Schools & Health

Our Nation's Investment

Diane Allensworth, Elaine Lawson, Lois Nicholson, James Wyche Editors

Committee on Comprehensive School Health Programs in Grades K–12

Division of Health Sciences Policy

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.
1997



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School & Health: Our Nation's Investment Schools & Health Our Nation's Investment Diane Allensworth, Elaine Lawson, Lois Nicholson, James Wyche Editors Committee on Comprehensive School Health Programs in Grades K–12 Division of Health Sciences Policy INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1997

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School & Health: Our Nation's Investment National Academy Press 2101 Constitution Avenue, NW Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the Councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competences and with regard for appropriate balance. The report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. Additional copies of this report are available for sale from the National Academy Press, Lock Box 285, 2101 Constitution Avenue, N.W., Washington, DC 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP on-line bookstore at http://www.nap.edu/nap/bookstore. Call (202) 334-2352 for more information on the other activities of the Institute of Medicine, or visit the IOM home page at http://www.nas.edu/iom. Library of Congress Cataloging-in-Publication Data Schools and health : our nation's investment / Committee on Comprehensive School Health Programs in Grades K-12, Division of Health Sciences Policy, Institute of Medicine ; Diane Allensworth … [et al.], editors. p. cm. Includes bibliographical references and index. ISBN 0-309-05435-4 1. School health services—United States. 2. School health services—United States—Planning. 3. Health education—United States. I. Allensworth, Diane DeMuth. II. Institute of Medicine (U.S.). Committee on Comprehensive School Health Programs. LB3409.U5S33 1997 371.7′1′0973—dc21 97-21177 Copyright 1997 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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School & Health: Our Nation's Investment COMMITTEE ON COMPREHENSIVE SCHOOL HEALTH PROGRAMS IN GRADES K–12 DIANE D. ALLENSWORTH (Co-chair), Executive Director, American School Health Association, Kent, Ohio JAMES H. WYCHE (Co-chair), Associate Provost, Brown University BEVERLY J. BRADLEY, Certified Health Education Specialist, San Diego City Schools, California DOROTHY R. CALDWELL, Director, Child Nutrition Programs, Arkansas Department of Education, Little Rock JOY G. DRYFOOS, Independent Researcher, Hastings-on-Hudson, New York STEVE A. FREEDMAN, Director, Institute for Child Health Policy, Gainesville, Florida LA BARBARA GRAGG, Superintendent of Schools, Pontiac, Michigan (retired); Palm City, Florida JUDITH B. IGOE, Associate Professor and Director, School Health Programs, School of Nursing, University of Colorado, Denver ELAINE L. LARSON,* Dean, School of Nursing, Georgetown University JOSEPH D. McINERNEY, Director, Biological Sciences Curriculum Study, Colorado Springs, Colorado PHILIP R. NADER, Professor and Director, Child and Family Health Studies, Community Pediatrics Division, University of California, San Diego ELENA O. NIGHTINGALE,*† Scholar in Residence, Board on Children and Families, National Academy of Sciences, Washington, D.C. GUY S. PARCEL, Director, Center for Health Promotion Research and Development, the University of Texas Health Sciences Center, Houston KEN RESNICOW, Associate Professor, Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University AARON SHIRLEY,* Director, Jackson Hinds Comprehensive Health Center, Jackson, Mississippi BECKY J. SMITH, Executive Director, Association for the Advancement of Health Education, Reston, Virginia LENORE K. ZEDOSKY, Director, Office of Health Schools, West Virginia Department of Education, Charleston *   Institute of Medicine member. †   Resigned committee September 1995 due to health reasons.

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School & Health: Our Nation's Investment Study Staff VALERIE P. SETLOW, Director, Division of Health Sciences Policy LOIS NICHOLSON, Study Director (through May 1996) ELAINE LAWSON, Research Associate LINDA A. DEPUGH, Administrative Assistant MARGO CULLEN, Project Assistant (through October 1996)

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School & Health: Our Nation's Investment Preface In late 1994, an Institute of Medicine (IOM) committee was convened to carry out a study of comprehensive school health programs (CSHPs) in grades K–12. These programs are a new concept that combines—in an integrated, systemic manner—health education, health promotion and disease prevention, and access to health and social services at the school site. Whereas earlier generations of school health programs were predominantly concerned with stemming the threat of infectious disease, these problems have now to a large extent been ameliorated and replaced with the "new social morbidities"—injuries, violence, substance abuse, risky sexual behaviors, psychological and emotional disorders, and problems due to poverty—and many students' lack of access to reliable health information and health care. Because schools touch all families and schools are, for the most part, where the children are, CSHPs hold promise for addressing many of the health-related problems of today's children and young people. When a study of CSHPs was first contemplated, the IOM was well aware that many groups were already active in school health and sought to determine whether it could make a unique contribution to the field. An outside planning group was convened in 1993 to advise the Institute on the need for and feasibility of its undertaking a study of CSHPs. The planning group identified a broad set of school health issues in the areas of (1) education and curriculum, (2) health promotion and disease prevention, (3) health services, and (4) national strategies and policies that could potentially benefit from the results of an IOM study. The planning

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School & Health: Our Nation's Investment group also noted that the IOM—and its partner organization, the National Research Council—had special expertise in such relevant areas as K—12 science education, child and family policy, nutrition, health promotion and disease prevention, and health care policy. Based on the planning group's recommendations and encouragement, the Institute then began the necessary groundwork to assemble the committee and launch the full study. The resulting 17-member Committee on Comprehensive School Health Programs in Grades K–12 represented a diversity of backgrounds, including physicians, nurses, health educators, science educators, social scientists, basic scientists, school administrators, and experts in public and child health policy. The original charge to the committee was to (1) assess the status of CSHP's, (2) examine what factors appear to predict success (or failure) of these programs; and if appropriate, (3) identify strategies for wider implementation of such programs. This charge was refined by the committee at its first meeting to better describe the scope of work to be undertaken. The revised charge states that the committee will develop a framework for (1) determining the desirable and feasible health outcomes of comprehensive school health programs; (2) examining the relationship between health outcomes and education outcomes; (3) considering what factors are necessary in the school setting to optimize these outcomes; (4) appraising existing data on the effectiveness (including cost-effectiveness) of comprehensive school health programs; and (5) if appropriate, recommending mechanisms for wider implementation of those school health programs that have proven to be effective. At the onset of the committee's work, it became evident that a broad range of constituencies had become interested and involved in CSHPs and that a variety of opinions existed about what these programs are and what they do. The members of the committee themselves came into the study with a diverse range of backgrounds and experiences; therefore, they determined that it would be useful to establish their own working definition of the term "comprehensive school health program" to use as a guide for further work and to stimulate discussion and feedback from others in the field. In the spring of 1995, the committee developed, published, and distributed an interim statement presenting this working definition and identifying issues that the committee planned to address in its study (IOM, 1995)1. The definition and models for CSHPs are further discussed in Chapter 2 of this report. 1    Institute of Medicine. 1995. Defining a Comprehensive School Health Program. Washington, D.C.: National Academy Press. Although this report is now out of print, the full text is available on line at www2.nap.edu/readingroom.

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School & Health: Our Nation's Investment The committee met four times during the course of the study. At its first meeting, representatives from various federal agencies presented their programs and priorities in the area of school health. The committee expresses its special thanks to the following agency representatives from the U.S. Department of Health and Human Services, Public Health Service: Linda Johnston, Health Resources and Services Administration, Maternal and Child Health Bureau; Jane Martin, Bureau of Primary Health Care, Health Resources and Services Administration; William Harlan, Office of the Assistant Secretary for Health, Department of Health and Human Services, and Office of Health Promotion and Disease Prevention, National Institutes of Health; Evelyn Kappeler, Office of Population Affairs, and Peter Cortese, Division of Adolescent and School Health, Program Development and Services Branch, Centers for Disease Control and Prevention; and Connie Garner, U.S. Department of Education, Federal Interagency Coordinating Council, Office of the Undersecretary. A public workshop was convened in conjunction with the first meeting to examine selected elements of a CSHP in depth. The committee appreciates the contributions of the following workshop speakers: Tom O'Rourke, Ph.D., M.P.H., professor, Department of Community Health, University of Illinois, for his review of new directions in health education; Mary Jackson, B.S.N., M.Ed., nurse consultant, Bureau of Women and Children, Texas Department of Health, for her analysis of the relationship of health education to the core curriculum; Eulalia Muschik, M.S., R.D., supervisor of food services, Carroll County (Maryland) Public Schools, for her examination of nutrition education and food services; Karla Shepard-Rubinger, M.S., The Conservation Company, and John Santelli, M.D., M.P.H., medical epidemiologist, Baltimore City Health Department, and adjunct assistant professor of Maternal and Child Health, Johns Hopkins School of Hygiene and Public Health, for their presentations about school-affiliated clinics and service delivery; and Genie L. Wessel, R.N., M.S., project director, Making the Grade Program, Maryland Governor's Office, for her presentation on approaches for integrating school health programs. Because research and evaluation are major challenges for CSHPs, a subcommittee on research and evaluation was appointed after the first meeting to examine issues in this area. At the second meeting, the subcommittee reported its findings on the status and results of current research to the full committee and outlined the most difficult problems and obstacles in conducting research on these multifaceted programs. As a result of the full committee discussion, a paper by Mary Ann Pentz, Ph.D., was commissioned, which stresses that schools are just one part of a broader community system and describes various evaluation studies on school–community programs and interactions. (See Appendix A.)

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School & Health: Our Nation's Investment Also at the second meeting, one day was devoted to a discussion of financing school health programs and services. The committee thanks the following speakers for their presentations on the topic: Harriette Fox, M.S., of Fox Health Policy Consultants; Susan L. Lordi, administrative project director, School Health Programs, Los Angeles County Office of Education; and Ruth Rich, Ed.D., director of Drug, Alcohol, and Tobacco Education Programs, Los Angeles Unified School District. The third committee meeting examined school-affiliated services. The committee appreciates the views expressed by the following speakers at that meeting: Phyllis L. Gingiss, Dr. P.H., associate dean of research, College of Education, University of Houston, for her presentation on the education and training of school health personnel; Deborah Klein Walker, Ed.M., Ed.D., assistant commissioner, Bureau of Family and Community Health, Massachusetts Department of Public Health, for her overview of school-affiliated services; and Thomas W. Payzant, Ed.D., assistant secretary for elementary and secondary education, U.S. Department of Education, for his analysis of school-affiliated services from the educator or administrator's point of view. The committee also thanks the following individuals for their participation in a panel discussion on school-affiliated services: Kevin Dwyer, M.A., NCSP, assistant executive director, National Association of School Psychologists; Isadora Hare, ACSW, LCSW, National Association of Social Workers; Olga Wright, representing the National Association of School Nurses, from the Alexandria (Virginia) City Public Schools; and Judith Ladd, representing the American School Counselor Association, from Prince William County (Virginia) Public Schools. At the fourth and final meeting, the committee met in working session to finalize the report and its recommendations. Thus, in the final analysis, the committee has responded to its charge throughout the chapters of this report. The committee's response to the first element of the charge, to develop a framework for determining the desirable and feasible health outcomes (including mental, emotional, and social health) of CSHPs, can be found in Chapters 3 and 4. The second element, to examine the relationship between health outcomes and education outcomes, is addressed in Chapter 1, in which the committee found that dropouts are more likely to have costly medical problems, and Chapter 2. The third element, to consider what factors are necessary in the school setting to optimize these outcomes, is addressed in Chapters 3 and 4. The fourth element, to appraise existing data on effectiveness (including cost-effectiveness) of comprehensive school health programs and identify possible additional strategies for evaluation of the effectiveness of these programs, is discussed in Chapter 6. The fifth and final element, to recommend mechanisms for wider implementation of those health pro-

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School & Health: Our Nation's Investment grams that have proven to be effective, is discussed extensively in Chapter 5. This important report would not have been possible without the excellent staff work at the Institute of Medicine. The committee thanks Valerie P. Setlow, Ph.D., Director of the Division of Health Sciences Policy, for her revisions to the text, constant enthusiasm, encouragement, and guidance during the study and throughout the report review process. Thanks also are due to Study Director Lois Nicholson, M.S., who provided staff leadership during the course of the study by weaving together the separate contributions of individual committee members to develop the original draft of this report. The committee also thanks Research Associate Elaine Lawson, M.S., for developing the study concept at its inception, and for her efforts in gathering and organizing information, working with committee members in writing their contributions, and helping to develop the response to review. Appreciation is extended to Project Assistant Margo Cullen for her excellent administrative support in making meeting and travel arrangements, and facilitating communication among committee members and staff. Sincere thanks go to Linda DePugh, Administrative Assistant, for making editorial corrections to the entire report and for producing the tables and figures and the camera ready manuscript for publication. Thanks also go to Claudia Carl for her patience and guidance in shepherding the report through the review process; and Mike Edington for getting the report to the press in rapid and good condition and for finding Florence Pollion, who edited the report. Finally, we thank the sponsors, NIH, CDC, HRSA, and the Department for Education for their support and vision about the need for this report. We are greatly appreciative of their confidence throughout this process. The co-chairs thank all the committee members for their extraordinary spirit of teamwork and dedication. Working with such a distinguished and dedicated group has been a wonderful experience; all of us have learned from each other and are richer for the opportunity. Diane Allensworth, Co-chair James Wyche, Co-chair

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School & Health: Our Nation's Investment Support for this project was provided by the Centers for Disease Control and Prevention (Division of Adolescent and School Health), the Health Resources and Services Administration (Bureau of Primary Care and Maternal and Child Health Bureau), the National Institutes of Health (Office of Disease Prevention, Office of the Director, National Cancer Institute, National Institute of Environmental Health Sciences, National Institute for Drug Abuse, National Institute for Dental Research, National Center for Research Resources, and National Institute of Arthritis and Musculoskeletal and Skin Diseases), the U.S. Department of Education, and the U.S. Department of Health and Human Services, Public Health Service (Office of the Assistant Secretary and Office of Population Affairs). Support for dissemination of this report was provided by the Kaiser Family Foundation and the Centers for Disease Control and Prevention (Division of Adolescent and School Health). This support does not constitute an endorsement by the U.S. Health). This support does not constitute an endorsement by the U.S. Education of the views expressed in the report.

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School & Health: Our Nation's Investment Contents     EXECUTIVE SUMMARY   1     Background   1     Findings, Conclusions, and Recommendations   3     Moving School Health Programs into the Future   14 1   INTRODUCTION   16     Background of the Study   16     The Current Context for School Health Programs   18     The Comprehensive School Health Program   28     Major Issues and Questions Considered by the Committee   29     Organization of the Remainder of This Report   29 2   EVOLUTION OF SCHOOL HEALTH PROGRAMS   33     Historical Overview   33     The Comprehensive School Health Program   50     Summary   76 3   EDUCATION   81     The Role of Physical Education in Comprehensive School Health Programs   81     The Role of Health Education in Comprehensive School Health Programs   99     Summary of Findings and Conclusions   139     Recommendations   140

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School & Health: Our Nation's Investment 4   SCHOOL HEALTH SERVICES   153     Introduction   153     Overview of Basic School Services   161     Extended Services   181     Research on School Health Services   186     Matching Level of Services to Needs   199     Confidentiality of Students' Health and Education Records   204     Financing of School Health Services   206     First Steps for a Community in Establishing School Services   216     Summary of Findings and Conclusions   225     Recommendations   226 5   BUILDING THE INFRASTRUCTURE FOR COMPREHENSIVE SCHOOL HEALTH PROGRAMS   237     The National Infrastructure   238     The State and Local Infrastructure   246     Summary of Findings and Conclusions   261     Recommendations   261 6   CHALLENGES IN SCHOOL HEALTH RESEARCH AND EVALUATION   271     Overview of Research and Evaluation   271     Methodological Challenges   276     Challenges and Future Directions for School Health Education Research   280     Summary of Findings and Conclusions   288     Recommendations   289 7   THE PATH TO THE FUTURE   296     The Unique Position of the School   296     Moving School Health Programs into the Future   297     An Investment in the Future   299     Concluding Remarks   301     APPENDIXES         A THE SCHOOL—COMMUNITY INTERFACE IN COMPREHENSIVE SCHOOL HEALTH EDUCATION   305     B GUIDELINES FOR COMPREHENSIVE SCHOOL HEALTH PROGRAMS   337     C MODELS OF HEALTH BEHAVIOR CHANGE USED IN HEALTH EDUCATION PROGRAMS   356     D NEW APPROACHES TO THE ORGANIZATION OF HEALTH AND SOCIAL SERVICES IN SCHOOLS   365

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School & Health: Our Nation's Investment     E GUIDELINES FOR ADOLESCENT PREVENTIVE SERVICES   416     F FEDERAL FUNDING STREAMS FOR COMPREHENSIVE SCHOOL HEALTH PROGRAMS   430     G-1 A VISION OF INTEGRATED SERVICES FOR CHILDREN AND FAMILIES   443     G-2 THE WEST VIRGINIA EXPERIENCE: AN INFRASTRUCTURE MODEL   456     G-3 CONNECTICUT SCHOOL HEALTH SERVICES MODELS   463     ACRONYMS AND ABBREVIATIONS   474     INDEX   478

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