglas County School District: Profi Je of Demographic, Geographic and Economic Indicator s Douglas County School District Profile* Douglas County 2000 Census Data Fastest-gro wing school district in Colorado: 32,000+ students in FY2000 (11,000 in 1988 3,000 new students and 300+ teachers in 20 00)* 51 schools (including 6 charter schools) $120 million bond for construction (fall 1 997 and again in 2000) The estimated median h o usehold income for 1999 was $82,929.** Popu lation es tima te 215,226 as of January 1, 2003) ** Race distribution: White (non-Hispanic) 89.7% ; Hispan i c 5.1 %; Asian; 2%; Afr i can Am erican 1 %; other 2 2% *** Large suburban area (867 square miles) located between Denver and Colorado Springs .** 191% population increase between 1990 and 2000 made i t the nation s fastest growing county for the decade. Doub le-digit growth is predic ted to continue through 2025. http : // www aft.org/research / models / dou gco / s h ow2 000 / pppslid / tsld004.htm, March 2, 2004 ** http:/ / www.douglas.co.us / Manager / About_bottom htm March 2 2004. *** http: // quickfacrs.census.gov / qfd / states / 08 / 08035.html, March 2, 2004 107

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Based on observations from teacher-guided tours of the schools where interviews took place each school had at least one computer lab with 30 or more computers and approximately 8 to 10 computers in its library. Two of the 7 schools visited h ad t wo fully equipped 1-Mac computer labs wit h 25 to 30 computers in each, one l ab for sevent h a nd one for eighth grade. Classroom Observations Th e middl e school computer lab where I observed s tud e nt s using CT h ad 31 1-Mac computers, one for the teacher and th e remaining computers for student u se. On the day of the observation the st u de nt s arrived in the lab, a nd took seats at their computer s t at ions. The teacher introduced me and told the students that, 'Mr. Young works for the company that built Consider This. He would l ike to watch you use the progr a m a nd m ay ask you a few questio n s when we are done tod ay."' The tud e nt s placed headphones over their ears and lo gged -on to the CT program by clicking the URL tha t the teacher had previously pasted into the browser address box of each computer in the computer l ab The classroom was almost instantaneously quiet and remained so for approximately 20 minutes. Student s were tran sfixe d, focusing on the computer monitor, he adp hone s on their ears and hands manipulating the keyboard and mouse. At approximately 20 minut es into the class p e riod, there was some growing disruption in the class. Seven or eight students had been knocked off of their Internet connection or their computer were locking-up. A quick scan of the classroom revealed that trouble was encountered whe n the students had reached the Media Mall section of Module 3 of CT, a section that was particularly demanding of bandwidth. 108

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Douglas County elementary and middle feeder sc ho ols shared aT l, high bandwidth Internet line with their l ocal high school. Thus when Internet traffic in those five or six schools peaked, the Tl lin e had in s ufficient capacity t o carry the demanded bandwidth load. The CT Media Mall activity is especially bandwidth demanding because of the audio and video content and the interactive nature of that page, so when many students would encounter this p age simultaneously a bottleneck would result and computers would Jock-up. Thi s IT/ health educat ion teacher was especially p repared to deal with this technical problem and the resu l tant disrupt i ve behavior that quickly spread through the students w h o were no longed onl i ne. Quick to recognize this technology problem, she helped many students log back onto the Intern e t and others s he redirected to complete a written ten-que s tion quiz that she h ad prepared and distr ibut e d at the beginning of the cla ss period. (Sample quiz questions were availab l e from the CT teacher's manual.) The class r e-grouped after this disruption and continu ed work in g on the CT program, bu t never completely regained the previous level of focus th at was enjoyed during the first twenty minutes. Ten minutes before the end of this 50-minute c l ass period, the teacher had the students remove their headph ones, stop the customary middle school youth, classroom banter and discuss the l essons that they had l earned that day. A few of the students expressed their surprise at all of the poisons that are included in tob acc o and tobacco smoke and one was especially grossed-out"" that rat poison (arsenic) was included. When asked w h at the y liked and disliked abo ut th e CT program a few stude nt s spoke up. One said that he "l i ked the way that the program was about me a nd how it was private." Another said that h e 'did not lik e the voice of the gir l who 109

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talked on the program," th e virtua l hostess. A third student expressed frustration that he was kicked-off the program and then cou ld not return to the place where he l eft off. Despite the probl ems e n countered with the technology. the teacher capita l ized on this imperfect l earning opportunity by d i scussing the l essons a nd h aving the students compl ete and hand-in their wri tten quiz. During the class period s he repeatedly remind ed the students that they would be graded on the CT quiz. Students were free to discu ss quiz answers among themselves before handing the quiz to the teacher. The skill with which thi s IT / hea lth teacher ma n aged the classroom and th e technology problems pre s erved t he learning experience for these seve nth grade sc ho o l studen ts. This c l a ssroom o bserva t ion was extremely benefici a l for an improved understanding of the clas sroom context in which CT was implemented. This observation occurred in what may have been the best of circumstances, since this teac her was th e only he a lth t eac her interviewed who h ad formal responsibility for teac hin g computer c l a s es She was also particul a rly ade pt at managing ado l escen t behavior. The l esso n s learned from this c l assroom observat ion were as follows: Students became fully engaged in the CT program once th ey were l ogged on and the headphones in place. The a u dio, v ideo and interactive func ti onality was captivating; The content appeared to be new and informativ e; Students l iked the tailoring a nd privacy featu r es of CT; 110

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While this teacher demonstrated exceptional classroo m management skills in the computer lab, classroom man age ment for teachers l ess comfortab l e with computer technology wou ld mo s t likely be very challenging; and Fru st ration in get tin g and keeping the progra m to funct ion on the Internet by t eachers and students was evident a nd was a barrier to implementation. Diffusion of Innovat ors. CT Adoption Characteristic Study pat1icipant perceived a ttribute s of the CT c u rriculum it self are important to understanding adoption of this innovation. In a review of dissemination research literature Rogers found that 49% to 87 % of the variance in the rate of adoption is explained by five attributes-relati ve advantages compatibility. complexity, trialability and observability (Rogers, p. 206) The fol l owing sect ion of the Findings reports the CT adoption a ttributes that study participants id e ntified. Relative Advantages Study participants disclosed th e follow in g attribu t es of the CT webs it e as relative advantages over other tobacco educatio n curricula: a) "up-to-date and correct information statis tic s;" b ) "gives correct information in a manner that middle sc hool kids re a lly sort of l atch onto;" c) "put-together in a lo gica l way;" d) web-based;" e) 'allow s for differentiation (appea l s to a vat i ety of l earning styles); and f) convenient to u se. The relative advantages of using CT that were disclosed through the interview s include those factors in Table 5.5. 111

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Table 5.5: Relative Advantages to Using the Consider Thi s Tobacco Prevention Curriculum Relative Advantages of Consider This Up-t o-date, accurate infor mation Free for schools to use Convenient for teachers to use All ows for teacher differentiation of learning styles Appeals to student s Up-to-date Information. This attr i bute m ay b e a refl e ction of either outdated text-based information now available to teachers or the ease with which teachers a n d st ud e nt s can access tobacco-related information from this web-ba sed program. Delivery Method. The method or structure by wh i ch the information is presented or delivered was identified as a r e l ative advantage Most of t he teache r s intervi e wed who h ad used CT referred to its positive appeal to kids a nd the modular structu r e of the cuiTic ulu m a nd /or the Teacher's Manual. These were th e most widely mentioned adva n tages over ot her curricu l a (CT has six 30 to 50 minute, interactive vis u a l and auditory modules that are sequenced to structure studen t leaming and to fac ilit a t e teacher m anagement of the learning experie n ce.) The reference to 'web -b ased" (re l ative advantage 'd' above) was a specific reference t o the need for information th at i s readily accessib l e to small, remote sc hool districts where adequate "fina nci a l resources and interactions with other teachers and other districts do not exist." Th erefore, "web-b ased i s a euphemism for "free-ofcost." Three t eac h e r s indicated that they did not h ave a tob acco ed ucation curr i c ulum in their school, so for these t eac h ers it was a new resource against which th ey had no ex i s tin g curr iculum to comp are CT. 112

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Allows for Diffe r e ntiation 'CT was especially nice fo r kid s a t differ e nt reading l evels," it also 'prov id es variety'' and a n ot her avenue of l earning." These statem e nt s reflected the se ntiment s of man y teachers w ho saw the CT pro gra m as a learnin g a pproach th at allowed for "differe nti a tion in l earni n g sty l es and abi liti es Di ffe rentiation was a nother emerg e nt th e m e that int ersec t ed with both the DOl and PRECEDE model s wi th it b e in g b o th a rel at i ve adva n tage and a reinforcing factor. On e -thir d of the st u dy participant s charac t erized differe nti ation as a re in forcing factor (o n e that t h ey i dent i fied a an inc entive for t hem t continue i ts u e) This factor h ad n ot p reviou s l y b ee n i d e ntified by the chan ge age n ts or in n ova t ors of CT (Coo p e r In s titut e researchers) as a predisposing factor (rat ional or moti va ting f actor), one th a t could be us e d to promote a d opt i on. The di ffere nti ation advantage of CT is a l so r eflected in the more discri minator y a n alysis of R elative Ad va ntages that follo w s-an a n a l ysis of teacher observat ion s of s tudent re spo n ses t o CT. Expanding on her mention of diffe rent iatio n as an adva nt age of CT, one te ac her r efe r e nc e d "learnin g sty l es and "multiple i nte l ligen ces .. a nd G a rdners work in thi s a re a ( G ardner H, 19 99) According to Gardner individu a l s develop copi n g st r a te g i es to compensat e fo r their weaknesses and capitalize on their stre ngth s In his work h e identified thr ee princ ip l e l ea rn i n g sty l es visual, a uditory and kinesthetic a nd seven ty pe s of multi p l e inl e lli gences. Thi s teacher h a d apparent l y observed that u s ing the CT c ur r i cu lum r e quired u se of all three l earning s t y l es. Multiple int e lli ge n ces are seve n different ways to demonstrate int ellectu a l ability. ( See T able 5.6.) 113

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Tab l e 5.6: Gardner's Multiple In telligence Types7 Multiple Intelligence Types Visual / Spatial Intelligence Verbal /Li nguistic Inte lligenc e Logical / Mathematical Intellige n ce Bodily /Kines thetic I ntelligence Musica l /R hythmic Inte lligenc e Interpersonal Intelligence lntrapersonal Inte lligence While not planned to be re ponsi ve to the multiple intelligences mode l CT's in structiona l design includes educational activities that require visual / spec ial int e lli gence (a physical manipulation game), bodily/kine s th etic inte l ligence ( man i pulation of the mouse), musical / rhythm i c intelligence (listen ing to young persons playing a guitar), interpersonal intelligence (ro l e-played peer interaction s) an d in trapersona l intelligence (students examine methods to resist t he media and learn ways to dea l with stress). This teache r recognized th at CT activities address all but the Verbal / Linguistic type of intelligence, for a l earning experi e nce that engages st udents by appealing to their preferred l earni ng sty le or intelligence type. This curriculum therefore. helps teachers "differentiate" or appeal to a varie t y of learning s tyles for a more relevant student learning experience. Conven i ence. Whi l e thi s term was not used expressly, convenience was a theme th at emerged as an implicit relative advantage of CT during the in terviews The following quotes from teac h ers s uggest that CT was convenient o r easy for teacher s to use. 114

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"(CT) is r eally ni ce It had all The actil'ities planned out. You didn't r ea ll y have to put a lot of tim e into l esso n plans ... you just went through the l esso n itself so you knew what th e kids would be doin g .. .there wasn't a lot of outside time involved.,. I do n o t hav e to c om e up wiTh the c urri c ulum myself" "As a teacher I think The one nic e thing i s i t pretty much run s it self Basi c ally (as a reache r ) you'r e just There (in t he c la ssro om)." "So it 11 as nic e not havin g to co me up w ith those lessons, those activities for studenTs T o be doing.'' "Very easy for t e a che rs ; you ba s i ca lly. ifyou don't want to, y o u don't hav e to do a n y t hing. /mea n you r eally cou ld just put the kids in fron t of the com puter and they wo ul d ge t a wonde1jul tobacco progra m. And you wouldn't hav e to d o any th ing " It s easy 1 0 c reme worksheets and worksheets ar e already c r e ated for you so you ca n railor it to your own classes in any way that you want and that's a positive . "It's r ea ll y nic e it had all th e a ctiviTies alr e ady plann e d out: you didn r really ha ve to put a lot of time into l es son plans. ' 115

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These statements suggest that CT provided a break from the arduous tasks that are associated with planning lessons and leading classroom activities. Conv e nience i s another adoption factor that inter sects both the PRECEDE and DOl mod els It is both an enabling factor and a relative advantage. In this regard, it could perhaps be a powerful factor when promoting or encouraging teachers to adopt the CT curriculum. Relative Advantages for Students (Teacher P ers p ectives). Teacher s often represented the inte res t s of s tuden ts in their re sponse to que st ion s regarding the adva nt ages of using CT. As educator they wer e able to see how s tudent s responded to CT and ofte n inter reted those responses as advantages over traditional "pencil and pap r"' learning. I observed tha t si nce teacher-reported s tud e nt reaction to the curriculum was very favorable, te achers responded favorably to the curriculum, despite t ech n o l ogy problems that they may have encountered. Following are a few teacher quotes that reflect the advantages to students. "I think they' II stick with it because you knoll t hey can jump from one area to the other. "They like !he activity pan of it, they lik e 1he fast paced part of it they like, ah, as a way of learnin g as opposed to pencil, paper-they l oveto be on the computers, ah, they think it'sfun." "The kids really do enjoy it and they get the knowled ge and they get the activities that they need in order to make good decisi o ns about smoking, so that's the whole pwpose of the thing.' 116

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"For the most part, t he kids enjoy the complller and they've been raised with it. As a consequence I think it probably would be ve ry advantageous if they cou ld do something they enjo y and pi ck up some l earn ing at the same time ..... CompatibilitY. Based on the DOl model adopt i on of new technologies is i n part dependent upon the exte n t to which an innovation is compatib l e with t he values, experience and need s of the population of possible adopters. This a n alysis identified many factors that make CT compatible with te ac her school and school distr ict values, experience and needs. Tab! 5 .7 summarizes the compati bilit y fac tors associated with u se of Consider Thi s Table 5.7: Compatibility Factors Associated with Use of the Consider This Tobacco Prev e ntion Curriculum Compatibility Factor s Associated with C onside r This School athletic values I nterest in hands-on (tac t ile) i n structional me t hods Role modeling of non smoking behavior S u pport for continuing educa tion Schoo l Ath l etic Values A few participants mentioned that educating midd l e schoo l chil dren about tobacco use i s compatible with school athletic values." Smoking ha s long been acknowl edged as being incompatible with athletic performance and as a reason fo r teens (especially boys) to want to quit. (Cooper, Gey, & Botten berg, J 968; A u ng, Hickman, & Moolchan, 2003 ) CT compatibility wi th schoo l ath l etic values is therefore, no t only a f ac tor that i nflue n ces adoption t hro u g h schoo l va l ues, but i t i s o n e with a valid scientific basis. 117

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Tactile Experience. Many participants mentioned t hat they were upportive of instructional methods or tools, such as CT, that are hand s -on and that CT also satisfied middle school student intere s t s in using computers. Since CT requires direct manipulation of the key board and mou se to n av igate through each of the six module s, it is a hand s -on or tactile experience for stude nts. Role Modeling of Nonsmokin g Behav ior. The quantitative portion of this study (Chapte r 4) determine d th at smok ing prevalence among the s tudy partic ip a nts i s 5 6 % This lo',v prevalence r ate is approx im ately one-fourth of the adult population smoking rate in Colorado (CDC, 2004) Clearly, most teachers value non smok ing behavior. One participant s ummed up the predominant sentiment of many whe n s he stated: "It doesn't seem rhat we have very many reachers or other staff members that use toba cco or smoke cigarettes. I think that s a powerful message to the kids.,. Role modeling implied in this quotation, w a s therefore an underlying theme that was compatible with teacher non s mokin g values and one that a ppeared to influence nearly all study participants. With one exception ( a participant who identified himself as a smoker on his survey response) all of the participants interviewed reflected this value. When asked to describe CT during a telephone interview, this participant stated the following : Teacher: "I'd say it's (CT) a very pro gress ive, integrat e d t ec hnolog y program. I wouldn't say it's very unbiased. It's ce rtainly one s id e d to ge t students t o stop smoking.,. 118

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Investigator: "Do you think yo ur smoking your attitude abou t the curriculu m ?" Teacher: "No. I co uld b e happy t o teach a non-smoking cur riculum .. While his .vords reflected tha t he may have upheld th e role-modeli n g value, his tone of vo i ce when the t ape tr a n sc ript was re-played and his use of the wor d "could" cast some doubt on th e sincerity with which h e would teach a t obacco education curriculum. With this possible e x ception. role-modeling of healthy behavior i s a predominant value of teachers that makes CT compatible w ith teaching interests and personal values. Thi s compatibility incr eases the lik eli hood of curriculum adop tion. Support for Continuing Educatio n Working in a n educationa l setting necessarily means that participants val ue education, a nd for themsel ves, continuing ed ucati on. Training or continuing education incentives, l ike tho se offe red to sc hool s a nd t eachers when CT was first introduced, are compatibl e with teac her interests an d n eeds. T eac h ers are also required t o complete contin u ing ed uc at ion hours to retain their license to teach in Colorado Every study participant indicated that their sc ho o l district encouraged their pur uit of continuing ed u cat i on opportuni ties. While being compatib l e with teacher values and ne eds, thi s fac tor i s a l so supported by a s tate continuing education s tatute a nd Colorado Depa rtment of Education's License Requirem ents. In this regard, it i s also a predisposing polic y factor. Compl ex ity. The deg ree to which a n inn ovat i on i s perceived as difficul t to under sta nd a nd use its comp l exity, is one of th e DOl c h aracter i stics that influences the rat e of adopt i on. Complexity can be described in two domains-the broad technological domain and the n arrower CT c u rriculum content domain Rogers' suggests that innovations like CT are not v iewed si n gular l y by individual s, but as an int errelated bundle of new id eas (1995, p 235). In thi s study, teachers most ofte n 119

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discussed th e CT curriculum with littl e distinction between th e CT software a nd the medium that delivered it, the Int ernet. Thi s l ack of cleaT bound aries is what Roge r s called a technology cluster. ( Thi s concep t i s di c u ssed in some grea ter detai l in the B arriers sec tion of this chapter.) Tab l e 5. 8 su mm ar i zes the compl exity fac tor s associa ted w ith use of Consi d er This. In the t ec hn o l ogica l domain. p rob l e m s with downloading the plu g-ins and bandwidth problem s \ ere most f r eque ntl y m e n tioned. The technica l t erms that teachers used in th e interviews are suggestive of the perceived compl ex i ty of CT. Some of the common u se d te rm s that s u gges t ed the comple xity were: down l oad ing plug-ins firewalls, and bandwidth. Each o f the e phrases or words ha s become an increasingly recognized part of the vocabu l ary sunoun ding use of comput ers. Table 5.8 : Complexity Factors Assoc i a t e d with Use of the Consider Thi s Tobacco Prevention Cuniculum CT Complexity New terms like download ing, firewal l s and bandwidth suggest that CT is complex The CT program itself was e asy fo r students and teachers to use Rel iable Internet access was a problem t ha t defi ne d CT as complex for some teachers Teachers with limited knowledge of compute r technology were no t successful. Downlo ading Plu g -in s and Firewalls Dow nlo ad in g plug-ins ( pro grams ava ilable o n the We b that e n a ble operation of cert ain as pect s of a softwar e p rog ram) enab l e the CT program to operate i s an esse nti a l techno lo g i cal act i o n th at mu s t take place in order for the CT curr iculum to operate It is a re l ative l y s impl e pro cess of 120

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entering a website address in a browser address box and clicking the 'GO' button or in the case of CT clicking on hypertext on the CT registration page. However, if school computers were networked and IT staff had installed a firewall to protect the computer system, then downloading the plug-ins most lik e l y required assistance from a system administrator to bypass the firewall. This was the first ob tacle that many teachers faced when trying to access CT. To many teachers, it was one of the definitive action required that defined the curriculum as complex to some users Three of the i nt erviewed teachers: I) did not know that firewalls even existed in the world of computer technology; or 2) if they knew firewalls e xisted, they did not recognize that a firewall on their computer system was blocking the plug-in downloading operation; or 3) did not kno'vv what to do to by-pass the firewall if they recognized that their system had one. For these teachers, accessing the CT program was complex. None of the three teacher s who reported that they were unsuccessful wit h downloading the plug-ins, due to encounters with a firewall, ever used CT in their cla ssrooms Bandwidth. Bandwidth is defined as "the amou nt of information that can be carried in a given time period (usually a second) over a wired or wireless communications lin k It is ex p ressed as bits (of data) per second (Search etworking. co m 2004). Websites with audio, video, and interactive features like CT demand a lot of bandwidth in order to operate efficiently.8 In add iti on to the program itself requiring l ots of bandwidth, whe n multipl e users are using the same Internet connection sim u l taneously, the communicati ons path can b e overloaded causing the connection to be bro ken or lost. This very problem was encountered by all of the teachers who u se d CT. 121

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Investi ga tor: "Any negative expe ri ences with Consider Thi s that you can r e member ?" Teacher: "You know, it comes down t o th e numbe r of students t ryin g to ge t on ther e a t t h e same t ime. Thin gs are just very s l ow a t tim es and, as you know, with any I ntern e t use. it s going t o fluctuate throughout the day. You know, in the m orning we were pro bably pretty good about getting in there and ge tting stuff done, but as the aftern oo n roll d around, end of the day or for me starting at about 1 :40 o r so. later in the day i t was r ea lly s l ow and we we r e starting to have a lot of probl e ms with, you knmv. compu t e rs lo c kin g up and not being abl e to ge r int o certain m odu l es The a b ove quotation is anothe r example of ho w teachers perceive CT as a techno l ogy cluster, a nd not as a software progr am distinct from the Int ernet service connection. The observed complexit y was not how ever, a prob l em that discouraged use of CT for all teachers. It appears that the t eache r s who used it s uccessfully acknowledged and accepted the limit a tio ns of u sing Internet technology by e ither limi ting th number of s tudents who were o n the website simu ltaneously or by stagge ring stude nt start times o n th e program to avo i d c reatin g a ba n dw i dth bottlen eck CT band width bottl e n ecks occurred when too many st udents encountered a particul arly bandw idth intensive ac t ivi ty of the CT program sim ultaneou sly (e.g., Med i a Mall in Module 3 ) The compl exity of t h e CT program it self ( di st inct from the tec hn ology clus t er) was unanimous ly reported by those w h o u sed it to be very easy. When asked, ''How easy was it for you to try Consider This?" the following t wo responses were typical: ''Oh t errib l y easy," a n d I thought it was pretty s imple. I thou gh t it was very well 122

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done. I t flowed very well. . In s umm ary, CT was p erce iv ed to be s impl e to u se, yet the complexity of computer techn o l og y wa s a deterrent to u e for many teacher s Trialability The degree to which a n innovation m ay be experimented w ith on a limited b as i s, or it s tr i a / ab ili ty is o n e of the five DOI key c h arac teri stics of an I innov ation that is adopted r ap idly. Thi s charac t eris tic i s very c l ose l y as ocia t ed with the complexity of CT and especially w ith th e complexi t y in the techno l og i ca l domain. Since d ownload i ng plug-ins an d circ u mventing computer network firewall s is a prec ursor to tryi n g CT, if a te< cher cannot n v i gat these technica l obstacles, th e n the innovat ion w ill n ot be tried. Once obstac l e i s circumvente d a nd a broadba nd Internet connection i s acce ssed any teacher who ha access to the World Wide Web and who i s comfor t ab l e w ith comput r t ec hn o l ogy can ''try CT at this address: W\\'W. comJdt::rthisusa.net. Observability. Perhap s the most d ifficult DOl construct to d efine in this invest i gation was the degree t o which the re s ult s of t he C T inno at i o n were vis ibl e t o ot h ers. The obse r vability rea lm was divided int o proces s a nd outco m e domains. Thi s inves tig atio n was not intended to determine me asu r ab l e i mpacts or outcomes that the CT c u rr i culu m had o n stude nt u se of tobacco-the outcome dom ain. S o th e findin gs descri b ed h ere we r e lim it ed to the obse r va t ion s that teachers made a bout u e of CT, the process do main. Since CT c l as es were h e l d in the i so l at i on of schoo l computer l a b s a nd chool s were i so l ate d from eac h other, there was littl e oppo rtunit y for outside observers (i.e., pot e nti a l adop ter s) to witness the imm e diat e influence or pro cess of CT. N o ne of the t eac h ers who s uccessfull y u sed CT reported that ot her t eachers h ad observed their c l asses Additio n a lly, o ut s id e of the DCSD t eacher participant s, th ere 123

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was no evidence of any interaction among tea chers regarding CT after they attended the training seminars. In conc lu sion, despite its easy access on the World Wide Web, the lack of identifiable factor s that promote observability of CT appears to be irrelevant to the successfu l adoption of thi innovation. Social System Member Charac teri s tics. Among the teachers and administrators interviewed in DCSD, ther e \ ere two who stand out as early These participant s were al o opinion le aders within their school district. Brief case descriptions of these participants follow. The first of the s e cases. a schoo l di trier administrator. could be characterized as an innovator. Thi s participant's leader hip or gatekeeper actions, encouraging adopt i on of CT and interest in new ideas, l ed t eachers "outside of her peer network" toward a more cosmopolitan tobacco educati on approach. In thi ad ministrative capacity. this person used positional or formal authority tor quire t h a t other sc hool district empl oyees attend one of the CT training sem i n ar The second case. a teacher in a large school d i trict, se lfide ntified as an e arly adopter. Thi s individual' s influence regarding CT wit hin the district was refere nc ed by three o ther participants who were intervie we d thus indicating that this person was al o an opinion l eader. Thi teacher was particularly adept at navigating the technical computing environment and he encouraged teachers who disc o ntinued use of CT due to technical d i fficulties to try it again. The following is evidence of I this observation. Somebody from a different school said it really went fine and he didn't have any problems, so I thought, great we're all set. (This 'somebody' was l ater identified in this interview to be the opinion leader to whom thi s case is referring.) His informal l eaders hip was recognized and ac ted upon by his peers. 124

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These opinion leader cases demonstrate that organizational or formal authority and earned or informal authority can influence the adoptive behaviors of others in their organizational and socia l networks (e.g., work places). These participants (opinion leaders) were members of a social system (school district) who were ab l e to "influence att itud es or overt behavior informally in a desired way w i th relative frequency" (Rogers, J 995. p.27). Communication Channels I Diffusion etworks. How study participants first heard about CT and more pecifically, the communications channel s through which they heard about it are p o tentially important adoption facilitators. Rogers defines a communication channel a the mean by which messages get from one individual to another ( 1995, p.l8) The survey portio n of this study (Chapter 4) disclosed that teachers most often heard abou t CT through sources other than the mailed brochures and l etters that were sent via a general mailing addressed to health education teachers a nd principals to middle at middle. junior and high schools. The interviews verified that intra-school communications channels were the mo t freq u ently mentioned channel through wh ich study participants heard about CT. Some quotations a nd a narr ative dialogue that illustrate this find ing follow: Teacher: "My principal asked me to atrend the training here in [ciry name]." School nurse: "!was approached by the PE I health teacher at my school.,. Teacher: "/think I originally heard about Consider This from one of ou r counselors [ who] came to us with something, with a pamphlet." In vestigator: "How did you.first hear about Consider This?" Teacher: "By a mailer that came to the school ... Investigator: "No'>l' did you receive the mailer?" 125

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Teacher: "Actually my prin c ipal did." Investigator: "And th e n h e o r she forwa rded it t o you, is that ri ght?" Teacher: "Yes. There were only two r efere n c s to inte r -di s trict communication s a nd the se were made b y te acher who worked in rur a l areas of the s tat e. In vest i g at or: How did you hea r abou t the Consider Thi s c urri c ulum ? .. Teacher A: "Sc h ools up and down 1-70, occas i o n a lly 1 ve will ge t roge the r and we 'II discuss things tha t are going on with our school .. T eac her B: "Ac tu a ll y from the middl e schoo l h eal th t eac her in [ city n a m e]. Sh e's a fri en d of mine ... Socia l network communications a mon g t eachers played a n import a nt role in ho w te acher firs t heard abo ut CT. PRECEDE Adoption Ch arac teri stic In contra s t t o the DOI mod el w hich addresses characteristic that are s p e cific to the inn ovat i o n itse lf, th e PRE CEDE mod e l encompasses bro ad environmenta l factors. PRECEDE constructs includ e: th e s ocial! enviro nm e nt a l motivation or r a tionale for adoptio n (p r e dispo sing factors); the factor s that a llow thi s motivation to b e realized (e n ab ling factor ); a nd the re wards for ado ption that are created or emerge s ub se quent to the desired b e h av i o r (reinforcing fac tor s). 126

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Th ese PRECE D E mo de l fac t ors ar e a ssoc i a t e d with s u ccess ful pro g r a m implem e nt at i o n in th e communit y o r soc i a l d o m ain. P redis p os in g Fact o rs. Th e r at i o n a l e fo r adoptio n includ es multiple fac tor s tha t predi s p o e a n i nn ovatio n t o b eing a d o pt ed by socia l sys t e m m e mb e r s. Th e pr edo min a nt t hem es tha t emerged thro u g h t h e a n a l ys i s of p red i s p osing fac t ors for CT pr og r a m adoptio n are descri bed in T a ble 5 9 L aws and P olic i es. Schoo l d i s t ric t t obacco free pol ic i e s th e st a t e l aw (CRS, 25 -14 1 03.5) t hat r equ ires sc hool s b e tobacco-free a n d t eac h e r cert i ficatio n r e quir e m e nt req u ir i ng cont in uing ed ucat io n are influe nti a l fac t ors tha t moti vate a d o ption of C T a nd o t her t ob acco educat i o n c urric u la. T a ble 5 .9: P red i s p osi n g F actors Assoc i a te d w ith A d o ption of Co n s i de r Thi s T o b acco Prevent ion Curr i c ulum Predispo sing Factors for Adoption of CT Sch o o l dist rict po lici es on health edu ca tion and tobacco use ; State and loca l laws that discourage sa l e to and possession of to b a cc o b y mino r s ; Sta t e s t an d ards for teacher certificat i on ; and Teacher interest in and pursuit of alternat i ve instruct i onal metho d s 127

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In Douglas County there is also a youth access law that makes it illegal for merchants to sell and youth to purchase or possess tobacco. This backdrop of state and local laws provide a cle ar soc ieta l pronouncement of the importance of preventing youth from becoming addicted to tobacco Every participant interviewed described that their schoo l did not allow tobacco use i n the schoo l bui l ding or on the sc hool ground and that there were very few violations of thi s policy. The following quotation from one of the teacher study participants su m s up the genera l sentiment among the participants interviewed. "We have ::_era rolerance as jar as the studen t s are concerned. No cigarettes in the schoo l n o n e in the i r l ockers and that type of stuff" Standard Seven ( Know l edge of Technolog y) of the Col orado Standards for Te ac her Certification is a predi spos ing factor that influence adoption. (See Table 5 .10 and; Colorado Standard s, 2000.) This standard, while not explicitly referenced by any of the participants, estab l ishe s an expectation for teacher perform a nce that is in the policy domain DCSD participant s and a few others reported that as a matter of schoo l di s trict po l icy they are encouraged to integr a te technology into their te ac hing. 128

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Tab l e 5.10: Teacher Certification Standard Seven: Knowledge of Technology Standard Seven for Colorado Teacher Certification; Knowledge of Technology The teacher is skilled in techno logy and i s knowledgeable about using technology to support instruction and enhance student learning. The tea che r has demonstrated the ability to : 7.1 Apply technology to the delivery of standards-based instruction. 7.2 Use technology to increase stude nt achievement. 7.3 Utilize tech nology to manage and c omm unicate information. 7.4 Apply technology to data-driven assessments of learning. 7 5 Instruct students i n basic technology s kills. Health edu ation is a required course in some scho o l district middle schools, with s tate law declaring hea lth education to be 'a vo l untary program in \ hich schoo l d i stricts and boards of cooperative services may participate through the creation o f l ocal comprehensive health ducation pro g rams" (C S, 22-25J 04 ). Subsection (I) of this statute defines .. tobacco, alcoho l and other drug u se as a topic that shall be included. This law, de s pite its volunt ar y compliance nature, appears to have established a motivation, or at lea s t the backdrop, within which school districts deve l oped hea l th education program s Alternative In tructional Methods. A motivating or predisposing factor for adoption of CT that was predominant among the patticipants int erviewed was that CT provided a n alternative method for teaching a nd student learning. "It's an a l te rn ative to paper and penci l t eaching The interviews disclosed that teachers were int erested in a nd l ooking for teaching methods that wou l d make the s ubj ect matter more compellin g for stude nt s Teachers reported that their stude nt s were interested in a nd enjoyed working on co mput ers CT was recognized as an alte rn at i ve teaching too l a n d therefore, a motivating factor for teacher s t o pursue adopt i on. 129

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Two teachers mentioned their .. se n se of community" or 'wa ntin g to resolve what wa heard to be an increase in youth smoking'' as predisposing factors. This intrinsic motivational factor may have been more broadly inherent among the participant interviewed, but it was mentioned too infrequently and without enough conviction to be included as a significant predispo ing factor. The demi e of DARE (Drug Abuse Re istance Education, a law enforcemen t substance abuse prevent i on program) and the need for a replacement program or curricu lu m that discour a ged tobacco u e was mentioned by one participant as a reason or motivation for trying CT. DCSD hea lth educators reviewed their health education standards for 7'h graders and dete rmin ed that eit h er Project Alert or CT shou l d be taught. Thi recommendation was forwarded to the DCSD Curricu lum Council. Thi internal schoo l district recommendation made by DCSD health educators provided at least some minimal rationale for DCSD use of CT. The above mentioned broad predisposing factors provided the rationale or foundation for adoption of the CT curricu lum Enabling Factors. Factors that motivate a teacher to try a curriculum ( pr edisposing factors) are not enough by themse l ves to assure adoptio n of that curr i culum Schools and sc ho o l districts must have resources, systems, strategies and peer n etworks that enable them to adopt a curriculum or new technology. The e nablin g factors that are assoc i ated w ith adoption of the Consider This curri c ulum are summarized in Table 5.11. 130

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Table 5.11: Enablin g Factors A ss ociated with Use of th e Con si d e r Thi s T o bacco Prevention Curriculum Enabling Factors for Adoption of CT Computer avai lability and accessibi lity Teacher knowledge of and skill with computer technology Teacher access to peer networks Support for c ontinu ing education Specific CT training Teacher self-motivation I determ i nation Inf ormat ion techno logy support. Computer Availability a nd Acces ibilit y Computer avai lability a nd access ibili ty were found t o be core factor which e n ab l e adoption. Thi s finding was discovered b y d i s closin g wha t t eachers who succes fully u sed CT did not say a bout computer avai l a bilit y and access and contrasting it agains t those w ho h ad sig nificant problems. T eac h ers who s uccessfull y accessed and used CT d i d not report h av ing s i g nifi cant difficulties with computer availa bilit y a nd access. It was implicit in the text of those int e r view s tha t computer were ava i lable a nd access ibl e. Since DOl and PRECEDE are models (model s th a t ten d to b e bia sed toward ado ption), liabi lities or barrie r s like lack of availabi lit y a nd access to compute r s are not discussed he re In s t ead barriers are disc u ssed in the Emergent I Non-theoretical Adoption Ch arac teri s tics sec tion of Cha pt e r 6. T eac her Knowledge and Skill. Teacher know ledge of a nd s kill with comput er te c hnolo gy we re i dentified as an enabling factor. The following int erv ie w excerp t with a teacher wh o taught science a nd hea l th in a s m all, rur a l Colora do sc h oo l w ith s tudent s in all grade le ve l s, illustrate s how t eac her k no w ledge a nd skill can enabl e not 131

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only a doption of CT but can prom o te a d o ption of technol og y in th e broader realm. Inve stiga tor: ''What d o y ou teach ?" T eac h er: "/rea ll y d o n't, li ke I sa y th e kids a r e all d o in g c omput e r cl asses, co ll ege cl asses and high sc h oo l cla sse s wir h in srruc r ors a t diffe r enr l oc ati o ns. You see we'r e a ve ry s m all schoo l di s 1 r i c t a n d we don t offe r a l o r of the classes rhar k ids want S o we h ave a fair n umbe r of kids d oing th ese co m pur e r co u rses through d iffe r e n t community co ll eges ... Bri g h am Youn g Uni1ers ity, an d the n we h ave a l ocal C olorado o r ga ni::.ati o n for on lin e clas s es as we ll ... ' In vestigat o r : S o it sou n ds as t h oug h m osr of the instru c ti o n i s o n-lin e? T eac h er: O ne hun d r e d p e r ce lll." Inves t igato r : S o w h a t a b our access t o compu t e r s? W h a t k ind of access do \ 'Oll have?" T eac h e r : M y classr oo m i s set up w ith 1 8 IB M compari b l e compute rs. We h ave a Tl line, and the kid s a r e o n those co m p ut e r s just abo ut e1'er y peri o d a ll day l o n g. We've go t so m e k i d s doin g fYI; o or th ree classes in m y r oo m. S o m e ca n arte n d co ll ege cl asses a s l o n g a s the y a l so m ee t hi g h sc hool r eq uir e m e nt s .. The r e i s o n e cl a ss so m e ofth e kid s lik e t o ta ke ; it's S oc i a l Probl e ms. I ca n r r e m embe r exaoly th e n ame of rhe cl ass, so m e thi ng t o d o w i t h soc ial and b i o m e di c al prob l e m s and thin g s in rhe prese nt and ir ge ts int o clo nin g but it al so in that case 1alks ab o ut hea lth in11 hi c h they 'r e wo rri e d ab o ut di e t and s m o kin g and so m e thin gs li ke th at. B u t th e y r e workin g w ith an i nsrruc tor at th e o th e r end. In vestig ator : "A r e these cl asses f o r th e m o r e adv an ce d s tud e nts?" T eac her : "/have fir s t throu g h fifth g rad e r s that are pus hin g th e g ift e d and 132

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tal ent e d area and n ee d something more, something faster. I have a gro up of seventh and e i gh th gra der s that were b e hind in their English skills almos t remedial in a way, and so they ca m e mer and started a lo we r l eve l class and we >vork e d th em up almo s t t o grade / eve/ l as t year Thi s te acher's knowled ge of and comfort with te chnical l a n g uag e a nd creative u se of computer technology to a d va nc e s tudent l earni n g was indicati ve of hi s knowled ge and confidence in the technology domain. Base d on t he interviews conducted in thi s study, it appears th a t the t eac her qualities that t hi s teacher possesses are s till th e exception. While h e u sed CT o n a l imited b asi and made it availab le a s a n option for students, the a bo ve exchan ge i llu stra t es how w ith hi knowl edge, he was ab l e to integr a te t ec hnology int o his cl assroo m H e brought e d ucat i o n a l re ources a nd experience t o a sc ho o l that wou ld otherwise have been without th em. Peer Networks. Access to peer n e twork or oci a l I communication ys tem s within sc hool s a re an enablin g factor that h e lp ass u re that reachers hear about CT and get feedback on u se of CT that help s encourage c o ntinu ed a tt e mpt s to tr y it. if they were un s uccessful a t fir st. After b eing asked, 'Did you ever see a flyer, a brochure on Cons i d e r Thi s?" one te ache r re s pond e d "!didn' t but see, a lot of tim es if something c omes int o the office abou t h ea lth edu catio n the y 'll put it in [m y supe r v i so r's] box because he sour department h ea d and the n he' II ge t that informati o n ou t to the r est of us." After reporting that he had been unsucces s ful at u sing CT because of the b a ndwidth problem s, a nother teacher indicated that the success of a teacher in a nearby middle school encouraged him t o try it again. On the seco nd try he was s uccessfu I. 133

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Investigator: "Who was it tlwt you h eard that th e connect ion 1 vas working well using the wireless computer lab?" Participant: I don't know his last name, his first nam e's [name]. I think he's at [name] middle school. Yeah, okay okay. But he said it 1 vorked rea lly well, so I thought 'grea t', we're ready to roll. These two exampl es illu trate that the peer network can play an import a nt enabling role that provides motivation t o adopt CT and to try it again if at first a teacher was unsuccessful. Continuing Education. Wh n asked to de scr ib school district continuing education policies, all but one of the twenty-three participants who were interviewed indicat ed that their schoo l district was support i ve of conti nui ng e duc ation. Another indic at i on of this s upp ort i s that all of the participants were granted permission to attend the CT tra inin g eminar where continuing educat io n credits were offered. Teacher preparat ion or con tinuin g educatio n i s an enabl i ng factor that has probably contributed s i g nifi can tly to the advances that h ave been made thus far in using computer technology in schoo ls. CI registration records from the CT training seminars disclosed that 35 % of the teachers who atte nd ed the se min ars, applied for continuing education units (CEUs) through the University of Colorado. Specific CT Training. The proximate availability and quality of th e training seminars that CI staff provided on how to use the CT curriculum were clearly a factor that enabled adoption. All but one of the participant s int erviewed indicated that they would not have us ed CT had it not be e n for the se minars. Close ly associated with this factor were the incentive s that were provided to sc hools for their staff to attend these seminars (i.e., no cost training, reimbursed substitute teacher and travel expenses, free lunch, and CEUs). The fo llowing exchange was typical of the responses received. 134

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In vestiga t or: D o you t hi n k _vou wo uld h ave u se d C o n s id e r Thi s w ith o ut atte n ding the t rai nin g? T eac h e r A : No. Teac h e r B : "We we r e jus t very impr essed w it h t he tr ai nin g and t h a t's rea ll r w h v we dec i ded ro d o it [ u se CT}. .. T eache r C: / think it g n es b a ck to t h e e mai l abo ut free i ng people t o arren d !r aining. [an e m a i l fmm a di str ic t administrator] ... in th a i we cou l d g e l t r ainin g for a day. l r v v a s r ea l big. Teac h r D : \'it lwut the !rainin g I mi g ht hal'e gotte n a litt l e bit m o r e frustra t e d and just g i ve n u p on i f." A dmi n i s tr a t or: "\Vh a t w as r ea ll y appealing was !ha t if was r esearch b ased, tha t they [ t he r esea r c h ers ] we r e in the process of l ooking a t 1h01 the trai n in g was for fre e t hat t h ey II' er e payi n g for m ileage, and that people h a d an o p po r tu n ity for c redit and that they were p aying for s ub s Thai was h u ge .... I think some people we r e p r e tt y i nspired fro m t h e t ra inin g Th e a b ov e quot a tion s d e m onstra t e th a t t eac her p repara tion a n d t e ac her a nd sc h o ol tr a ining a tt e nd a n ce incenti ve s were c l early a factor th a t e n ab l e d a d o ption of CT. S e l f -m otivatio n I D e terminatio n S e lf motivat i o n i s a t he m e that w as ex plicitl y s t a t e d onl y o n ce but it c learl y was a p rec u rsor to successful impl e m e nt atio n of CT. Th e f o llowin g quot atio n i s th e ex pli c it s t a t e m e nt o f th a t th e m e : B ecause of o ur fi r ewa ll so m e tim es t e a c h e r s h a d t ec hni c a l diffi c ulti es, i t was h a rd t o ge l in. So th a t wasfru srrOli ng for p eople. W e ha ve proac tiv e p eop l e that kinda pu s h e d thr o u g h that .... but you h a d robe r ea ll y self m o ti v at ed. 1 3 5

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Information Technology Support. IT support was i dentified as an enabli n g factor. The l e 1e! of support varied considerably from school to schoo l and the quality appeared to be personnel depe n dent. A t the top le ve l of support one teacher reported, In our schoo l well we have two computer teachers who do computer cla sses, but then we have a buildin g tech person w ho just does. right now she's doing the, s h e does all the server problem s h e does general repair and m a intenanc e of computer s.'' The quality of upport a n d the i ndication that quality is dependent upon the person who i s prov idin g it i s refl ec ted in the following quotation from the same teacher, who inci de nt ally was th e most frequent user of CT st atewide during sc hool year 2002-03. acher: "In our school/ think we're supponed pretty well, that's within our sc h ool. Novv from the distri c t standpo int I don't know that the r e i s as much support ther e Inve s tig a tor: "Why is that different in yo ur school?" Teacher: "The computer tech person in our sc h ool is really good. She really goes ow of her way t o make sure r eache rs ge t wha t they need to make thin gs work ... Dialogu e with anothe r teacher in the same district revealed th a t IT support i s not a l ways as h e lpful to teac h ers as des ir ed. Teacher: "We ha ve two t echnology support staff and they wou ldn t help me with it. In vestigator: "So, what's th eir job if they're not to help the teachers with ...... Te ac her: Well they said they wou l d h elp me if I h ave a strugg l e with my 136

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conzpute1; if my compurer, ca u se sometimes it crashes. So they'll come out there if I can't ge t ir recharged. And they 'II come our there and help me with that but they wouldn't help m e down load all that [th e plug ins]. Reinforcing Factors. These factors are the rewards or incentives that s trengthen adoption behavior. DOl theory suggests that social s uppo rt, peer influ e nce sign ifican t others, and expl i c it reinforcement are all theme s that are within the domain of re i nforcing factors. The reinfo rcing factors that are associated with adop tion of the Consider This curriculum are summari zed in Table 5. J 2. Table 5. J 1: R e inforcing Factors A soc iated with Use of the Consider Thi s Tob acco Preventi o n Curricu l um Reinforcing Factors for Adoption of CT P ositive student responses to CT CT is convenient for teachers t o use Respite from st udent behavior (students are quietly focuse d on their computers) Tec hnical features of CT website engage students in lesso n s Effective classroom management structures Positive Student Respon ses. T eac hers reported and the investigator's classroom observation verified t h at students were enthus i astic about the interactive features and confidentia l nature of the CT vvebsite. As ev i denced in the teacher quotations below stu dent react i on s to CT provided interand intra-socia l system reinforcement needed for teachers to be interested in susta i n i ng use of CT. "The students liked Consider This and at every opportunity were asking to get on the websiTe." 137

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"The kids love it, they're very positile abollt it and very excited about doing it because, of course their curriculum is only 9 weeks l ong and so each 9 weeks th ere's a new group of about 50 kids that come in and the y '1e heard from the other kids that it's fun so they 're exc it ed about doing it. On face va lu e it appears that teacher perceptions of student responses to CT were a most important reinforcing determinant for continued use of CT. But upon c l oser examination of the in terview data. it ap p e ars that the underlying convenience or ease of l esson preparation that teacher s who succe ss fully used CT had was perhaps even more important reinfor c ing factor Convenien ce After asking teachers to identify what they lik ed most abo ut CT, m a ny responded with response s s imil ar to the three that follow. I don't have to come up with the curriculum myself Uh-huh. It's educatio n al, pret(v mu c h it and it's eas y and r he kids love, th e kids are very t echnic al in this. The y like to do thin gs on the c omputer whene1er I use this student disciplin e i \ not a problem at all. And that kind of surpr i sed m e !hat s t udents came in, they sat down, !hey got on the co m p ut e rs and k n ew what they ne eded to do, and that was great.'' "Not hming to co me up with those le ssons, those acti1 i1iesfor sllldents 10 be doing .. that was one positive thing.'' I find that when students have a \\'e ll-desi g n e d web or t ec hnology curricu lum that has intrinsic motivation with it, that discipline problems go down. They stay pretty focused." 138

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Thes e quota tion s a nd comme nt s fro m t wo other te ac her s s u gg e s t tha t CT was a curriculum tha t r e quir e d minim a l l esso n plannin g was th e r efore c onveni e nt for th e m t o u se The commo n the m e in th ese comm e nt s was tha t CT i s con venie nt t o u se It m akes th e i r j o b eas i er. (Co n ve n ience was a l so ide nti fied as a re l a t ive a d va n tage to u sing CT. ) Respite from S t u de nt B e h av i or. Sin ce stu d e nt s wear h ead p ho n es a n d are e n gaged wit h th e a udit o ry, vi5u a l and tac t ile fea t ures of th e c u rr i c ulum classroo m di c iplin e i s n ot a p roblem. CT i s a mode r a tor of st u den t b ehav ior w hil e on lin e a n d therefore i s a f ac tor that reinforces teacher use. Si nce stude n ts are intrin s i cally m otiva t e d a n d s t ay focused w h e n u s in g CT, t eachers c a n enjoy a res pit e fro m w h a t are o rdinarily ph ys i cally a nd v erb ally act i ve s tu de nts. The above qu o t atio n s a nd o th e r s s u gges t tha t t eachers we l c o me the qui e t classroom t i m e th a t C T offers t o the m They do n o t h ave to b e as v i gila nt of s tu de n t class room be h a v ior a nd e n fo r ce class ro o m deco rum as th ey o rd i n a ril y do. T ec hn ical Features. T h e t ec hni ca l f eat u res of th e websi t e t ha t e n gage s tud e nt s in learnin g are collective l y a factor that r einfo r ces teach e r ado pti o n o f CT. Th e a udi o, v i d e o, c o n fide n tia l se l f -p aced a n d int e r active feat ur es a dd var i e t y t o classroo m lesson s fo r the s tud en t a n d th e teac h er. S tu den t feed ba ck a n d teac her r es p o n se to the c urri c ulum a re fac t ors th at r einforce teac h e r u se of th e c urri culum. In vestigator : "What p os i r i ve and negali ve e xperi e n ces h a 1e you had wi1h CT?'' Teach e r A: Ob1 i ous y it's !he h ands o n a n d !hey ca n go a t th e ir p ace and they c an go back and forth. /like th e idea that they feel/ike th ere's between th e m an d w h a t th ey 'r e doin g 139

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Teacher B: "Its so differe/11 than any other units that we do because there 5 so much more to it; there s games, there s video, there's questions that students need ro answe1: So l think one of th e advantages is, its rea!ly a change of pace for students." Teacher C: "One of the positive things is the hands-on material-kids get tired of me lecturing andjust going through the book and I thin k l really like it for that and just the little bit tha t I've t a lked abou t it kids hme it.'' lnvestigator: "Were there some indications of[student} excitemem?" Teacher: / mean students ask, who's on the computer first? ( f aside] You know we hm e first or we hm e second.) f'm done with my work, can l get on n ow? They really wanted to finish other work that they 11 e r e doing so they cou ld get on the computers." The compelling graphics, audio. video and other features of CT provide rewards for teachers and students a like and therefore s u ggest that it is a reinforcing factor. One DCSD teacher reported what may be a unique resource that reinforced use of the CT curriculum in th t school-the presence of a Buildin g R esource Teacher (BRT). Teacher: "/work with 3 dijj'erent teams throughout the schoo l yem; so I'm IVorking with those teams l talk to th ose teachers quite a bit. [name}, shes our school BRT and I talk ro her quite a bit just about t eaching in genera l ... and so we a lway s say, I'm doing this unit right now and this is what I'm trying to do." 140

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Investigator: ''BRTyou said, wha t is that?'' Teacher: "Our Building Resource Teacher (BRT). She helps to make sure our teachers are up on their training, that the teachers are doing okay, wlzat do we need. So she's helpful in different things.,. This in-school resource was not identified in any other school district. While not explicitly identified as a factor that influenced use of CT, BRTs (or the educator's educator) appears to h ave great potential as an enabling factor (continuing education vehic le ) that could also reinforce its use. Since BRTs were not universally availab l e and were mentioned by only one teacher this resource was not identified as a ge ner alized reinforcing factor. Effective Classroom Management Structure. Given the shortage of computers in nearly all of the schools that were a part of thi investigation teachers had to discover for themselves a c l assroom management struc tur e that enabled successfu l implementation of CT. I f a s u cces ful structure was found, then that discovery reinforced continued use. The following example of how one teacher used J 5 computers from a m obi l e computer l ab for a clas s of 30 student is a case in point. "The way I had my class set up was I had I 5 students on computers and then I had I 5 students doing the other activities that came from the website. We go t hold of tho se [the list of supplemental activities pr01 id e d on the 11ebsite] and looked through them all and picked 4 or 5 activities that the students wer e working on. While one group was on the website, and then halfway through class we switched." Thi teacher was the only t eac her who disclosed that h e had discovered a method for managing his class when there was a s horta ge of computers His se lf-moti vat ion 141

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resourcefulness or creativity in hi s pursuit of ways to m anage his class resulted in a classroom management struct ure that reinforced use of CT. Non-DOJ or PRECEDE Emergent Adoption Factors Barriers. Since each of the theoretical models that were used to develop the initial code book embodied constructs that tended to emphasize identification of factors that supported the theory as though the constructs were as et up on which dissemination efforts cou l d be built. factors that impeded or obstructed adoption of CT are reported separately in thi s section. These factors could perhaps have been discussed as factors that were the inverse of DOl or PRECEDE theoretical constructs (e.g .. relative disadvantages, disab lin g factors), but for ease of di cussion they are grouped here in one category. At the risk of some redundancy, the fo llowin g discussion focuses on the factors th at work against adoption of CT. This obstr ucti oni t approach to examinin g adopt i on factors is perhaps more consiste nt with and typ ic a l of the problem-oriented public health approach. Designing and building diffusion interventions using the problem-oriented approach consciously acknowledges the obstructions that can imp ede adoptio n of inn ovations and this approach equally important as using DOl and PRECEDE con tructs to tructure these promotional efforts. The following account of Cl dissemination efforts illustrates this assertio n CI staff offered incenti ves that addressed relative adva nt ages. a nd compatibility with teacher values. They a lso built promotional efforts aro und known predisposing and enabling factors to attract teachers and schoo l employees to the training seminars. But despite these theoretically so und approac he s, they failed to acknow ledge and 142

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respond to factors that obstructed adopt ion of CT. Two of those were the l ack of teacher preparation to effectively use techn o lo gy as an educational tool in the classroom or how to manage Internet programs whe n b a ndwidth bottlenecks become a problem. Collectively, all of the factors that obstructed adoptio n of CT were grouped under the he ading Baniers. The banier to adoption of the Consider This cuniculum are summarized in T ab le 5.13. Table 5.13: Barriers to doption of the Consider This Tobacco Prevention Cuniculum Barriers to Adoptio n ofCT Attrition (turno ver) of teachers Discontinued training program for CT Too few computers Poor access to the computers that are available in schools ( schedul ing and restricted use) Frustrat ion I Lack of IT support on technical problems Teacher perceptions of low tobacco use prevalence Social tolerance (indifference) towards tobacco use Limited school and tea che r capacity to combine technical and instructional knowledge in the classroom Questionable reliability of the CT technology cluster C ommunicatio n barriers between health education teachers and IT staff Attrition. A systemic barrier to adopt ion is the attrition or turnover of teachers who were trained to use CT. When attempti n g to schedu le interviews with DCSD s taff who attended aCT training seminar, it was discovered that 3 of the 14 staff who had been trained had been reassigned or transfened to other po itions within the 143

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district or had le f t DCSD employment entirely. Los of approximately 20% of th e trained teachers in about 15 month s is a s i gnificant l oss. At this rate of attrit i o n with n o repl acemen t, there wou ld b e n o trained te ac her in five years. Discontinued Training Program. Closely associa ted with the attrition b arr ier i s th e l ack of a sustained training program for CT. If there was a s u stai ned training prog r am those trained te achers who left for po s ition s where th ey co uld n o l o nger u se CT cou l d b e rep l aced w ith new trainee s S u s tain ed t r aini n g is of course dependent on sustained funding. Too Few Computers Whil e all of the participa n ts in terv iewed reported that they h ad computer. avai l a ble in their sc hool m os t repo r ted th a t there were too few compu ter for eac h s tud e nt in a c i a s to h ave access to his or her own computer. In some schools, teachers reported h av ing s tudent s s h are a computer (s imult aneo u s u se) as th ey u sed CT. Shared u se of a computer compromises the pri va te or confide nti a l n a ture of thi s interactive curricu lum for the st u dent, w h ere sensitive question s abo ut cigarette use are aske d. Students might be influenced to a nswer CT program qu es tion s to sat i sfy what they b elieve the s tud e nt who i s s h aring the computer might wan t to see S haring the compu ter a l so e lim inates the a udit ory portion of the program and the tacti l e as p ects of the c u rr iculum fo r the s tudents w h o are observing. Sharing a computer eli mina t e tw o of t hr ee learnin g sty l e approac h es Lo s ing the aud it o r y a n d tactile mechani s m s of CT dimini s h es the appeal of the CT program t o s tudents, compromi es program fide lity, a nd probably the potenti a l effectiveness of the c urri c ulum Poor Access to Computers. Not h av in g access to e nou g h co mput ers for each s tudent in a c l ass to have their own a nd not h avi n g computers readily avai l ab l e (e.g., 144

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easy sc h e duling of the l ab) are sig nificant banier s to adoptio n of CT. The following quotation s provide the ev idence for the se assertions. In ves tigator: "What are some of the barri e rs t o u sing CT?" T eacher A: "We ha ven' t been able to ge t into the compute r room and we share it w ith th e high sc h oo l and othe r middl e schoo l s ... ' T eac her B : Ou r problem i s schedu ling, ll'e 'r e s u c h a sma ll school t ha t our problem i s scheduling, t o b e able t o get in there [the computer l ab]. .. Fru s tration I L ack of IT Support. Whil e IT suppo rt was ide ntifi ed as a n enab ling fac t o r that e n co ur ages u se, a t the other end of t h e IT s upport s p ec trum l ack of IT support i s a s i gnifica nt b arr ier to adop tion of CT. A seco nd teacher in the same sc hool di trict where a teacher r e port ed that his IT su pport was really good ' reported h e r tot a l lack of IT s upp ort: In ves tigator: "So you didn t have e n o u g h compute r s for an e ntir e class. I s t hat ri g ht ?" T eac h er: Y es I didn t have eno u g h compwers for an y o n e of m y classes ,for them t o all be in there. A n d then I thou g ht well, I could have them doing other thin gs w hil e halfare maybe on the but the n it got to th e point of downloading all that info rmation o n the r e Inve stiga tor: "And the t ec hn o l ogy staff there co uldn't do that for you? T eac h er: "No, I wou ld have had t o do that all on m y own Investi ga tor : Ok ay T eac h er: So that w as ver y frustrating for me." 145

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This teacher expressed the sen tim ents of m any teachers who were un s uccessful in either trying to use or sustaini n g u e of CT when she said that the l ack of computers and having no IT support wa fru s trating." This quotat i on did not require interpret a tion or an effort to d i still its meaning. Her frustration was not only c learl y evident from her words, but a l so from the emotional rise in her voice. This quotation disclo sed fiustrarion with getting the technology to function a intended was a significant. although not always articu l ated, them e that was a barrier to adoption among many of the teachers interviev ved. Adequ ate IT s upport cou ld have mitigated thi s frustration. Tobacco use prevale nce was acknow l edged as being generally very low in the middle s chool population. It is po ssib le that this perceived low preva lence may have had a ubtle neg a tive influence on adoption. "We' r e not ha ving too much of a problem wirh c i ga r ette smoking h ere at our sc hool ... "Not many kids smoke cigaretTes fimn what yo u can see.'' There was however, no textual evidence from these interview s to support this hypothe sis and no probing questions were asked about it. It i a hypothesis that cou l d be t ested in future studies. Social Tolerance of Tobacco Use. While there is a state law requiring schoo l s to be tobacco-free (no tobacco in any buildings on sc hool grounds, o r at school sponsored events), some schools still tolerate tobacco use, in vio lation of that law. Two rural schoo l participants reported that parents smoke outside of school-sponsored sports events 146

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"At football games people smoke outside b y their cars and they don r have anybod y running around tellin g th e m the y can't, even thou g h there are signs all over the plac e and people l e ave the gym for a ba ske tball game and go outside and smo k e." Indiff erence towards tobacco use as a communit y public h ealth problem is tantamount to pas ive encouragement. Limited School a nd Teacher Capacity. The potential influence of community and schoo l district tobacco control policies, continuing education policie a nd Colorado Teacher Certification Standard Seven ( Knowledge of Technolog y) on adoption of CT and o ther t ec hnolo gy-drive n curricula ha s not been fully re alized. It appears t hat sc hool and teac her capacity to apply technolo gy in the educationa l environment wa inad e quate for effective adoption of CT. C apacity in the classroo m domain requires an interface of the technical and instruct i onal domains The ins truction a l d omai n require s hum an knowledge a nd skills i n combination with th e physic a l hardware and software needed to support computer -based learning In other words, c a pacity i s t he embodiment of hum a n a nd h ardware re so urce s needed for effective stude nt learning throu g h technology. H owever it i s defined, the lack of capacity i s a barrier to ado ption. Ques tionable Reli a bility of the T ec hnolo gy. The questio n a ble reliability of the CT technology cluster i s an important and perva sive barrier that impedes adoption. The following quotation addresses this concern. Note that in the c lo s ing phrase the study participant u ses the word "rely." In vestigator: "What are some of the adv a nta ges to non -t ec hnolo gy curriculums?" 147

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Teacher: "There's a little more, I want to say flexibility, in s tandard curriculums .. Um, 1 g u ess, I mean, l guess theresa little more .flexibility when you're using some of the other programs (non-technology programs), you don't have to rely on the technology." T eac her need to know that a le sson wh ich is planned will be delivered as planned. A observed in the CT c l assroom, students can become disquieted and perhaps unruly if l essons do not go as planned. Te a c hers want conven i e nt and reliable cunicu l a that are easy to access with readil ) ava ilable too l s for implementation and maintenance. It is important to note that when the t eacher, quoted immediately above, was referring to "the t echno! gy," he was combinin g the CT program and the Int ernet as one e ntity. Once again, the concept of a "techn ology clus ter" arises. D etermini n g the boundaries arou nd a technol ogy or where one technology ends a nd a nother begins is an intr actab l e problem. The a bove quotation illu st rates how the boundaries between CT and the Internet were blurred. Barriers imp eding adop tion of CT could arise when any element of the "technology" fails. Consequently, CT is dependent on the p e1formance of what R ogers calls a 1 echnology cluster. He defines the hardw are in a technol ogy cluster as .. a tool that embodie the t ech nolo gy as a materi a l or physical object ' ( 1 995, p. 235). In this case, the hardware is the Internet and the reliability of it software interface (Internet se r vice providers, telephone, cable and sate llite connections), are all important factors that influence perceived reliability of the Consider This software. Consequently, thi s intertwined, highly dependent relationship between the hardware a nd softw are determine the perceived reliability of CT. Yet, the hardware and the hardware interface are independent (p ublic utilities ) th at are outside of the control of the developers / innov a tors of the 148

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Communicati on B a rriers. Communi ca tion barrier s b e tween health ed uc at i o n teachers a nd IT or keyboarding t eac h ers a pp ear to obstr u ct optimal s tud e nt access to computers in so me sc hools. Thi s b arr ier was so perva sive that it even influ e nced access in a sc hool where there was an ade quat e n umber of computers for a n e ntire c l ass. Some co mputer or keyboard teachers ap pear to hav e taken a po s ition o r impos ed a p olicy that th e computer l ab i s the ir domain a nd th a t it n eeds to be protected from u se other th an t ech n ical computer in truction or keyboardi ng. Th ese po s i t i o n s or unwritten policies, whi l e probab l y int ended to protect the operation of co mput e r s fo r I T or keyboarding c l as es, h ave alienat ed some health educa tion tea c her s w ho wan t t o u se th e computer J a b s for instructional purpo ses with curr i cu l a like CT. Since the IT teac h ers h ave posit ional a nd proximate aut horit y over the compu ter l abs, so m e h eal th t eac her h ave not b een ab l e t o access comput e r s for their cl asses a nd felt powerl ess to influ ence these re strictive policies. The followi n g brief case his to ry offe r s a noth e r bit of evide nce s uppo rti ng the h ypothesis that communicati on barriers exi t betwee n IT a nd he a lth educat ion staff in so me sc hool s On e s tud y parti ci p a nt a young h ea l t h t eac h e r who expresse d confide n ce in her ability to u se computers, was not aware of the sec u rity firewall that was operational on her sc hool' s computer n e twork. She tri ed for over two hour s t o down l oad the plug-ins necessary to ope r a te CT. D e p it e her grea t frustrat i o n s he did n o t purs ue technic a l assi t a n ce f r om the sc hool IT s t aff per so n because s he e ith e r fe l t es tr a nged fro m or h ad never built a relat i onship with the IT s upport per son. B ase d on thi s a nd o th e r te ac her inter v iew s, teacher r eluctance to ask for IT s taff assista n ce ma y a l so h ave re s ulted in part from the compartmenta l ized str u c ture of sc hool s ( i.e. h ea l th educatio n team, soc ial s tudie s team, IT team). B ased on the interviews 149

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and the J ack of data tha t indicated a n int e raction IT staff and he a lth teacher s do not routinely communicate. When the y do communicate, the l a n g u age of their respective profe ssio n s differ s enough th a t communications may not a lw ays be effective. Unwritten policies (firewall requirements) and communication a nd organization barrier s lik e the se appear to h ave created environments where IT was difficult t o integrat e wit h h ea lth educatio n in structio nal act i vities. Whil e communications problems b etween IT staff a n d so m e health educ at ion teach ers h ave resulted in underutilization a n d adopt ion of CT, if there were a s uffici e nt number of computers in the chool s, providing b roader avai lability, this wou l d not be a problem Age B arr i e r The only demographic factor that was mentioned b y s tud y participants as a b arrie r to adopt ion of CT was age and thi s factor was mentio ned by only one he a lth education t eac her. "Some of u s older people h e r e in o ur 50's (and we're trying t o l e arn it) we probably half of us pro babl y don't u se a ll the faciliti es tha t the compute r has t o offer Cen s u s data s ugge s t th at age may b e a s i g nific a nt and va lid barrier. Sixt ynin e p e rcent of p e r so n s ages 9 -17 u se th e Int e rnet (a marker for comput e r u se) comp ared to 3 7 % of p erso n s older than 50 years of age (US Census, 200 I). D a ta from a s tudy conducted b y th e U.S. Departm e nt of Education fo und that t eac her s with fewer years of teaching experience were more like l y t o feel prepared t o u se computers or the Intern e t than th e ir more ex p erie nced colle ag u es (USDOE, 1 999) Thi s inverse corre l ation between Int erne t u se and age i s prob ably due to a gener a t i onal effec t and the d a ta fro m this s tudy s u gges t th at age i s not uni versa lly influenti a l on u se of CT. 150

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The data do suggest however, that there is a tendency for older teachers to be less comforiable with u ing computers for instructional purposes and for students to be more comfo11able with computer technology than teachers. Attitudes. Teacher's personal attitudes about their jobs and/or computer technology appear to influence adoption of CT. The following attitudes were eit her mentioned specifically or were inferred from the text of the interviews: apathy about one's job; comfort with computer technology; confidence in one's ability to succe sfully use CT; a nd motivation to change or adopt a new curriculum that is technology-b ase d (i.e., try CT and per s ist if problems arise). Apathy. One teacher offered hi op ini ons regarding barrier to dissemination of the CT website in the following dialogue. Inve s tigator: Did o1her 1 eache rs in your school u se CT? Teacher: "There wasn't a whole lot of r ea lly r eq uest s 10 do formal in se rvice for i t so we didn t go ahead with it." Investigator: "Wh y would you say that is?" Teacher: "Apa thy Apathy." Investigator: "Is if apathy about teachin g in general or abou t web -based curricula?" Teacher: "/think it w as just something nell added to the curricula for a bunch of people who were pretty happy with what they were doing." This teacher's response suggests that change (using a new curricul um ) and the extra effort that is as ociated with it may encounter apathy or indifference as a barrier. Therefore, promotional efforts that outreach to and encourage teachers to adopt CT must be done using methods that excite a nd motivate teachers to tr y it in their classrooms. 151

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Comfort. C omfort w ith computer t ec hn o logy was disclosed in th e ur vey portion of this st ud y as a factor th at influenc ed ado pti o n of CT a nd the t ex t of interviews in thi s qualitat i ve p ort i on of th e study reinforce th a t finding. One of the few s tud y participants who h e l d an adm ini strative position observed that "Adoption really depends o n h ow co m fo rt able teachers are wi th technology, a nd change." Teacher characteristics identified in this study. such as know l edge, skills, experience, and confidence in using computer tech n ology can be combin ed to for m a broad on truct, "comfort." T he comfort con s truct or theme was a s i gnifica nt factor in the adoption rate of CT. Teachers who were "comfortable" w ith computer technology were more w illin g t o try CT and more w illin g to persevere ( inclu ding r eac hin g out for technic a l assistance) tore o l ve those problems. Self-mot i vation. ince CT i s not a required course in any Col orado schoo l teachers m u t be self-motiv a ted t o learn h ow t o use this approach and then to implement it in their classrooms There wa s no perfo rm ance accoun t a bil ity syste m in place in any sc h oo l or sc ho o l d i s trict th at exp l icit l y requi1ed that a t eac her u se CT. While there were many policies that predi p osed or e n ab led teacher u se of CT, none of th e study participants disc l osed that a sc ho o l or sc h oo l district policy required CT use. Capacity. Capacity is defined as 'innate potentia l for growth, development, or accomplishment.'" (Dictionary, March 2004) In this study, capacity was an emer ge nt constr u ct that refers to th e potential to grow, develop, a nd accomplis h adva n ces in u se of computer technology. It could be defined more specifically as the combined resource of teacher attitudes towa1 ds their profess i o n ins tru ctiona l a nd t ec hni ca l k n ow l edge and skills in the u se of computer technolo gy a nd th e ava ilability of 152

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and access to computer hardware This convergence of t wo previously identified factors (ins t r u c tion a l knowledge I skills a nd availabi lity / access t o computer ) into one con s truct, "capacity," e mph as i zes how indi s tinct these factors really are. The co llecti ve hum a n resource (sc hool ad mini s trator s, prin c ipal s, health t eac h ers a nd IT s upport staff and teachers) was the fo und atio n upon which adop tion of new t echno l ogy was built. However, witho ut adeq u ate availab ilit y of and access to compu ter hardware, this k n ow l edge was no t effective l y realized or a ppli ed in man y c l assrooms. This collective human re so urce is categorized h ere (correctly or incorrect l y) as an att itude. Critical M ass R ogers asse rt s that c riti cal mass occurs at the point a t which e nou gh individu a l s h ave ado pt ed a n i nno va tion so that the innov a tion's f urther rate of adoption become s se lf-ustaining. ( R ogers E. p 3 1 3) The promise of a c ritic a l m ass was very grea t within the D CS D since fo urteen staff were trai ned to use CT. Ho wever, it appears that failure of the dev e lopment of an effect ive, sustai n ed diffusion network, impeded u se of CT beyond tho se w h o were trained Th e fa ilure of the development of a cri tic a l m ass was due t o a numb e r of facto r s : a ttriti o n or turnover of trained p erso nnel ; l ack of s u s t ained CT tr ai nin g initiative; insuffic i en t o nsit e IT support for teachers w h o were n ot comfortable w ith computer technology; a nd l ack of s u s tained, effect i ve o utr each efforts by CT project s taff that capitalized on sc hool diffusion n e tworks. 153

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Summary of Qu a lit ative Findin gs Cl ass room Observa t io n T h e fin dings from the classroo m o b servat i o n w h e r e CT was b e in g u sed b y 3 0 seve nth g r ade s tud e n ts wer e as follows. S tud e nt s were ca p t i vat e d by t h e CT prog r a m o n ce they were l ogged o n and th e h e adp h o n e s i n place T he aud i o, v i deo a n d i nt e r active func t ion a lity act i ve l y engaged them in t h tob acco u s e prevent i on a n d ed u c ation les ons. Whil e l ogged on t o CT, students were quiet a n d s t ill except for eye m ove m ent across t h e comp uter c reen a n d h a n d movem e n ts to manipul ate t h e m o u s e. Studen t com m nt s s u gges t e d th at th e cont e nt was n ew a nd informat i ve a n d th a t they l i ke d the tailorin g a nd p rivacy fe a tu r es o f C T Wh i l e th e teach e r o f th e observed cl ass de m o nstrated exceptional c l ass r oom m a n age m e n t skill s in the comput er lab. classroo m m a n age m e nt for teachers l e s co m fortab l e w ith computer tech n o l ogy would mo t like l y b e c h alle n g in g Teac her a n d stude n t f ru s tr a tion was ev i de n t when techno l ogy prob l e m arose T h ese p ro b e m s a n d t h e assoc i a t ed fr u s tr atio n are ike y b anie r s toco nti nued impl e ment ation. P a rti c ip a n t Int e r v iews R e l ativ e Ad va nt ages. Th e s tud y p art icip a nt int e r v iews di sc lo se d th at th e r e l ative a d va nt ages over prese nt l y u sed t o b acco educatio n c urri cula we r e : 154

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CT provide s up-to-date inform a tion ; The online, int erac tiv e delivery m ethod of CT i s appealin g to stude nt s and teachers and the teachers liked the modul ar l esson str uctur e; Teach ers l iked tha t stu dents co uld learn a t their own p ace a nd that it ap peal s to mu ltipl e le arning s t y l es; Teachers indicated that CT was convenient ( i .e., lesso n planning was minimal cuni cu lum was free and readily accessible). Compatibilit Y Fac t ors. Compatib ilit y factors ide nti fied in the int e rvi ews included: CT (as do other tobacco prevention cunicula) was compatibl e with sc h oo l communit y a thl etic values; Teachers valued the h ands-on or t actile aspect of CT; CT was compatib l e with teacher intere sts i n and\ illingness t o role model nonsmoking b e h avior: The tr a inin g se minars offered by CT innovators (c hange age nt s) are con s i s t ent wit h teacher, sc h oo l d i s tr ict a nd s tate s u ppor t for continui n g ed ucation Compl ex ity Fac tors. Th e compl exity of CT was ack nowl edged as ea y to u se by those teachers who s u ccessfully lo gged-on a nd u sed it in th eir classro oms. H owever, th ose teachers w h o were n ot s uccessful a t logging-o n defined complexity thr o u gh express ion s or term th a t are reflective of the t ec hn o l ogical n ature of the cuniculum. Those t erms include t erms that are not u sed commonly b y t eac h ers firewall s, downloading, b a nd w idth b rowser, e t c. These term s reflected th e complexity of CT, especially for th ose te ac her s who were un successful downloading 155

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the plug-ins, the first step in using CT. These terms were often expressed with a re a l stro n g sense of fru tration. Their frustratio n was not necessarily with CT but with the technology cluster (Internet, ISP, In ternet connection, computer) that encompasse the realm of CT. Complexity is defined as a function of teacher knowledge of and comfort wit h technology and their determin ation to find solutions to technology barriers. Observa bility. While CT i s avai lable for free on the Internet, it s observabi lit y once it i s operational is very limited. I so lation of schoo l computer l abs from other cla ssroo ms limits the observability of CT within a sc hool and s ince a relatively small number of students access it at a n y given time. the word-of -mouth or communication netvvork or "buzz" needed to create demand i s al o restric t ed. Isolation of one schoo l from anot her prohibit the observat i on of successfu l c l assroom experiences Social networks between schools appear to be nearly non-exi s tent between schoo l s, especially among sc hools in different sc hool districts. Research outcome on CT have n o t been reported so outcome observations h ave not been available to validate its effect i veness. H aving outcome data is especially important in schoo l enviro nm ents where proven effective curricula are the only curricula tha t some schools will permit. The atio n a l Training Partn ersh ip an organization l a unched in J 996 with support from the Centers for Di sease Control and Prevention h a a list of proven effective tobacco education curricula and CT is not on this list. This further inhibits its observability. (Nat ional Training Partnership 2004) Social System Member Characteristics. Persons in admin i strat ive positions (sc hool principals and district administrators) influenced adoption of CT by assert ing po sitio nal authority and requiring that teachers atte nd aCT tr ai nin g semi nar or by 156

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gran tin g permission for teachers to a tt e nd. In the case of the DCSD, an administrator decided that that district wo uld have all of its he a l th education teachers trained to u se CT. This person was a n ear l y adopter a nd by virtue of her po s ition was a n opin i on l eader. Opinion l eaders w h o a re in po s itions of authority can a l so influence adopt i on informally by sharing their experiences and so luti ons to technical problems encountered whe n moving toward s implementation. In DCSD a critica l mass of teachers who were u s ing CT was crea t ed by the training of fourteen sc hool dis tri ct personnel. H owever, other factors that cou l d have increased the rate of adopt i o n and rendered CT se lf-sustaining were not i nft uential. One of those factors was the social network. It was not strong enough to build a critica l m ass. Predispo s ing Factors. School distric t policies on health educat i on and tobacco u se, state and local l aws that discourage sale and posse s i on of tob acco, state standards for teacher certificat ion and teac her int erest in a n d pur uit of alternative instr uctional methods were the key predi s posing factor that provided the rationale or motivation for u se of CT and for tobacco use prevention curricu l a in general. Enabling Factors. Computer availability and accessibility, teacher know l edge of and skill with computer technology access to peer network s, support for continu ing educat i on, specific CT training t eacher se l f-motivatio n a nd information technology support were all fac t ors that enab l ed implementation of CT t o take place in sc h oo ls. R einforci n g Factors. The factors th a t reinforced u se of CT were: positive st ud en t responses to CT; its co n venience for tea cher u se; it provides a re spite for 157

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teacher (student behavior is moderated); teachers observe that stude nt s are active ly engaged in the l essons; and, an effective teacher-empl oyed classroom management str uctur e. If an effective means of classroom delivery of the CT curriculum is identified by teachers (e.g., wireless computer Jab, when computers are limited ass i gn students in shifts on the computers) they are more likely to continue using it in the classroom. Barriers. The factors that imped e d adoption or di s semination of CT were attrit i on (turnover) of teachers, l ack of a su tained training program for CT to rep l ace those who disc o ntinued use too few computers available for entire classes to use, poor acce s s to the computers that are available in school (scheduling and restricted use), f rustration with technical problem s, soc ial tolerance of toba co use, limited schoo l and teacher capacity to apply instructional knowledge in the techn ical environment, questionable reliability of the CT technolog y cluster communication barriers between health educat i on teachers and IT sta f f and a ge of the health education teacher Attitudes. Teacher attitudes toward technology, teaching and CT influenced the frequency of CT u se. The specific att itud es that were identified has having influence on use were apathy (indifference or readiness to change), comfort with technology, and teacher self-motivation to resolve technical problems encountered while trying or using CT. 158

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Conclusion The findings from the cia sroom observation and the participant interviews summarized at the close of this chapter are factors that promoted or impeded adoption of CT. They were not disclose d s t atistically in the survey findings. While the adoption factors identified in thi s chapter are pecific to the CT curriculum, they provide clues to diffu s ion of Intern et -b ased health education curricula. Further investigations into diffu s ion of this type of t echnology and the adoption factors identified here will help adva nc e use of Internet-based curricula in sc ho o l classrooms and specifically serve to verify the validity and reliabi lit y of these adoption factors. 159

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CHAPTER6 DISCUSSION The effort that went into the di semination of CT in Colorado schools was well-planned and for a brief time resource intensive. The findings from this study validated the dissemination strategies u s ed b y CT dissemination project staff. For exampl e, CT project staff offered system incentives to schools (e.g., reimbursed substitute teacher and travel expenses) and persona l incentives to schoo l staff (e.g., continuing education credits) in order to attract attendance at training seminars. They offered and, when requested, provided fo llo w-up technical assistance to teachers who had operational problems with CT. On the other hand the incentives provided and the follow -up offered did not assure that CT was utilized t o its fullest extent. The incentives were useful in attracti n g teachers and other school personnel to atte nd the training seminars, but did not ass u re classroom implementation. Building a more effective bridge from dissemination (promotion and training) to adoptio n (c l assroom use) through maintenance (sustained use) cou l d have improved the rate of CT adoption. While the evidence of substantial teacher enrollment in CT training semi n ars suggests that dissemination baniers were overcome, the bridge between dissemination and adoption needed to more effectively acknowledge and address barriers or obstr ucti ons to adoption. In retrospect, the offer of technical assistance made by CT project staff was too passive a s t rategy to be effective. Many teachers simply tried to l og-on, enco unt ered a technical problem, and never tried it again. A proactive, individualized fol low-up plan that contacted trained teachers in their 160

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sc hool s after th ey h ad tried CT in their own sc h oo l wou l d very like l y h ave increased ut ilizat i on. Three conclu sio n s th at Rogers mad e in a study of family planning adop ter s are relevant here: I ) Incenti ves inc rease th e rate of adoptio n of a n inno vat i o n ; 2) A lthough incentives increa e the q u a nt ity of adopters of an innovatio n the quality of adoption deci i o n s may h ave been relatively l ow. limiting the i n t ended consequ e n ces of adopt i on; a n d 3) Adopter incentives l ead to adoptio n of an inno vation by individuals different from those who would other wise a d opt"' ( R ogers, I 995), In this st udy, there was ev i dence to s u ggest that the incentives t o adopt CT a ttr ac t ed teachers a nd schoo l systems that would n ot ot h erw i se have b ee n ab l e to afford the cos t of a full-day tr a inin g semi n ar Conversely, for so m e of th e teachers w ho a tt e nded the CT tr aining se min ar the close proxim i ty to home or sc hool and th e continuing educatio n credits m ay h ave been th e prim ary reaso n s for th e ir int e r es t in CT. Th ese teachers m ay not h ave been act i vely contempl ating a cha nge in their t o b acco educat ion c urri c ulum w h e n th ey registered for the trainin g se min ar, s i gnifying that they were not ready to active l y take steps to c h ange after the t ra inin g sem inar. A proactive follow-up effort w h e r e teach ers w ho were t rained to use CT were co nt acted in their schoo l s ( t e lephon e a nd /or personal visit) m ay h ave moved so m e of these te ac h e r a l o n g the DOl decision continuum closer to the adoptio n implem e nt atio n a nd m ai nt e n a nce s t ages. The asse t sb ased approach that rel i e d exclu s i ve l y on DOl or PRECEDE constructs t o design and implement the CT di sse mination effort may h av e blinded 161

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CT project staff to the need to address potential barrier (liabilities) to adoption a nd implementation. Theoretically sound assets-based strategies were u ed exclusive l y in the design of th e CT dissemination p l an. Rogers' adopt i on characteristics (i. e., relative advantage, compatib ility, etc.) were used to guide development of the promotional and marketing (dissemination) efforts to attract teachers to the training eminar The e adoption characteri s tic were used by CT project s t aff during the training seminars to encourage use of CT. The complexity of the curriculum and the anticipated technology cluster barriers were also described to training seminar attendee However, these barriers to adoption were not adequately accounted for with an active outreach strategy after the CT training seminars. An unrecognized risk of building a dissemination plan built exclusively on assets-based constructs, from models like DOl and PRECEDE, was that the significance of counter-adoption factors (barriers or liabilities) related to diffusion were not sufficient l y addressed. CT project staff invested their plan exclusive l y in the assets that are embodied in these theoretical constructs s ub consciously anticipating that addres ing these factors would compensate for known technology barriers to adop tion and implementati on of CT (e.g., inadequate n etwork bandwidth to run CT, bandwidth bottlenecks, etc.). Had adequate time and resources been available to CT staff, a pilot-test training seminar with follow-up to a small group of teachers would likely have disc l osed the individual and system barriers that impeded classroom adoption and identified methods for managing these problems. For example, the consequences of not being ab l e to download plug-ins needed to run CT could have been observed and a plan for circumventing this barrier developed and implemented. 162

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Assets-based approaches u sing DOT and PRECEDE constructs can however provide guidance for the development of effective diffusion strategies if barriers (liabiliti es) are acknowledged and factored into dissemination plans. Diffusion of Innovations Adoption Characteristics Relative Advantages Other than th e up-to-date information (content) provided by CT, the principal advantages to the CT curriculum identified by interview participant related to the unique aspects that were a product of the technology. The online, int eractive delivery method, the student's abi lit y to learn at their own pa e, and the convenience of minimal lesson planning were all factors th at were a product of the CT technology cluster. The CT curriculum i s a student-centered educational experience that is focused on the individual learner not on the teacher's presentation of material. By removing the focus from the teacher, CT provides an educationa l experience that i s t a ilored to the needs and int erests of the student, easier for the teacher to deliver and compatible with teacher and sc hool district int erests in st ud ent-centered learning. Compatibility Factors By virtue of it an ti-tob acco use mission, CT i s compatible w ith schools that value athletic performance and with non-smoking teacher int erests and willingness to be good role model s for st udents. These factors how ever, do not make it unique from any other tobacco use prevention curriculum. The compatibility factors that 163

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are perhaps more uniqu ely related to CT are the tactile or hands-on ature of the curriculum. The student-centered approach that appea l s to multiple le arning sty l es was an impmtant feature that attracted teacher attention and support for CT. The interviews with teachers suggested that they wanted to be assured that they l eft n o stude n t behind in the learning proce s. Thus, the appea l t o multiple l earning sty l es was compatible w ith teacher value Since CT w as introduced in C o lor a do with an opportunity for continuing education credits, it appealed to teacher and s chool district intere s ts and ne e ds for continuing education credits and the intrinsic interests of educators to sustain their personal learning. On the negative side of the compatibility equation, CT was often incompatible w ith teacher knowledge of and comfort with technology and chool and schoo l di trict technical capacity The speed with which information could be transmitted across the Internet lines was a barrier with which even the most computer literate teachers strugg l ed. I f teachers were able to overcome the technical problems they encountered when u ing CT, then they perceived CT to be compatib l e with their int erests and were successful to varying degrees with imp l ementation, adoption a nd maintenance of CT. Complexity Factors Complexity was associa t ed with s u ccess in u sing CT. It was a l so a factor th a t wa entangl ed w ith the technology cluster. Teacher perceptions of CT's complexity were uni versally associated wit h the technology that was u sed to transmit it to the classroom, not n ecessari l y the CT program itself. Statements regarding compl ex ity 164

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nearly all mentioned problems downloading software (p lug-in s) f rom th e Int e rnet bandwidth problems, browser r elated issues, etc. There was a ge n e ral inability to separate the CT program from the technology used to deliver it to the clas sroom. Frustration was th e mo s t frequently used adverb when describing the complexity of CT. The frustrat i on of getting CT to function properly o n school Int ernet connectio n s that were often compromi sed by bandwidth bottlenecks prevented many te achers from advancing from th t e mporary u ser category to the trial user and adopter categories. While the complexity of this technol ogy cluster (downloading plug-ins, bandw i dth problem etc.) prevented many teacher s from adopting CT, those teachers who used CT successfully indicated that the program was easy to use. Trial a bility Factors Consider This i s accessib l e on the World Wide Web, therefore, in the stric t es t definition of tr i a l abi lity, anyo n e with access t o the I nterne t can try it. On the CT home page there i s a hyperlinked text box entitled "Thinking abo ut u sing Consid e r This in your classroom? D EMO.'. This portal to aCT demonstrat i o n and freque ntl y asked questions page makes it easy for t eac h ers to discover the adva nt ages to u sing CT. This Web page also describes why this typ e of educ at ion is important how the CT site provides personalized information, what types of things st ud e nt s will be doing, and h ow to int egrate the curriculum int o the c l assroom. Also on th e home page i s a button that opens to the registration page for t eac her All of these feat ure s make it fundamentally easy for teachers to tr y CT before actual impl e m entation in their cia rooms 165

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The in centives offered to Colorado te achers and sc ho o l d i str ict s extended the trialability to teachers by providing ed ucation a l I training semi n ars throu ghout th e state These incentives however, may h ave attracted teac her and othe r educators who were not necessarily con templating a change in their tobacco ed u cation curr iculum who attended si mpl y because it was c lose to home or sc h oo l or w h o were just looking for a way to accumulate tate-required conti nuin g educati on credits. Making it eas y to register and attend the training seminars may have optimized trialability for teachers, but the concept of trialability needed to be exte nd ed beyond the t r a inin g se m inars to the classroom environment. Follow-up technical a sista n ce u s ing outreach strateg i es wou ld like l y have increased trialability amo n g the 40 % of the teachers who never t ried CT once they returned t o their sc h oo ls. Observability Factors Observability, or the degree to wh i c h the results a r e observab l e, was limited by the limi ted peer interaction within teacher communication networks a nd lon g term s tud ent o utcome (smok in g uptake) that was not readily observab l e. In small pruticipating schoo l districts where there were only one or two middle schoo l s little enthusiasm was generated about CT. Th ere were a lso relatively few health teachers for the crit ical mass needed to suppmt an effective communi cations or soc i a l network to promote observab ility School computer l abs are isolated from other c l assrooms and one schoo l fro m ano th er, inhibiting observability. The compl ex ity of th e t ec hnic a l lan g u age assoc i ated wit h W e b-b ased programs was r e l at i ve l y new to teachers, creating a communication barrier th a t impeded observabi lity. 166

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Communication Networks The survey or quantitative portion of this study disclosed that schoo l diffusion or communication networks were very effective in disseminating knowledge of CT, but the interviews di clo ed that these networks less effective in promoting implementation or adoption. There was no evidence of intra-school district communication after the training eminars and little evidence of inter-school district communications about CT. The CT promotional brochure announcing the training seminars created a ''buzz" in schools where more teachers heard about CT through their network than actually saw the promotiona l brochure. The survey data provided evidence suggesting that the buzz may actually have been more about the incentives offered to attend the training than the CT curriculum it self. School communication networks to deliver information about CT were largely ineffective. Had an effective, post-training communication and technical assistance network been active, teachers like tho e who encountered firewalls as the defining barrier to CT access, would more likely have been able to obtain peer assistance in resolving this barrier. Teachers who were unable to find ways to manage bandwidth bottleneck problems that caused computers to lock up would have heard from those teachers who h ad found solutions. While the incentives were successful in activating school personnel communication networks, creating knowledge of CT, attracting teachers to the uaining eminar and to trying CT curriculum, there is littl e evidence to suggest th at they moti vated broad adoptio n implementation and maintenance of CT. CT project staff m ay h ave failed to cap it alize on the potential of communication n etworks by 167

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doin g such thing as creating a follow-up lis t serve where te ac her s could s hare their ado pti o n a nd implementati o n experiences o r ac tiv e l y contacting te ac her s a nd /or providin g t ech nic a l ass i t a nce visits after the tr ai ning se min ars Building on the co mmuni ca tion n e tw o rk s th a t were opened throu g h th e CT training seminars could h ave paid di vide nd s of increa ed diffusion of th e CT curriculum. Critical Mass CT did n o t become se lfs u s t a ining in part because a critical m as of teachers who adopted a n d implemented CT was not achie ed. A critical mass was not a ttained becau se th e re were too many barri ers t o utili zation, especially for t hose teachers who did not p ersist in finding so lution s t o techn ical barri e r s Many teachers h ad t o reso l ve technol ogy probl e m s by them se l ves o r a t l east fe lt tha t th ey had to do thi s Teacher unwillingness to seek t ec hnical ass i s t a nce m ay at l eas t in part been due to their reluctance t o ad mit th at they were h av in g problems using thi s techno l ogy. Pro-innovati o n bia ses imply that knowledge of th e technology i s n ecessary for advancement in thi s pro fess i on. T o admit s h o rtcomi ng s w ith know l e dge o f and s u ccess with this technology m ay h ave impeded t he development of the critical ma ss of teach ers needed fo r CT to be broadly adopted. Te ac h ers h a d littl e or no reinforc e ment for u se of CT among their peer s, a factor that could hav e contributed to the devel o pment of a critica l ma ss Innovation Developm ent The C o n s id er Thi s curricu lum was develop e d u s ing proven effective s tr a tegie s for tob acco u se prevention and education a nd instr uctional de s i g ner and educator 168

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input. The innovators knew that this innovation was on the leading edge of the computer technological capacity of many schools, yet developed this curriculum to advance instructional classroom technology in health education. CT bandwidth and computer requirements were more advanced than the capability of some sc hools and schoo l computer network s and it required more knowledge of computer technology th a n many teachers possessed. Th e innovators of CT, at lea s t s ubconsciou s ly, may have hoped that pro-innov a tion bia es and the high education a l level of teachers would motivate or challenge educators to prevail over technology gaps. While many teachers rose to this ch al lenge man y more simply aba ndoned use of CT when they encountered problems that required a n additional investment of their time Dissemination After more than five hundred mailings and targeted phone calls to se lected sc hool personnel, 147 Colorado educators received training on how to access and u se CT. Thi s evidence t h a t suggests that dissemination efforts and the resultant knowledge of CT was at least mod erate ly s uccessful. This success did not however re s ult in adoption. Forty pe rcent of thi population never tried CT in their classrooms and therefore did not advance to the adop tion s tage. Adoption Sixty percent of the educators trained to use CT adopted it at least briefly. The adoption decision was defined as having tried it in at least one or a few classes. Sixty percent of the teachers trained to use CT were identified with this group. One third of 169

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this group of teachers failed to advance to the next stage in the diffusion process. These teacher s were s ucc essfu l a t downloa ding the plug-ins, had adequate access to computers in their sc hool had tri ed CT but were frustrated e nou gh by bandwidth, computer l ab sc h ed ulin g difficulties and the extra time it took to initi ally se t up the computers that they did n o t tr y it for very lon g. Implementa tion Thirty-nine percent of the teacher s implemented CT ( u sed it for multiple class periods for one or two class groups) in the c l assroom. Appr oxima t e l y half of thi s gro up (21% of all trained teachers) who impl emented CT, did n ot advance to the confir m ation s tage. These teachers the temporary users, had re olved or successfull y downloaded the plug-ins required to run CT, l earned to manage bandwidth problems and had adequate access to computers in their schoo ls, but did not adva nce to the confirmation or maintenance s t age. Comments from the interview data s u ggest that the failure to sustai n or maintain u se were due to conti nu ed difficulties in gaining adequate computer lab time for their classe and persistent bandwidth problems Maintenance Approximately l teacher in 6 (17.5% ) surveyed indi cated that they had use CT for three or more c l ass groups. This group (adopters) demonstrated that they had confirmed u se of CT and were in a mainten a nce mode. These teachers had successfull y downloaded the plug-in s, had adequate access to computers, had goo d IT su pport in their sc hool s uc cessfu lly managed the bandwidth problems, overcame the frustrations associated with u s in g CT and developed a cla ss room management 170

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structure t h a t was satisfactory for students an d teachers. They h ad s u stai n ed u se of the inn ovat i on, had overcome implement at i on barrier s that precluded or impeded use of the cuniculum and had confirmed its relative advantages, overcome its complex i ty, observed its val u e, and con c lud ed that it was compatib l e with their teaching s tyle and va lu es. This group was perhaps the most ready to m ake a c h a n ge in their tob acco ed u cation curriculum. Thi s qu a ntit a t ive characterization of t h e Stage of Diffu sio n must however, be qu a l ified s ince it represents a simple cross-sectional view of diffu s ion. It does n ot acco unt for decis i o n s to con tinue adoption, adopt CT at a l ater time discontinue use or conti nu e rejection. E ac h of these decision point s cou l d change the d i ffusion outco m es for CT a time passes from t h e date of ini tia l d i sse minati on. It i s however, most lik e l y that w i thout reinforced dissemination effort s a n d upd at ing of curricu lum content, CT will n ot beco m e w id e l y implemented a n d m ai n tained in Colorado schoo ls. PRECEDE Adoption Characteristics Predi s po s ing Factors Laws, policie s a nd teacher certification sta ndard s established the rationale or moti vation for imp lement atio n of tobacco ed u catio n c urri cu l a like CT. These sta t e ment s of community or soc i e t a l rule s and va lu es guide the act i o n s of schoo l di s trict administrators and teachers as they pur s u e the f ulfillm en t of th e profess ion a l responsibilities t o which they are entrusted A s part of these re s pon s ibilitie s, this study disclosed th a t t eac h ers are always in purs uit of better or alternative methods for 1 7 1

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conveying the educational materials that th ey are expected to provide for tudents. CT offered and provided an alternative means for delivery of tobacco use prevention ed uc ation material that was satisfying to teacher s and st ud ents. Enabling Factors Human and physical resourc e s allowed the motivation for de l ivery of the online CT curriculum to be realized. Strengths and weaknes es in this resource pool were responsible for the a doption or rejection of the CT curriculum. Those strengths and weaknesses were largely in the human resource domain, with the exception of limited computer availability and bandwidth connectivity, resources that were in the physical or technical domain. The human resource that influenced adoption inclu ded teacher know ledge, skill and comfort with computer techn o l ogy, access to peer network that supported adoption, teacher and scho I supp011 f o r continuing education, training avail a bility for CT, teacher motivation and determination, and avai l abil it y of information tech n ology support. R e infor cing Facto rs Those factors that rewarded or prov ided continued incentives for implementation of CT after it was adopted b y teachers reinforce it use. lf an effect i ve classroom management structure th at compensated for the shortage of and limit ed access to computers and the questionable reliability of the CT technology c lu ster was discovered by teachers then teachers who we re ab l e to successfully access CT were likely to continue using it. They were lik e l y to continue use because students l iked the CT program a nd teachers observed that students were active l y 172

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engaged in CT le ssons since it appealed to multiple l earning styles. An added benefit to teachers was that while CT was being used by students the clas room, usual middle schoo l student behavior was moderated. They were quiet and focused on the computer screen thus providing teachers with a respite from the usual noisy and active middle school classroom. Emergent Adoption Characteristi c Through the analysis of the urvey, observationa l and interview data barriers to adoption. implementation and maintenance of CT emerged. These factors were reported outside of theor e tical contexts because the assets-based approach of both DOI and PRECEDE constructs does not specifically reference tho se factors that could be lia bilitie s in the adoption equation. Adop tion (A) / Implementation (I) I Maintenance (M) of CT is a function of sc hool human and technical assets and liabi l itie (banier ) + the resource of the change agent. This relationship is represented mathematically by the fol l owing simple equati on: AIM= ](school assets+ liab ilities)+ (amo unt and durat i on of change agent assets+ liabilities) While this equation is an overs implification of a compl ex interaction of human and physical resource s it demonstrates the interchange of the schoo l a nd the change agent (C T project staff). School and change age nt assets were described previously in this chapter under the headings of DOl and PRECEDE Adoption Characteri s tics. The schoo l a nd change agent lia bilitie s are di cussed here. 173

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I Attrition or. turnover of teachers who were trained to u se CT emerged on the liability side of the adoption equation. While this barrier to adoption is a naturally occuning event in any empl oyment e nvironment, lo ss of teachers to employment changes was not accounted for in the implement at ion plans of the change agent. This lack of planning for the se event was due in part to the nature of the one-year grant that funded dissemination of CT in Colorado schools and the re s ult an t lack of resources for s ustained training activity. Too few computers and limited access to computers are s imilar but unique problems. Too few computers is a function of chool resources. As mentioned in an earlier chapter, Colorado schools have a student to computer ratio that i s better than the U.S. ratio but school in genera l do not have enough computers for each tudent to ha ve full-time access to one. Management of access to computers that are presently avai lable is perhaps a factor that can be improved. Access to computers in Colorado middle schools i manag ed by an IT staff person or keyboarding or computer teacher. Access to computers appears to be dependent on the management structure th a t is established by these individuals some of whom are perhap s over l y controlling and prote c tive of the hardware in their computer labs. These computer teachers establish scheduling systems that restrict or limit u se of the computer lab. Other school computer personnel have established management systems th at appear to be satisfactory to teacher s who desire use of the computer lab Technical problems associated with the CT technology clu ter often resu lt in frustration among teacher who are less sk ill ed or comfortable wit h technology. These problems are compounded when a schoo l does not have adequate or responsive IT support or when the change agent does not provide proactive, sustained technical s upport after initial training on use of the technology. 174

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Social tolerance of t obacco use in th e community may be an und erlying barrier to effective adoption of CT. The degree to which a community tolerates tobacco use may influence the v igor w ith which teachers pursue adoption of tobacco use prevention curricula. Limited school and teacher capaci t y to imp lement a technology-based curriculum is a bundled combination of environmental a nd human resource barriers that includes knowledge of the technical and instructional aspects of how to use online curricu l a in the educational I classroom setting and the availability and accessibility of computers in school Data from the study suggest that capacity to u se computer technology in the c l as room will increase as comput ers a r e availab l e and easier to access Perhaps one of the most important barriers to adoption of CT is the questionable reliability of the CT techno l ogy cluster. The CT program itself had been running successfully for 2-3 years prior to this study, so any problem that were e n countered with the technology were with the technology that supported the operation of the program (i. e., the Internet connection). The static var i ab les in the s upport configuration included th e Internet service provider, the schoo l computer server, the school district's network or the bandwidth capacity of the Internet connection. The dynamic vari ables included the amount of traffic that was on the schoo l Internet connection at a n y given time, and the CT page that the c l ass is on at the tim e problems are encount ered I f a class arrives s imul taneously at a page that demands high b and widt h then the comput ers are at risk of lockin g-up or of disconnecting fro m th e Internet. 175

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Synthesi s of Findings Table 6. 1 combines the major findings of this quantitative a nd qualitative study by each of the guidi n g theoretical models and the factor that emerged that were outsi d e of the l itera l int erpretation of the DOT a n d PRECEDE constructs. Tab l e 6.1: Factors th a t Contribute to Adopt ion Implementation and Maintenance of the Consid e r This C u rriculum Diffusion of Innovations Factors Communication networks In-school; and intra-district. PRECEDE Model Factors P r edisposing Factors 1) School district policies on health education and tobacco use; 2) State and local laws that discourage sale to and possession of tobacco by youth; 3 ) State standards for teacher certification ; 4) Teacher interest in CT as an alternative instructional method. 176 Non-DOl or PRECEDE Emergent Factors Barrier Fac tor s 1) Attrition (turnover) o f teachers; 2 ) D iscontinued training program for CT; 3) Too few computers; 4 ) Poor access to the computers in schools (scheduling and restricted use) ; 5) Frustration I lack of IT support on technical problems; 6 ) Social tolerance (indifference) towards tobacco use; 7) Limited school and teacher capacity to combine technical and instructional knowledge in the classroom; 8 ) Questionable reliability of the CT technology cluster; 9) Communication barriers between health education teachers and IT staff; 1 0) Teachers 50 years old and older may not be inclined use CT. ___J

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Table 6.1 (Con tinu ed) Diffusion of PRECEDE Model Factors Non-DOl or PRECEDE Innovations Factors Emergent Factors Incentives to be trained on Enabling Factors Attitude Barriers use of CT 1 ) Computer availability a n d 1) Apathy toward change: accessibility; 2) Discomfort with computer 2 ) Teacher knowledge of and skill with technology; computer technology; 3) Lack of self-motivation; 3 ) Teacher access t o peer networks; 4) School and teacher capacity 4) S upport f o r continuing education; implement technology-based 5 ) Spec1fic CT trainin g ; curricula. 6 ) Teacher motivation I determination; 7 ) Information technology support. Relative Advantages Reinforcing Factors Critical Mass (factors related to include: 1 J Positive s tuden responses to CT; failure to achieve a critical mass) 1 ) provides up-to-date 2 ) CT is convenient for teachers to use; 1) Attrition; information; 3 ) C T is a respit e from usual student 2 ) Lack of sustained trai n ing for CT; 2) online method of behavior; 3) Insufficient onsite IT support; delivery; 4 ) Technica l features of CT engage 4) Lack of sustained outreach by CT 3) allows f o r d ifferentiation students in lessons; project staff. of student learning 5 ) Effective classroom management styles; structures. 4 ) convenient for teachers to use. CT is Compatible with: 1 ) school athletic values; 2) student and teacher preferences for tactile learning experiences; 3) teacher interests in rol e modeling non-smoking behavior; 4 ) teacher support for continuing education 177

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Table 6.1 (Contin u ed) Diffusion of PRECEDE Model Factors Non-DOl or PRECEDE Innovations Factors Emergent Factors Complexity of CT is defined in terms: 1) technical domain Internet accessibility, firewalls, bandwidth, downloading, Reliability of Internet access was a problem; teachers with limited knowledge of and comfort with computers were unsuccessful; 2) curriculum domain easy for teachers and students to use. Tria/ability of CT: 1) available on the World Observa bility of CT: 1) obstructed due t o relative isolation of computer labs and classrooms; 2 ) individualized nature of CT curriculum obstructs ability to observe outcomes. Social System factors: 1) innovative district administrators can influence adoption; 2) Opinion leaders who are early adopters can influence adoption. 178

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Hvpothesis Test H ypot h esis: "Teach ers w h o adopt CT are more lik e l y to A) self-identify as earl y adopters. B) possess personal characteristics, C) participate in social systems, and D ) ob erve e n v ironmental and inn ovation-specific characteri stics assoc i ated with the DOI and PRECEDE model." Evidence from the su r vey portion of thi st ud y suggested that self-classified early adopters wer e not more likely t o ha v e adopted CT ( P art A of the h ypothes i s). While they more lik e l y to h av agreed to be i nterviewed for the interview portion of thi study they did n o t adopt more freque n t l y than later adop t ers. This concl u s i o n must be qualified since s e l f-classifi ation of adopt i o n practice s is s ubj ect to proinnovation bia s Parti cipants may not have accurately c l assified themselves. Misclassification results in skewing of adopt i on class i fica t i on data t the right and therefore does not provide e nough discrimi natio n i n the data to detect gro up differences. The interview port i o n of the study verified that se l f-cia sificat i o n of behavioral adopti on practices m ay not be a valid and r eliable method for classifying t eachers. For example, o n e teacher w h o classified herself as a n early adopter of computer technology could not even successfully download the plug-ins required to run the CT webs it e. Teachers who self-repo rt ed as earl y adopters were not more like l y to adop t the CT c u n iculum. The following personal a nd communi catio n s sys t e m s characteri stics were tested to determine their assoc iation w ith frequency of CT u se: how they h eard about CT; incentive factors that influenc ed registration for a trainin g seminar; person a l a nd sc hool district adoption c h arac teri stics (e.g., early adopter, l ate m a jority etc); co mfort le ve l with computer technolo gy; formal tr a inin g in u se of computers or Intern e t ; 179

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the year that the participant recei ved hi s or her undergraduate degree; the presence of a n d advanced degree: gender; and age. None of th ese variables was statistically associated with adoption of CT (Parts B of th e hypothe s i s). This l ack of a posit i ve finding from the s ur vey data to s up port the h ypothesis may have been due to the small sampl e size in thi s study, and to the pro-innovation bia s th at po s iti ve l y skewed th e adopt i on c l as c ification data. The we i gh t of e iden ce from the interview data however, suggest that th e most infl uent i a l personal ado ption characteri s tic s were: teacher interest in a lternative ins tructional me tho d that allow for differe nti ation of s tudent learning styles; CT i s con ven i ent t o access and free to use; positive student response to u sing computers in schoo l : availabi lit y of sc hool IT support and persona l relations between te ac her s and IT s t aff, and; o rgani za t iona l (schoo l district and sc h oo l admini tr a tion ) support for use of comput ers in the classroom and the resultant ap plicati o n of sc hool district resources. There was limited but co n vincing ev idence sugges ting tha t soc i a l / communi catio n s ystems can promote disse mination but m ay on l y be effective within a sc hool district ( P art C of the h ypothesi ). Te acher informat i on and soc i a l n etwo rk s h e lp ed create know ledge about CT th a t resulted in its disseminat i o n H owever, these socia l systems did not promote adoption decision s, implementation or confirmation of u se across sc ho o l districts. One interview p articipan t reported that h e h ad rejected the CT curriculum after having problems accessing it a nd th en l ater adopted it after l earning from a n other teacher in a faculty meeting w ithin the sa m e sc h oo l di s tri ct, how to m a n age the t ec hni ca l problems he h a d e ncoun tered. No simi lar communication accoun t was recorded in thi s in vest i gatio n that disclosed p ost-trai nin g 180

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communications acro ss sc hool dis tri cts. This data suggest th a t partic i pati o n in social sys tem s influences adoption pr actices only within a s ph e re of communication w h e re there i regular inter actio n Th e interview data di sclosed that tho se te ac her s who adop ted, i mpl e m e nt ed a nd were maintaining u se of CT were mor e likel y to describe: the re l ative advant ages of CT; how it was compatible with th eir professional inte r ests and pedagogic approac h es to tea hing; how i t was easily t r i ed, and; how the complexity of th e program and the technology cluster were easy to manag e The teac hers who had s uc cessfully impl emented C T also found ways to re-i n vent th e innova ti o n to fit their te ac hin g sty le a nd the co mputin g e n v ironm en t wi th in which th ey wo rked. While they ack nowl edged th e barriers to implementation, they described effective use of sc hoo l district IT re so u rce a nd good communications w ith IT s upport staff. These teachers more frequently de sc ribed environmental facto r s t h a t predi s po sed (e.g schoo l di s trict ad mini st r a t ive s upp ort and resource allocation), enab led (e g., l oca l IT s upport ade qu a t e access t o computers) a nd reinforced (e.g., stude nt feedback, s u ccessfu l classroom management) adoptio n and implem e nt ation of CT. T eac her s who adopt e d imp l e m e nt e d a nd were maintaining CT were more lik e l y to h ave observed th e po s iti ve or asset -b ased con s tru c t s from the DOl and PRECEDE mod e l s ( P ar t D of th e hypoth e i s) While they o b served barrier factors. th ey were more likely to de sc rib e them as challenges th a t they h ad to overcome. 181

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CHAPTER 7 CONCLUSIONS This research found that individual and environmental factors can influence dissemination and adoption of a web-based tobacco education cutTicu lum. While it collected data from individual teachers and administrators, it disc lo sed that many of the factors that influenced dissemination and adoption of the CT curriculum were in the environmental domain. For example, while teacher knowledge and skill with computer technology and teacher motivation I determination to use the CT program were imp ortant individual factors that influenced adopt i on, school e n vironmenta l factors such as too few computers or poor access to computers were factors that potentially superceded those individual characteristi s. It is therefore important for change agents and educators to consider both in dividua l and environment a l factors when planning and implementing technology-based curri cula in schoo ls. The DOI and PRECEDE model s provide excellent frameworks for planning and evaluating dissemination and adoption strategies. However, strict reliance on the constructs in these theoretical models when planning dissemination (e g., promotion of relative advantages, getting input from se lf-id entified early adopters) may blind change agents to the barriers that can significant l y impede adoption and impl ementation. Individual teacher characteristics (e.g., teacher interest in a lt ernative instructional methods, teacher perception of positive student response to usin g computer s in schoo l ) can provide the motivation for adopt ion of technology-based 182

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classroom curricula, but the sc ho ol e n v ironment and sc ho o l policies (e.g reliability of the school's te c hn o l ogy cluster, syste m s th at regu l ate or schedu l e computer use) enabl e this motivation to be realized. Since time is a precious commodit y for teachers and struggles with technol ogy can take more professional or personal time than some t eachers are wi llin g t o devote (e.g .. downloading plug-ins on 30 computers in a computer lab cou l d take many hours). many teachers will abandon their efforts to use technology if problems are encoun t ered in the environmental realm. It appears that many teacher are easi l y disco ur aged from u sing computer s for instructional purposes if hardware access or utilization prob lems are encount e red Previous un satisfactory experie n ces w ith u sing comput ers in the c la ssroom may eve n discourage many teachers from trying new computer innovations. R eco mm endat i ons for Policy Change School administrators s h ould assure th at teachers h ave easy access to computers for instructional purposes and tha t t echnica l s upp ort for use of computers is available to ass ur e that they will succeed with the ir efforts. Assessmen t s of the effect i veness of present gate-keeping syste m s that regu l ate computer l a b orato r y access wou ld be a first step toward im p r oved computer access. Do current compu ter l ab schedu l ing systems faci lit ate or impede u se of computers for instructional purposes? What schedu lin g sys tem s optimi ze stude nt access to comput e r s? What charac t erist i cs of these sys tems and comput e r l abs tend to promote st ud e nt access? What other sc ho o l -specific baniers to u se of comput ers for in struct ional purposes exist a nd how could they be e limin a ted? 183

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Since IT s upp ort s taff in sc ho o l s s upp o rt the in structio n a l effo rts of t eac h e r s, sc hool ad mini stra t ors could require that t hese personnel regularly con duc t cus tomer satisfaction surveys to assess teacher and st udent satisfaction with the computin g e n v ironm e nt a nd to identify methods for improvin g that e n vironment. Operational plans to support c l assroom use of comput ers cou l d l ead to more u se r fri e n d l y comput i ng enviro n ments and better trained t eachers. Teachers can be effective users of computer if t h e computin g environment i s easy to access, rel i ab l e and s upported by IT staff. Otherwise on l y t h o e teacher s w h o are techni cally savvy will succeed. School a dmini s trators are therefo r e, challenged to ide nti fy the resou r ces (hardwa r e, software, IT support, broadband con n ection) ne eded t o create and support a productive instr u ct i o n al computi n g environment. Computer l aboratories b y th e ir n ature are not a l ways readi l y available for teacher and stude nt u se. T hey are most often "down the hall.'" away from th e i mmediate instr u ctiona l I learnin g enviro nm e nt. C l os in g thi s gap is p e rh aps one of t he most c ignificant s t ep that can be taken towards improved use of computers i n the classroo m One promising model for clo s ing the gap betwee n th e c l assroo m a n d the computer l ab was discovered during this investigat i o n the mobile co mputin g l ab. The m obi l e l ab described by one of the st udy participants was a cart that contained 1 5 l aptop compu t ers with w i re l ess Internet connections. The cart was rolled into the classroom w h e n a nd w h ere it was needed. IT staff, wit h teacher input a n d as i sta n ce, assured that the software was operationa l a nd fully funct i oning before it was moved to the c l assroo m Thi s model deserves se riou s consideration as a mean s to improv e u se of computers in sc h oo l s Teach e r tr ain in g o n c l assroom m a nagement and pedagogical te c hniqu es w hen utili zing on l ine curricu l um could h e lp prom o t e effective u se of computer 184

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technology a nd online curri c ula. The training tha t was pro vided b y CT Projec t staff is a n example of thi s type of tr a inin g but i t mu st be sustained if it is to effectively influ e nce teacher attitudes and practices regarding c l assroom use of computers. Training efforts s hould directly address teach e r attitudes and beliefs regarding classroom use of computers and their traditiona l instructional styles if they are t o be effective (Hannafin, Savenye;1993). Testing of teacher technical and pedagogic capac it y to de l iver on lin e programs is a n important fir s t step for sc hool districts that are committed to use of online curric ulum Teachers who are deficient in these skill areas coul d be e ncouraged to compl e t e continu in g education c l asses to provide them with the skills and confidence to effective l y u e computers a n d online curri cu la. H ir i ng qualifications for teachers cou l d require so m e level of cert i fication in computer use. Teacher preparation in titutions cou l d add or redirect their instructional effo rt s to include use of onlin e c u rricu l a as a component of teacher preparation curricu la. Teacher preparation a n d /or certi fication policy chan ges could be impl e m ented at the state a n d l ocal school district levels. Future R esearch Future research into effect i ve dissemination strategies for web-based curri cula sho uld preliminarily u se qualitative methods (focus groups, interviews, observation s) t o id entify spec ific barri ers t o dissemination. B efore designing and testing on lin e cl assroom c urri cula, ed ucator s, web-designers and program evaluators s h ou l d invest i gate e n v ir o nm enta l predisposing, enablin g, reinforcing and barrier factors that could influ e nce the fide lit y of the curriculum a nd ultimately influence expected 185

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outcomes. Awareness of the se factors will provide change age nt s with information to help maximize the effect ivene ss of fut ure online cuniculum dissemination efforts. Focus g r o up s and other qualitative methods could help identify sc hooland schoo l district-specific barriers to dissemination of online curriculum in the cl assroom. While u se of theoretical models like PRECEDE and DOI can guide sound theoretical dissemination strategi s, the) may lead change agents to be complacent and to focus sole l y on the assets side of the dissemin tio n equation. thu s failing to address the liability side of the equati on. Active int ervention efforts to address barriers to dissemination disclosed in thi research (e g .. lack of sustai ned technical support after training, limit ed teacher ca pacit y to impl ement technology-based cunicula) could be tested agai n s t more p ass i ve approaches, such as the approach that was used in the 200 1-02 dissemination of CT in Colorado schoo ls. Systematic, active, post-training session o utr eac h stra tegi es by change agents providing technical assis tance (e.g telephone calls to teachers on a bi-monthly ba is) would likel y increase adoptio n of online school curricu lum. Conducting pre-dissemination assessments of teachers and administrators to determine whether or not they are contemplating a curr iculum change, prior to future dissemination efforts. may help change age nt s focus their effo rt s on the most ''changeable" teacher thu s making the se effor t s more efficient and effective. Similarly, a n assessment of schoo l technical capacity (h um a n and technic a l resources) prior to dissemination may h e lp focus curric ulum dissemination efforts on schoo l s that have the greatest potential for adoptio n. Deve loping and testing of such assessment instruments is an area for future rese arch. 186

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Testing th e effective n ess of mobile computer l aboratories w ith o utcomes s uch as teacher and student satisfaction, technical func t ioning, ease of acce s maintena n ce costs, operational problems (sc h edu lin g, mobility) and security is a potenti a lly important area fro investigation. Creating social/com munication networks of potential curricu lum adopters may ha ve potential to promote adoption of onli ne curriculum. While this i s a more passive approac h that change agents co uld use it may be a very practic a l one since funds a r e often n ot available to change age nt s for active outreach to or fo llow-up with teachers who are tr ained to u e s pecific online curricula. Since man y health education teachers are i so l ated from their peers, particularly in small rural schools creat in g a s upp o rt networ k, where curriculum adoption uccesses and prob lems cou l d be shared. holds potenti a l to promote more widespread adopt i on of on lin e c unicula. Establishing an email l ist erv or a buddy system approach where a techno l ogy-compete nt teacher is partnered with a teacher who i s le ss competent cou l d be an effective me a n s of promotin g curriculum ado ption. 187

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APPENDIX A Consider This Follow-Up Evaluation This questionnaire is intended to gather information from Colorado educators who attended a training session for t h e Consider This online tobacco education curriculum in the Fall of 2001. The pur pose of this study is to evaluate how well this curriculum has been disseminated to Colorado schools. Your input is essential to the success of this study, so p lease take a few minutes and answer the following questions. Return t he q u estionnaire in the enclosed post-paid envelope Your responses will be ke p t confidential. 1 My records indicate that you attended a training seminar on the Consider This (CT) Online Tob acco Education Program sponsored by AMC Cancer Research Center i n the Fall of 2001. Is this correct? ( Check one.) D Yes (If YES continue with this questionnaire ) D No (If NO please do not comp l ete this questio n naire but return it in e n velope p r ovided.) 2. Check the category that best describes your position in your school district in the Spring of 2002. ( Check one.) D Teacher Admin i strator Principal D D D D Information technology staff Othe r (Describe) ________________ 3. How did you initially hear about CT? ( Check .ill! that apply .) D Brochure or poster rece ived in the mail 0 Principal told me D Another teacher in my school told me D A district administrator told me D A computer technology staff person told 0 Don t remember D Other Describe) _________________ 188

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4. What factors influenced your registration and attendance at this tra inin g seminar? (Ch eck ill! that apply ) 0 The training seminar was free 0 Our schoo l needed a new or supplemental tobacco education curriculum 0 Substitute teacher expenses were reimbursed 0 Travel expense (mileage) was reimbursed 0 The training session was relatively close to my home or school 0 Online instructional as pec t of curriculum was appealing 0 I was required to go by a supervisor or administrator 0 AMC provided lunch at the seminar 0 CT is compatible with national educat ion standards 0 CT is a student-directed tailored interactive curriculum 0 CT is free for schools to use 0 Cont inuing education credits were offered 0 Other ___________________ 5 The training seminar for the CT program was ... . (Check one.) 0 Very helpful 0 Helpful 0 Unhe l pfu l 0 Very unhelpful TEACH ERS ONLY-QUESTIONS 6-10 -ALL OTHER SKIP TO QUESTION #11. 6. How frequently did you use C T in your classes? (Check one.) 0 Never (GO TO NEXT QUESTION.) 0 I tried it for one class period only and did not use it again} 0 I tried it for a few class periods and did not use it again SKIP TO 0 I used it for multiple class periods for one class group Q. 8 0 I used it for multiple class periods for two class groups 0 I used it for 3 or more class groups 189

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7 If you never used CT why not? (Check all that apply.) 0 I could not fit it into my class schedule 0 My school did not have the appropriate Internet connection SKIP 0 The techno logy was too cumbersome to use TO 0 I was uncomfortable using technology in the classroom Q. 11 0 It was too difficult to arrange computer lab time for my classes 0 I did not have time to learn how to use it 0 The support mater i als w ere not useful 0 Other ---------------------------------------8 Did you use CT during the 2001-2002 school year? (Check one.) DYes 0No 0 I don t remember 9 Did you use CT dur ing the 2002-2003 school year? (Check one.) 0 Yes 0No 0 I don t remember 10. If you used Consider This overall how satisfied were you with the CT program? (CIRCLE one number on the scale i f you used CT (CHECK HERE if you never used CT. 0 1 2 3 4 5 6 7 8 Not at all Satisfied 190 9 10 Completely Satisfied

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11. When a new or innovative idea I technology comes along, when does your school distr ic t adopt it? (Check one.) 0 We are usually among the first to try it 0 We usually try it after a few others have tried it 0 We usually try it after most others have tried it 0 We usually try it long after most other people have tried it 12. When a new or innovative idea I technology comes along when do you adopt it? (Check one .) 0 We are usually among the first to try it 0 We usually try i t afte r a few others have tried it 0 We usually try it after most others have tried it 0 We usually try it long after most other pe o ple have tried it 13 How would you describe your comfort level with computer technology? (Ch eck one.) 0 Very Comfortable 0 Somewhat Comfortable 0 Somewhat Uncomfortable 0 Very Uncomfortable 14. Have you had any formal training in the use of computers and/or use of the Internet? (Check one.) 0 Yes (If Yes Describe the training ___________ 0 No 15. When did you get your undergraduate college degree? Year --16. Do you have an advanced degree? 0 Yes (If YES Degree _______ 0 No 191

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17 Gender M 0 F 0 18. Age: Years ---19. During the past 30 days, on how many days did you smoke c i garettes? (Check one ) 0 0 days 0 1 or 2 days 0 3 to 5 days 0 6 to 9 days 0 10 to 19 d a ys 0 20 to 29 days 0 All30 days 20 What is your ethn ici ty (or race)? ( Check one ) 0 White 0 Black 0 Asian / Pacific Islander 0 American Indian/Alaska Native 0 Other [specify] 21. Are you Hispanic or Latino? (Check one ) 0 Yes D No D Don t Know 22 Are you willing to help further with this research by being interviewed on the telephone for 15 to 20 minutes? (Check one.) D 0 D Yes (Please check YES to help me proceed toward my doctoral degree.) No Don t Know If you are willing to be interviewed please enter your name phone number and e-mail address where you can be contacted during the summer months Your name and contact information will be held in strictest confidence. (The human 192

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subjects aspects of this research have been approved by the Human Subject Research Committee at the Univers i ty of Colorado Denver.) Should you agree to be interviewed I will contact you to arrange a convenient time. I promise to take no more than 20 minutes of your Summer. You need not have used Consider This to be eligible for the interviews. For this study to be successful I need to interview users and non-use rs, adm i n i strators principals and information technology staff who attended one of the train i ng seminars I hope you will he l p me with th i s study. It will help determine the fac t ors that i nfluence dissemination of online instruction a l curriculum in schoo l s Your Name : ______________________________ __ School Phone : ( ) __ -__ H o me Phone Number: ( ) Summe r e-mail address: Please r e t urn this que s tionna ire in the enclosed postage pai d envelope to: Walter Young [Home address] 193

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APPENDIX B Con s i der Thi Int erv i ew Guid e Participant name: ___________ Date: _______ School: __________________ __ Thank you for agreeing to help with this resea rch. Once again the information you prov i de in this int erview will he l p me descr ib e the dissem i nation process for Conside r This and identify the fac t ors that i mpede rei nforce and enable adoption and implementation of the Consider This ( CT) onl ine curriculum 1. Tell me about t he t obacco use among DCSD middle school students 2 How has the School Distr i ct responded ? 3 Have you hea r d of the onl i ne Consider This tobacco use prevent ion curricu l um? YES NO If YES have you used the CT curri c ulum in the classroom? YES NO __ N / A ( admin i strator ) __ NO ( New Teacher 2002-03) If YESTell me how you first heard of CT. (explo r e lo cal vs non-local communication channe l s and socia l system networks : e.g. who? when? how? and why?) PROBES-What promotional materials did you see regarding the CT curr i culum? What happened in your school or school district to encourage use of CT? What do you do to teach your students about tobacco use? How often did you or others that you work with use the CT curr i culum last year? Have you used the CT curriculum this year? Did you attend a training? 194

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I f N O If subject has never heard of the CT curricul u m ask them: What do you do to educate your students about tobacco use? Why did you choose that curriculum or approach? Why did you not use the CT curriculum? 5. How did you initially hear about CT? 6. How well did the training semi n ar prepare you to use the CT program? _Very well Somewhat well Not well at all 7 Would you h ave used CT w i thout having attended the training? Yes No _No (If NO why not?) ______________ 8 Who among DCSD employees do you consult w it h most f r equently on health education matters? Name School 9 What outside sources of health education information do you consult with most frequently? Name Organization GO T O #14 I F AN ADM I N I S T RATOR 195

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TEACHER QUESTIONS 10. Have you had any experiences implementing Consider This (or other Web-based curriculum) that were especially positive or negative? A. Please tell me about the last such incident. What happened? PROBESWhen did this occur? What was especially pos i tive or negative about that experience? What led up to the incident? Who was involved? How did their invol v ement influence the outcome? What was the outcome of the incident? What do you believe to be the most important factors that influenced the outcome? B Any o t her positive or negative incidents implementing CT? What happened? Same PROBES as above. 11. If asked by teachers or administrators in other school distric t s to describe the CT curriculum, how would you describe it? PROBESHow w ould you describe the CT content? How would you describe the CT technology? How would you describe student r esponse? How would you desc r ibe DCSD technical support for CT? 12. Describe the advantages to us ing the CT tobacco use prevention curriculum 196

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13. Describe the advantages to using non-technology-based to bacco use prevention curricula. 14 How often did you use the Internet in your health classes before using the CT program? ever Once or twice before 3 or more times 15. How often have you used an Internet-based h ealth curriculum in your health classes before using the CT program? Never Once or twice before 3 or more times 16. Overall, on a scale of 1-10 (with 10 being completely sat isfied) how satisfied were you with the CT program? Record number 17. Will you be using CT in any of your classrooms during the remainder of this school year? YES NO If YES. can I obs e rve one of these cla sses and ask your class about their experience using CT? WHEN? GO T0#24 197

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ADM I NISTRATOR QUESTIONS 18 From an administrator's perspective how would you describe CT to others? 19. From an admin is trator s p e rspective lis t the advantages to using A technology-based tobacco use preve nti on curricula like the CT tobacco use pre v entio n curriculum. 20. List the adva nt ages to using non-technology-based tobacco use preven tion curricula. 21. Describe how CT fits with instructional values of DCSD teachers 22. Describe how CT fits with values of IT personnel? 23 When a new or innovative idea I technology comes along when does DCSD ad o pt it? READ CHOICES We are usually among the first to try it (early adopters) We usually try it after a few others have tried it ( early majority) We usually try it after most others have tried it (late majority ) We usually try it long after most other people have tried it (laggards) GO TO# 24 198

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POLICY QUESTIONS (ALL PARTICIPANTS) 24. What tobacco use prevention curriculum did DCSD use prior to CT? 25. Why did DCSD decide to adopt CT last year? 26. What tobacco use prevention curricu l um is DCSD using this year? 27 Describe DCSD policies regarding teacher I staff continuing education 28. Describe the policy regarding continuing education during work hours. Incentives? 29. Describe the attitude of administrators regarding continuing education during work hours. 30. Describe the attitude about computer-based instruction among administrators. 199

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31. Describe the attitude about computer-based instruction among teachers 32 How many times during the past year have you taken continuing education classes during school hours? Never Once Twice 3 or more times SUBJECT CHARACTERISTICS {ALL PARTICIPANTS) 33. W hen a new or innovative idea I technology comes along when do you adopt it? READ CHOICES I a m usually among the first to try it (early adopters ) I usually try it after a few others have tried it (early maj ority ) I usually try it after most others have tried i t (late ma j ority) I usually try it long after most other people have tried it (laggards) 34 How would you d e scribe your comfort level with computer technology? READ CHOICES Very Comfortable Somewhat Comfortable Somewhat Uncomfortable Very Uncomfortable 35. When did you get your undergraduate college degree? Year -36. Do you have an advanced degree? Yes_ No (If YES Degree _______ 200

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37. Have you had any training in the use of computers and/or use of the Internet? Yes No (If YES, Describe training ) _______ 38. How often did you use the Internet as an in-class instructional tool before using CT? Never Once or twice before 3 or more times 39 How often do you use email? Never _A few times per month Once or twice per week _Daily 40. Desc ribe yo ur previous use of health educa tion curriculum (su bstance abuse tobacco use) 41. Smoking History Never smoker Former smoker How long ago did you quit? Years Current smoker Months How many cigarettes per day? _____ Cigarettes How many years? Years 42. Is there anything else about dissemination or use of the CT curriculum in your school that you would like t o tell me? 43 Gender M F 44. Age : ____ Years 45. Race : White: African American : Hispanic : __ Asian : __ Thanks for helping me with this research! 201

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APPENDIX C E mpl oyee Con se nt Employee consent to participate in the study entitled -" Understanding factors that influence the dissem i nation of Web-based health education curr icul a 1) Who is conducting the study? This study involves research being done by Mr Walter Snip Young (pr i ncipal investigator ) with perm i ssion fro m the Douglas County School District ( DCSD) He is a doctoral student at the University of Colorado Denver and works at The Cooper Institute Golden Colorado The I n sti t utional Rev i ew Boards a t the Univers i ty of Colorado Denver ( UCD) and The Cooper I n s t i t ute (CI) hav e approved this research p r oject. 2) Why is this study being done? The goal of th i s study is to discover the factors that influence the use of the Web-based tobacco use preven t io n health education curricu lum, Consider This (CT) a product of Cl. Identifying and understanding these factors will help educators and resea r chers advance the use of information technology in classrooms 3) How will this study involve me? We are asking you and other DCSD employees to take part in the research project entitled Understanding factors that influence the dissemination of Web based health education curricula Your consent to participa t e allows the principal investigator t o record and analyze your impressions or observations of the factors that infl u ence use of the CT curriculum Mr. Young will be interviewing approximate l y 30 DCSD pe r sonnel to record impressions or observat i ons related to the research topic. He will be asking questions related to the curriculum itself the school environment, teacher preparedness and the information technology environment. In a separate part of this study he will be observing classrooms where CT is being used and asking questions of three or four students 4) How long will my participation in the study last? This study requires an interview with Mr. Young for approximately 30-60 minutes You may be called by Mr. Young after the interview, to clarify or expand on a response(s) to his questions. 202

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5) What are the benefits, if any, of joining this study? Researchers at the PEW Trust reported that, there is a substantial disconnect between how students use the Internet for school homework and how they use it during the school day and under teac her d irection." This study will provide an improved understanding of how teachers and students can use the Internet in sch ool. There will be no direct benefit to you. 6) What are the risks in joining the study? You will be asked to reveal your impressions and observations related to the barrier and enabling factors to use of the Internet in the Douglas Count y School District. While confidentiality of the information that you reveal Mr. Young is protected by federal statute and he is required to take all necessary precautions to protect that information there is a very small risk that the information you reveal could be disclosed. In the unlikely event that this i nformation should be disclosed to your employer and the nature of your replies is objectionable your standing in the DCSD could be jeopardized. This is however, highly unlikely since Mr. Youn g will at no time report or disclose interview responses with identifying information on study subjects F ield notes will be coded and subject ide nti fiers removed The decod ing l og will be kept in a separate location from the field notes. Audiotapes wil l be coded during ana lysis and destroyed once the study is complete. Whi le not designed to elicit embarrassment you may find that some questions may embarrass you 7) Are there other ways to answer the research questions? No method of data collection was thought to be as effective as interviews with school district personnel. Survey questionnaires were considered as an alternative data collection procedure but i t was determined that interview data and related i nter-personal interactio ns would be a much richer source of information 8) What will happen to the information the study keeps? All the information you and othe r DCSD employees provide will be kept private and confidential. No names or indivi dual responses will be reported. Completed interview transcripts and audio tapes and computer files will be kept in a locked file at Mr. Young s home, with access limited only to Mr. Young. 9) What will happen if I say "No" to this study? Participat ion in this study is strictly voluntary. If you decide not to participate no one other than Mr Young will know Your refusal will not be revealed to anyone 203

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1 0) Who do I speak with if I have questions about the study? If you have any questions before, during or after the study your rights as a research subject you may call the office of academic Affairs CU Denve r Bui lding Suite 700 (303) 556-2550 In addition i f you have questions about taking part in this study you may call Walter Young the Pr i ncipal Investigator, at (303) 237-5519 Agreement This consent form and my part in the research study are clea r to me. If I have any questions or problems wit h the study I can contact the Principal Investigator I agree to partic i pate in this research study and have been given a copy of this consent form for my records. Study Subject: __________________ Date : ---------204

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APPEN D IX D Internet Use from A n y Location by Individua l s Age Three and Older ------------. Internet use (percent of total Oct. 1997 Dec. 1998 U.S. popul a tion) Aug. 2000 Sep. 2001 --..___ __ -------1 Total Gender 22. 2 % 32. 7 % 44.4% 53.9% Male 24. 3 3 4 2 44. 6 53.9 ----------_.....,._. __________ ----------------------Female 20. 2 31.4 44. 2 53.8 Race/origin - ---------White 25.3 37.6 50. 3 2 9 3 59.9 39. 8 Black Asian American & Pacific I s lander Hispanic Employment status --------Employed Not employed' $75.000 & above Educational attainment Less than high school High school diploma orGED Some college Bachelor' s degree -----Beyond bachelor' s degree 13.2 19.0 ------------26.4 35. 8 49.4 60.4 __ ......_ --------------11.0 16.6 23.7 31.6 --_j___ ------------------28. 5 42. 5 56. 6 65.4 12.4 19.5 28.9 36. 9 22. 8 34.7 57. 1 32.3 45. 5 67.3 --"44.5 58. 9 ..1. 78. 9 1.8% 8.8% 12.8% 9.7 30. 6 39. 8 1 24. 8 38. 6 54.2 62. 4 80.8 83.7 -+ t----5 8 _.4 51. 9 I ..J 205

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Internet Use from Any Location b y Individua l s Age Three and Older Age 3-8 Age 9-17 ----r----] --it2 -__j_-t Age 18-24 ._ _A.'}_ e 25-4_? -__ ---Male Female Age 50+ 29. 3 41.7 54.1 61. 8 1 25.1 4 0 2 56. 5 66. 0 Mal e Femal e 1 1 2 4.6 8.4 19. 3 2 2 8 16.4 Geographic location o f household in which the individual lives 29. 6 32.7 26.9 37.1 39.9 34.6 Rural n.a. 29.3 42. 5 52. 9 -------+------. --------------Urban n.a. 33. 9 4 5 0 54.2 Urban no central city r----------Urban central city n.a. n.a. Household type in which the individual lives Married couple w /children <18 years old Male householder w /children <18 years old Female householder w /children <18 years old Family household without children .....__ 18 years o _ld _____ Non-family household 26.7 18.2 47.9 57.4 I ------< 40. 6 49.1 ---1..----.J...-. ---____,. --------37. 6 50. 6 62. 0 25.4 34.5 45. 8 22.3 32.9 45.3 30. 0 41.4 so.s ___ J 32.9 42.7 47.6 I U.S. p o pulation: I 997: 255,689,000; I 998: 258,453.000: 2000: 262 620.000: 200 I: 265. I 80 000. 2. Age 16 and older. 3. Both peop l e who are unemplo ye d and people n ot in the l a bor f o r ce. 4. A g e 25 and o lder. Sour ce : U .S. Bureau of the Cen s u s, Current Popul a tion Sur vey s upplement s O ct. I 99 7 D ec. 1 998. Au g 2000, and Sept. 200 I. 206

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E D OTES 1 The Safe and Drug-free Schools Program is a program of the Colorado Department of Education that funds staff position that work to reduce the use tobacco, alcohol and other drugs in selected schools throughout Colorado. 2 From Wil on, Sherry Dobrovolny, B a tty & Ryder, adapted fro m Ely, 1999. From: http:.I\\WW.oa-. ... amh:-.
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