The Evolution of Skills-Based Health Education

The concept of teaching young people essential health skills they’ll need throughout their life is nothing new. Within the National Health Education Standards (which were created in 1995, revised in 2007, and are about to go through another revision led by SHAPE America), seven of the eight standards refer to skills we want young people to develop.

However, many health and physical education programs in the United States and beyond still place a greater emphasis on health knowledge acquisition rather than on skill development.

When we first started our journey into skills-based health education (SBHE) it was because, while there was an emphasis on assessing the skills of the National Health Education Standards, there was not an emphasis on supporting young people in developing the skills.

Thus began a conscious shift from this emphasis on assessment to the way health education was being taught. At the core of the skills-based approach was intentionally designing units, lessons and learning experiences to prepare students to use the skills in meaningful ways that support and promote positive health outcomes.

Even since we began our work in this area in the early 2000s, the ways in which a skills-based approach “shows up” in the health education classroom has evolved. We highlight some of the important features of that progression in this article.

A New Definition for Skills-Based Health Education

To get us started, let’s get on the same page about skills-based health education. In our new book, The Essentials of Teaching Health Education: Curriculum, Instruction and Assessment, 2nd Edition, we define skills-based health education as:

A planned, sequential, comprehensive and relevant set of learning experiences implemented through socio-ecological and socio-cultural perspectives and participatory methods to support the development of skills, attitudes, and functional knowledge needed to maintain, enhance, or promote health and well-being of self and others across multiple dimensions of wellness.

This definition has evolved since we first put out a definition of skills-based health education in 2016. The definition encourages a strength-based lens that is grounded in a salutogenenic approach to health and well-being, as described in “The Salutogenic Model as a Theory to Guide Health Promotion” by Aaron Antonovsky.

In simplest terms, it means focusing on a path to health that supports developing health and well-being as opposed to emphasizing disease and disease prevention. As we all know, a person can be on a pathway to health, but it is not a straightforward construct.

As we note in The Essentials of Teaching Health Education: Curriculum, Instruction and Assessment, 2nd Edition, “health is a state of well-being … we acknowledge that individuals are not ‘healthy’ or ‘unhealthy.’ We have health, and that health lies somewhere on the continuum ranging from ‘dis-ease’ to ‘ease’ or ‘healthy’ and we tend to be closer to one end of the spectrum than the other.”

Particularly, the addition of teaching through socioecological and sociocultural perspectives frames health education in a way that both affirms and places our health and well-being among a variety of factors. We cannot teach health education in a way that assumes if a person “tries hard enough” they will automatically be “healthy.”

Rather, this recognizes that there are both social determinants of health (“conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health”) and structural determinant of health (governing policies and “root causes” that work collectively to impact health at the individual and community level).

This definition also recognizes that we want to help individuals develop the skills, attitudes, and functional knowledge across multiple dimensions of wellness. That is, while we may have positive health in one area of our life, such as our physical health, this does not guarantee or ensure that we are well in other areas of our life, such as mental and emotional health or in our financial health.

Therefore, health education needs to be designed in a way that allows and promotes the exploration of health:

  • At individual and community levels for the purpose of recognizing where positive health outcomes are more likely;
  • In areas where additional development or support is needed; and
  • In ways that provide students with the skills they need to be able to build on strengths and address areas of need or growth.

The Evolution of Skill Development

A second key area of change within skills-based health education is skill development. The more we think about what this means in a health education classroom — and connect skill development with learning theory — the more it is apparent that we need to keep, front and center in our minds, the idea that skill development is a process that cannot be an “add on.”

In other words, skill development must be central in our design and implementation in the health education classroom.

While this last part is not new to our thinking of skills-based health ed, we have reconsidered what it means to develop health-related skills. The below graphic of the skill-development model is a revision from our previously used model. You will note that two key changes have occurred.

  1. Skill Development as a Process — We re-imagined the model into “chunks” of learning experiences that take time for skill instruction, skill practice, and then skill performance. Each of these are critical parts of the skill development process. We cannot simply jump into having students practice a skill without setting them up for success by teaching them the skill.

    Similarly, once we have students practice and receive feedback, we will want to evaluate their ability to support skill transfer by having them apply the skill through authentic experiences.
  2. Practice, Feedback, Transfer This model recognizes that practice and feedback go together. That is, if we have students practice a skill but do not allow opportunities for them to receive feedback in ways that support their ability to apply the skill in meaningful ways within their life, then we have not sufficiently set up students to be able to then transfer their learning outside of the classroom.

    To build off of this, when we design performance assessments to measure students’ ability to apply their new learning, we want to ensure that it is explicitly related to their real world. We do not want these learning experiences to be an “exercise,” but rather an opportunity for growth, learning, and understanding.

Why the Changes

While the changes presented here don’t reflect a dramatic shift in thinking, they do reflect forward progress and recognize the need to address the upstream, social and environmental factors that influence our health.

We need to teach health education through trauma-informed and equity-focused approaches. When we do this, we acknowledge, honor and affirm the students in front of us in our classrooms. For most of us, this is why we do the work — it is for the students.

We have an opportunity — and we may even go as far as to say an obligation — to create a space that provides trauma-informed, culturally-responsive/sustaining, strengths-based, inclusive and affirming health education experiences for each of our students. They deserve it.

The other key reason for the changes is to recognize how students learn and what it takes to support transfer of learning outside of the classroom environment to practical application in our lives. We owe our students health education experiences that challenge them to consider the complexities of health and the strengths they bring to the table — and give them space to develop an understanding of their role in impacting the health and well-being of themselves and of the community around them. While this is a tall order, we can design spaces that offer young people this opportunity.

Additional Resources

Holly Alperin

Holly Alperin, Ed.M, MCHES, is clinical assistant professor at the University of New Hampshire. Her work in skills-based health education began in early 2000s when she was training health educators on assessing the National Health Education Standards and recognized it was not enough to assess students if they weren’t being taught how to develop the skills in meaningful ways.

Sarah Benes

Sarah Benes, MPH, EdD, CHES, is an assistant professor and program coordinator of the School Health Education Program at Southern Connecticut State University. Sarah works in schools locally and nationally, and writes and presents on various health education topics. She currently serves as SHAPE America president. Reach her on Twitter at @sarahbenes12 or via email at