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:

A comprehensive school health program is an integrated set of planned, sequential, school-affiliated strategies, activities, and services designed to promote the optimal physical, emotional, social, and educational development of students. The program involves and is supportive of families and is determined by the local community, based on community needs, resources, standards, and requirements. It is coordinated by a multidisciplinary team and accountable to the community for program quality and effectiveness.

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



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