In the quest to promote lifelong health and well-being among students, school-based health and wellness education is a cornerstone. But there is always a persistent question: how do we deliver these programs to maximize their effectiveness? The answer lies in the concept of "multiple doses"—delivering health promotion instruction repeatedly over time. Grounded in developmental theories and behavioral frameworks, repeated delivery of health promotion programs aligns with how adolescents learn, grow, and make decisions.
The Importance of Repetition
The idea of "dose" in education is borrowed from healthcare, where the timing, frequency, and amount of a medication all influence that medication’s effectiveness (Conn & Chan, 2016; Rowbotham et al., 2019). Similarly, in health promotion programs, "doses" represent lessons or interventions delivered for various lengths of time and/or at various intervals (Rowbotham et al., 2019). Developmental theories suggest that delivering these doses throughout a student's development—rather than all at once—aligns with the dynamic nature of adolescent growth.
Developmental frameworks like Relational Development Systems Metatheory and Dynamic Skill Theory emphasize that adolescents develop skills in a context-rich, non-linear way (Fischer & Bidell, 2007; Lerner et al., 2018). Skills such as decision-making and self-regulation require practice and reinforcement over time. These theories explain that:
Adolescents are constantly interacting with their environment, peers, families, and societal norms, making their developmental journey highly individualized (Lerner et al., 2018).
Skills develop through repeated practice in constantly changing contexts, enabling adolescents to transfer knowledge across contexts into real-life situations (Fischer & Bidell, 2007).
In short, skill-building is not a one-and-done affair. It requires intentional scaffolding over time, tailored to the changing needs and experiences of students.
Bridging Theory and Practice
Three major behavioral theories justify why repeated exposure to wellness promotion are essential:
Social Cognitive Theory: This well-documented framework, developed by Albert Bandura, proposes that learning occurs through interaction between personal, behavioral, and environmental factors (Bandura, 1986). Crucially, the concept of self-efficacy—the belief in one's ability to succeed at a given task—requires exposure to both direct practice and observed behaviors (Bandura, 1986). By revisiting concepts, like digital literacy and health promotion topics, over time, educators can strengthen self-efficacy and help students apply their knowledge in a variety of scenarios.
Health Belief Model: This model explains that perceptions of risk, benefits, and barriers influence health behavior (Rosenstock, 1974). Children’s understanding of risks and benefits evolves as they age. For example, a child understands the risks associated with online privacy very differently at age 8 compared to age 18 - privacy breaches can influence mental health in very different ways at these different ages. This underscores the need for periodic education to match their evolving cognitive and emotional development.
Reasoned Action Approach: This set of theories focuses on the role of intentions in predicting behavior (Ajzen, 1991, 2020; Ajzen & Fishbein, 1980; Fishbein & Ajzen, 1975). Intentions, shaped by attitudes, social norms, and perceived control, are reinforced through repeated engagement (Fishbein, 2008). Regular lessons allow students to refine their attitudes and beliefs, which inevitably shift over time shaped by their ever-changing context, solidifying intentions that may lead to decisions that promote health and well-being for themselves and their peers.
Building Skills Over Time
We generally want young people to take action in their lives as a result of health and wellness education. Skill development is where that action begins. Dynamic Skill Theory, described earlier, offers a particularly compelling justification for multiple doses of classroom instruction over time (Karlin-Resnick, 2024). Adolescents may demonstrate mastery of a health skill in one context but struggle in another (Fischer & Bidell, 2007). For example, knowing how to stand up for someone against toxic online behavior might not translate immediately to success in a real-world situation. But, through repeated lessons over time and in different contexts, students build a web of interconnected skills, gradually increasing their competence across a variety of settings (Fischer & Bidell, 2007).
While many developmental theories suggest that skills are collected step-by-step along a predictable path, some researchers have proposed that skill development is more like a spiral (Arbeit, 2014). Revisiting topics that support student health and well-being at different grades allows young people to approach these with greater maturity, linking past lessons to new challenges (Karlin-Resnick, 2024). For example, children might learn about how to engage in positive ways with friends in online games in elementary school. Those same online social skills could later be relevant in high school when it comes to text-based online social communication if they have romantic relationships.
The Bigger Picture
Health promotion in schools is not just about imparting knowledge—it’s about equipping students with lifelong skills. Children and adolescents are navigating a complex web of personal, social, and environmental factors that shape their decisions. By delivering multiple doses of skills-based instruction to support health and social literacy over time - not just in 3rd grade or 8th grade, but across all the grades in between - educators can provide the scaffolding students need to make informed, confident choices.
The theories are clear: learning is a process, and so is healthy development. Let’s move beyond one-time interventions and invest in programs that grow with our students, ensuring they have the tools to thrive—today, tomorrow, and beyond.
This blog post was written with help from ChatGPT based on research Abi Karlin-Resnick conducted for her dissertation.
References
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Karlin-Resnick, A. J. (2024). Examining the Effects of School-Based Sexual Health Education Implementation Dosage: A Quantitative Explanatory Study [Doctor of Education, Drexel University]. https://doi.org/10.17918/00010708
Lerner, R. M., Brindis, C. D., Batanova, M., & Blum, R. W. (2018). Adolescent health development: A relational developmental systems perspective. In N. Halfon, C. B. Forrest, R. M. Lerner, & E. M. Faustman (Eds.), Handbook of Life Course Health Development (pp. 109–121). Springer International Publishing. https://doi.org/10.1007/978-3-319-47143-3_6
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Rowbotham, S., Conte, K., & Hawe, P. (2019). Variation in the operationalisation of dose in implementation of health promotion interventions: Insights and recommendations from a scoping review. Implementation Science, 14(1), 56. https://doi.org/10.1186/s13012-019-0899-x
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