Development of a grounded theory for teacher decisions to adapt research-based health education curricula

Material Information

Development of a grounded theory for teacher decisions to adapt research-based health education curricula
Hurley, James P
Publication Date:
Physical Description:
x, 161 leaves : ; 28 cm

Thesis/Dissertation Information

Doctorate ( Doctor of Philosophy)
Degree Grantor:
University of Colorado Denver
Degree Divisions:
School of Education and Human Development, CU Denver
Degree Disciplines:
Educational Leadership and Innovation
Committee Chair:
Wilson, Brent G.
Committee Members:
Goetz, Jami
Levinson, Arnold
Lauer, Pat


Subjects / Keywords:
Health education (Elementary) ( lcsh )
Education, Elementary -- Curricula ( lcsh )
Grounded theory ( lcsh )
Education, Elementary -- Curricula ( fast )
Grounded theory ( fast )
Health education (Elementary) ( fast )
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )


Includes bibliographical references (leaves 148-161).
General Note:
School of Education and Human Development
Statement of Responsibility:
by James P. Hurley.

Record Information

Source Institution:
|University of Colorado Denver
Holding Location:
|Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
780196530 ( OCLC )
LD1193.E3 2011D H87 ( lcc )

Full Text
James P. Hurley
B.S. Ithaca College, 1991
M.Ed. John Carroll University, 1994
A thesis submitted to the
University of Colorado Denver
in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
Educational Leadership and Innovation

This thesis for the Doctor of Philosophy
degree by
James P. Hurley
has been approved
Brent G. Wilson
Arnold Levinson
Pat Lauer
17 kk

Hurley, James P. (Doctor of Philosophy, Educational Leadership and Innovation)

Hurley, James P. (Doctor of Philosophy, Educational Leadership and Innovation)
Development of a Grounded Theory for Teacher Decisions to Adapt Research-Based
Health Education Curricula
Thesis directed by Professor Brent G. Wilson
Educators are continually searching for the most effective and efficient way to
support student learning and achievement. In health education, educators must
address the specific need to change or modify behaviors, particularly when teaching
youth about decisions regarding the use of drugs. The decision by youth to engage in
risky drug behavior can have long-lasting implications for their health over a life
course as well as a broader societal impact. Research-based curriculum have been
proven to reduce risky behaviors in youth when implemented in schools with fidelity.
However, as these curricula come in contact with the school setting, the curriculum is
often adapted to fit the needs of the school and local community.
The purpose of this qualitative grounded theory study was to develop an
adaptation theory through examination of the adaptations that teachers make to
research-based health education curricula during implementation. Classroom
observations and teacher interviews of four teachers were conducted to examine these
factors. More specifically, the study examined the types of adaptations that teachers
make, how and when teachers come to the decision to adapt or not adapt the

curriculum, and their reasons for adaptation. In examining the adaptations that
teachers made to the curriculum, teachers adapted the curriculum to comply with
local policies, meet student needs, and engage students in learning. Policies related to
standards and assessment, as well as academic initiatives drove adaptations. Some
teachers adapted to ensure a caring, supportive environment and to engage students
though a variety of learning activities. Teachers also adapted based on student needs
and academic ability, as well as other unique student needs. These unique student
needs included current drug use, family dynamics, or other conditions reflected in
local data. Additions were the most common adaptation, with modifications less
common, and omissions least common. The research-based curriculum was used as a
guide for teaching, with local needs informing adaptations. The curriculum was
taught with fidelity to the extent that it aligned with local needs. Teachers take the
role of sense-maker, making sense of how the research-based curriculum fit into the
local classroom environment and the needs of their students.
This abstract accurately represents the content of the candidates thesis. I recommend
its publication.
Brent G. Wilson

This dissertation is dedicated to my wife, Megan, and my four children, Ella,
Caden, Connor, and Erin, for their support and inspiration to press on, sometimes
sprinting but always moving forward. To my parents, Virginia and Francis Hurley,
for instilling the value of education and the belief that you can succeed through hard
work and effort. And last, to my loving wife, thank you for your understanding, your
unfailing encouragement, and your constant support.

Pursuing a doctoral degree has been a long and arduous process, especially
when personal, family, and career obligations compete for time and attention. It is
with this in mind that I extend a great deal of gratitude to my family, friends, and
colleagues; I would like to thank and acknowledge the caring and kind support that
you have given me. I would especially like to thank my wife, Megan, for being
supportive, caring, and loving throughout this long endeavor.
I would like to thank and acknowledge the members of my dissertation
committee, Dr. Brent G. Wilson, Dr. Jami Goetz, Dr. Arnold Levinson, and Dr. Pat
Lauer. In particular, I would like to thank Dr. Brent Wilson for his encouragement,
guidance, advice, and support throughout this journey. I would like to thank Dr.
Judith Duffield for her initial support as I entered into this doctoral program. I would
also like to acknowledge Dr. Mark Bodamer for inspiring me from afar to keep
moving forward and focusing on the finish.

LIST OF FIGURES........................................................ix
LIST OF TABLES.........................................................x
1. INTRODUCTION..........................................................1
Statement of the Problem..........................................1
Purpose and Significance of Study.................................3
Conceptual Framework..............................................5
Adaptation of Research-Based Curricula......................5
Teacher Cognition and Pedagogical Decision-Making...........7
Research Design and Methodology...................................8
Limitations of Study..............................................9
Researcher Stance.................................................9
Organization of Study............................................10
2. LITERATURE REVIEW....................................................11
Curriculum Fidelity..............................................12
Factors Supporting Fidelity of Implementation....................15
Adaptation of Research-Based Health Education Curricula..........21
Teacher Cognition and Pedagogical Decision Making................29
Theoretical Framework............................................35
Organization of Study............................................38
3. METHODOLOGY..........................................................39
Research Questions...............................................39
Research Design..................................................39
Access to Participants/Sites.....................................42
School Setting...................................................44
Overall School Population........................................44
Teachers Stories................................................46
Life Skills Training Curriculum..................................51
Data Collection Procedures.......................................54
Data Analysis Procedures.........................................56
Validity of Interpretation.......................................59
Limitations and Delimitations of the Study.......................59
Ethical Considerations...........................................61

4. FINDINGS..............................................................64
Student Engagement in Learning....................................66
Create a Safe, Supportive Learning Environment.............67
Engage students through varied learning task or activity...72
Student Needs.....................................................82
Student academic needs.....................................83
Unique student population..................................86
Local Policies in Practice........................................89
Local Curriculum, Standards, and Assessment................89
School policies............................................93
Types of Adaptations..............................................98
Adaptations During Planning and Enactment.........................99
Introduction to Discussion.......................................104
Grounded Theory for the Adaptation of Health Education Curricula.105
Discussion of Findings...........................................110
Role of Teacher as Sense-Maker............................110
Creating an Environment for Learning......................113
Culturally Responsive Teaching Practices..................115
Pedagogical Practices.....................................116
Local Policies in Practice................................122
Implications for Implemented..............................129
Implications for Curriculum Developers....................131
Implications for Professional Development and Training....135
Implication for Educational Reform Efforts................136
Suggested Topics of Inquiry......................................138
A. Subject Consent Form.........................................142
B. Initial Interview............................................145
C. Pre-Observation Interview....................................146
D. Observation Matrix and Post-Observation Questionnaire........147
E. Matrix Coding Example........................................148

Figure 2.1 Key Domains and Constructs Associated with Curricular Adaptation.22
Figure 2.2 Factors Affecting Teacher Adaptation of Curricula: Reflection Enactment
Figure 5.1 Teacher as pedagogical sense-maker to implementation.............107

Table 3.1 School and State Totals by Race/Ethnicity..........................45
Table 3.2 School and State Totals by Free and Reduced Lunch Rates............46
Table 3.3 Participants and Site Summary......................................51
Table 3.4 Life Skills Training Curriculum Summary............................52
Table 3.5 Observation and Interview Times by Participant.....................56
Table 4.1 Themes, Dimensions, Codes, and Classroom Examples..................65
Table 4.2 Additions, Modifications, and Omissions by Participant.............99
Table 4.3 Summary of Findings...............................................102

Statement of the Problem
Educators are continually searching for the most effective and efficient way to
support student learning and achievement. In health education, educators must address
the specific need to change or modify behaviors, particularly when teaching youth about
decisions regarding the use of alcohol, tobacco, and other drugs. The decision by youth to
engage in risky drug behavior can have long-lasting implications for their health over a
life course as well as a broader societal impact. Smoking alone kills more people than
alcohol, AIDS, car accidents, illegal drugs, murders, and suicides combined with, and this
does not count the additional deaths caused by spit tobacco use. Of the roughly 400,000
youth who become regular smokers each year, almost a third will ultimately die of it. In
addition, smokers lose an average of 13 to 14 years of life because of their smoking
(Centers for Disease Control and Prevention, 2008). When the impact of drug abuse is
examined, many of the effects cannot be quantified; however, the Office of National
Drug Control Policy reported that in 2002, the economic cost of drug abuse to the U.S.
was $180.9 billion (National Drug Intelligence Center, 2006). The impact of tobacco and
drug use on society cannot be overlooked and prevention must start at an early age.
A number of effective research-based prevention programs have been shown in
evaluation studies to prevent the onset and escalation of alcohol, tobacco and other drug

use during adolescence (Dusenbury & Falco, 1995; Skager, 2007). Coherent school
policies with community and media initiatives strengthen a comprehensive school-based
drug prevention program (Centers for Disease Control and Prevention, 2007).
Many of these programs have been developed for implementation in the school
setting. To ensure positive results of these curricula, program developers typically advise
classroom teachers to administer the curricula with fidelity as identified in the curriculum
guides, and as the researcher has intended (Drug Strategies, 1999). The need for
translation of effective interventions from research to real-world settings is especially
noteworthy in the area of substance abuse prevention (Rohrbach, Grana, Sussman, &
Valente, 2006).
Even though effective strategies for drug prevention have been identified, schools
today are under greater pressure to decrease the achievement gap and focus on student
academic learning, as opposed to student health and wellness. Beyond these pressures
there are a myriad of other community, school, classroom, student level, and implementer
factors that affect implementation of these curricula. These factors can influence the
ability of schools to implement research-based curriculum with fidelity, and lead to
changes, modifications, re-invention, or adaptation of the curriculum to meet specific
community, district, school, or student needs. A 1999 national sample of public and
private middle schools teachers reported that 79.8% adapted their alcohol and other drug
curricula according to local needs (Ringwalt, Ennett, Vincus, & Simons-Rudolph, 2004).
These adaptations can take many forms and occur anywhere along the
implementation continuum, from choosing the curriculum, to planning, to teachers

reflection on curriculum implementation. Types of adaptations can range from
modifications to the language used in a curriculum to the addition of entirely new
activities or lessons, or to the omission of lessons. In some cases, the omission of the
entire curriculum can take place.
If prevention efforts using school-based drug prevention curricula are to continue,
then examining what types of adaptations teachers makeand how teachers make the
decision to adaptwill be imperative to ensure support of these curricula in schools.
Examining these factors can inform three main groups in the prevention arena:
curriculum developers, curriculum trainers, and professionals implementing the
curriculum. Informing these three key groups regarding curricular adaptation and reasons
for adaptation can better support implementation of these curricula and ensure the
intended curricular and behavioral outcomes.
Purpose and Significance of Study
The purpose of this grounded theory study is to develop an adaptation theory
through examination of the adaptations that teachers make to research-based health
education curricula. More specifically, the study will examine the types of adaptations
that teachers make, how and when teachers come to the decision to adapt or not adapt the
curriculum, and the teachers reasons for adaptation. This study will be exploratory in
nature to identify these factors as they emerge from the natural implementation setting.
Ringwalt, et al. (2003) have quantitatively examined the factors associated with
adaptation; however, observation with the specific intent to build an adaptation theory
has not been endeavored. By examining the factors that influence adaptation, curriculum

developers can be better informed so they can develop modifications to their curriculum
that address the needs of communities and schools or give guidance to support
appropriate adaptations in curricular manuals. This research can also inform the
development of effective training on research-based curricula by identifying adaptations
that take place. This knowledge can help better prepare professional developers in
addressing the need to align the curriculum with community and student needs.
Curriculum implementers can be informed as to when adaptations are commonly made so
they can address those concerns prior to implementation.
Examining the implementation of these curricula can have an impact on the health
and welfare of youth. The prevention of tobacco and other drug use is an important part
of any comprehensive health education curriculum. Delaying or preventing the onset of
tobacco and other drug use can not only increase the health and well-being of the
individual but can also have broader impacts on societal health. Among adults who have
ever smoked, 70% started smoking regularly at age 18 or younger, and 86% started at age
21 or younger. In 2009, 20.6% of adults over the age of 18an estimated 46 million
peoplewere current smokers. The health impacts of smoking cost the U.S. over $193
billion in 2004, including $97 billion in lost productivity and $96 billion in direct health
care expenditures, or an average of $4,260 per adult smoker (American Lung
Association, 2011). Adding to this is the $180.9 billion economic cost of drug abuse to
the U.S. With these economic and societal costs of tobacco and drug use, only effective
drug prevention efforts should be undertaken. With the development of curricula that
have been shown to prevent, delay, or reduce the use of alcohol, tobacco, and other drugs,

implementation of these curricula in schools can have a significant impact on the health
of individuals and on the broader society.
The educational system is continually reforming and being put under increased
pressures to impact student achievement. Several current reform movements can also be
informed by this research. As the U.S. Department of Education moves towards national
core standards, and school districts develop district-mandated curricula, examining the
adaptations that teachers make to predefined health education curriculum can also inform
broader implementation efforts.
Conceptual Framework
The implementation of curricula in a school is grounded in a complex system of
interactions between the written curricula, the socio-cultural environment of the school,
and the pedagogical perspective that the teacher brings to the classroom. In examining
these complex interactions, two conceptual frameworks provided useful scaffolding for
this qualitative study of teacher decision-making and adaptation of research-based health
education curriculum. One conceptual area involves factors that influence teacher
adaptation of research-based curriculum, while the other involves teacher cognition and
pedagogical decision-making.
Adaptation of Research-Based Curricula
In a 2002 study of prevention programs, only 19% of the schools were found to be
implementing research-based prevention programs with fidelity (Hallfors & Godette). A
national sample of public and private middle school teachers reported that 79.8% adapted
their alcohol and other drug curricula according to local needs (Ringwalt, Ennett, et al.,

2004). Although research-based curricula have been identified, and curriculum
developers encourage implementation with fidelity, the reality is that, as these curricula
are implemented in the real world, they are being adapted to meet a multitude of local,
school, and community needs, which seem to take precedence over the need for fidelity.
When the written curriculum and factors at the local setting are not congruent, a tension
between fidelity and fit builds to the point that adaptation occurs. These are the factors
that need to be examined to identify the reasons teachers adapt curricula.
Teacher adaptation of research-based health education curricula has been
primarily examined by Ringwalt, et al. (2003), who initially identified broad categories
that may lead to adaptation: (1) school context considerations; (2) implementation system
considerations; (3) student considerations; and (4) teacher considerations. Their study
examined these factors quantitatively in U.S. middle schools. In a subsequent study,
Ringwalt, et al. (2004) expanded these factors and quantitatively identified factors that
most often influence adaptation. The factors cited most frequentlyin over half the
nations middle schoolsinvolved students sexual activity or discipline problems.
Between 40% and 50% the nations middle schools adapt curricula in response to issues
pertaining to youth violence, youth with substance abusing parents, and youth who
themselves have substance abuse problems.
Examining factors that influence how teachers make decisions will be important,
since teachers ultimately make curricular decisions on what they teach in their

Teacher Cognition and Pedagogical Decision-Making
Every teacher has his or her personal approach to curriculum and teaching that is
built on pedagogical knowledge of ideologies, values, beliefs, understandings, emotions,
and assumptions. This personal pedagogical knowledge interacts with a variety of social,
cultural, and curricular constructs that guide teacher practice.
Teacher decision-making is a complex process that begins with the thought
process that teachers engage in prior to classroom interactions, the classroom interactions
themselves, teachers theories and beliefs (Clark & Peterson, 1986), as well as reflective
practices after teaching. An examination of the interaction between teachers thoughts
and the decisions they made in the classroom during instruction reveals that a number of
different factors may influence how teachers make decisions. Although one would expect
that teachers beliefs would guide classroom practices, inconsistencies have been
observed; the complexities of the classroom can constrain the teachers ability to provide
instruction which aligns with their theoretical beliefs (Roehler & Duffy, 1991). This
suggests that the contextual factors can have significant influences on teachers beliefs
and, in turn, affect classroom practices.
Donald Schon (1983), in The Reflective Practitioner: How Professionals Think in
Action, defines reflection-in-practice as a means by which a professional spontaneously
examines an experience as it is in progress in order to better understand it. Reflection-on-
practice is the purposeful examining of experience by professionals (Schon). This is the
conscious examination of practice, after instruction has occurred, that allows a teacher to
solve problems occurring in an environment as unique and complex as the classroom

(Schon). It is important to examine these two factors together to understand how
reflection impacts teacher decision-making and instructional practices. Decisions to adapt
may occur during planning or during teaching as teachers reflect-in-practice, while other
decisions may take place as teachers reflect on their teaching.
Research Design and Methodology
To uncover and examine the complex interaction between the developed
curricula, the community, the school, the classroom setting, and the teachers pedagogical
perspective, a qualitative grounded theory approach was used. A grounded theory
approach centers on the systemic generation of theory from data that is systemically
obtained from social research, in contrast to theory verification or only description. The
goal of a qualitative grounded theory approach is to generate a theory that accounts for a
pattern of behavior that is relevant and problematic for those involved (Glaser, 1978).
The research design employed observation and interviews to examine teacher
implementation of the Life Skills Training Curriculum (LST). Four participants agreed to
share their implementation of the curriculum to allow their adaptations to be examined.
Participants were interviewed prior to teaching the curriculum to allow identification of
any adaptations that were planned. Along with these pre-observation interviews, the
study also included observations, and post-observation interviews. Pre-observation
interviews examined planned adaptations and reasons for adaptation, while post-
observation interviews examined adaptations that occurred during teaching and identified
reasons for those adaptations. In total, 20 observations took place and a total of 38
interviews took place.

Limitations of Study
One limitation of this study is the sample size of four participants. Another
limitation isdhat participants, as volunteers recruited from the population of teachers
teaching LST in middle or high schools, are a self-selected sample. This sample has the
common characteristic of being willing to share their experience and allow for
observations and interviews. Their willingness to participate may indicate that they hold
positive perceptions around the curriculum or adaptation. The sample population is not a
true cross-section of teachers teaching research-based health curriculum.
Another limitation is the fact that not all lessons of the curriculum were observed,
and the content of the sample lessons that were observed could have influenced the types
of adaptations and influenced the reasons for adaptation. A longer time frame with
observation of all the lessons, allowing varied data collection and analysis, may produce
a more substantial theory and may generate additional themes that could be explored.
However, this limitation may be tolerable since the observations were across three
different levels of the curriculum, and observations included lessons representing a wide
variety of topic areas, employing a variety of teaching strategies and styles.
Researcher Stance
This study is of particular interest to me as it is a way for me to examine a real-
world dilemma that educators struggle with when implementing research-based
curriculum. As a Health Educator, I often found myself struggling with this idea of
fidelity in the face of the daily pressures of the classroom and the school. I found myself
adapting lessons that did not seem to fit my students or my style of teaching. In one case,

I stopped teaching a curriculum simply because I got tired of teaching it. Going into this
study, I had to step outside of my own experience of implementing the curriculum and be
open to and aware of the experiences, commitments, and constructions of others.
I also believe that effective educators are professionals who have the knowledge,
skills, and ability to make curricular and classroom decisions, and that they are not
merely deliverers of the written curriculum. Adaptations are occurring, and teachers are
making these decisions to adapt the curriculum. Teachers are the gatekeepers to what is
and what is not taught to students in their classrooms. Although many outside factors
influence these decisions, what is enacted in the classroom ultimately hinges on the
teachers ability to make sense of the myriad pressures from the community and the
school, and his or her beliefs about the needs of students.
Today, the health and wellness of youth is a topic of great importance, and
schools can play a vital part in a comprehensive approach to prevention efforts. The
teaching of health education curricula is one component of this comprehensive approach,
and schools are in a key position to provide youth with the knowledge and skills to make
healthy decisions.
Organization of Study
The literature review that follows examines research related to research-based
curricula, curriculum fidelity, and adaptation research, as well as teacher cognition and
decision-making. The literature review concludes with a conceptual framework that
guided the methodology and underpinnings of this study.

The bridge between a promising idea and the impact on students is
implementation, but innovations are seldom implemented as intended.
(Berman & McLaughlin, 1976)
Noonan used an analogy for the adoption of scientific advances: If you build it,
they will come. (Noonan et al., 2009). In other words, if a scientific advance is shown to
work in research trials, and it is built, others will use the innovation. Many researchers
and prevention scientists have supported this sentiment in the implementation of
research-based curriculum. However, the reality is that when the curriculum is
implemented, a variety of other factors come into play that impact how others accept the
curriculum in the real-world setting beyond the realm of research.
A better way to view adoption of research-based curriculum was pointed out by
Emshoff (2008):
Build it and they will never know about it
Build it and they will hear about it but not understand it
Build it and they wont think the seats will fit if they do come
Build it and they will think they already have one
Build it and it will be irrelevant to their needs or users
Build it and they will decide to build their own
Build it and they wont be able to read the map
Build it and they will come and rebuild it into something unrecognizable
Build it and they will assign it to a committee and forget about it

These are all scenarios that might explain what happens to research-based curriculum
brought into the real-world setting beyond the realm of the research and the effectiveness
studies. The challenge of building the curriculum is only the beginning; bringing a
curriculum to scale provides many additional challenges. Although effective health
education curricula have been built, their implementation brings them into contact with
the real-world context far removed from the research setting where the original results
were identified. As the curriculum comes into contact with factors in the school and the
community, and the knowledge and beliefs of the implementer, the curriculum is often
adapted to meet local needs in a way that may alter its effectiveness.
Curriculum Fidelity
Sometimes referred to as integrity, adherence, or quality of program delivery,
fidelity refers to the degree to which teachers and other program providers implement
programs as intended by the program developer (Dane & Schneider, 1998; Dusenbury,
Brannigan, Falco, & Hansen, 2003). This perspective has its roots in behaviorism and
positivism that support a technological and linear manner of implementation (Cho, 1998).
The focus is on specific outcomes that can be implemented in a stepwise manner and in
any situation.
Rogers (1995) Diffusion of Innovation theory provides a way of understanding
the process by which new ideas are put into practice. It has been used to understand
implementation in a number of fields, including education, psychology, and public
health. In the 1960s and 1970s, the Research, Development, and Diffusion (RD & D)
model commonly used by federal policy makers was introduced. This model emphasized

the importance of rigorous evaluation and validation of projects (Rogers, 1995). In this
model, the researcher determines the effectiveness of a curriculum or program through
experimental or quasi-experimental methods. A basic assumption of this model is that
consumers will value the results of these evaluation studies and base their decisions about
whether to adopt an innovation on these evaluation studies. Consumers were largely
viewed as passive in this model and it was expected that consumers would implement
validated programs as intended by the researchers. This perspective also posits that any
changes to the curricula at any level could negate any of the potential benefits supported
by the original research. Build itresearch it, prove its effectivenessand they will
come. Programs have been built and, in the process, measures of program fidelity to
ensure program effectiveness have been developed.
Measures of fidelity can ensure that the program is being implemented as
intended during evaluation trials. If the program is not implemented as the researcher
intended, it is possible that the findings could be due to the lack of fidelity and not due to
the conceptual or methodological underpinnings of a specific program. This lack of
implementation fidelity has been termed a Type III error (Dusenbury, et al., 2003). To
minimize the risk of Type III errors, a number of measures of fidelity have been
developed with a primary purpose of identifying the extent to which programs are
implemented with fidelity during evaluation trials. Although specific measures of fidelity
of implementation (FOI) vary considerably, Dane and Schneider (1998) have identified
five primary components: (1) the amount of the program delivered to students (dosage);
(2) adherence to methods or implementation that conforms to the guidelines of the

program; (3) the quality of program delivery (the way a teacher delivers the program); (4)
the responsiveness of program participants; and (5) program differentiation or the degree
to which critical components can be differentiated from one another. Studying fidelity
can allow researchers to identify what has been changed in the program and how changes
impact outcomes. For example, if the quality of delivery of a program negatively impacts
short-term outcomes related to student attitudes and behaviors, it will be important to
ensure that training and implementation standards identify the importance of quality of
delivery. Finally, studying fidelity can reveal important information about the feasibility
of an intervention or the likelihood that the program can and will be implemented with
fidelity. Although the importance of fidelity is supported by many prevention specialists,
Durlak and DuPres (2008) review of nearly 500 studies and meta-analyses found that
only 59 studies assessed the relationship between fidelity and outcomes. Of those studies,
76% reported that fidelity had a significant positive association with targeted program
outcomes and that positive program outcomes occurred with at least 60% fidelity
Research has supported the need for programs to be implemented with fidelity to
ensure the intended outcomes. Numerous studies support the claim that children exposed
to research-based programs delivered by instructors who maintained fidelity had better
outcomes than those exposed to the program implemented with low fidelity (Hansen &
McNeal, 1999; Pentz et al., 1990). For this reason, a number of initiatives have supported
the implementation of research-based curricula with fidelity.

In 1998, the U.S. Department of Education initiated the Principles of
Effectiveness policy, stipulating that districts receiving Safe and Drug-Free Schools and
Communities funds must implement programs that have been shown to be effective
(Slavin, 2003). More recent federal mandates such as the No Child Left Behind Act of
2001 have stated that teachers must use only research-based teaching methods and select
programs proven to be effective (NCLB, 2002). With these policies in place, curricular
choices have been limited and a greater focus given to the importance of fidelity of
implementation. In health education, various federal registries specifying substance abuse
prevention curricula that have been empirically proven effective in reducing adolescent
substance use have been developed to support the dissemination of research-based
curricula (National Institute on Drug Abuse, 2003; SAMHSA, 2007). These policies have
also supported research on the FOI, which has identified a number of factors that support
fidelity of implementation.
Factors Supporting Fidelity of Implementation
A variety of factors have been identified that support implementation fidelity.
Factors related to the school, community, and the individual implementer have been
found to support program fidelity. When certain factors are in place at these levels,
fidelity of implementation has improved. Although a comprehensive list of critical
elements has not been identified, a number of possible key elements have. The Rand
study (Berman & McLaughlin, 1976) identified these key elements to successful
implementation: (1) adaptive planning which is responsive to the needs of participants;
(2) training tailored to local sites; (3) a critical mass of participants to provide support

and prevent isolation; and (4) local materials development to support local audiences.
Other factors such as teacher training, program characteristics, teacher characteristics,
and organizational characteristics have more recently been identified (Dusenbury, et al.,
Program or model characteristics include the structures and materials defined by
the program themselves, which may include the number of lessons, complexity of the
intervention, program materials for implementation, and training materials. Complexity
of the intervention has been identified as a key characteristic influencing fidelity
(Bauman, Stein, & Ireys, 1991). When the intervention consists of many elements and
requires a wide variety of skills and coordination of a number of individuals, fidelity may
be compromised. In contrast, interventions that are packaged to simplify the task of
implementation are more likely to be viewed as effective and implemented more
completely. Specific implementation guidelines and clarity of the manual have also been
identified as key to implementation fidelity (Fullan & Pomffet, 1977). Successful
program implementation is more likely when the program materials are visually
appealing, user-friendly, relevant, and easy to use (Gottfredson & Gottfredson, 2002).
The quality of delivery or the extent that teachers are engaged in teaching the
program also supports fidelity. If the implementer is engaged and enthusiastic about
teaching the program, fidelity is more likely. Although this factor also relates to the
implementer, the program itself can influence the extent to which teachers are engaged
when teaching and their enthusiasm for the program. Participant responsiveness is also an
important factor to examine. If participants are responsive, engaged, and indicate that

they like the program or acknowledge the benefits of the lessons and activities,
implementation is more likely to continue to happen as intended.
Beyond the program itself, the implementation support system also has factors
that can support fidelity. Pre-planning is defined as any preparation made by the school
before the implementation of an identified intervention. Pre-planning can include a
variety of system factors that can impact fidelity, including identifying the need for
change, readiness for change, capacity to effect change, building awareness of the need
for change, commitment or engagement in the change process, incentives for change and
the history of successful change (Greenberg, Domitrovich, Graczyk, & Zins, 2005). If
these factors are not taken into consideration, implementation can be compromised. For
example, if the need for an intervention has not been communicated to staff or the
community, programs are not likely to be implemented as intended. Gaining a
commitment to the intervention, by involving implementers in the pre-planning process,
and identification of the intervention can support buy-in and implementation. Supporting
capacity building by providing training and supporting implementers through coaching
can be supportive of fidelity as well. These factors can support implementation by
preparing participants for implementation and enhancing or addressing their readiness for
change. A top-down administrative approach mandating implementation may not be the
best way to ensure fidelity. Involving implementers in the pre-planning process is an
important and often overlooked aspect of implementation. It is also important to ensure
that the programs goals and objectives are supported by the schools and districts goals.
If the goals and objectives are congruent, the program is more likely to be supported or

seen as a priority when decisions are made regarding continuation and future support of
the program (Greenberg et al., 2005).
School-level characteristics, such as administrative support for the intervention
and integration of the program into normal school operations or existing programs,
support fidelity (Gottfredson & Gottfredson, 2002). Adequate materials, financial
support, and time in the schedule are also important.
Teacher training has been identified as a key component to support fidelity of
implementation. Certain components of teacher training support fidelity: participants
must deem the training effective (Ringwalt et ah, 2003); and the training should include
time for teacher planning for implementation. Technical assistance or coaching during
implementation at the school-level has been found to be more effective than outside
consultation (W. Penuel, Fishman, Yamaguchi, & Gallagher, 2007).
Classroom-level factors including teacher characteristics have been found to
influence program adoption or maintenance. Teacher attitudes toward prevention
education, and their support and enthusiasm for it, support fidelity, as does their
confidence in teaching interactive teaching strategies (Gingiss, Gottlieb, & Brink, 1994;
Rohrbach, Graham, & Hanson, 1993). Many programs require interactive teaching
strategies which may include classroom discussion, role-play activities, or student
interactions; if the implementer is confident in their ability to integrate these teaching
strategies, they are more likely to teach the lessons that require these strategies and thus
implement the program as intended. Those teachers who were new to the profession
have also adopted or maintained program fidelity more often (Ringwalt et al., 2003).

These factors have been found to support fidelity of implementation. As fidelity of
implementation is better understood and key factors that support fidelity are identified,
program implementation would be expected to improve.
Despite policies to support the use of research-based interventions and research
identifying factors supporting fidelity, a 1999 study of middle schools nationwide
reported that only 35% of public middle schools and 13% of private middle schools were
using one or more of the ten prevention curricula rated effective at that time (Ringwalt et
al., 2002). Even when programs are implemented, the level of fidelity varies widely.
Research conducted in the mid 1970s by the National Diffusion Network examining the
adoption of educational innovation revealed that over half (56%) of the organizations that
adopted innovations ended up modifying the intervention and implementing only certain
parts of the program (Emmick et al., 1977, cited by Rogers, 1995). Hallfors and Godette
(2002) surveyed Safe and Drug-Free Schools Coordinators from 104 school districts in
12 states and revealed that only 19% implemented evidence-based programs with fidelity.
Tortu and Botvin (1989), report that teachers implementing the LST curriculum
implemented between 44% and 83% of the curriculum points and objectives with an
average of 65%. Rohrbach et al. showed that teachers in the first year of implementation
of an adolescent alcohol prevention program delivered 75% of the program; however, in
the following year, only one in four teachers taught any of the program (Rohrbach et al.,
1993). An assessment of implementation of the Know Your Body curriculum observed
that only 47% of the intended procedures were completed upon classroom observation of
lessons (K. Resnicow, Baranowski, Ahluwalia, & Braithwaite, 1998), and a study on the

Teenage Health Teaching Modules assessed the long-term implementation of the
program and reported that most teachers (84%) reported that they omitted at least one of
the modules. Teachers reported that they most often omitted role-play, family
communication, and community involvement from the curriculum (Tappe, Galer-Unti, &
Bailey, 1995).
Life Skills Training, developed by Dr. Gilbert Botvin, has been subject to
extensive empirical research on its effectiveness and fidelity of implementation. For
instance, in a study testing the effectiveness of the LST program in 56 New York State
schools (Botvin, Baker, Dusenbury, Tortu, & Botvin, 1990), implementation rates were
observed by trained monitors. Results showed that, on average, 68% (ranging from 27%
to 97%) of the material in the curriculum was implemented. One in four students had
teachers who implemented less than 60% of the important points of the lessons. When
examining inner-city schools (Botvin, Griffin, Diaz, & Ifill-Williams, 2001), the
proportion of LST program points covered by program providers was 48% across all
program sessions. These findings suggest that adaptation occurs more frequently in inner-
city and urban schools compared to other predominantly suburban schools.
While curriculum-in-theory is regarded as that which is written by external
experts describing what is to be taught (Shkedi, 1998), the reality of the implemented
curriculum refers to the process by which individual teachers interact with, draw on, refer
to, and are influenced by the material resources designed to guide instruction (Munby &
Russell, 1990). It is in this natural setting, where curricular materials, the local
community, the school and classroom environment, the instructor, and instruction come

together, that the curriculum takes its final form. When the written curriculum and factors
at the local setting are not congruent, a tension between fidelity and fit builds to the point
that adaptation occurs. It is these factors that need to be examined to identify the reasons
teachers adapt curriculum.
Adaptation of Research-Based Health Education Curricula
Studies have examined the reasons teachers adapt or re-invent curricula during
implementation. Teachers appear to adapt curricula for a wide variety of reasons, with as
few as 15% reporting they follow curriculum guides closely (Ringwalt, et al., 2003).
Conceptually, the literature provides two general domains for adaptation of curricula in
the classroom. One domain pertains to the curriculum itself, including its specificity,
length, complexity, and the associated training; the other is the context or system in which
it is implemented (Fullan & Pomffet, 1977). Ringwalt et al. (2003) have expanded these
domains and identified the following key domains and constructs associated with
curricular adaptations: (1) school context; (2) curriculum implementation system; (3)
curriculum implementers; and (4) audiences targeted. Figure 1 represents these key
domains and the key constructs associated with adaptation of research-based curricula.
These constructs were examined in a random sample of 1,674 private and public
middle schools from 50 states including the District of Columbia who were teaching a
substance use prevention curriculum for which there was likely to be a curriculum guide.
The analysis revealed that school context had the greatest contribution to adaptation.
Within this construct, those teachers who believe that they have discretion in what topics
they cover in substance use lessons are more likely to adapt.

Figure 2.1 Key Domains and Constructs Associated with Curricular Adaptation.
Ringwalt, C., Ennett, S., Vincus, A., & Simons-Rudolph, A. (2004). Students' special needs and problems
as reasons for the adaptation of substance abuse prevention curricula in the nation's middle schools.
Prevention Science, 5(3), 197-206.
Teachers from private schools were less likely to adapt compared to their
counterparts in public schools. Lack of school principal support for substance use
prevention also emerged as a key to explaining curriculum adaptation. Lack of support
increased the likelihood for adaptation. One-fifth of respondents indicated lack of
principal support diminished curriculum fidelity. This variable accounted for 5.8% of the
total variance in curriculum fidelity.
When examining the domain of the curriculum implementation system, key
findings highlighted the effectiveness of training and how recently teachers had been
trained. Those who indicated that they felt well prepared and were recently trained were

less likely to adapt. Those respondents who perceived inadequacies in training,
instructional materials, and time to attend training adapted more often, as well as those
who integrated the curriculum into other subject areas outside of health education.
Within the curriculum implemented domain, instructors who liked to teach
substance use prevention lessons, and were confident in their ability to teach the subject
adapted less often. It should also be noted that those who believed that the substance use
curriculum was effective adapted less often. In the domain of audiences targeted,
increased school poverty level and student level of interest were associated with greater
adaptation. Overall this model revealed that variables pertinent to each of the domains
were significantly associated with curriculum fidelity. However, the explanatory power
of the model was is limited with only 9.6% of the variance explained by the model.
Another study using the same data investigated the reasons teachers adapted
substance use prevention curricula that were related to students special problems or
needs (Ringwalt et al., 2004). The data revealed that 79.8% of those surveyed reported
adapting their curricula at least to some extent in response to students special needs. The
needs cited most frequently, by over half of the nations middle schools, pertained to
students sexual activity or discipline problems. Between 40% and 50% of the nations
middle schools adapt curricula in response to youth violence, youth with substance
abusing parents, and youth who themselves have substance abuse problems. The least-
cited problem was adaptation for students with limited English proficiency, which was
mentioned by 15% of teachers. It was also noted that curriculum that could be readily
integrated into other curriculum were more likely to be adapted, and those teachers who

had less time to plan or attend curriculum trainings tended to adapt more. It is interesting
that teachers cited adaptation to these student special needs while indicating that they are
closely following the curriculum guides faithfully. It was also interesting to note that
teachers who most recently attended training adapted more readily.
Finally these same data were examined based on school-level poverty (Ringwalt
et al., 2004a). The study revealed that, after controlling for school-level and teacher
characteristics, teachers in schools with a high number of minority students were more
likely to adapt curricula in response to youth violence, limited English proficiency, and
various racial/ethnic or cultural groups. Youth violence and a need to address students
substance abuse or address substance abusing parents were cited as reasons for adaptation
by 40% of participants.
None of these studies examined the extent to which adaptations occurred and the
consequences, either positive or negative, of curricular adaptation. It is apparent that
teachers of substance use prevention curricula are adapting curricula for a variety of
reasons. The framework proposed by Ringwalt et al. (2003) has not been able to account
for all the reasons for adaptation; however, it does provide a framework to begin
examining the adaptation of curriculum.
An observational study of the LST program examined the quality of
implementation and determined that teachers taught an average of 65% of teaching
objectives and 58% of main points. Observers examined the valence of adaptation by
noting how activities were altered from those outlined in the manual. Researchers
subsequently assessed the number of changes and rated whether these were consistent

with or detracted from the programs objectives. All observed teachers altered the LST
program. The average teacher made 3.5 definable alterations with 63% of adaptations
judged by researchers to be negative. Some examples of adaptations were noted. One
teacher had students role-play a situation rather than discussing it. Conversely, one
teacher had students estimate peer marijuana use, but never compared the estimated rates
to actual rates. Others added materials to lessons to make them more culturally relevant,
including reading material, videos, testimonials from drug addicts and the use of puppets
at the primary grades (Dusenbury, Brannigan, Hansen, Walsh, & Falco, 2005).
In this observational study (Dusenbury, et al., 2005), the numbers of adaptations
listed by teachers were negatively correlated with observers countsthat is, the fewer
adaptations mentioned by teachers, the greater the observed adaptations in their
classroom. This raises a question as to whether teachers can be expected to accurately
report whether they adapted a curricula. It is possible that teachers cannot recognize when
they are making changes to the curriculum or that they feel that the changes are in line
with the curriculum. Observational studies are needed as opposed to teachers self-
reporting to truly examine teacher adaptations to the curriculum.
In examining other prevention programs outside of the school setting, Hill,
Maucione, and Hood (2007) identified adaptations to the Strengthening Families Program
for Parents and Youth 10-14 (SFP). The SFP is a community-based program
implemented by facilitators in community-based organizations; the participants in this
study were a heterogeneous group ranging from parent volunteers to local social service
agencies. It should be emphasized that these were not classroom teachers. The single

most frequently cited reason for additions to the program materials, accounting for 41%
of the reasons stated, was the need to clarify concepts. The most frequently cited reasons
for deletions of program material, accounting for 75% of the reasons stated, were lack of
time to cover content, forgetting material, or disagreeing with content. The most frequent
reasons for changing content, accounting for 50% of the reasons stated, were group
attributes, clarification, and lack of time to cover materials as intended. It should also be
noted that the facilitators beliefs related to deletions and changes were significantly
correlated but not congruent with their practices. When participants were asked whether
they believed it was acceptable to delete or change materials, they indicated that it was
not acceptable; however, their actions showed significant deletions and changes.
Prevention researchers generally appreciate that cultural mismatches will
undermine program effectiveness (G. J. Botvin, 2004). For this reason, the need to adapt
curriculum based on cultural differences in the classroom is supported. Castro has
identified contrasting conditions between the group used to validate a prevention
program, the validation group, and the current consumer group. These contrasting
conditions, or mismatches, if not addressed can, lead to adaptation during
implementation. Major sources of mismatch include: (a) group characteristics such as
language, ethnicity, socioeconomic status, urban or rural context, student risk factors, and
family stability; (b) program delivery staff characteristics such as the type of staff and the
staffs cultural competence; and (c) administrative/community factors including
community consultation during implementation and community readiness. For example,
if a model program has been developed and validated primarily with suburban White

middle-class youth, it may lack the fit and relevance necessary to address the needs of the
community that is urban and ethnically diverse (Castro, Barrera, & Martinez, 2004).
Cultural adaptation of a family-based program led to substantial improvements in
engagement, higher retention rates, greater acceptability, and better recruitment (Marek,
Brock, & Sullivan, 2006). Other studies have examined the issue of cultural adaptation as
a mismatch between the curriculum and the characteristics of a cultural group. Making
adaptations to be more culturally relevant for students may not only benefit students but
may foster curriculum sustainability, participant attendance, and participation, and may
lead to behavior change by supporting students needs (Botvin, 2004; Castro et al. 2004;
Kumpfer et al. 2002). Recently researchers have proposed a balance between adaptations
and fidelity (Backer, 2002; Berkel, Mauricio, Schoenfelder, & Sandler, 2011; Domenech
Rodriguez, Baumann, & Schwartz, 2011).
Backer, (2002) concludes that attention to both program fidelity and adaptation
during the complex process of program implementation is critical to successful, sustained
implementation. With this in mind Backer provides guidelines for adaptations consisting
of a 12-step process that includes some key elements: understand the core components of
the program; identify the potential adaptations in planning; consult with the program
developer regarding adaptations; and develop an overall implementation plan. This
process is time-consuming and it may be unrealistic for an individual teacher to
undertake such a process to develop adaptations and implementation plans. Others have
supported adaptations through the use of a Cultural Adaptation Process model which

systemically identifies adaptations through a community-based participatory model to
identify adaptations (Domenech Rodriguez, et al., 2011).
Others have identified important dimensions to guide adaptation strategies,
including adaptations to minimize the mismatch between program and community. These
dimensions include: Cognitive information processing, characterized by adaptations to
language and age development level; Affective motivational characteristics as related to
gender, ethnic background, religious background, socioeconomic status; and
Environmental characteristics that include ecological aspects of the local community
(Castro, et al., 2004).
Berkel et al. (2011) have proposed an integrated model of program
implementation that acknowledges the interactions between fidelity, quality of
implementation, and adaptation. The integrated implementation model proposes that,
through a balance of adaptation and quality implementation, participants will be more
responsive to the curriculum, thus increasing attendance, active participation, practice,
and student satisfaction. With the balance of quality and adaptation to support students
needs, fidelity in itself will be supported.
To meet the needs of students as the curriculum is implemented, adaptations can
take many forms. The most commonly examined adaptations are enrichment (additions),
elimination (omissions), or modification (changes) (Hill, Maucione, & Hood, 2007).
Enriching the curriculum consists of adding materials, resources, and lessons to the
curriculum. An example of enriching might be having students not only examine
advertising techniques but develop their own advertisements that depict the actual

consequences of tobacco use. Elimination may consist of eliminating complete lessons,
portions of lessons, activities, or completely eliminating the use of the curriculum.
Teachers might eliminate activities in a lesson due to time constraints, or due to the fear
of losing control of the class during role-play activities. Teachers may modify the lesson
or teaching strategies; for example, a lesson may call for an interactive role-play to
examine internal and external influences on an individuals decision. The teacher might
not feel comfortable with the facilitation of a role-play and decide to use a more didactic
method of teaching internal and external influences. These adaptations can take place at a
number of key intersections during the planning and enactment of the curriculum.
Teacher Cognition and Pedagogical Decision Making
Philip Jackson, in his book Life in the Classroom (1968), was the first to bring
attention to the importance of the study of teacher thought processes. His descriptive
report was in sharp contrast to the previously held expectation that teachers would
implement research-based practices due to their effectiveness alone. His examination of
the classroom shed a very different light on the classroom and its complexities. Jackson
argued that the mental life of teachers greatly influences their instructional practices and
effectiveness. He stated, beneath the surface of classroom events lies the complex world
of individual psychology (p.172).
Other educational researchers have shown interest in the study of teacher beliefs
or their thought process, which serve as determinants of pedagogical practice (Clark &
Peterson, 1986; Fang, 1996). Nespor (1987) supported the importance of this type of

inquiry by stating that to understand teaching from teachers perspectives we have to
understand the beliefs with which they define their work (p. 323).
Teacher decision-making is influenced by personally held belief systems. Every
teacher has his or her personally held belief system, relating to the curriculum and
teaching, that is built on pedagogical knowledge, ideologies, values, beliefs,
understandings, emotions, and assumptions. This personal pedagogical knowledge
interacts with a variety of social, cultural, and curricular constructs that guide teacher
practice. According to Shulman (1986), teachers general knowledge of the process of
teaching can be examined through three dimensions: subject matter content knowledge,
pedagogical content knowledge, and curricular knowledge. Subject-matter content
knowledge includes knowledge of the subject matter and how the discipline is organized,
and the language of the discipline. Pedagogical content knowledge consist of the
dimensions of teaching such as how ideas, in a content area, are best presented and
formulated to make it understandable to others. Curricular knowledge includes
knowledge of alternative curricular materials for a given subject/topic within a grade
level and across other grade levels. This may also include knowledge of the curriculum
that students are coming in contact with outside of the content area. Curricular knowledge
is an understanding of the broad curriculum content taught to students. Beattie (1995)
added a fourth dimension, personal practical knowledge, which he defined as teachers
experiential knowledge of students learning styles, interests, needs, strengths, and
difficulties, as well as teachers repertoire of instructional techniques and classroom
management skills. These four dimensions of knowledge help guide teacher decision-

making and have been supported by a number of more recent studies that have examined
teacher curricular decisions and interactive thoughts processes.
An examination of teachers interactive thoughts and the decisions teachers made
in the classroom during instruction reveals that a number of different factors may
influence how teachers make decisions. In the implementation of science curriculum,
teachers beliefs are reported to dominate teachers reactions to and implementation of
reform-based curricula (Roehrig, Kruse, & Kern, 2007). Tobin and McRobbie (1996),
identified four underlying beliefs that impacted the enactment of science curriculum:
transmission of knowledge, efficiency, maintaining the rigor of the curriculum, and
preparing students to be successful on examinations. Cronin-Jones (1991), identified
similar prevalent beliefs and reported that beliefs about how students learn, the teachers
role in the classroom, the perceived ability of students, and the nature and importance of
content topics, strongly influenced the enactment of a prescribed middle school
curriculum. In examining how these beliefs interact with the curriculum, certain
components enhanced the success of the curriculum while others were incongruent with
the underlying philosophy of the intended curriculum and hampered successful
implementation. When teacher beliefs about how students learn and beliefs about their
role as a teacher are not congruent with the curriculum, teacher beliefs can guide
enactment of the curriculum. Although one would expect that teachers beliefs would
guide classroom practices, inconsistencies have been observed. The complexities of the
classroom can constrain the teachers ability to provide instruction which aligns with
their theoretical beliefs (Roehler & Duffy, 1991). This suggests that the contextual factors

can have significant influences on teachers beliefs and, in turn, affect classroom
practices. Fang (1996) found that, although reading teachers were able to articulate their
beliefs about reading outside their classroom, their actual instructional practices were
guided by the nature of instruction and classroom life. Teachers based their decisions on
classroom realities such as mutual teacher-student respect, classroom management,
routine, the amount of assistance needed by low- or high-ability students, the way
students learn, social and emotional characteristics, and the textbook.
The idea of teacher sense-making has been proposed. This perspective proposes
that as policies are implemented, teachers decisions to implement the policies require
them to reconcile their pre-existing knowledge and beliefs with new policy messages and
with the specific needs of their students. As explicit or implicit policy messages or new
curriculum enter the classroom, teachers must balance the pressure of accountability with
what they believe to be best for their students (Palmer & Snodgrass-Rangel, 2010). In
their study of high stakes testing and accountability, Palmer and Snodgrass-Rangel found
that teachers changed their practice based on policies, but at the same time they struggled
to teach students in an authentic way with a balanced curriculum not driven solely by
accountability testing, but balanced by their knowledge and beliefs.
Teacher decisions are guided by personal pedagogical knowledge of ideologies,
values, beliefs, understandings, emotions, and assumptions. This personal pedagogical
knowledge interacts with a variety of other social, cultural, curricular constructs and
policies that guide teacher practice.

Teachers' thought processes have been categorized into three fundamental types:
(1) teacher planning; (2) teachers' interactive thoughts and decisions; and (3) teachers'
theories and beliefs (Clark & Peterson, 1986). Teacher theories and beliefs have been
discussed. Planning and interactive thoughts and decisions define how and when teachers
reflect on practice and make decisions. These categories are based on Jacksons (1968)
conceptual distinction between pre-active, inter-active, and post-active phases of
teaching. The first category represents the distinction between the thought processes that
occur before (i.e., pre-active thoughts) or after (i.e., post-active thoughts) classroom
Teacher planning (or pre-active thoughts) prior to teaching is conceptualized by
both process and practical activity. Examining the psychological aspects of the planning
process, Clark and Peterson (1986) define planning as a set of basic psychological
processes in which a teacher visualizes the future, inventories means and ends, and
constructs a framework to guide his or her future actions (p. 20). An examination of this
planning process found that teachers made decisions on the basis of what had worked in
the past, the school schedule, the availability of instructional materials, and the interests
and abilities of students (Sardo-Brown, 1988, 1990). During this planning, the lesson,
activities, and learning outcomes are defined. It is during this time that the written
curriculum, as well as the other factors that influence these planning decisions are
examined to guide instruction.
Donald Schon (1983), in The Reflective Practitioner: How Professionals Think in
Action, defines reflection-in-practice as a means by which a professional spontaneously

examines experiences as it is in progress in order to better understand it. Reflection-on-
practice is the purposeful examining of experience by professionals (Schon). This is the
conscious examination of practice, after instruction has occurred, that allows a teacher to
solve problems occurring in an environment as unique and complex as the classroom
Classroom conditions change in unpredictable ways, and information arises
during the act of teaching that by necessity must inform teacher practice. Reflecting on
these complexities, teachers make hundreds of non-trivial decisions each day working
with children (Good & Brophy, 1994). As the curriculum is enacted, the practitioner may
be reflective in practice and make additional adaptations based on teacher judgment, the
rigors of the classroom, student reaction to the curriculum, student needs, behavior issues,
or time constraints. The use of reflection-in-practice may be limited due to the lack of
time or opportunity to reflect on these decisions during instruction. It is important to
examine classroom practices during actual teaching and not solely based on teacher
beliefs, due to the fact that teacher beliefs may not always translate into teaching practice
(Ashton as cited in (Fang, 1996). Although reflection-in-practice is difficult, teachers
often adapt based on what is happening during teaching. This reflection-in-practice
should be examined to identify the reasons teachers adapt during the enactment of the
Teachers may also make instructional decisions after instruction has been
completed, when the teacher has time to reflect on the lessons and the decisions that have
been made during planning and instruction. Schon (1983) termed this reflection after

instruction as reflection-on-practice. Reflective practice of teaching and the impact that it
may potentially have on teacher behavior has been examined. Teacher reflective practice
involves thinking about and learning from ones own practice and from the practices of
others so as to gain new perspectives on the dilemmas and challenges inherent in the
educational setting. The practice is normally examined after teaching has occurred, in a
retrospective manner. This practice has been supported by a number of researchers as key
to improving teacher practices (Loughran, 2002). It should be noted that the extent to
which educators use reflective practices in the classrooms as intended may be limited
(Mena Marcos, Sanchez, & Tillema, 2008). However, reflection-on-practice should
inform future teaching of the next lesson in the sequence of the curriculum, and possibly
subsequent teaching of the curriculum. This cyclical process of planning, enacting the
curriculum, reflecting in practice, and reflection-on-practice with subsequent planning, is
termed the reflection enactment cycle. Teacher decision-making can take place during
any phase of this cycle. During this reflection enactment cycle, factors that influence
teacher decision-making may vary due to the unique dynamics of the classroom and
school setting.
Theoretical Framework
The theoretical framework that I propose brings together considerations for
adaptation, teacher pedagogy, a cycle of teacher planning, and enactment, as well as
reflection-in-practice and reflection-on-practice. At the center of the model is the core
decision to adapt or implement with fidelity. This decision is guided by considerations
from four broad categories that have been identified by Ringwalt and colleagues (2004):

(1) school context considerations; (2) implementation system considerations; (3) student
considerations; and (4) teacher considerations.
These considerations come into play as teachers begin planning for
implementation. During this time the written curriculum comes in contact with the real-
world implementation system of the community, school, the teachers pedagogical
beliefs, as well as the knowledge that an educator brings about their students. These
factors can influence the initial decision to implement with fidelity or to re-invent
through enrichment, elimination, modification, or accommodation of the curriculum. As
teachers initially implement the curriculum, additional decisions are made to follow the
curriculum guide or re-invent the curriculum based on teacher observation of the students
and classroom considerations. These adaptations are termed reflection in practice. These
are the fluid adjustments made during teaching that are not planned and happen during
classroom interactions.
After the lesson is taught, teachers may reflect on the lessons and make decisions
regarding fidelity or adaptation. This is termed reflection-on-practice. Reflection-on-
practice can influence how the next lesson will be taught or how a particular lesson will
be taught in subsequent teachings. This is a cyclical process that occurs as lessons are
implemented in the naturalistic setting of the classroom. This framework integrates
considerations for adaptations as well as a when the decision to adapt might occur.

Factors and Considerations Affecting Teacher Adaptation of Curriculum
/ Reflection Enactment x
Jf" cycle 'A
Figure 2.2 Factors Affecting Teacher Adaptation of Curricula: Reflection Enactment
Adapted from Ringwalt, C., Ennett, S., Vincus, A., & Simons-Rudolph, A. (2004). Students
special needs and problems as reasons for the adaptation of substance abuse prevention curricula in the
nation's middle schools. Prevention Science, 5(3), 197-206.
This chapter examined the literature related to curriculum fidelity and identified a
variety of measures for curriculum fidelity. Curriculum fidelity was identified as a need
to ensure the intended outcomes of the research-based curriculum. Although the goal of
fidelity is supported, the reality is that very few schools are implementing with fidelity. A
variety of factors have been identified that impact fidelity, including factors related to the
instructor, students, and implementation system as well as the school content. Teacher

decision-making has been examined and the role that teacher beliefs play in pedagogical
decisions as well as the potential role of the classroom environment on decision-making.
The reflection enactment cycle has been portrayed: teachers plan, enact the curriculum,
reflect in practice, and then reflect on practice to guide future instruction. A conceptual
framework has been described that presents how teachers may make decisions to adapt
the curriculum during the reflection enactment cycles.
Organization of Study
This study is organized into three chapters. In Chapter 3,1 will identity the key
research questions that guide the study and describe the research design, the participants,
and the data collection and analysis procedures. Chapter 4 discusses the results of the
study and the key themes that emerged from data analysis. In Chapter 5,1 identify the
grounded theory that describes adaptation of research-based curricula, and discuss the
findings. I will also make recommendations as well as suggesting future research.

Research Questions
Three main research questions were identified to focus the research:
(1) What factors or considerations influence health educators decision to adapt
(2) When do health educators make adaptations to the curriculum?
(3) What types of curricular adaptations do health educators make to curriculum?
Research Design
Due to the complex interaction between the developed curricula, the community,
the school, classroom settings, and the teachers pedagogical perspective quantitative
research cannot adequately uncover this complex phenomena. For this reason a
qualitative grounded theory (Glaser & Strauss, 1967) approach was used to uncover the
interactions within these systems as they relate to teacher adaptation of research-based
health education curricula. A grounded theory approach centers on the systemic
generation of theory from data, which is systemically obtained from social research, in
contrast to theory verification or only description. Its goal is to generate a theory that
accounts for a pattern of behavior that is relevant and problematic for those involved
(Glaser, 1978).

Grounded theory is a rigorous inductive methodology involving constructing
theory through inductive, open-ended data collection (Corbin & Strauss, 1998).
Theoretical sampling and continual comparison of data with categories that emerge
during analysis are characteristics of grounded theory (Creswell, 1998). Grounded theory
is the most widely used and popular qualitative research method across a wide range of
disciplines and subject areas (Bryant & Charmaz, 2007). This methodology has been used
in various social science and health related fields since its inception in the field of nursing
in the 1960s (Benoliel, 1996).
One core tenet of grounded theory is theoretical sampling, defined by Glaser and
Strauss (1967, p. 45) as the process of data collection for generating theory where the
analyst jointly collects, codes, and analyzes data and decides what data to collect next and
where to find them, in order to develop theory as it emerges. The process of data
collection is guided by the emerging theory and theoretical relevance. This sampling
allows the researcher to strengthen emerging theories by defining the properties of
categories and how they relate to one another.
Data analysis identifies core categories as they emerge from coding and become
the central theme of a grounded theory that integrates all aspects of that theory (Glaser,
1978; Strauss & Corbin, 1998). Initial data analysis involves coding data on a line-by-
line basis, with constant comparison of various indicators for similarities and differences.
The core category is a theme that occurs frequently over the course of data analysis,
which connects with other categories, and generates theory based on the research
questions. (Charmaz, 2008; Glaser, 1978).

After completion of the open-coding process, resulting in the initial categorization
of the concepts into phenomena, the analysis moves to the axial coding process. During
axial coding, the dimensions and properties of the category are discovered. In axial
coding, data that was broken down during the open coding analysis are reassembled. This
process involves an analysis of how the categories relate comparatively and differentially,
and relates the categories to subcategories along the lines of properties and dimensions
(Corbin & Strauss, 1998)
Theoretical sampling allows the researcher to develop and refine tentative
categories with the goal of reaching theoretical saturation, which occurs when all data can
be coded into categories and no new categories among the data emerge (Charmaz, 2006).
Theoretical saturation guides data collection. The number of participants is determined
based on theoretical saturation or when no more new categories are identified in the data.
Morse (1994) suggests that 30 to 50 interviews are needed; however, Noerager Stem
(2007) recommends 20 to 30 interviews and/or hours of observation as adequate to reach
According to traditional grounded theory, too much literature review is thought to
contaminate or clutter the researchers ability to analyze codes that emerge from the data
(Glaser, 1992); however, Corbin and Strauss (1978) recommend that the researcher
engage proactively with the literature, returning to it and weaving it through the research
process as though it were another voice.
Creswell (1998) recommends the presentation of data using a coding diagram or
logic diagram in which the central phenomena, conditions, strategies, the context,

intervening conditions and the consequences for the adaptation phenomena are identified.
Additionally, the codebook provides transparency on method that can be used by other
researchers wishing to examine the coding method in detail. The theory is written in
narrative form and describes the categories, the relationship between them, and the
properties and dimensions of each of the categories (Creswell, 1998).
The goal of this study was to generate theory about how teachers implement
research-based health education curriculum in the real-world setting. For this reason
examining these phenomena using a grounded theory perspective allowed a fuller picture
to emerge of what occurs in the implementation of these curricula in the real-world
Access to Participants/Sites
Choosing informants (participants) for this study was crucial for gathering
reliable data to inform the grounded theory. Lincoln and Guba (1985) highlight the
importance of choosing useful participants:
The useful informant is one who is a legitimate, committed, and
accepted member within the local context, but who is, at the same
time, willing to act as a member of the inquiry team, even if only
informally. ... Such informants can provide the inquiry team with
an inside view of the norms, attitudes, constructions, processes,
and culture that characterize the local setting, (p. 258)
Initial participant sampling included Colorado Department of Education certified
teachers who were implementing one of two research-based tobacco prevention curricula,
Life Skills Training (LST) or Towards No Tobacco Use in a middle or high school
setting. Potential participants were trained on one of these two curricula by a non-profit
organization that has been providing training on these curricula for over 15 years. During

the training participants were asked to identify their estimated curriculum implementation
dates as a standard training protocol. Potential participants were initially identified based
on training records, and because their estimated curriculum implementation date aligned
with the research timeline.
To initially ensure rich data for adaptation, teachers working with youth who are
at high-risk for tobacco use were identified. From the list of potential participants,
schools supporting students who are disparately affected by tobacco were identified.
Identification was based on the Colorado Department of Public Health and Environment
criteria for disparately affected populations for tobacco use and Colorado Department of
Education school-level data from 2009 (Colorado Department of Education). The
following criteria were used to identify the initial teachers for participation: 1) Schools
with an overall school academic performance categorized as low or unsatisfactory; 2)
Schools with a high proportion of the student population eligible for free or reduced
lunches; and 3) Schools with a high proportion of African Americans, Latinos/Latinas,
Asian-Americans/Pacific Islanders, or Native Americans. Based on these criteria,
participants were contacted as potential study participants. Three teachers were identified
using these criteria. Due to lack of recent trainings and the above criteria, no teachers
were identified as teaching the Towards No Tobacco curriculum. The fourth participant
was identified due to his vast experience teaching the LST curriculum as well as his
experience as a trainer in the LST curriculum. The school does not meet the identified
criteria for teaching disparately affected youth; however, the focus of this research is not
based on that premise, but primarily to identify those individuals who are more likely to

adapt the curriculum (Ringwalt, Vincus, Ennett, Johnson, & Rohrbach, 2004). Consent
was gained from teachers and administrators prior to interviewing and observation. See
Appendix A for consent forms.
School Setting
This research took place in three public middle schools and one high school
located in Colorado. The four sites varied widely from large urban districts to small rural
and mountain schools. All sites were currently teaching the LST curriculum during the
study period. Two schools were in one large district that spans both urban and suburban
areas. School #1, an alternative high school serving grades 9-12, is located in an urban
area, and School #2 in this large district is a middle school serving grades 6-8. School #3
is located in a predominantly agricultural area located in a mountain valley. School #4 is
located in a mountain town serving a large ski area. These four sites offered varied socio-
cultural contexts for examining implementation of the curriculum.
Overall School Population
Student diversity in these schools included differences in socioeconomic status as
well as diverse cultural backgrounds. According to data from the Colorado Department of
Education (2010a) the students within the schools varied widely (Table 3.1).

Table 3.1 School and State Totals by Race/Ethnicity
School/State Totals
#1 #2 #3 #4 State
n % n % n
American Indian Native Alaskan 13 4.0 9 1.3 3
Asian 0 0.0 36 5.4 0
Black or African American 2 0.6 17 2.5 1
Hispanic Latino 186 57.2 252 37.6 122
White 41 35.1 176 50.0 4
Native Hawaiian or Other Pacific Islander 0 0.0 4 0.6 0
Two of More Races 10 3.1 17 2.5 0
Total 282 511 133
% n % n %
2.2 1 0.4 7452 00.9
0 1 0.4 24493 2.9
0.8 2 0.8 40537 4.8
91.0 21 7.9 266098 31.6
6.0 125 90.1 479327 56.8
0.0 1 0.4 1844 0.2
0.0 0 0.0 23565 2.8
151 843316
Free and reduced lunch rates indicate that three of the schools had higher than
average rates compared to state totals (Colorado Department of Education, 2010b)

Table 3.2 School and State Totals by Free and Reduced Lunch Rates
School/State Totals
#1 #2 #3 #4 State
n % n % n % n % n %
Free and
Reduced 1,016 71.2 351 52.4 121 90.3 52 19.5 327,304 40.3
Teachers Stories
In order to gain insight into the perspective that these four teachers bring to
curriculum and adaptations, as well as their unique understanding of implementation, it
was important to understand their background. During initial interviews of the four
participants, background information was obtained from the participants. I describe
below their educational background, teaching philosophy, and the setting that they teach
Sara, alternative high school. Participant #1 I will refer to as Sara. Sara teaches in
an alternative school in a large school district in an urban area. The school serves 282
students. Sara teaches the High School level of LST to students ranging from 15 to 19
years of age. Sara has been teaching for 13 years, with past experience teaching middle
school English in Japan, teaching reading in Micronesia, and teaching English as a
second language in China. More recently, Sara taught in Florida for three years at an

international boarding school teaching English as a second language to students from 50
different countries. She has been teaching in Colorado for three years. Sara currently is
teaching English and LST. She has no background in health education except for the
initial training that she received on the curriculum. A team of teachers developed the
implemented LST curriculum. They met collaboratively to identify what should be taught
from the curriculum as well as adaptations. Sara describes her school and some of the
challenges that she faces daily:
Different, difficult at times, our student population is very transient. We
have attendance issues, so its really hard to keep everybody at the same
pace. So its definitely a challenge working here. I think that if we didnt
have the staff we had, I would have been out of here the first week. All the
other schools that Ive been teaching at, they wanted to be there. The kids
had great attendance. Education was valued differently. Here our students
have dropped out and are re-entering; their attendance is always an issue.
It seems like you can never go forward, youre always going back to re-
teach because the majority of the class is not there. So, its a little bit of a
challenge, but at the same time the kids are super sweet and Life Skills I
think has made a difference in our school. (Sara, Alternative School
Seven students are registered for the LST class that meets from 4:25 pm to 5:30
pm. The school offers a flexible schedule to accommodate working students and provides
extensive online courses; this is the only face-to-face course that Sara teaches. LST is a
required course for graduation at this alternative school. Saras teaching philosophy
focuses on making the curriculum relevant and engaging for students. She focuses on the
needs of students in the alternative school as well as the gender differences as ways to
engage students.
Belinda, large urban middle school. Participant #2, who I will refer to as Belinda,
teaches in a large school district in a middle school with 511 students. This was her fifth

year teaching in the school district. For two years she taught first and second grade
physical education as well as middle school physical education. After two years split
between two schools, she was hired full time to teach seventh and eighth grade physical
education at her current middle school. This was Belindas second year teaching Level
One of the LST Middle School curriculum in her middle school health class. She
describes her school as diverse in this way:
I mean we have the gifted and talented program, we have kids that are
homeless, we have kids who that have both parents at home that are
supporting them. We have kids that dont have any parents, one parent is
in jail. Theyre pretty much their parents. So its, we have all different
levels, and I get that in my health classes too. Its a great mix of kids.
(Belinda, Middle School Physical Education and Health Teacher)
The current health class is an elective offered to seventh and eighth grade
students. Belinda saw health education as a need while she was teaching physical
education; she went to her principal and asked if she could teach a health class as an
elective, and her principal supported her. She was able to build an elective health class
offered each trimester. She did not collaborate within the building to develop the course.
Classes met every day for 50 minutes from 12:30 pm to 1:20 pm. Belinda had 28 students
in her health education class. Belinda teaches two health classes per day.
Belinda describes her teaching philosophy and how kids learn: Kids learn
through discussion group work and hands-on in-class activities, skits where they are
getting up and interacting. She sees movement as a key to learning, and believes in
building an environment where kids feel comfortable in the classroom.
Kathy, rural mountain school. Participant #3, who I will refer to as Kathy, teaches
a mixed seventh and eighth grade health class to all 133 students in a rural mountain

school. Kathy is a counselor by education, with no formal classroom or health education
experience. She has been teaching health education for 12 years. Kathy teaches Level
Three of the LST Middle School curriculum to all 134 seventh and eighth graders in the
school. The class that was observed had 15 students in it and met for 45 min from 12:30
pm -1:15 pm. Health is a requirement for all students and is taught two days a week
opposite physical education. Kathy describes her students as:
Oh, I love the students. I do. I think they are, they lack some background
knowledge. Most of the time theyre pretty motivated, but they have a lot
of outside issues that theyre dealing with. So I think when it comes to
health, that can cloud your thinking and they have to make new thinking
patterns, new ways of behaving that may be different [than their] family
behaves. And so, theyre struggling in some of those things. I think they
want to be successful, though. They want to grow. Its tough to figure out
how and find that motivation to do that.
(Kathy, Health Teacher/Counselor)
Kathy is involved in a wide variety of after-school activities and is coordinator of
the school peer mentor program. In the development of the course Kathy has not
collaborated with others to develop the courses that she teaches. Kathy has attended a
number of trainings on the curriculum and has been involved in professional development
for teachers at the school-level.
Kathy describes her teaching style as:
Oh, I like to do things, you know. I like to be moving and doing things
and engaging. I like [to] engage [students]. I try to meet different
mindsets. I like to engage visually, auditory, you know. You know, I try
to engage them in different modes so that they are moving. And they have
different state changes that maybe if I see it visually, or I hear it, whatever,
however it might impact them, I try to do that.. I think if you can use a
little technology, use some music, use some video, use movement. I think
they respond to that. And I think they absorb it in a different way.
(Kathy, Health Teacher/Counselor)

Jerry, small mountain middle school. Participant #4, who I will refer to as Jerry,
teaches in a small mountain town near a large ski area. The school is a small middle
school with 155, in grades 6-8. Jerry has been teaching for 30 years. He has been taught
at the elementary school for 12 years, then moved to the middle school to teach sixth
grade so he could teach the same students that he coached. As a sixth grade teacher, he
has taught health and social studies for 18 years. Jerry has taught a wide variety of health
education curricula since the early 1980s. He has an undergraduate degree in elementary
education and physical education, and a Masters degree in special education with an
emphasis on gifted and talented teaching. Jerry has also provided training for teachers
and districts on the LST curriculum. Jerry has been teaching the LST Curriculum for nine
years. Jerry has worked with other health educators in the district to align health
education efforts through curriculum mapping and alignment. He is currently teaching
Level One of the LST Middle School Curriculum to sixth grade students. The class meets
for 60 minutes from 8:00 am to 9:00 am. The class has 25 sixth graders enrolled. Jerry
describes his students as:
Were pretty homogeneous, pretty homogeneous. Our population has
dwindled dramatically. We have a population, a year and a half ago we
were about 1300 students1350. Were down to about 1250. Weve
hadseen a huge drop in our Hispanic population, because construction is
our big employer, and people arent building. So were seeing ... our free
and reduced lunches have doubled. You know people are trying to hang on
but there just arent the jobs. You know the ski areas and the school
district are the two biggest employers, and you know a lot of cuts in pay, a
lot of laid-off people working two and three jobs just to make ends meet.
So it seems like we have that clientele, but we still do have a very wealthy
clientele, which the recession has not really affected.

In Table 3.3 you will find a summary including, teacher experience (years),
school setting, grade level, LST curriculum level being taught, length of classes, school,
and the number of student in each class for each site.
Table 3.3 Participants and Site Summary
Participant Experience (yrs.) Setting Grade LST Curriculum Class Length (min) Students
Sara 13 Urban Grade 9-12 High School 65 7
Belinda 5 Urban Grade 7-8 Level 1 50 28
Kathy 12 Rural Mountain Grade 7-8 Level 3 45 15
Jerry 30 Small Mountain Grade 6 Level 1 60 25
Life Skills Training Curriculum
Botvins LST curriculum has had significant research identifying its effectiveness
in reducing the onset of and use of alcohol, tobacco, and other drugs in adolescents, and
reduction in violence. The initial LST curriculum was developed and evaluated in the late
1970s with the first evaluation study supporting its effectiveness in delaying the onset of
cigarette use (Botvin, Eng, & Williams, 1980). Since this initial study a number of
evaluation, replication, as well as implementation studies have been conducted to
examine the use and effectiveness of the LST curriculum (Elliot, 2002). In this study the
middle school and high school levels were observed. The LST levels observed were
appropriate for the grade level being taught. Three levels of the LST curriculum were
observed, two middle school levels and the high school versions of the curriculum.

The goal of the curriculum is to prevent tobacco, alcohol, and drug use among
adolescents. This is done through the development of important personal and social skills
to reduce interpersonal motivation to use drugs and reduce vulnerability to pro-drug
social influences. This is done through the development of skills to resist peer and social
pressures, develop positive self image, develop decisions making skills, solve problems
independently, manage anxiety, communicate effectively, build healthy relationships, and
deal with social situations with confidence. These skills are developed through lecture,
student discussion, interactive activities, and student practice. Table 3.4 provides a
summary of the LST curriculum in this study, including grade level, year of copyright,
recommended grade level, number of sessions and optional lessons. It should be noted
that not all of the lessons for these curriculum were observed during this study.
Table 3.4 Life Skills Training Curriculum Summary
LST Level Copyright Year Grade Level Class Sessions Optional Sessions
High School 2006 9-10 10 0
Level 1 2000 6-7 15 3
Level 3 2000 8-9 10 4
This study used multiple data-collection instruments to triangulate data. Initial
data collection consisted of semi-structured interviews. The interview protocol contained
thirteen open-ended questions, beginning with open informational questions to build
rapport, progressing to more open-ended reflective questions (Appendix B). This initial

set of questions was used to gain background information on participants teaching
experience, teaching philosophy, administrative support, and training experience, as well
as gaining insight into changes participants have made to the curriculum in their
planning, prior to teaching. If available, lesson plans, student handouts, and curriculum
maps were collected during this initial interview. This initial interview collected data to
support reasons for adaptation and data that indicates when teachers came to the decision
to adapt the curriculum during pre-planning
The second component of data collection consisted of a pre-observation interview
using the Pre-Observation Questionnaire (Appendix C). The lesson that would be
subsequently observed was used to guide this discussion. During these interviews,
participants were asked to identify what they planned on teaching during the observation.
This interview identified planned changes and the reasons for those changes. It was
essential to have a pre-observation interview to identify planned changes before
The third component of data collection was classroom observation of five lessons.
Classroom observation used several tools to guide data collection. First, all data from the
pre-observation interview was added to the Observation Matrix and Post-Observation
Questionnaire (Appendix D). This allowed the researcher to identify the key components
from the LST lesson that had been modified prior to teaching. During the lesson, this
matrix and the actual LST lesson were used to track changes. Using the LST lesson plan,
additions were written by hand in the margins and highlighted in green; sections of the
lesson that were omitted were highlighted in red; modified items were highlighted in

yellow; and completed items were highlighted in blue. All observable reasons for
changes were noted and highlighted in orange. Upon completion of the observation, all
of this data was entered into the Observation Matrix and Post-Observation Questionnaire.
This matrix was used to guide follow-up interviews to identify reasons for adaptations.
The fourth component of data collection was the post-observation interviews after
each lesson. These interviews used the Observation Matrix and Post-Observation
Questionnaire as well as the notated LST lesson from the observation to guide questions
and complete the matrix. The post-observation interview was developed to elicit reasons
for adaptations that occurred during observation, and to confirm observed reasons for
adaptation. The questions used during these interviews were guided by the interview
questions; however, the interviewer and the participant engaged in a naturalistic,
conversational way that also guided the questions.
Interviews and observations were conducted at the schools of the teachers being
interviewed and scheduled at the participants convenience. All post-observation
interviews were conducted within 48 hours of the observation. Due to this constraint
some post-observation interviews were combined with the pre-observation interviews for
the subsequent lesson. All interviews lasted 30 to 60 minutes.
Data Collection Procedures
Collecting data for this study occurred over the course of the 2010-2011
academic school year. Upon participant consent, the researcher worked to identify five
lessons for observation as well as and pre- and post-interview times and dates.

In the first phase of data collection, pre-observation interviews were conducted.
Interviews were recorded with participant permission, after reminding participants of the
purpose of the study, assuring confidentiality of their responses, and obtaining their
consent to participate in the research study. Upon completion of the interview, the
interview was reviewed to identify follow-up questions. Data from the first interview
were then transcribed and entered into NVIVO 9 qualitative software (QSR International,
2010), coded, and analyzed, resulting in emergent themes and reflection.
Data-collection procedure for observations followed a separate procedure. Prior to
each observation, participants were interviewed using the Pre-Observation Questionnaire
(Appendix C) as well as the LST lesson that was to be observed. Upon completion of the
interview, data related to the observation was entered into the Observation Matrix and
Post-Observation Questionnaire (Appendix D). This was used during the observation to
help identify planned changes and unplanned changes.
During the observation, this matrix along with the actual LST lesson was used to
track changes from the planned lesson using the color highlighting scheme described
above. All observations were video-taped to ensure that observed adaptations and
observed reasons were accurate.
During the-post observation interview, data from the observation matrix and the
post-observation questionnaire were used to identify reasons for adaptations that occurred
during the observation. The post-observation interview allowed for member checking.
During the post interview observed adaptations were confirmed and reasons for those
adaptations were identified. Member checking was also done to confirm any adaptations

that had been discussed during the pre-observation interview. As grounded theory
contains a constructive element, member checking is important as meaning is constructed
between the researcher and the participant (Charmaz, 2006).
Upon completion of the post-observation interview, data from the interviews were
transcribed and put into the observation matrix. Data from this matrix were then entered
into NVIVO, coded and analyzed, resulting in emergent themes and reflection. Themes
were considered to emerge when the same phrases and ideas appeared repeatedly. These
themes were then used to guide additional or more focused questions for subsequent
observations and interviews (Charmaz, 2006). Data was collected from four participants
and five observations of lessons were completed for each participant with pre- and post-
observation interviews. Table 3.5 identifies the participants, number of observations in
minutes, and the total interview times.
Table 3.5 Observation and Interview Times by Participant
Participant Observations # Observation (min) Pre and Post Interview (min)
Sara 5 325 183
Belinda 5 250 183
Kathy 5 225 200
Jerry 5 300 215
Total 20 1100 781
Data Analysis Procedures
Analysis began immediately upon completion of the first interview and collection
of data. Data collection occurred at each of the four sites in the same way. First, the initial
audio interviews were reviewed with initial coding beginning using a word document.

This hand coding was used to identify follow-up questions and to begin the open coding
process. After initial hand coding the initial interviews were transcribed into written text.
In the interest of time I used a transcription service to assist me with the transcription of
all interviews. Data was entered into NVIVO 9 software and I began to make sense of the
data through the formation of additional codes and categories.
Data collected for the observations were analyzed in a slightly different way.
Since many of the observations occurred directly after or soon after the pre-observation
interviews, data could not be thoroughly coded immediately. The data from the pre-
observation interview was entered into the Observation Matrix (Appendix D). As
described in the instrumentation section data was collected during the observation using
the matrix and the LST lessons. After each observation, the video-tape as well as notes
and noted lessons were reviewed and follow-up questions were developed based on the
adaptations that were made. Upon completion of the follow-up interview, all data was
entered into the Observation Matrix and Post-Observation Questionnaire. Upon
completion of transcription of the pre-post interviews, that data was also entered into the
matrix for each lesson. This was then entered into NVIVO for in-depth data analysis. All
data was analyzed based on the research questions. First, coding was done to classify
adaptations as additions, modifications, or omissions. During coding, if the added activity
was not aligned with the lesson objectives or the core intent of the activity it was coded
as an addition. Additions were identified based on the lesson objectives. If the adaptation
was in line with the core objectives of the lesson or the intent of the activity the addition
was coded as a modification. An example of a modification would be the use of a

different teaching strategy that met the core objective of the lesson but was modified
from the activity recommended in the curriculum. Other modifications might include
changing role-play scenarios or statistics to be more closely aligned with the local setting.
Omissions were coded if the activity or lesson was completely omitted.
At the same time, the observation matrix was analyzed to identify reasons for
adaptation and to determine when the adaptation occurred. In this way, coding was
developed that addressed the key research questions. Appendix E, Matrix Coding
Example, illustrates how the matrix was coded.
As interviews and observations continued across sites, a constant comparative
analysis was used in an initial effort to develop provisional categories. Thus, analysis and
data collecting proceeded simultaneously and were influenced by each other. Theoretical
memos were used throughout the data collection process.
After completion of the open coding process, resulting in the initial categorization
of the concepts into phenomenon, the analysis moved to the axial coding process. Axial
coding did not begin until all data was coded. During axial coding, the dimensions of the
category were discovered; the data that was broken down during the open coding analysis
was reassembled. For example, during open coding observations from the classroom and
interviews were examine and coded to identify the reason for the adaptation. These
reasons for adaptation were then examined to identify how they related to each other
through the identification of categories and phenomenon. In this process the codes that
were previously broken down were put back together in a new way as they related to each

other. These categories and memos were then sorted by hand to develop the grounded
theory. A codebook using NVIVO software was kept to assess the consistency of coding.
Validity of Interpretation
Efforts were made to ensure the reliability and validity of the qualitative data.
Responses across different forms of the same question were used in examining reasons
for adaptation. Analysis across the study was done consistently within the framework of
grounded theory.
Data triangulation was done through pre-observation interviews, observations,
and post-observation interviews. This allowed the researcher to confirm reasons for
adaptation during several different interviews. Pre-observation interview data was
triangulated with observations as well as with post-interview data. This design also
allowed for confirmation and data-checking by the participants. Observations and
identified reasons for adaptations were checked for accuracy during follow-up interviews.
(Frankilin & Ballan, 2001).
Limitations and Delimitations of the Study
One limitation of this study is the sample size of four participants. Another
limitation is that participants, as volunteers recruited from the population of teachers
teaching LST in middle or high schools, are a self-selected sample. This sample has the
common characteristic of being willing to share their experience and allow for
observations and interviews. Their willingness to participate may indicate that they hold
positive perceptions around the curriculum or adaptation. The sample population is not a
true cross-section of teachers teaching research-based health curriculum. If the

curriculum is taught in other settings beyond the school setting the results of this study
may not apply to those implementers of the curriculum. The study is also limited to
examining only one curriculum.
Another limitation of this study is the fact that not all lessons of the curriculum
were observed. Only a sample of the lessons was observed; the content of the lessons
could have influenced the types of adaptations and influenced the reasons for adaptation.
A longer time frame with observation of all the lessons may produce a more substantial
theory by allowing varied data collection and analysis, and may generate additional
themes that could be explored. This limitation may be minimal since the observations
were across three different levels of the curriculum; observed lessons represented a wide
variety of topic areas, and participants used a variety of teaching strategies and styles.
A delimitation of this study is that it only examined one research-based
curriculum, thus the theory may not be generalizable to other research-based curricula.
Although the LST curriculum is widely used, it is unique in its theoretical perspective of
prevention, and its defined outcomes. The study may not be generalizable to other
Another delimitation of this study is that all participants were trained by the same
organization. Training is essential and can impact curricular implementation (Dusenbury,
et al., 2003). All participants were asked how effective the training was and their
impression of the training, all participants revealed that they thought the trainings were
effective and that fidelity was a focus of the training; however, a number of participants
stated that they learned about adaptation during the training. Without observations of the

trainings it is difficult to identify to what extent the trainings impacted adaptations or
This study did not attempt to identify the impact of the adaptations on the
intended outcomes of the curriculum. The researcher aligned adaptations with curriculum
objectives to determine if they were in line with the curriculums core components;
however, the study was not intended to identify how the adaptations impacted intended
The study was delimited to examining adaptations and not intended to examine
the extent to which the curriculum was implemented with fidelity. Although the results
are related to fidelity it was not the intent of the study to examine fidelity of
Ethical Considerations
In this study, several ethical considerations were addressed including issues
related to collegial relationships of the researcher with several participants,
confidentiality, and teaching observations. These ethical considerations were taken into
consideration and addressed during the study as well as in the research design.
The researcher has collegial relationships with several of the study participants.
The researcher is a health educator providing professional development and training to
health educators, and has daily interactions with health educators across the state. The
relationships were in the context of providing support and training to schools and districts
related to coordinated school health and school-based tobacco prevention efforts. The
relationships prior to and during the study were not supervisory in nature and the

researcher held no authority over the participants. In a qualitative research study such as
this, the interaction between the participants and the researcher is to be expected. The
relationships that were built prior to this research only enhanced the ability of the
researcher to engage participants in a meaningful way.
The primary ethical consideration of this study was protection of participant
confidentiality. Consent forms were reviewed and discussed prior to the interviews and
observations. All audio and video recordings were digitally recorded and downloaded to
a password-protected hard drive, which was stored in a locked file cabinet in the
investigators office. All audio and video recordings were edited or transcribed to ensure
that no personally identifying information was visible on them. All video and audio
recordings with identifying information were deleted from the hard drive upon
transcription and editing. Videotaping did include students; however, the camera was
placed to minimize students in the video frame, and any video or audio that had
identifying information was edited as stated above. Results of this study will be shared
with participants in several ways. A summary of research findings will be sent to
participants. Contact information will be included in this summary so that the researcher
can be contacted in order to more fully explain the study or its findings. The researcher
also plans to use this research study as the basis for articles, which will be submitted for
publication in scholarly publications supporting implementation science, health
education, and curriculum development.
Participants were observed in their classrooms and were asked to reflect on their
teaching and the how they made the decision to adapt the curriculum. Teachers were not

asked to change what or how they were teaching in any way. Observations were
scheduled when teachers were teaching the LST; if other lessons related to other curricula
were being taught during that time, teachers were asked to teach the unit just as they
would in normal teaching practice.
In this chapter, I presented the methods used to investigate three research
questions. I described the research design, describe the procedures I used to recruit and
select participants, described the school and participant background, and described my
data collection and analysis procedures. I concluded this chapter with an assessment of
the validity of interpretation of results and strengths and limitations of the study.

In this chapter, I present the results of this study as they pertain to my research
questions. The research questions that guided this study were: (1) What factors or
considerations influence health educators decision to adapt curriculum? (2) When do
health educators make adaptations to the curriculum? and (3) What types of curricular
adaptations do health educators make to curriculum? Findings will be presented based on
the research questions. A grounded theory will be presented in Chapter 5.
When examining factors that influenced teacher adaptation, three key themes
emerged from the data and analysis. Reasons for adaptation fell into three main themes
across all four cases. Teachers adapted the curriculum (1) to engage students in learning;
(2) to support student needs; and/or (3) to support policies in practice. Teachers beliefs
about how students learn drove many of these adaptations. I begin by examining the
major themes and their sub-categories. These major themes, dimensions, and codes, as
well as classroom examples are summarized in Table 4.1.

Table 4.1 Themes, Dimensions, Codes, and Classroom Examples
Themes Dimensions Categories Classroom Experience/Examples
Create a safe supportive environment Create a safe a learning environment Modified or added classroom norms or team- building activities. Some omission occurred due to student comfort level.
Make personal connections with students Lessons or activities were modified or added to make personal connections with students or to get to know students.
Student Engagement Make it relevant for students Modified or added scenarios that were more relevant to students. Changed statistics.
To engage students through a learning task or activity. To make connections for students Modified or added activities or lessons that make connections for students across the curriculum or with other curriculum in an attempt to engage background knowledge.
To encourage student sharing and interacting Modified or added activities to share ideas (e.g., pair-share, small group discussion).
Student learning styles Added or modified to allow for varied teaching techniques aligned with varied learning modalities.
Application of concepts and skills and practice Increased application of knowledge and skills.
Student academic Additional background knowledge needed Providing additional definitions or expanding concepts.
Student Needs needs Student academic skill level Low reading ability or academic skills led to additions or modifications.
Unique student population Student population Additions, modifications, or omissions based on unique student populations.
Assessment Assessments were developed and added to the curriculum.
Local curriculum, standards, and Standards Standards guided the curriculum and led to adaptations if not aligned.
Local assessment Curriculum maps or guides Understanding the full scope and sequence of health beyond the classroom led to omissions, additions, and modifications.
Policies in Practice School scheduling School schedule influenced the students that were enrolled in the health education class which led to adaptations.
School policies Class size Influenced the types of adaptations that teachers made.
School-wide initiatives School-wide academic and health initiatives lead to curricular adaptations.

Student Engagement in Learning
This sentiment sums up teacher decisions to make adaptations to engage students
in learning:
So I don't know ... when I read through the lessons, and personally I think
aagh I would be bored. If I just ya know if, as I read through this, and it
says have the students copy these notes, talk about this, tell the students
this, have the students work in their work book. To me it's just too dry for
my personal teaching. Just to get them up and moving and having it relate
back to the (lesson), instead of having it just coming from me or seeing it
on the white board. (Belinda)
The need to engage students emerged as a theme that drove a variety of
adaptations. It appears that teachers see the engagement of students as a necessary aspect
of the curriculum; if it is not present, teachers are adapting to ensure student engagement.
Teachers engaged students through a wide variety of teaching strategies and techniques,
and by using visual aids. These adaptations were implemented through additions,
modifications, and omissions. Most adaptations consisted of modification of additions to
the curriculum; however, a number of omissions did occur due to lack of student
engagement. The alignment between curriculum fidelity and adaptations made for student
engagement was mixed at best, with some additions supporting the core tenets of the
curriculum while others were not supportive and were added purely to engage students.
Other adaptations may have been counterproductive to the curriculum. Adaptations that
teachers made to engage students fell into one of two sub-categories: 1) to engage
students to create a safe, supportive learning environment; and 2) to engage students
through varied learning tasks or activities.

Create a Safe, Supportive Learning Environment
Teachers engaged students in the creation of a safe, supportive learning
environment for all students. This was done by creating a safe learning environment, and
by making personal connections with students.
Create a Safe Learning Environment
Adaptations that supported the development of a safe and supportive learning
environment such as team building activities or development of classroom norms were
found to be common additions or modifications for all participants. Activities that
teachers identified as not supportive of a safe environment such as role play were omitted
or modified to ensure that students felt comfortable in the learning environment.
Teachers modified activities to support the active development of classroom
norms, as opposed to just presenting norms to students as suggested in the curriculum.
These classroom norms were repeated again during teaching when certain topics were
controversial, such as role-playing refusal skills or drug use. All participants took the
time out of the curriculum to develop these classroom norms. These classroom norms
were posted in all classrooms and generally aligned with the suggested norms in the LST
Other teachers built on these norms by adding activities to get to know students
and by developing a safe, supportive environment for student sharing. Teachers believed
that an environment that supported sharing was necessary for success: If these students
arent comfortable and willing to share, this curriculum is hard to teach. (Sara). This
same teacher added activities every day that had nothing to do with the lessons in order to

get students thinking and to allow them to share and feel comfortable with each other.
She told students that these were activities that have nothing to do with todays lesson.
When asked why she added these activities, her response was That's how they get to
know each other. Every day we have some kind of icebreaker that we do ... I pick them
based on their personalities and what's worked before in the past. Another teacher
expressed this idea in this way, I did this to get them comfortable with each other. They
will be working together for the rest of the unit. Activities were added to help develop
teams that would be working together throughout the semester, What is it that I need to
be a good teammate? What is it that I need to contribute in my group? So thats why I
chose that. (Kathy). These were all additions to the curriculum that were seen as
important to support an overall supportive classroom environment, as well as supporting
students feeling safe in the classroom.
Another participant said this about her allowing students to move off topic during
I allow them to; they think they are sidetracking me, getting me off topic. I
allow that to happen. I think that needs to happen for them to continue
sharing. If I shut them up every time that they talked off topic they would
never speak. So I try to share what is appropriate. I heard them talking
You get side-tracked so easily. Im thinking this is planned. This is what
Im looking for to build that trust. (Sara)
Another participant discussed the need for students to feel comfortable in her class in this
The more class discussion, I think, the better. Especially when youre
talking about the substance abuse issues or sex ed, these type of issues
where kids may not feel comfortable. You know elsewhere, I want them to
feel comfortable in the classroom. You know I try to do as much
classroom discussion, tons of group work, skits where they are getting up

and interacting with each other, just because they dont do it enough, and
with it being such a diverse population you can a lot of times pick out the
groups, so its nice to when you can have them in one classroom and say
that you three are working together. You dont know each other at all but
you will be working together. So yeah, mainly just a lot of group stuff,
class discussions. (Belinda)
These types of student-teacher interactions occurred during all observations and were
used not only to build trust but also to get to know students and build a rapport with
them. All teachers built in activities to encourage students to feel safe and build trust in
the classroom. Activities or lessons that teachers felt students might not feel safe or
comfortable with were omitted or modified to limit student discomfort.
The omission of practicing role-play scenarios due to teachers concern over the
comfort and safety of students was identified. One teacher reflected back on her learning
experience and described that she would not have been comfortable participating in the
activity and felt like her students would not participate in the activity. This was based on
her specific students, her specific class, and her past experiences:
No, it depends on your class. I had a class that was all girls and they loved
that. They got up in front of the class and did stuff like that, all the time.
These kids, I think Dan would do it. Hes good in his seat doing that. I
dont think Chris would feel comfortable doing that. I dont think David
would do it. I think David would give up halfway through and say, oh, I
cant do this, and sit down. And I also think about how I would feel. Im
not comfortable doing those activities. I dont want these kids to feel
apprehensive or nervous, going oh God, whats she gonna have us do
today. There are some activities I make them get up to do in a circle, and
theyre fine with that. But if they have to get up there in front of other
people, I dont want to terrify the kids. I want them to participate. If they
are able to stay in their seats, and work with a partner, Ill take that. (Sara)
Another teacher planned on doing role-play activities, but after one class did not feel
comfortable doing the role plays, she decided to just talk about the role plays instead of

practicing them. This was also caused by student lack of interest in doing the role play.
Another teacher gauged whether she would do a role-play based on her observation of
It just depends on how they are, when they come in... If I dont feel like
we're going to get an actual good discussion, for the kids to come up and
read it and do a role-play, and then have a discussion, then I'll just have
them read it at their desks. And you knowshorten the discussion.
Although omission of role-play practice was not noted across all of the participants, three
out of four did modify or omit the role-play practice, due to concerns about how students
would react to the activity, or due to discomfort for the teacher or students. In each of
these cases the reason for adaptations was slightly different. Most teachers saw role-play
as important, but did omit or modify the activities due to student comfort levels.
Participants worked to create a classroom environment that was safe for learning,
and where students felt comfortable sharing their ideas and thoughts. However, this
reasoning also led teachers to omit or modify activities that were essential to the
curriculum. The omission or modification of role-play scenarios may have been
counterproductive and could potentially impact the intended outcomes of the curriculum.
Make a Personal Connection with Students
Other activities were added to the curriculum to get to know students and in turn
make connections with them. This need to make connections with students presented
itself in several different ways; some were direct adaptations to the curriculum while
others were part of the daily interactions that teachers had with students. Many teachers
made connections with students outside the scope of the curriculum. Participants saw this

as an important aspect of teaching LST. Teachers showed this in a number of observable
ways: stopping to ask a student about how soccer was going, asking what everyone did
over the weekend, taking time to ask students what they were doing over break etc. These
observable interactions with students were part of the daily routine of all of these
teachers, not part of the curriculum. One teacher put the importance of knowing students
in this way: And it brings back that you make connections with the kids outside of the
classroom, theyre going to be more apt to come in, no matter what way you teach,
theyre going to come in and do it. (Jerry)
Three of the teachers were very involved in after-school activities that supported
this idea of getting to know students outside of the classroom. These interactions were
not part of the curriculum but were based on beliefs that guided how teachers interacted
with students on a daily basis.
Other teachers built these types of activities into the LST lessons through
additions. Sara described why she added these activities to her lessons:
So I get to know them, too, so I know how to tailor the lessons toward
them. So really it's a learning exercise for me. I look at it more like that so
I can see how far they're willing to go, what they're comfortable with and
then I know how to plan my lessons. So it's more of a tool for me than an
activity for them. (Sara)
Other teachers built these types of activities into existing lessons with students sharing
their information about their families and friends, as well as goals that they have set for
the semester based on a LST lesson. It appears that in general these activities support the
core fidelity of the curriculum, although some of these activities take a significant amount

of time to complete, which may lead to adaptations later in the curriculum due to time
Engage Students Through Varied Learning Task or Activity
Adaptations were made to engage students through the use of varied learning
tasks or activities. Learning tasks designed to support varied learning styles and
adaptations to make connections for students, to make the content relevant, to engage
student thinking and reflection, and to encourage student sharing and interactions were all
adaptations made to the curriculum. These adaptations were made based on teachers
perception of how students learn.
Student Learning Styles
Teachers added and modified lessons to reach a variety of learning modalities to
engage students, Kathy put it this way when she discussed how she engaged students:
I like to be moving and doing things and engaging. I like [to] engage
[students]. I try to meet different mindsets. I like to engage visually,
auditory, you know. You know, I try to engage them in different modes
so that they are moving. And they have different state changes that maybe
if I see it visually, or I hear it, whatever, however it might impact them, I
try to do that.... I think if you can use a little technology, use some
music, use some video, use movement. I think they respond to that. And I
think they absorb it in a different way.
Other teachers described how they addressed different learning modalities as:
Well, if I have an activity that shows them this is actually how you do it or
that has them getting up and talking to someone new or getting up and do
something challenging. Then they will see that I just improved my self-
esteem by doing that. (Belinda).
These teacher beliefs of how students learn and these teaching styles ultimately
led to adaptations to curriculum. For example, Kathy modified a lesson that was written

in the curriculum as a simple class discussion into an activity that had students write
reasons for starting to use tobacco on post-it notes, sharing with other students, and
finally posting them on the board into defined categories with individuals sharing and a
large group discussion. This particular teacher saw this activity as a way to engage
students in an active way, while providing a visual component to the curriculum that was
missing. This activity was clearly aligned with the LST lesson objectives but modified to
meet students personal learning styles and the teachers beliefs about how students learn.
Lessons that were written in LST that required students to read were modified as
auditory read aloud activity:
Instead of the kids sitting, theyre reading. Were going to read it aloud.
Making it more engaging... getting students more engaged kind of thing, I
find that if you have the kids just sit and read, a lot of times they will not
sit and read it, or will a little bit and kind of space out. If you have them
read aloud I feel like the kids are more engaged, that they are paying
attention to what is going on. (Belinda)
Another example was the addition of an activity that added artistic expression to
the lessons. Instead of doing the LST curriculum that asks students to list strengths,
weaknesses, and things to change, the activity was modified to use a shield handout
where students depicted strengths, weaknesses, and things to change in a picture. Shields
were then posted in the classroom. It was also used as a way for students to introduce
themselves. Another teacher had students develop media that visually depicted the
dangers of smoking based on the advertising techniques that they learned. Other
examples of additions included the addition of board games that examine anger and
techniques to deal with anger.

Other teachers added interactive kinesthetic activities to engage students in the
short-term and long-term effects of tobacco use:
I add a lot of hands-on stuff, you know, for smoking, we do smoking
aerobics where the kids are going to try and exercise while breathing
through a straw so they can truly feel the effects of smoking,, so they can
actually see, oh yeah that does affect me, rather than just taking notes on it
or reading something... I have students exercise for 10 minutes normally
before breathing through a straw, we take their heart rate before and after.
Then I have them do the exact same exercise routine but this time
breathing through a straw I then have them take their heart rate again.
Then we talk about the difference and how this relates to smoking
tobacco. (Belinda)
Other examples of this type of interactive activity were the addition of technology that
used an electronic student response system to engage teams in a quiz game about the
dangers of tobacco use. Yet another example included the use of a class team-building
initiative that engaged students in how they make decisions.
All of the participants used visual aids such as video to engage students in
learning, although the visual aids did not always align with the lesson objectives of the
LST curriculum. Often different terminology was used in the video, which had to be
aligned with LST or else the curriculum had to be modified to encompass the change in
terminology. Here is how Jerry described how he has used video in his classroom:
Now for example the decision-making video, in the Life Skills its clarify,
consider, choose. In the decision-making I actually bought a decision
making program. They dont use the exact same terminology, but I
adapted it. So they have four steps, and I just use clarify, consider, and
choose, but I can put the four steps in. Clarify is what is the problem,
thats how they explain it. The consider are the consequences, and
what they have on that decision-making film is theres two things you look
at. You look at your future, and you look at your values. So those are the
two things I just incorporated in to consider. You know, I said when you
consider consequences here are the two things you look at, and then
choose and then you make a choice thats right for you. So it really does it

just takes a little bit of tweaking, but it still fits. My perfect world would
be the terminology is all the same in everything you use, but everyone
comes up with their own little bit of thing. But you know it seems to work
pretty well, I mean you can make those [connections] you know when you
look at it. (Jerry)
Although teachers were aware of these differences they thought that the
advantages to using the video outweighed the potential confusion for students. Visual
aids were often chosen because they showed students of the appropriate age, or because it
showed the consequences of decisions. Engaging students through these other learning
modalities was apparent and driven by the teachers beliefs as to how students learn:
You know, I think they learn a lot from their experiences; which is really
difficult in health, because sometimes the learning is by experiencing. But
if you experience that and experience the bad things, sometimes you cant,
it could be health- and life-endangering. So I think thats one thing is to
experience it. So you try and let them maybe experience and when I talk
about health, I let them try to experience through other people, see other
peoples situations. And thats why I do use a lot of video scenarios in my
teaching. Because for them to stand up here and tell them or to have them
write about it or read about it, I dont think is very effective as much as
seeing it in action. (Jerry)
All teachers added video to the curriculum. The effectiveness of these videos was not
addressed, but they were used to engage students.
There are other reasons for adding these videos that did not emerge as a theme but
should be noted. In one case a participant used a video to scare students. Here is the
discussion that occurred when the addition of the video was discussed:
The video is amazing. They went [go] into prisons, and talk to everyone,
from a carj acker to someone who killed somebody. They interview the
kids, and they talk about what its like to be in prison. They show prison
life. Its narrated by Mark Wahlberg, which the kids all know and the
poetry and music is by Mos Def, and the kids all know who that is. So its
pretty relevant. A lot of our kids have been in trouble or are currently
wearing ankle bracelets. It basically talks about what its like once youre

in the system. Thats why we use it as a benchmark...Here are the Juvies
questions. We always get really positive feedback on the Juvies video. So
we used funding from the district to buy it because it was really hard to
find it from the library.
Researcher: Did you mostly pick that because it fits your students well?
A: And to scare them too.
A: Researcher: Does that work? Yeah the stories are unbelievable. It
blows them away, usually when its just silent in the room. Then after
about five minutes I put some discussion questions on the board. Its a
very powerful video. Its awesome...
Researcher: So thats completely out of the scope of unit 7?
A: Oh yeah, we just do it at the end. (Sara)
Another teacher described why he added videos to the curriculum:
They watched a video, Truth or Dare, which is a pretty good talks a lot
about the what smoking does to you, that kind of stuff. Just your basic
general kind of thing. Its really sort of a good one, too, to get them
hooked. Its got it shows the dead persons body, the real lungs, its not
so much as the fear factor as it is the interest. Just to get it going. It has a
tearjerker thing in it where this model, her dad died and shes crying and
all that kind of stuff. So I show a lot of those snippets. (Jerry)
These are isolated examples of a reason for adding a video. It is important to note that the
use of scare and fear tactics were used in the classroom, and are often used to engage
students in a meaningful way. Jerry saw the video as a way to engage student interest,
while Sara clearly used the video to scare students.
Student Relevancy
Additions and modifications also were done to make the curriculum more relevant
to students. Although participants did not mention culturally responsive practices or
cultural adaptations, this was clearly to align with the students, school, or community
culture. One teacher modified scenarios to make them more relevant for students. I
changed these, Yeah, this is summer and youre working at a day camp. To me, not too

many of our kids would really even have gone to day camp, unfortunately. We live in the
mountains, but it costs a lot of money (Kathy). In other cases, the teacher created
scenarios or students created scenarios that were more relevant to their school and
community setting.
In the alternative schools setting, significant modifications were made to ensure
that the activities met the needs of students and that it was relevant for that population.
For example, one lesson in LST was written to examine a family tree. The lesson was
modified to ensure that students who did not have traditional families were not left out of
the activity. For that reason friends and girlfriends were added as potential family
Because a lot of these kids dont have families. Moms in jail, dads in jail,
they live with grandma. We did not want to make an assumption that
everyone had a mom or dad. The family tree is a way for me to see what
background they are coming from when it comes to family. (Sara)
All participants used statistics to better represent their students more closely; this
included the addition of local or state statistics, as well as data reported by high school
students as opposed to adults. In each of these cases the data supported the intent of the
lesson objectives, which was to examine social norms, but used data that was more
relevant to students. Adaptation to make the curriculum more relevant to students was
apparent across all participants, and guided a number of adaptations. These adaptations
appeared to support the fidelity to the curriculum, with modifications and additions the
primary types of adaptations that took place.
Making Connections for Students

Beyond these activities, teachers made adaptations to engage students by making
connections within the curriculum, or with other curricula. This was done in a variety of
ways, through adaptations that were planned and in some cases added as the teacher
reflected-in-practice. One specific example was referring back to concepts and skills
taught in previous lessons within the curriculum. These connections may not have been
made in the curriculum, so teachers tend to make these connections for students.
Unit four, I try to bring in as much [media influences] as I can ... So thats
something that I keep saying, Well okay, what do you think about the
media? What kind of role is it playing in this? And the media also in their
decision-making, things like that. You know, it came up again when we
talked about building the perfect person. You know how much of that is
media. (Sara)
In this case, media was not a part of this unit; however, the participant thought it was an
important discussion to have that linked the current discussion back to previous lessons.
Participants made a point to focus on these connections to ensure that students had
opportunities to reflect on how previous learning is built upon.
Other teachers made connections within the curriculum by moving or changing
the order of activities or lessons in the curriculum:
I did move the goal-setting piece just because I want to tie that in basically
because of that video that ties goal-setting with decision-making. I
probably could do it earlier, but I dont know if it would mean as much to
them. I cant make the connection as easily. Well you know you need
goals for decision-making, were gonna learn about decision making next
week. You know, I could do the decision-making and say, now its easier
for me to say, Guys this is why were doing goals. Remember what does
it take to make good decisions? Youve got to have goals for your future.
Oh yeah, yeah, yeah, yeah, yeah. So that to me makes a better
connection there. (Jerry)

Other teachers changed the order of the activities within the lesson; for example, instead
of having a discussion about alcohol with students, a teacher moved these discussion
questions to be done during a reading activity. The questions from the curriculum were
used during the reading as opposed to during the introduction of the lesson. This was
done to make a better connection for students during the reading. In other cases,
participants made connections to previous curriculum. For example a decision-making
model discussed in a previous teaching was integrated into the LST decision-making
lesson. Teachers made the decision to make these connections to previous teachings to
ensure that they built on previous learning and to consciously make connections for
Other activities were added to engage student background knowledge. So, and
then this one, the alcohol ice-breaker ... it kind of just gets the kids sharing their stories
and talking about what they, you know their background knowledge kind of thing with
alcohol. (Belinda) This was an activity that was added to the curriculum to engage
student background knowledge. Another activity to engage prior knowledge was
described in this way:
I wanted to start them thinking about how everyone in their family plays a
role and what their role is. Basically what this activity comes down to, it
makes them start thinking about their role.... So we have to initiate their
background knowledge and bring it to the forefront so they can go ahead
and do these activities. So that was kind of like an introduction to get them
thinking. (Sara)
These changes were made to the curriculum through modifications and additions to the
curriculum. Engaging student background knowledge was something that all teachers did
throughout the curriculum in virtually every lesson that was observed.

Participants made conscious adaptations to the curriculum to ensure that
connections were made for students. These adaptations included additions and
modifications to the curriculum, which consisted of the addition of activities and
discussions as well as changing the order of lessons and activities. Engaging student
background knowledge was also a way to make these connections for students. Teachers
did move lessons and activities outside of prescribed sequence to make better connections
for students.
Encourage Student Interactions and Sharing
Adaptations occurred to encourage students sharing with other students and
interacting with each other. Teachers took simple activities from the curriculum and
modified them to encourage sharing among students and student interaction with each
other. For example, teachers added students pairing and sharing about the personal goals
that they wrote and sharing of factors that influence them. Other teachers added
movement to the sharing: Get up and find a partner to share what you learned from the
reading. Another strategy used was grouping of students to write out their thoughts prior
to sharing them with the larger group. Another teacher described how she encourages
movement and interaction with other students. I mean, being a PE teacher I try and get
them up and moving as much as I can and interacting with each other as much as they can
... I have 10-15 minute activities lessons or activities to hammer in the point and get the
kids really moving. (Belinda) Belinda continued to discuss how she encouraged
interaction and movement:
Instead of having them write in their work book, I do an art walk for them
to go around, and the papers will say decisions I make at home, school

then we talk about who influences those and that there are all these
influences, and they realize that ultimately it should be you that should be
making the decision. Again, I think it's just my teaching style that if they
are sitting for a little bit they need to get up and do something and after
that I see that they respond better, you know when they are up and can
interact instead of just sitting and writing in their work book, and some
days it doesn't work. I'll say Let's just and move and do something and
it just fails. So I say All right. Sit back down. We are going to do it this
way. It can go class to class, trimester-to-trimester; its kind of just
knowing your class and making adjustments. (Belinda)
Not only does this quote by Belinda speak to the addition of activities to get students
interacting, it also highlights the need for teachers to adapt their lessons based on each
class and semester. Teaching is not a static process but a dynamic process that is based on
knowing students and making adjustments to support students needs.
Application of Concepts and Skills
Teachers also made additions to enhance the application of concepts and skills
and to practice skills. This theme emerged as a way to engage students in applying
knowledge to a real-world scenario or setting:
You know, so they had to write a letter, like a Dear Abby letter, heres the
situation, you know, and they have to do that. And they have to use one of
these, one or more of these to help that person through their situation. So
thats [how] I sort of get that writing in. But thats not part of the
curriculum, but its a huge, you know, to me its more of that practice
really utilizing that. (Jerry)
Jerry saw this as a way to take knowledge and use it in a practical way. Other teachers
regularly encouraged students to reflect on their own life and identify ways that they
could change their life and make better decisions. One teacher added four lessons from
another curriculum to provide more practice in refusal skills and decision-making. This
was due to his need to provide more practice of these skills:

Well the refusal skills in Life Skills... they just give you a lot of real quick
things. Just say no. I mean like, you know, like real quick and easy kinds
of things. And thats OK. I think thats OK to practice some of those
things too, about really fast. But I really like this more in-depth study of
it. And we will talk about this, then, when we get into marijuana and that
kind of stuff. Because, you know, sometimes you just dont have time to
think. So what are all the different waysand Ill spend probably 15
minutes and really this page-I sort of have a run off just about like that
just say no, broken record, no (Jerry)
Kathy consistently made specific modifications or additions to the curriculum to
encourage students to identify personal values and support.
The need to engage students emerged as a theme that drove a variety of
adaptations. Teachers see the engagement of students as a necessary aspect of the
curriculum. If it is not present, teachers are adapting to ensure student engagement.
Teachers engaged students through a wide variety of teaching strategies and techniques,
as well as though the use of visual aids. These were implemented through adaptations to
the curriculum that included additions and modifications as well as omissions due to lack
of student engagement.
Student Needs
Another major theme that emerged was the need to adapt the curriculum based on
student needs. These adaptations were made based on students academic abilities, which
were driven by formal and informal assessments that identified the need for additional
background knowledge. In addition, the curriculum was adapted to match the unique
school population. Adaptations were guided by teachers knowledge of their students and
their specific academic, social, and emotional needs and abilities. These adaptations were
guided by both formative assessments and informal observations and adjustments in

practice. All teachers used assessments and knowledge of students to guide these
Student Academic Needs
Student academic abilities led to adaptations for both high and low-achieving
students. In many cases, additional student background knowledge was needed. Teachers
made adaptations to the curriculum based on the classroom dynamics and identified
student needs.
Provide Background Knowledge
If it was identified through observation or assessment that additional background
knowledge was needed to continue lessons or to start the unit, background knowledge
was readily added to the curriculum. One common example was the need for additional
background knowledge related to basic definitions of drugs beyond what the curriculum
Because again, a lot of the kids don't have that background knowledge.
They just know it as, you know, the drug that kids use or their friends use
or their family is using kind of thing. And just kind of start the class off
that way [with definitions and types of drugs]. (Kathy)
In another case the adaptation to build background knowledge was based on teacher
observations from previous lessons. It was identified that students did not have the
prerequisite knowledge that was needed to continue on, so background knowledge was
... just to add to the background knowledge because I feel like a lot of
them like I said don't really know what it is. And theyso kind of
knowing about THC, what it's going to cost them to get high and stuff like
that.. .so I have to add to that knowledge (Belinda)

Sara, a high school teacher, described a similar situation in this way:
I think talking about it, making them aware of it again, you know, whats
the word mean, no one knew the word. I mean our vocabulary here is very
low. A lot of our kids are reading on the seventh grade level. So when you
put the word, you know, assertive on the board, Tim was the only one
that knew it. And I wasnt surprised. I, you know, thats what happens
with a lot of these vocabulary words. Well introduce stuff, theyre like, I
dont know what that means. You explain it to them, they get it. (Sara)
The lack of vocabulary and background knowledge led to additions or modifications to
the curriculum. These additions and modifications did align with the content of the
curriculum; however the ideas were often expanded on to better prepare students for the
Student Academic Ability
Student academic skills led to adaptations that allowed them to complete
identified tasks. Lessons and activities were adapted in a variety of ways to support
students with varied academic skills. Additions and modifications were most often done
based on classroom needs as opposed to individual students. In most cases the
adaptations were made related to literacy skills.
I think that, sometimes with this lower class, dont always write every
little single thing in. The higher kids, like when I did it with the higher
kids before. I had them fill that in, before we even started. Because I
thought they said, okay you guys, I want you to just read those questions
and fill them in. These guys, this is with the reading and the
understanding, just went ahead and did it as a discussion, rather than
having them fill it in first. Because I just know some of them would look
at that and probably have a million questions. And then Id be going, I
should have just started out, by telling them this stuff so I dont have a
million questions. Yeah thats why I sort of did that. (Jerry)
With my low reading group I will spend a lot more time, you know, asking
the kids to come upwhats your goal? You know, to sort of help them
through that process a little bit more. Where that high reading group I can

get through them in a day, I mean, ten minutes I can get through twenty
kids. Just about ten, fifteen minutes because they can come up, say OK
whats your goal? They knew exactly, they were on track, they were right
with it. These guys are gonna need a lot more processing time, a lot more
steps, a lot more examples. (Jerry)
Although the need for modification based on literacy skill was noted, the need for
additional teaching based on formative assessments also drove additions. These
adaptations were made for a variety of reasons but primarily because students did not
have the knowledge or skills needed to continue the lessons as proposed. This was
different than providing background knowledge in that teachers identified the need to re-
teach based on what they saw in their classrooms
I mean I had them do the review at the beginning with the nicotine and
carbon monoxide mainly because, like, fifth hour I went in and started
asking them about the warm-up question and they kind of just looked at
me. So I thought ok these are points they need to know, this is something
that I need to make sure they understand. So, I didnt think that it would
hurt to do the same thing with sixth hour whether some of them got it
yesterday, they could still use the review to kind of focus on. Okay thats
what were going to be looking at is smoking and your heart rate today.
This is an example of how reflection-on-practice informed modifications to the
curriculum. Without the addition of these formative assessments teaching may have
continued without knowing that students did not have the knowledge needed to move
forward. Other teachers added more modeling and explanation and more practice for
those classes that had lower academic ability.
I think talking about it, making them aware of it again, you know, whats
the word mean, no one knew the word. I mean our vocabulary here is very
low. A lot of our kids are reading on the seventh grade level. So when you
put the word, you know, assertive on the board, Dan was the only one
that knew it. And I wasnt surprised. I, you know, thats what happens
with a lot of these vocabulary words. Well introduce stuff, theyre like, I

dont know what that means. You explain it to them, they get it. Ive
heard that world before, but. So. I think just doing this for one day, and
role playing two scenarios was enough for them, kind of remind them, that
this is something they do, do and this is a vocabulary to describe it. (Sara)
These adaptations were basically aligned with the curriculum lesson objectives
and supported fidelity. It should be noted that some of these activities were additions to
the curriculum that took a significant amount of time, and in some cases led to omissions
later in the curriculum. The role-play scenarios discussed above were modified to have
students discuss the scenarios and what they would do.
Unique Student Population
Adaptations were made to link the curriculum with the unique populations that the
curriculum was taught to. The four settings that were observed provided varied
populations of students, as well as a wide variety of ages. The specific level of the LST
curriculum was aligned with the appropriate age of students; however, adaptations based
on their unique needs were evident. Teachers understanding of their student population,
the community, and data drove the decisions to adapt the curriculum. Here is an example
that sums up this key emergent theme:
I know a lot of them had already tried smoking, or they have already
smoked, theyve already had sex, or just not the best backgrounds I guess.
So that changes it in that I feel we have to have more discussion if not... if
they are just sitting there reading facts theyre going to just blow them off
kind of thing. And they actually, I mean, it made me... they challenged me
on some of the facts that were in Life Skills. About the percentages of kids
that smoke marijuana and that its just as bad as smoking tobacco. It was
good, it challenged me and actually made me add in new facts and bring in
videos and show them the truth. And some of them it changed their minds,
and some of them, they were still determined that smoking marijuana
wasnt as bad as smoking cigarettes kind of thing. (Belinda)

For all of the teachers, student marijuana use was a concern. This was partially driven by
recent laws legalizing medical marijuana in the state, as well as local statistical and
anecdotal data that identified increased use. Significant discussion and activities around
marijuana were added by a number of participants:
Well, I mean, the marijuana unit in itself. After last year, having so many
kids, just having more background knowledge. I had to, instead of just
going from what's in this book, I had to look at more facts, find more
sources, find more information, input stuff, you know, add in the role-
playing, add in more activities for them and spend, instead of spending a
couple of days on it, spending four days on it. And now that's kind of
built in, thats okay. I have four days blocked off for marijuana. (Belinda)
Another teacher added a reading about Michael Phelps and his marijuana use to engage
students in this topic area. Jerry developed additional refusal skills scenarios focusing on
refusing marijuana. All of the teachers made significant additions and modifications to
these lessons due to the unique populations that they had in their classrooms. Others
added discussions and information about other drugs based on data that was collected
during a school and district-wide risk behavior survey. One example was the addition of a
discussion around energy drinks and steroids.
Beyond these specific additions based on drug use, teachers made other
adaptations. One teacher described her students and their needs in this way:
I think this was intended for like a general population but we have a very
specific population here. So we have to do warm-up activities and
brainstorming things all the time, it also gets them talking. A lot of these
kids shut down, and if they see this piece of paper [LST student handout],
for example, Dean as soon as he sees something he doesnt get he shuts
down, says its stupid, and pushes it away. I have to introduce this in a
way that he feels comfortable and yes, I can do this. I have him in
English class, and so we dont necessarily do this all the time. He is
struggling. But he is the norm of our population. (Sara)

Jerry talked about the struggle to align the curriculum with local needs and the unique
populations that exist in this way:
So the standards help drive if were hitting everything, but as far as my
nine-week curriculum, then a lot of it is based on our local, what our data
is showing. I think that drives it more than anything. I think thats come a
lot because of, not only in experience, but just because of training and
being able to go to a lot of different school districts to see how their needs
are very different. Even though kids are still doing drugs and alcohol and
all that kind of stuff here, I go to the valley, I go to the city, there is some
different stuff going on that they need to address a lot differently.
Different issues, different concerns, different focal points, even though
they might all go with standards and all that stuff, its just a little bit
different emphasis. And that could change, if all of a sudden we have kids
that are doing the choking game or kids that are into inhalants, then we
need to shift our focus a little bit and say, Okay, whats going on here?
What do we need to do? (Jerry)
Assessment, teachers prior knowledge of students, and data guided adaptations
meant to support students need for additional background knowledge, students academic
abilities, the application of concepts and the practice of skills, as well as the unique needs
of individual students.
All of the teachers struggled with this idea of aligning the curriculum with the
unique academic and behavioral risks that their students come to class with. Participants
used a variety of data to determine which additions, modifications, and omissions to
make to the curriculum. These adaptations were generally aligned with the LST lesson
objectives; however, adaptations based on unique populations were not always driven by
data to support what additions and modifications need to be made. Some of these
adaptations took a significant amount of time that led to modifications later on in the

Local Policies in Practice
Local policies in practice emerged as a major theme that guided teacher
adaptations. These policies ranged from the need to develop local assessments to the
policy-driven standards that guided curriculum and local academic initiatives.
Participants viewed these local policies as more important to guiding what was taught in
the classroom than the LST curriculum itself. Participants struggled to align these local
policy needs with the curricular fidelity.
Local Curriculum, Standards, and Assessment
Local and state standards emerged as a reason for adaptations. Three of the four
participants stated that health education standards guided adaptations:
I change things, too, I think because you know if I dont think its totally
adequately addresses my standard, then I have to add something else to
make sure it goes to standard. Overall it does, but that really guides
changes. (Kathy)
For these teachers who had standards-based curriculum, the specific standards drove
modifications to the curriculum. It was clear that teachers looked to those standards as
guidance for adaptations. The standards were what teachers were being held accountable
to, and thus they taught to them when perceived conflict arose:
This is our curriculum [pointing the standards]. And these are the tools or
the vehicles to drive our curriculum. And thats why for me when Im
pulling it in from brain pop [video], or I pull from, well Im trying to
think, my Activities That Teach [book] or I pull from a health text book. I
dont feel bad about moving away from this [pointing to LST] because this
is just one tool, that oh, this helps me analyze the influences really well.
But it doesnt help me too well with accessing valid sources of
information. So thats the way I look at it. (Kathy)
Belinda talked about how she had to modify lesson objectives to meet standards:

I look at standards. I look at standards because most of mine, you know, I
try to match the standards with my lesson, but not all of the time.
Sometimes I have to tweak them. Its kind of whats going on in here too.
The curriculum is aligned to standards as teachers adapt lesson objectives and outcomes.
In some cases, lessons and activities are added to the curriculum to more clearly align
them. As stated above, standards drove assessments and led to adaptations to the
curriculum. Most often, these were the addition of assessments or lessons, as well as the
modification of lessons to ensure alignment with the standards and the assessment.
Standards also guided assessment, which in turn led to modification and additions
to the curriculum. The High School LST curriculum is the only level that has assessments
and rubrics developed for the curriculum. The one HS teacher who was observed used
several of these assessments provided by the curriculum; she also made significant
additions to the curriculum to ensure appropriate assessment of students. For all other
LST levels observed assessments are not provided. This led teachers to develop their own
assessments to guide instruction and to identify student learning and growth.
I guess, I mean because we do standards-based grading and it started last
year when I started this class, so it was kind of like I have to do it right
away. So I guess its just as I was looking through each unit finding
either...finding ways that I could create an assessment to kind of go with
the topics that were in here as well as hitting...hitting the standards.
Maybe tweaking a lesson a little bit to make sure its hitting a standard I
guess would be one thing like the smoking, long-term and immediate
effects instead of just having the kids read about it, like actually showing
me that they understand it and creating that assessment. (Belinda)
Assessments took up a significant amount of time for teachers to develop and infuse them
into the LST curriculum. In some cases, these assessments were aligned with the
curriculum, while others were not. For example one teacher had students develop a