Schools and Health: Our Nation's Investment (1997)

Schools have been the site for health programming in the United States since the early colonial period. When public education became compulsory in the mid-nineteenth century, the strategic role that schools could play in promoting and protecting health became recognized; schools soon became the front line in the fight against infectious disease and the hub for providing a wide range of health and social services for children and families.

As times changed, school health programs have changed to keep pace with the changing needs of children and adolescents. The Centers for Disease Control and Prevention (CDC) has noted that six categories of behavior are responsible for 70 percent of adolescent mortality and morbidity: unintentional and intentional injuries, drug and alcohol abuse, sexually transmitted diseases and unintended pregnancies, diseases associated with tobacco use, illnesses resulting from inadequate physical activity, and health problems due to inadequate dietary patterns. A significant segment of our nation's youth is at risk for dropping out of school as a consequence of a broad range of health and behavioral problems; further, many children do not have access to basic preventive and primary care.

The concept of a comprehensive school health program (CSHP) was proposed in the 1980s to address many of the health-related¹ problems of

today's children and young people. CSHPs are intended to take advantage of the pivotal position of schools in reaching children and families by combining—in an integrated, systemic manner—health education, health promotion and disease prevention, and access to health-related services at the school site. CSHPs may be a promising way both to improve health and educational outcomes for students and to reduce overall health care costs by emphasizing prevention and easy access to care.

The original charge to the committee was to: (1) assess the status of CSHPs; (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 CSHPs; (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 the cost-effectiveness) of CSHPs; and (5) if appropriate, recommending mechanisms for wider implementation of those school health programs that have proven to be effective.

Early in the course of the study, the committee established its own working definition of a CSHP as follows:

In developing this definition, the committee examined a variety of models and definitions of school health programs. However, whatever the program model, the committee found that there are three critical areas that should be considered in designing a CSHP.

The first critical area is the school environment, which includes (1) the physical environment, involving proper building design, lighting, ventilation, safety, cleanliness, freedom from environmental hazards that foster infection and handicaps, safe transportation policies, and having emergency plans in place; (2) the policy and administrative environment, consisting of policies to promote health and reduce stress, and regulations ensuring an environment free from tobacco, drugs, weapons, and violence; (3) the psychosocial environment, including a supportive and nurturing atmosphere, a cooperative academic setting, respect for individual

differences, and involvement of families; and (4) health promotion for staff, in order that staff members can become positive role models and increase their commitment to student health.

The second critical area is education, which consists of physical education, which teaches the knowledge and skills necessary for lifelong physical fitness; health education, which addresses the physical, mental, emotional, and social dimensions of health; and other curricular areas, which promote healthful behavior and an awareness of health issues as part of their core instruction.

The third critical area is services, which includes health services , that depend on the needs and preferences of the community and services for students with disabilities and special health care needs; counseling, psychological, and social services, which promote academic success and address the emotional and mental health needs of students; and nutrition and foodservices, which provide nutritious meals, nutrition education, and a nutrition-promoting school environment.

Three of the most common models examined include the following:

• The Three-Component Model: This is the traditional model for CSHPs. According to this model, the three essential components of a school health program are health education, health services, and a healthful environment.

• The Eight-Component Model: According to this model, the eight essential components of a CSHP are health education, physical education, health services, nutrition services, health promotion for school staff, counseling and psychological services, a healthy school environment, and parent and community involvement.

• Full-Service Schools: In addition to quality education, these combine a wide range of health services, mental health services, and family welfare and social services for students and their families.

The committee determined that the most frequently encountered models and definitions for school health programs had much in common and that no single model was best. CSHPs must be locally tailored—with the involvement of all critical stakeholders—to meet each community's needs, resources, perspectives, and standards.

The committee examined four topics of school health in depth: education, services, infrastructure, and research and evaluation. The principal findings, conclusions, and recommendations pertaining to each area are presented in the remainder of this section.

The status of the two curricular components of a CSHP—physical education and health education—is sometimes questioned because they were not originally mentioned in the National Education Goals as "core subjects" in which students should demonstrate competence. However, with each updated report, the National Education Goals panel has added language emphasizing the importance of physical education and health education, affirming that these two subjects should be an integral part of the school curriculum.

Physical Education Research has confirmed a direct relationship between a physically active life-style and improved long-term health status. Therefore, the new generation of physical education programs is shifting emphasis from competitive sports to physical activity and fitness. Three recent documents—the National Standards for Physical Education, the School Health Policies and Programs Study² (SHPPS), and the CDC's Guidelines for School and Community Health Programs to Promote Physical Activity Among Youth—emphasize the new priorities and recommendations in physical education and collectively provide a sound basis for developing quality physical education programs in the future. The committee supports these recommendations.

Health Education The traditional health education curriculum has been based on 10 conceptual areas identified by the School Health Education Study of the 1960s: community health, consumer health, environmental health, family life, mental and emotional health, injury prevention and safety, nutrition, personal health, prevention and control of disease, and substance use and abuse. Recently, CDC recommended that the six major contributors to adolescent mortality and morbidity mentioned earlier be priority areas of emphasis for health education because these problems are based in behaviors that can be prevented or changed. The overarching goal of the recently released National Health Education Standards is the development of health literacy—the capacity to obtain, interpret, and understand basic health information and services and the competence to use such information and services to enhance health.

Research conducted since 1970 has shown that specific health education curricula are effective, for example, those focused on categorical problems such as tobacco avoidance. Studies have shown that in order for health education to produce behavior change, effective strategies, considerable instructional time, and well-prepared teachers are required. Students' behavioral decisions are also heavily influenced by environmental variables—peers, family, schools, community, and the media. A recent cost–benefit analysis shows that school health education is cost-effective, and several recent national surveys indicate that parents and students overwhelmingly consider health education to be very important and useful.

Despite the potential effectiveness and favorable perception of health education, SHPPS found a considerable gap between what health educators consider to be desired practice and actual current practice. Typically, only one semester of health education is required at the middle or junior high level and one semester at the high school level, and the attention given to certain priority topics falls considerably short of recommended goals. Although most teachers of health education have not majored in the field, there is not an overwhelming demand for staff development. This lack of demand may be due to a lack of awareness on the part of teachers and administrators of the potential and complexities of health education or the fact that teachers with majors in other fields prefer to teach in those fields and see no value in improving their skills in health education.

The committee believes that three recently released documents—the National Action Plan for Comprehensive School Health Education, the National Health Education Standards, and the SHPPS report—collectively provide comprehensive recommendations and a strong framework to move health education forward in the future. Beyond this, however, several aspects of health education merit further emphasis and discussion.

The committee believes that the period prior to high school is the most crucial for shaping attitudes and behaviors. By the time students reach high school, many are already engaging in risky behaviors or may at least have formed accepting attitudes toward these behaviors.

At all grade levels, instruction should focus on achieving the perfor-

mance indicators outlined in the National Health Education Standards. Early years might focus on such topics as nutrition and safety, but beginning at the late elementary or early middle school grades, instruction should shift focus to an intensive, age-appropriate emphasis on the CDC priority behaviors and should be provided by teachers who understand early adolescents and are especially prepared to deal with these sensitive and difficult topics.

According to SHPPS, 83.9 percent of all senior high schools already require at least one semester of health education, and within this 83.9 percent, the CDC topics are frequently emphasized. Thus, such an immediate requirement is not unrealistic. Additional courses or electives in health education at the high school level would be preferable to a single semester.

The committee debated how to reconcile the call for students to receive health education every year, from kindergarten through the twelfth grade, with the reality of the crowded curriculum at the secondary level and decided that the critical issue should be whether high school students achieve the performance indicators described in the National Health Education Standards, not the amount of "seat time." Thus, the committee recommends that the "seat time" be a minimum of at least one semester, but that student health knowledge and understanding be assessed at the end of this course. If a community finds its young people falling short on this assessment, the existing course must be improved or additional courses instituted. The committee believes that some form of health education must occur every year at the secondary level but that some of this education can take place through alternative approaches, such as "booster" sessions, health modules in other courses, field trips, assemblies, school-wide campaigns, after-school peer discussion groups, and one-on-one or small group counseling for students with identified needs.

Effective elementary health education is the foundation for the future critical middle school years, and well-prepared elementary teachers are the key for providing this education.

Although the scope of school health services varies from one school district to another, many common elements exist throughout the country. Most schools provide screenings, monitor student immunization status, and administer first aid and medication. Schools are also required to provide a wide range of health services for students with disabilities and special health care needs.

There is agreement among virtually all school districts that a core set of services is needed in schools, but the topic currently generating a great deal of discussion is the role of the school in providing access to "extended services" that go beyond traditional basic services, such as primary care, social, and family services. The committee believes that extended services should not be the sole—or even the major—responsibility of the schools; instead, the school should be considered by other community agencies and providers as a partner and a potentially effective site for provision of needed services—services that will ultimately advance the primary academic mission of the school.

Although the demands and complexity of basic school services have increased, these services are often supervised by education-based administrators who have no clinical preparation in the delivery of health services. Thus, it is important to develop closer links between the school and community health systems and to encourage greater involvement of community health care professionals in the planning and implementation of basic services. School-based health centers (SBHCs) and other extended services are a relatively new phenomenon, and research in this area is in its early stages. Studies have shown that SBHCs provide access to care for needy students and increase students' health knowledge significantly. However, it has been difficult to measure the impact of SBHCs on students' health status or high-risk behavior, such as sexual activity or drug use. This is consistent, however, with other interventions to reduce high-risk behavior—increased knowledge has little effect unless the environment and perceived norms are changed. The committee believes that access, utilization, and possibly a reduction in absenteeism may be more

appropriate measures of outcomes of effectiveness of SBHCs than change in health status or high-risk behavior.

In the planning process, school health services should be considered an integral part of the overall community public health and primary care system. The range of services actually provided at the school site must be determined locally, based on community characteristics and needs. Special concerns should be emphasized about two areas of services that a significant proportion of students need—mental health or psychological counseling and school foodservice. The committee believes that mental health and psychological services are essential in enabling many students to achieve academically; these should be considered mainstream, not optional, services. The committee also believes that the school foodservice should serve as a learning laboratory for developing healthful eating habits and should not be driven by profit-making or forced to compete with other food options in school that may undermine nutrition goals.

Many questions remain unanswered about school services, particularly questions regarding the relative advantages, disadvantages, quality, and effectiveness of providing extended services at the school rather than at other sites in the community. Thus, the committee recommends the following:

Additionally, the committee found that there is no current consistent school health data collection process among and between schools. Accurate data collection protocols and standards would greatly facilitate school health research of all kinds.

So that the privacy of families and adolescents be maintained, the committee recommends the following:

The lack of a consistent and adequate funding base has been a barrier to establishing school health services. Thus, the committee recommends the following:

Strategies that have shown promise and should be explored further include billing Medicaid for services to eligible students, developing school-based insurance groupings, forming alliances with managed care organizations and other providers, instituting special taxes, and placing surcharges or special premiums on existing insurance policies.

Many parts of the infrastructure—the basic framework of policies, resources, organizational structures, and communication channels—needed to support CSHPs already exist or are emerging. However, these parts are often fragmented and uncoordinated, and resources are typically transient or limited to specific categorical activities. Leadership and coordination at all levels—national, state, local—will be crucial for programs to become established and grow.

At the national level, the federal Interagency Committee on School Health (ICSH) was established in 1994 to improve coordination among federal agencies, identify national needs and strategies, and serve as a national focal point for school health. The National Coordinating Committee on School Health (NCCSH), which works closely with the ICSH, brings together federal departments with approximately 40 national nongovernmental organizations to provide national leadership in school health.

The responsibilities of the national leadership should include coordinating programs and funding streams, providing technical assistance to states, and advancing the CSHP research agenda.

At the state level, the infrastructure can be anchored by a structure similar to the ICSH–NCCSH arrangement at the national level.

The state coordinating council should coordinate state programs and funding streams, propose appropriate state policies and legislation, and provide assistance to local districts. Establishing a regional "school health extension service," modeled after the Agricultural Extension Service offers a particularly promising approach for providing technical assistance.

To anchor the infrastructure at the community or district level, the committee recommends the following:

Among its duties, the district coordinating council should involve the community in conducting a needs and resource assessment, developing plans and policies, coordinating programs and resources, and providing assistance to individual schools. Communities must be prepared to con-

front barriers in building their CSHP infrastructure, including time and resource constraints, turf battles, indifference, or controversy over sensitive aspects of programs. An effective method for mobilizing support has been to enlist parents and other community leaders as program advocates. Compromise on small issues may be essential for the sake of advancing the larger program.

At the school level:

Under this leadership, schools should address the major issues facing students and/or the components of the CSHP, develop policies, coordinate activities and resources, and seek the active involvement of students and families in designing and implementing programs.

Specific personnel needs are described in the full report. In general, an interdisciplinary approach is needed in the preservice and inservice preparation of CSHP professionals to enable them to communicate and collaborate with each other. Educators in all disciplines—particularly administrators—need preparation in order to understand the philosophy and potential of CSHPs.

Research and evaluation of CSHPs can be divided into three categories: basic research, outcome evaluation, and process evaluation. Basic research involves inquiry into the fundamental determinants of behavior as well as mechanisms of behavior change. A primary function of basic research is to inform the development of interventions that can then be tested in outcome evaluation trials. Outcome evaluation involves the empirical examination of interventions on targeted outcomes, based on the randomized clinical trial approach with experimental and control groups. Process evaluation determines whether a proven intervention was properly implemented and examines factors that may have contributed to the

intervention's success or failure. Basic research and outcome evaluation are typically conducted by professionals from university or other research centers and are largely beyond the capacity of local education agencies. The committee believes that process evaluation is the appropriate level of evaluation in local programs.

Research and evaluation are particularly challenging for CSHPs. Since these programs comprise multiple interactive components, it is often difficult to attribute observed effects to specific components or to separate program effects from those of the family or community. Determining what outcomes are realistic and measuring outcomes in students is often problematic, especially when outcomes involve sensitive matters such as drug use or sexual behavior. Furthermore, since CSHPs are unique to a particular setting, the results of even the most rigorous evaluations may not be generalizable to other situations.

Interventions associated with the separate, individual components of CSHPs—health education, health services, and nutrition services—should be developed and tested using rigorous methods involving experimental and control groups. However, such an approach is likely to be difficult—and possibly not feasible—for studying entire comprehensive programs or determining the differential effects of individual components and combinations of components.

A fundamental issue involves determining what outcomes are appropriate and reasonable to expect from CSHPs. The committee recognizes that, although influencing health behavior and health status is an ultimate goal of a CSHP, such end points involve factors beyond the control of the school. The committee believes that the reasonable outcomes on which a CSHP should be judged are equipping students with the knowledge, attitudes, and skills necessary for healthful behavior; providing a health-promoting environment; and ensuring access to high-quality services.³ Other outcomes—improved cardiovascular fitness or a reduction in absenteeism, drug abuse, or teen pregnancies, for example—may also be considered, but the committee believes that such measures must be interpreted with caution, since they are influenced by factors beyond the control of the school. In particular, null or negative measures for these outcomes should not necessarily lead to declaring the CSHP a failure; rather, they may imply that other sources of influence oppose and outweigh that

of the CSHP or that the financial investment in the CSHP is so limited that returns are minimal.

In order for CSHPs to accomplish the desired goal of influencing behavior, the committee recommends the following:

Research is needed about the effectiveness of specific intervention strategies such as skills training, normative education, or peer education; the effectiveness of specific intervention messages such as abstinence versus harm reduction; and the required intensity and duration of health services and health education programming. Evidence suggests that common underlying factors may be responsible for the clustering of health-compromising behaviors and that interventions may be more effective if they address these underlying factors in addition to intervening to change risk behaviors. Additional research is needed to understand the etiology of problem behavior clusters and to develop optimal problem behavior interventions. And finally, since the acquisition of health-related social skills—such as negotiation, decisionmaking, and refusal skills—is a desired end point of CSHPs, basic research is needed to develop valid measures of social skills that can then be used as proxy measures of program effectiveness. Diffusion-related research is critical to ensure that efforts of research and development lead to improved practice and a greater utilization of effective methods and programs. Therefore, high priority should be given to studying how programs are adopted, implemented, and institutionalized. The feasibility and effectiveness of techniques of integrating concepts of health into science and other school subjects should also be examined.

Since the overall effects of comprehensive school health programs are not yet known and outcome evaluations of such complex systems pose significant challenges, the committee recommends the following:

Specific outcomes of overall programs should be examined, including education (improved achievement, attendance, and graduation rates), personal health (resistance to ''new social morbidities," improved biological measures), mental health (less depression, stress, and violence), improved functionality, health systems (more students with a medical home; reduction in use of emergency rooms or hospitals), self-sufficiency (pursuit of higher education or job), and future health literacy and health status. Studies could examine differential impacts of programs produced by such factors as program structure, characteristics of students, and type of school and community.

A thorough understanding of the feasible and effective (including cost-effective) interventions in each separate area of a CSHP will be necessary to provide the basis for combining components to produce a comprehensive program.

Additional studies are needed in a number of other areas. First, more data are needed about the advantages (cost and effectiveness) and disadvantages of providing health and social services in schools compared to other community sites—or compared to not providing services anywhere—as a function of community and student characteristics. This information will require overall consensus about the criteria to use for determining the quality of school health programs. It is also important to know how best to influence change in the climate and organizational structure of school districts and individual schools in order to bring about the adoption and implementation of CSHPs. Finally, there is a need for an analysis of the optimal structure, operation, and personnel needs of CSHPs.

Schooling is the only universal entitlement for children in the United States. The committee believes that students, as a part of this entitlement, should receive the health-related programs and services necessary for them to derive maximum benefit from their education and to enable them to become healthy, productive adults. This view appears to be broadly accepted, since the committee has found that many of the components of a CSHP already exist in many schools across the country—health education, physical education, nutrition and foodservice programs, basic school

health services, counseling and psychological services, and policies addressing the quality of the school environment. The question then arises: What would it take to transform existing programs in typical communities into the vision of a comprehensive school health program?

First, although many components of a CSHP already exist widely, their implementation and quality require attention. New standards and recommendations have been released in many fields that have yet to reach the local level. Another serious deficiency is the apparent lack of involvement of critical community stakeholders in designing and supporting current programs. Perhaps the most difficult issue to resolve before existing programs can be considered "comprehensive" involves the role of the school in providing access to services typically considered the responsibility of the private sector, such as certain preventive and primary health care services. "Providing access" does not necessarily mean that services will be delivered at the school site; rather, it implies ensuring that all students are able to obtain and make use of needed services. Each community must devise appropriate strategies to ensure that all of its students have access to these basic preventive and primary care services.

Although there are divergent opinions about some categorical aspects of school health programs, the committee found a uniform belief that school health programs are important and valuable. Nonetheless, despite this uniform opinion, there is a wide gap between the conceptualization of programs and their implementation. Before school health programs can achieve their promise, concerted action will be needed to bridge this gap. Such action could include coordinating scattered activities; improving the quality and consistency of implementation; engaging the participation of crucial stakeholders; and providing an adequate, stable funding base.

Although dedication and cooperation will be required, the committee believes that the vision of a comprehensive school health program is attainable, and the situation is not so complicated that, even today, a local community could not begin to work toward this vision. The committee is not calling for schools to do more on their own; instead, it is asking communities to recognize and take advantage of the key role that schools can play in promoting and protecting the health and well-being of our nation's children and youth. An investment in the health and education of today's children and young people is the ultimate investment for the future.