1
Introduction

BACKGROUND OF THE STUDY

Times have changed, and so have school health programs. Many adults remember school health as consisting of lessons about first aid and the four food groups, with occasional visits to the school nurse for minor illnesses or injuries. While these issues have not disappeared, today's school health programs also are faced with a new array of difficult and seemingly intractable problems: the "new social morbidities"—violence, drug and alcohol abuse, acquired immunodeficiency syndrome (AIDS) and other sexually transmitted diseases (STDs), teen pregnancy, and depression; students' lack of access to reliable health information and health care; changing family structures; and increasing poverty. Traditional approaches to school health programs may no longer be sufficient to deal with these complex issues.

A new concept of school health programming—the "comprehensive school health program"—was proposed in the 1980s as a means to address many of these health-related1 problems of our nation's children and young people. Comprehensive school health programs (CSHPs) are de-

1  

Throughout its study and this report, the committee uses the term "health" in its broadest sense. Health is much more than simply the absence of disease; health involves optimal physical, mental, social, and emotional functioning and well-being. The World Health Organization has defined health as "a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity." (World Health Organization, 1996).



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 16
School & Health: Our Nation's Investment 1 Introduction BACKGROUND OF THE STUDY Times have changed, and so have school health programs. Many adults remember school health as consisting of lessons about first aid and the four food groups, with occasional visits to the school nurse for minor illnesses or injuries. While these issues have not disappeared, today's school health programs also are faced with a new array of difficult and seemingly intractable problems: the "new social morbidities"—violence, drug and alcohol abuse, acquired immunodeficiency syndrome (AIDS) and other sexually transmitted diseases (STDs), teen pregnancy, and depression; students' lack of access to reliable health information and health care; changing family structures; and increasing poverty. Traditional approaches to school health programs may no longer be sufficient to deal with these complex issues. A new concept of school health programming—the "comprehensive school health program"—was proposed in the 1980s as a means to address many of these health-related1 problems of our nation's children and young people. Comprehensive school health programs (CSHPs) are de- 1   Throughout its study and this report, the committee uses the term "health" in its broadest sense. Health is much more than simply the absence of disease; health involves optimal physical, mental, social, and emotional functioning and well-being. The World Health Organization has defined health as "a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity." (World Health Organization, 1996).

OCR for page 16
School & Health: Our Nation's Investment signed to take advantage of the pivotal position of the school in reaching children and families by combining—in an integrated, systemic manner—health education, health promotion and disease prevention, and access to health and social services at the school site. CSHPs are implemented in conjunction with other educational reforms to join together the movement toward quality education with health enhancement. CSHPs may be promising not only for improving health and educational outcomes for students but also for reducing overall health care costs by emphasizing prevention, adoption of health-enhancing behaviors, and early identification of health problems and by providing easy access to care. The Committee on Comprehensive School Health Programs in Grades K through 12 (K–12) was convened by the Institute of Medicine (IOM) to carry out a 15-month study to develop a framework for (1) determining the desirable and feasible health outcomes (including mental, emotional, and social health) 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 identifying possible additional strategies for evaluation of the effectiveness of these programs; and (5) if appropriate, recommending mechanisms for wider implementation of those school health programs that have proven to be effective. The committee found that many aspects of CSHPs are in place in numerous schools. However, a comprehensive, integrated, and synergistic program remains a concept in most school systems. The task of the committee was to examine the rationale, structure, and status of these programs and to consider whether and how the concept might become a reality. The committee began its study with the following basic assumptions: The primary goal of schools is education. Education and health are linked. Educational outcomes are related to health status, and health outcomes are related to education. There are certain basic health needs of children and young people. These include nurturing and support; timely and relevant health information, knowledge, and skills necessary to adopt healthful behavior; and access to health care. The school has the potential to be a crucial part of the system to provide these basic health needs. Schools are where children and youth spend a significant amount of their time, and schools can reach entire families. However, the school is only part of the broader community system; the responsibility does not and should not fall only on the schools.

OCR for page 16
School & Health: Our Nation's Investment THE CURRENT CONTEXT FOR SCHOOL HEALTH PROGRAMS A variety of important reports have been released in recent years raising concern about the health, education, and social condition of many of our nation's children and young people (Carnegie Council on Adolescent Development, 1989; National Commission on Children, 1991; National Commission on the Role of the School and the Community in Improving Adolescent Health, 1990; National Research Council, 1993; Office of Technology Assessment, 1991; U.S. General Accounting Office, 1993, 1994a, 1994b). These concerns include the fact that economically, children are the poorest segment of our citizenry,2 and infant mortality rates in some parts of the country are as high as those in many developing countries.3 Two seminal documents recently have been released containing new recommendations for the health supervision of children and adolescents in order to address the changing problems of today. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents4 emphasizes that new strategies are needed to address the major economic, social, and demographic changes that have occurred in recent decades and have had a dramatic effect on the health and welfare of children (Green, 1994). These changes include a decrease in the time parents spend with children, the disintegration of families and an increase in the number of children living in single-parent households, and a rapid escalation of the numbers of children living in poverty. Guidelines for Adolescent Preventive Services, published by the American Medical Association, recommends that new strategies are needed to deal with health problems of adolescents, which are now predominantly behavioral rather than biomedical (Elster and Kuznets, 1994). Both reports stress the need for a more comprehensive approach that involves families and for an emphasis on prevention of problems before they become established. The Importance of Education Concern about students' academic performance and our national competitiveness has led to a national education reform movement and volun- 2    The following poverty rates existed in 1992: children under age 18, 21.9 percent; adults 18–64, 11.7 percent; adults 65 and older, 12.9 percent (National Research Council, 1995). 3    For example, the infant mortality rate for U.S. blacks ranks 40th when compared with other countries' overall rates; countries ranking higher include Jamaica, Costa Rica, Malaysia, and Sri Lanka (Children's Defense Fund, 1994). 4    This document was developed by a large number of health professionals, in collaboration with consumers and experts in other fields, under the sponsorship of the Maternal and Child Health Bureau, U.S. Public Health Service.

OCR for page 16
School & Health: Our Nation's Investment tary national standards in core academic subjects. The relationship between academic achievement and student health status has been acknowledged by the National Education Goals, a bipartisan effort that began at a national governors' summit convened by President Bush in 1989. Among its directives, the National Education Goals call for (National Education Goals Panel, 1994) the following: students to start school with the healthy minds, bodies, and mental alertness necessary for learning, safe and disciplined school environments that are free of drugs and alcohol, access for all students to physical education and health education to ensure that students are healthy and fit, and increased parental partnerships with schools in order to promote the social, emotional, and academic growth of children. The future of our country depends on an educated, productive workforce. The unskilled blue collar jobs of previous generations are disappearing, and schools are expected to prepare all students, not just a select few, for the demanding workplace of the future (Marshall and Tucker, 1992; Secretary's Commission on Achieving Necessary Skills, 1991). The Hudson Institute's Workforce 2000 report notes that unless workforce basic skills are improved substantially, there will be more joblessness among the least skilled, accompanied by a chronic shortage of workers with advanced skills (Johnston and Packer, 1987). However, the U.S. General Accounting Office (GAO) has suggested that the education—and thus the future—of a significant segment of our nation's children and adolescents is being threatened by a broad range of health and behavioral problems, increasing poverty, and deteriorating family and community conditions (GAO, 1993, 1994a, 1994b). One of these GAO reports estimates that about one-third of the school-age population, or approximately 15 million children in 1992, is at risk of dropping out of school. This report cites a 1989 study that predicted male high school dropouts can expect to earn $260,000 less and pay $78,000 less in taxes during their lifetimes than male high school graduates; comparable estimates for female dropouts are $200,000 and $60,000, respectively. The report also notes that studies have shown that dropouts are more likely to be poor, have costly medical problems as a result of their economic status, and require job training. Currently, many dropouts populate U.S. prisons (GAO, 1993). Concern about the effect of school dropouts on the nation's budget, workforce, and ability to compete globally in the future is reflected in the National Education Goal to increase the high school graduation rate to at

OCR for page 16
School & Health: Our Nation's Investment least 90 percent by the year 2000. In 1992, the high school completion rate for people aged 19 to 20 was 84.7 percent, and for those aged 21 to 22, the rate was 86.2 percent. Although the difference between current school completion rates and the National Education Goal does not appear to be great, the graduation rate is significantly lower in many inner city and rural areas. Furthermore, the Bureau of the Census has projected that the population of academically at-risk children will continue to grow. Because these children are more likely to fail and drop out of school, the 90 percent goal may be more difficult to attain than the data indicate. To assist the growing number of school-aged children at risk of school failure, some experts have proposed comprehensive interventions that deliver a range of human services to students in schools (GAO, 1993). The New Social Morbidities A century ago, infectious disease and untreated physical defects put students at risk of school failure. Today, most of these problems can be addressed in whole or in part with immunizations, antibiotics, eyeglasses, and other medical treatments. Yesterday's problems, however, have been replaced by special health care needs, chronic diseases, and a new set of problems based in behavior and life-style choices, and these problems are not amenable to simple well-defined solutions. The Centers for Disease Control and Prevention (CDC) has found that the following six categories of behavior are responsible for 70 percent of the mortality and morbidity among adolescents: (1) behaviors that cause unintentional and intentional injuries, (2) drug and alcohol abuse, (3) sexual behaviors that cause sexually transmitted diseases and unintended pregnancies, (4) tobacco use, (5) inadequate physical activity, and (6) dietary patterns that cause disease (Kann et al., 1995). These problems are based in behaviors that can be prevented or changed. These behaviors usually are established during youth, persist into adulthood, are interrelated, and contribute simultaneously to poor health, education, and social outcomes. The CDC's Youth Risk Behavior Survey of 1993 (CDC, 1995) found that 19.1 percent of all high school students rarely or never used a safety belt, 35.3 percent had ridden with a driver who had been drinking alcohol during the 30 days preceding the survey, 22.1 percent had carried a weapon during the preceding 30 days, 80.9 percent had ever consumed alcohol, 32.8 percent had ever used marijuana, and 8.6 percent had attempted suicide during the 12 months preceding the survey. Among high school seniors, 89 percent reported having used alcohol, and 39 percent of seniors reported having five or more drinks at one time in the past two weeks. In addition, 53 percent of students in grades 9–12 have had sexual intercourse, and 19 percent of them have had four or more sexual partners

OCR for page 16
School & Health: Our Nation's Investment in their lifetime. Among twelfth graders, 68 percent have had sexual intercourse, and 27 percent of them have had four or more sexual partners in their lifetime. In addition, health-compromising behaviors frequently tend to occur in clusters; individuals engaging in one type of high-risk behavior also tend to engage in other types of high-risk behaviors (Donovan and Jessor, 1985; Donovan et al., 1988; National Research Council, 1993; Resnicow et al., 1995). Those who smoke are also more likely drink alcohol, drive after drinking, and have unprotected sexual intercourse. Dryfoos estimated that 10 percent of adolescents are at very high risk for dropping out of school because of engaging in a variety of risky behaviors, an additional 15 percent are at high risk, and 25 percent are at moderate risk (Dryfoos, 1990). Beyond these major risk areas, adolescents also engage in significant health-compromising practices that endanger health over the long term into adulthood. The CDC's Youth Risk Behavior Survey found that 30.5 percent of high school students smoke cigarettes, only 15.4 percent eat five or more servings of fruits and vegetables per day, and only 34.3 percent attend physical education class daily. The major causes of chronic disease and death among adults—cancer, heart disease, injury, stroke, and liver and lung disease—are influenced by health behaviors and lifestyles established during childhood and youth (U.S. Department of Health and Human Services, 1991). In 1979, the U.S. Public Health Service identified the four major factors leading to early illness or death and the extent of each contribution: heredity (20 percent), environment (20 percent), inadequate health care delivery system (10 percent), and an unhealthy lifestyle (50 percent) (U.S. Department of Health and Human Services, 1979). Studies by the U.S. Department of Health and Human Services have shown that 99 percent of health expenditures go to medical treatment and only 1 percent goes to population-wide public health prevention strategies. However, estimates predict that medical treatment can prevent only 10 percent of our nation's premature deaths, whereas population-wide public health approaches have the potential to prevent 70 percent of early deaths (U.S. Department of Health and Human Services, 1993).5 The debate surrounding the reform of health care delivery systems would be well advised to consider the fact that cost containment might be achieved by shifting the focus from medical care financing to an emphasis on illness and accident prevention. 5    Approximately 20 percent of premature deaths are attributable to genetic conditions and are not preventable, at least at this time.

OCR for page 16
School & Health: Our Nation's Investment TABLE 1-1 Ten Most Prevalent Conditions at Time of Death in 1990 Cause Number of Deaths Heart disease 720,000 Cancer 505,000 Cerebrovascular disease 144,000 Unintentional injuries 92,000 Chronic lung disease 87,000 Pneumonia and influenza 80,000 Diabetes mellitus 48,000 Suicide 31,000 Chronic liver disease 26,000 HIV infection 25,000 Total 1,758,000 NOTE: HIV = human immunodeficiency virus. SOURCE: McGinnis and Foege, 1993. Certificates filed at the time of death generally indicate the primary pathophysiological conditions identified at the time of death; although these conditions are commonly thought of as the "causes" of death, in fact they may not be the root causes. For 1990, the 10 most prevalent conditions at time of death are shown in Table 1-1. Noting that most diseases or injuries are multifactorial in nature, McGinnis and Foege (1993) carried out an analysis to determine the relative contribution of the underlying factors that led to these most frequently reported causes of death in 1990. Their results are shown in Table 1-2. McGinnis and Foege point out that most of these underlying causes of death are based on behavior and lifestyle choices, and these avoidable underlying causes impose a substantial public health burden. To improve the health of all age groups, the U.S. Public Health Service, in partnership with practitioners and private organizations, developed the Healthy People 2000 initiative, a set of nearly 300 national health promotion and disease prevention objectives to be achieved by the year 2000 (U.S. Department of Health and Human Services, 1991). An examination shows that one-third of these objectives can be influenced significantly or achieved in or through the schools (McGinnis and DeGraw, 1991). Problems Due to Poverty As mentioned earlier, the poverty rate for children under the age of 18

OCR for page 16
School & Health: Our Nation's Investment TABLE 1-2 Underlying Factors Leading to Death in 1990 Underlying Factors Number of Deaths Tobacco 400,000 Diet/inactivity patterns 300,000 Alcohol 100,000 Infections 90,000 Toxic agents 60,000 Firearms 35,000 Sexual behavior 30,000 Motor vehicles 25,000 Drug use 20,000 Total 1,060,000   SOURCE: McGinnis and Foege, 1993. is 21.9 percent, the highest of any age group in this country. The poverty rate varies considerably by race and ethnicity, however, with close to 40 percent of black children and 32 percent of Hispanic children living in poverty, according to 1990 figures. Between 1980 and 1990, the percentage of children living in low-income families increased and the percentage living in families with comfortable or prosperous income decreased across all racial and ethnic groups (U.S. Department of Commerce, 1993). The increasing number of poor and at-risk students requires schools to contend with more students who are potentially low achievers and who have health and other problems that interfere with learning. Even the youngest kindergartners arrive at school with backgrounds that will have a profound influence on their school experience; some are at a physical and mental disadvantage even before entering school, due to their mother's lack of prenatal care and to inadequate care and nurturing after birth. A report of the Carnegie Task Force on Meeting the Needs of Young Children found that there are three major "protective factors" that help a child to achieve positive outcomes: perinatal factors such as full-term birth and normal birthweight, dependable caregivers whose childbearing practices are positive and appropriate, and community support. Scientists have learned that brain development that takes place before age 1 is more rapid and extensive than previously realized, with infants' earliest experiences with their parents providing the essential building blocks for intellectual competence and language comprehension. Therefore, the care and nurturing that take place even before a child reaches kindergarten play an important role in that child's future (Carnegie Task Force, 1994).

OCR for page 16
School & Health: Our Nation's Investment A GAO study reports that poor children have more health problems than other children, their conditions are often more severe, and they are less likely to receive regular health care. Poor children typically receive only episodic and crisis-related care, leaving preventive, chronic, and dental health needs not met. For example, of the 19 million children eligible for Medicaid's Early and Periodic Screening, Diagnostic, and Treatment Program in 1992, fewer than 7 million had been screened. More than 40 percent of poor school-aged children had no dental visits in 1989, compared with 28 percent for all children. Children from poor families (those with less than $10,000 annual income) are nearly twice as likely to be hospitalized and spend more than twice the number of days in the hospital than are children from families with annual incomes of $35,000 or more (GAO, 1994b). Poor children are also more likely to be limited in school or play activities by chronic health problems and to suffer more severe consequences than children from high-income families when afflicted by the same illness (Newacheck et al., 1995). The new social morbidities, which are expressed as negative behaviors, also have a disproportionate impact on poor students. While school health programs attempt to address many of the social and environmental factors that influence human behavior, biomedical factors can also profoundly influence behavior and thus the effectiveness of school programs. For example, an obsessive–compulsive disorder would affect dramatically the ability of an individual to benefit from behavioral interventions. It may be that a significant share of the negative health behaviors currently ascribed primarily to social and environmental factors actually are caused by, or at least aggravated by, biomedical factors. Thus, health and education outcomes may be much less promising for a child with an undiagnosed and untreated neurological deficit—or other ''hidden" biomedical disorders—growing up in social and environmental deprivation. Schools with many children who live in poverty have higher rates of absenteeism and grade retention—or repeated grades—among their student populations. Further, these students have more health problems and inadequate nutrition. Compounding these problems is the increased mobility associated with poor and at-risk children. Changing schools frequently disrupts the child's education, making learning and achievement difficult (GAO, 1994a). Schools with higher percentages of students in poverty are often inferior structurally, may be unsafe, and may even be harmful to children's health. It is estimated that approximately $112 billion is necessary to repair or upgrade America's facilities. Of this, $11 billion (10 percent) is needed in the next three years to comply with federal mandates that require schools to make all programs accessible to all students; to remove or correct hazardous substances, such as asbestos, lead in water or paint,

OCR for page 16
School & Health: Our Nation's Investment materials in underground storage tanks, and radon; or to meet other requirements. Based upon a GAO study of a national sample of schools, although two-thirds of the schools reported that all buildings were in at least overall adequate condition, one-third reported that the schools needed extensive repair or replacement of one or more buildings. Fourteen million students attend classes in these buildings that have leaky roofs, unsanitary bathrooms, and inadequate plumbing that make them unsafe and harmful to children's health (GAO, 1995). The measure of the number of students in poverty in a school is the number of students who receive free and/or reduced-price lunches. In those schools that have 70 percent or more of students receiving free or reduced-cost lunches, the proportion of schools reporting unsatisfactory environmental factors greatly exceeds those schools with less than 20 percent of students receiving such lunches. In the highest-poverty schools, 19.1 percent report unsatisfactory lighting compared to 14.3 percent of schools with lower numbers of students in poverty; 22.6 percent report inadequate indoor air quality compared to 15.8 percent of low-poverty schools; 32.8 percent report unsatisfactory acoustics compared to 24.1 percent of low-poverty schools; and 30 percent report unsatisfactory physical security compared to 19.4 percent of low-poverty schools (GAO, 1995). It seems especially ironic that the one institution within the community that requires attendance of all students, rather than serving as a safe haven, may be a dangerous and unhealthy setting for many of our children who are most at risk. The deplorable physical state of some of these schools sends a message to students about their own self-worth and about the importance of their education, further exacerbating the downward spiral of educational and health outcomes. Changing Family Structures Involvement of the family is critical to a student's achievement. When schools involve families in meaningful ways to support learning, students tend to succeed not just in school but throughout life. Studies have found that the most accurate predictor of a child's success in school is the degree to which the family creates a home environment that encourages learning, has high expectations for the child's achievement, and becomes involved with the child's education. Students with supportive families are more likely to receive higher grades and test scores, have better attendance, complete more homework, have fewer placements in special education, attain higher graduation rates, and enroll more often in post-secondary education (Henderson and Berla, 1994). Social and economic changes have reduced the support and nurtur-

OCR for page 16
School & Health: Our Nation's Investment ing available from the family and have increased family stress. The number of traditional two-parent families with extended family nearby for support and assistance is dwindling. According to 1990 census figures, only 14 percent of children live in such "traditional" families with fathers who work year-round and mothers who stay home, and only 3 percent of children living in two-parent families have a grandparent in the home. In many families, parents are increasingly making the decision, often driven by economics, to have both parents work outside the home (Gordon, 1995); 15 percent of children live in two-parent families in which both parents work full-time, and another 24 percent live in two-parent families in which the father works full-time and the mother works part-time. For children living with their mothers, whether in single- or two-parent families, only 28 percent had mothers who stayed home full-time in 1990, compared to 40 percent in 1980 (U.S. Department of Commerce, 1993). Ambition to improve the family's standard of living has been frustrated because of the lack of growth in real wages. Between 1983 and 1992, the weekly earnings for full-time workers, adjusted for inflation, grew by a total of only 1 percent. In contrast, real family incomes grew an average of 4 percent per year during the 25 years of economic prosperity following the end of World War II. Particularly noteworthy are the declining earnings of young workers, which fell by 9 percent during the 1983–1992 period (Zill and Nord, 1994). Increasing numbers of children do not live in two-parent families (U.S. Department of Commerce, 1993). The percentage of children living in a one-parent family grew from 18 percent in 1980 to 24 percent in 1990. An examination of the family situation of 1-year-olds—children with which schools will be dealing well into the twenty-first century—shows that 27 percent of them lived in families with one or no parent in 1990, compared to 21 percent in 1980. For black children, 68 percent of 1-year-olds lived in families with one or no parent in 1990, compared to 60 percent in 1980. Similar figures for Hispanic 1-year-olds are 36 percent in 1990 compared to 29 percent in 1980. More than four out of every five children living with one parent lived with their mother. It is estimated that approximately half of American children will live in a single-parent family for some period of their lives (Cohen, 1992; Kirst and Kelly, 1995). In addition to the lack of financial progress, there is concern that time devoted to employment detracts from parents' ability to provide nurturing and supportive functions (Zill and Nord, 1994). It may be difficult for working parents to take their children to the doctor or spend time at home with a sick child (U.S. GAO, 1994b). For adults, the hours away from home required by full-time employment often do not match the hours that children spend at school. Latchkey children with time on their hands and without supervision are the result. Often the only "babysitter" is the

OCR for page 16
School & Health: Our Nation's Investment television. The Search Institute, in its analysis of 15,000 adolescents, found that the combination of inadequate supervision of children and more than three hours of television daily was directly related to a life-style marked by more health-debilitating behaviors than was the case with youngsters who were more closely supervised (Blythe and Rochlkepartain, 1993). With increased family stress and the decreased time and direct supervision that parents are able to give to their children, schools are increasingly asked to fill the role of surrogate or supplemental parents. Access to Health Care Estimating the number and percentage of children under the age of 18 with no health insurance is difficult, and different models give different figures. For example, estimates range from 8.7 million (12.6 percent) to 11.1 million (16.1 percent) uninsured children in 1993 (Lewit and Schuurmann-Baker, 1995), although a figure as high as 12 million uninsured children has been cited recently (American Medical Association Council on Scientific Affairs, 1990). Millions of other children have inadequate insurance plans that fail to cover even such basic preventive services as immunizations (National Health/Education Consortium, 1992). According to a recent GAO report, 12 million children do not get such basic preventive care as periodic physical examinations or immunizations at the proper intervals, and only about half of all elementary school children routinely receive health care. Although 7.5 children under the age of 18 require mental health services, fewer than one in eight actually receives them (GAO, 1994b). Oral health problems are significant among schoolchildren and often go untreated (National Institute of Dental Research, 1995). Of major concern is the decline of employer-sponsored health coverage for children. Solloway and Budetti (1995) report that between 1979 and 1986, 1.26 million children lost health insurance coverage because of reductions in their parents' employer-based plans. The largest decline occurred in conventional two-parent, single wage earner families, in which coverage of children decreased by 11.7 percent between 1977 and 1987 (Solloway and Budetti, 1995). Between 1987 and 1992, another 4.5 percent of children lost their employer-based coverage. Even if dependent coverage is available, high cost-sharing requirements for premiums and large co-payments or out-of-pocket expenses are major problems, especially for low- and middle-income wage earners. Further, uninsured children with chronic illnesses may be excluded because of preexisting condition, and lifetime benefit caps are an obstacle for those with insurance. In addition, young families are often the least protected and most

OCR for page 16
School & Health: Our Nation's Investment vulnerable in an unstable job market, frequently the first fired or working in temporary jobs with no employer-based insurance coverage. Access to health care can include concerns beyond mere financial issues. Transportation, convenience, and cultural sensitivity are also factors. In addition, parental support and encouragement, as well as understanding the importance of health care and how to approach the system, influence students' access to health care. Even with access to health care, young people may not be receiving the attention they need. When adolescents with access to physicians are asked what they want to discuss and what they actually discuss with the physician, the percentage drops on virtually every topic from nutrition, to sex, to drug use (Marks et al., 1983). Even those adolescents with insurance and family doctors do not seek help from health care professionals for problems of greatest importance for their high-risk behaviors. In fact, doctors themselves do not feel qualified to discuss most adolescent health behaviors—only 38 percent feel they have adequate training in alcohol and drug abuse, and a mere 11 percent feel qualified to discuss depression with a youth (Beringer, 1990). Studies have shown that an initial history and physical examination for a new adolescent patient should require 30 to 45 minutes. Although 23 percent of adolescent physician visits are first encounters, half of all visits last 10 minutes or less, 30 percent last 11 to 15 minutes, and only 4 percent are 30 minutes or longer (Klein et al., 1993). THE COMPREHENSIVE SCHOOL HEALTH PROGRAM The comprehensive school health program is seen as a new paradigm needed to deal with the problems of today's children and families. It became clear to the IOM committee at the onset of its study that although a variety of conceptions and models exist, coordinated comprehensive programs are still essentially an unrealized ideal in most communities. The committee members themselves came into the study with a range of backgrounds and experiences, and the committee determined that it needed to establish its own working definition of the term "comprehensive school health program," which would guide further work. This definition was published and distributed in the committee's interim statement in the spring of 1995, along with additional background information and an outline of issues the committee planned to address in its study. The definition of a CSHP, as well as various program models and essential components, is further discussed in Chapter 2 of this report.

OCR for page 16
School & Health: Our Nation's Investment MAJOR ISSUES AND QUESTIONS CONSIDERED BY THE COMMITTEE As mentioned above, early in its study the committee identified a set of issues and questions to be examined. These include the following: There is no consensus on what the responsibilities of the school should be relative to the health of children in this country. What are schools doing now? What have they done in the past? What should our schools be doing in the future? What is the status of CSHPs? What are considered their essential elements, and how do programs work? How does a CSHP differ from previous models of school health programs? Given the problems of today's children and young people, what are the desired outcomes of CSHPs? What outcomes are feasible and measurable? What factors appear to optimize these outcomes? What is known about the effectiveness (including cost-effectiveness) of comprehensive school health programs and their components? What are the data gaps and possible ways of filling them? In this era of cost containment, what are the implications for CSHPs of reforms in the health care delivery system and possible changes in Medicaid? How can effective CSHPs be disseminated and replicated? What are the barriers and obstacles to wider implementation of effective programs? ORGANIZATION OF THE REMAINDER OF THIS REPORT Chapter 2 traces the evolution of school health programs from their early beginnings in the mid-nineteenth century to today's definition and concept of a CSHP. Chapter 3 considers the two important educational components of CSHPs, physical education and health education. Chapter 4 examines the wide range of health-related services available in the schools—including health, mental health, and nutrition or foodservices—and some of the new approaches for providing extended services to students with greatest needs. Chapter 5 considers how the infrastructure—the basic interconnected framework and support structure—for CSHPs can be built, from the national level to the local school level. Chapter 6 reviews research on CSHPs and their components, noting the limitations and methodological difficulties in carrying out research on these complex systems. Chapter 7 provides a summary of the committee's findings and concluding remarks. Recognizing that schools are just one part of a broader community

OCR for page 16
School & Health: Our Nation's Investment system, the committee sought to understand the nature and potential of school–community collaboration in promoting and protecting the health of students. A paper by an outside author was commissioned that examines this topic; it can be found in Appendix A. Appendixes C and D contain material written by committee members that served as background for the committee; Appendix C examines some of the theoretical models of behavior change that form the basis for health education programs, and Appendix D describes and gives examples of new approaches for providing health and related services through schools. Appendixes B, E, F, and G provide supplemental background information. REFERENCES American Medical Association Council on Scientific Affairs. 1990. Providing medical services through school-based health programs. Journal of School Health 60(3):87–91. Blum, R.W., and Beringer, L.H. 1990. Knowledge and attitudes of health professionals toward adolescent health care. Journal of Adolescent Health Care 11(4):289–294. Blythe, D.A., and Rochlkepartain, E.C. 1993. Healthy Communities, Healthy Youth: How Communities Contribute to Positive Youth Development . Minneapolis: Search Institute. Carnegie Council on Adolescent Development. 1989. Turning Points: Preparing American Youth for the 21st Century. Washington, D.C.: Carnegie Council on Adolescent Development. Carnegie Task Force on Meeting the Needs of Young Children. 1994. Starting Points: Meeting the Needs of Our Youngest Children. New York: Carnegie Corporation. Centers for Disease Control and Prevention. 1995. CDC surveillance summaries. Morbidity and Mortality Weekly Report 44(SS-1), March 24. Children's Defense Fund. 1994. P. 14 in The State of America's Children Yearbook. Washington, D.C.: Children's Defense Fund. Cohen, D. 1992. Despite widespread income growth, study finds increase in child poverty. Education Week 11(40):24. Donovan, J.E., and Jessor, R. 1985. Structure of problem behavior in adolescence and young adulthood. Journal of Consulting and Clinical Psychology 53:890–904. Donovan, J.E., Jessor, R., and Costa, F.M. 1988. Syndrome of problem behavior in adolescence: A replication. Journal of Consulting and Clinical Psychology 56:762–765. Dryfoos, J.G. 1990. Adolescents at Risk: Prevalence and Prevention . New York: Oxford University Press. Elster, A.B., and Kuznets, N.J. 1994. American Medical Association Guidelines for Adolescent Preventive Services: Recommendations and Rationale. Baltimore: Williams and Wilkins. Gordon, E.W. 1995. Commentary: Renewing familial and democratic commitments. In School-Community Connections: Exploring Issues for Research and Practice, I.C. Rigsby, M.C. Reynolds, and M.C. Wang, eds. San Francisco: Jossey-Bass. Green, M., ed. 1994. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Arlington, Va.: National Center for Education in Maternal and Child Health. Henderson, A.T., and Berla, N., eds. 1994. A New Generation of Evidence: The Family is Critical to Student Achievement. Washington, D.C.: National Committee for Citizens in Education. Johnston, W.B., and Packer, A.H. 1987. Workforce 2000: Work and Workers for the 21st Century. Indianapolis, Ind.: Hudson Institute.

OCR for page 16
School & Health: Our Nation's Investment Kann, L., Collins, J.L., Pateman, B.C., Small, M.L., Russ, J.G., and Kolbe, L.J. 1995. The School Health Policies and Programs Study (SHPPS): Rationale for a nationwide status report on school health programs. Journal of School Health 65(8):291–294. Kirst, M.W., and Kelly, C. 1995. Collaboration to improve education and children's services: Politics and policy making. In School-Community Connections: Exploring Issues for Research and Practice, I.C. Rigsby, M.C. Reynolds, and M.C. Wang, eds. San Francisco: Jossey-Bass. Klein, J.D., Slap, G.B., Elster, A.B., and Cohn, S.E. 1993. Adolescents and access to health care. Bulletin of the New York Academy of Medicine 70(3):219–235. Lewit, E.M., and Schuurmann-Baker, L. 1995. Child indicators: Health insurance coverage. In The Future of Children: Long-Term Outcomes of Early Childhood Programs, R.E. Behrman, ed. Los Altos, Calif.: Center for the Future of Children, David and Lucille Packard Foundation 5(3):192-204, Winter. Marks, A., Malizio, J., Hoch, J., Brody, R., and Fisher, M. 1983. Assessment of health needs and willingness to utilize health care resources of adolescents in a suburban population. Journal of Pediatrics 102(3):456–460. Marshall, R., and Tucker, M. 1992. Thinking for a Living: Work, Skills, and the Future of the American Economy. New York: Basic Books. McGinnis, J.M., and DeGraw, C. 1991. Healthy Schools 2000: Creating partnerships for the decade. Journal of School Health 61(7):292–297. McGinnis, J.M., and Foege, W.H. 1993. Actual causes of death in the United States. Journal of the American Medical Association 270(18):2207–2212. National Commission on Children. 1991. Beyond Rhetoric: A New American Agenda for Children and Families. Washington, D.C.: U.S. Government Printing Office. National Commission on the Role of the School and the Community in Improving Adolescent Health. 1990. Code Blue: Uniting for Healthier Youth. Washington, D.C.: American Medical Association and the National Association of State Boards of Education. National Education Goals Panel. 1994. The National Education Goals Report: Building a Nation of Learners. Washington, D.C.: U.S. Government Printing Office. National Health/Education Consortium. 1992. Creating Sound Minds: Health and Education Working Together. Washington, D.C.: National Health/Education Consortium. National Institute of Dental Research. 1995. Personal communication. National Research Council. 1993. Losing Generations. Washington, D.C.: National Academy Press. National Research Council. 1995. Measuring Poverty: A New Approach . Washington, D.C.: National Academy Press. Newacheck, P.W., Hughes, D.C., English, A., Fox, H.B., Perrin, J., and Halfon, N. 1995. The effect on children of curtailing Medicaid spending. Journal of the American Medical Association 274(18):1468–1471. Office of Technology Assessment, Congress of the United States. 1991. Adolescent Health. Washington, D.C.: U.S. Government Printing Office. Resnicow, K., Ross, D., and Vaughan, R. 1995. The structure of problem and conventional behaviors in African American youth. Journal of Clinical and Consulting Psychology 63(4):594–603. Secretary's Commission on Achieving Necessary Skills. 1991. What Work Requires of Schools: A SCANS Report for America 2000. Washington, D.C.: U.S. Department of Labor. Solloway, M.R., and Budetti, P.P. 1995. Child Health Supervision: Analytical Studies in the Financing, Delivery, and Cost-Effectiveness of Preventive and Health Promotion Services for Infants, Children, and Adolescents. Arlington, Va.: National Center for Education in Maternal and Child Health. U.S. Department of Commerce. 1993. We the American Children. Washington, D.C.: U.S. Government Printing Office.

OCR for page 16
School & Health: Our Nation's Investment U.S. Department of Health and Human Services, Public Health Service. 1979. Healthy People: Surgeon General's Report on Health Promotion and Disease Prevention. Washington, D.C.: U.S. Department of Health and Human Services. U.S. Department of Health and Human Services, Public Health Service. 1991. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. DHHS Publication No. (PHS) 91-50213, Washington, D.C.: U.S. Government Printing Office. U.S. Department of Health and Human Services, Public Health Service. 1993. The Core Function Project. Health Care Reform and Public Health: A Paper on Population-Based Core Functions. Washington, D.C. U.S. Department of Health and Human Services. U.S. General Accounting Office. 1993. School-Linked Human Services: A Comprehensive Strategy for Aiding Students at Risk of School Failure . Washington, D.C.: U.S. General Accounting Office, December. U.S. General Accounting Office. 1994a. School-Age Children: Poverty and Diversity Challenge Schools Nationwide. Washington, D.C.: U.S. General Accounting Office, April. U.S. General Accounting Office. 1994b. Health Care: School-Based Health Centers Can Expand Access for Children. Washington, D.C.: U.S. General Accounting Office, December. U.S. General Accounting Office. 1995. School Facilities: Condition of America's Schools. Washington, D.C.: U.S. General Accounting Office, February. World Health Organization. 1996 [Online]. Available World Wide Web (WWW) site. http//www.who.ch/programmes/inf/facts/fact126.htm [August]. Zill, N., and Nord, C.W. 1994. Running in Place: How American Families are Faring in a Changing Economy and an Individualistic Society. Washington, D.C.: Child Trends.