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

Previous chapters of this report have described the concept of a comprehensive school health program (CSHP), examined some of its essential components, and proposed steps that might be taken to build an infrastructure to support and promote CSHPs. Some of the knowledge gaps about these programs and challenges to filling these gaps have also been discussed. Throughout the report, the analysis and rationale for many important recommendations are presented. This final chapter highlights several remaining overarching issues.

Many factors—the family, friends or peers, school, and community—exert tremendous influence on children and youth. Each of these systems may have assets or deficits, and each must share responsibility for children's health and well-being.

The basic question might be raised: Why focus on schools? The answer has to do with the unique position of the school. Of the four major "systems of influence" cited—family, friends or peers, school, and community—the school is the only one that is an organized public institution, amenable to being restructured and mobilized to promote societal goals. Schooling is the only universal entitlement for children in this country, and schools are the only institution that allows access on a daily basis to almost all children between the ages of 5 and 17 in the nation. Schools not only provide academic preparation but are one of the principal formal

community institutions responsible for transmitting culture and bringing about the socialization of children and youth.

Realistically, the potential impact of comprehensive school health programs is greatly diminished if deficits in other systems are large. Schools cannot be expected to overcome difficult family situations, pressure from antisocial and rebellious peers, or problems of impoverished and dysfunctional communities. On the other hand, schools are strategically positioned to serve as a linchpin or rallying point, capable of bringing together and aligning the other "systems of influence" to promote the health and well-being of students.

As stated above, schooling is the only universal entitlement for children in this country, and schools are the only institution that allows access on a daily basis to children between the ages of 5 and 17. The committee believes that as a part of this educational entitlement, students should receive the health-related programs and services necessary for them to derive maximum benefit from their education and enable them to become healthy and 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 services, and policies addressing the school environment (Collins et al., 1995; Davis et al., 1995; Pate et al., 1995; Pateman et al., 1995; Ross et al., 1995; Small et al., 1995). The question then arises: What would it take to transform existing programs in typical communities into a comprehensive school health program?

First, although the many components of a CSHP exist widely, the implementation and quality of many of these components require attention, as earlier chapters have noted. New standards and recommendations have been released in many of these fields that have yet to reach the local level. Further, since the Centers for Disease Control and Prevention's School Health Policies and Programs Study (SHPPS) did not address counseling and psychological services, less is known about their extent and quality, but anecdotal evidence reviewed in Chapter 4 indicates that this is an area of significant need. Another serious deficiency of current programs is the apparent lack of involvement of critical community stakeholders in designing and supporting programs. SHPPS found that only one-third of districts had some sort of district-wide school health advisory council; only about half of these councils had representation from the medical community, and only 14 percent had representation from the mental health community (Collins et al., 1995). In addition, although

SHPPS found that collaboration among the separate disciplines and components of a CSHP exists, by no means was collaboration universal. Interdisciplinary collaboration and communication are likely to be areas requiring constant emphasis and attention.

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. Depending on the community, many students may already be receiving such services and be covered through private insurance or Medicaid. However, as mentioned in earlier chapters, increasing numbers of students are uninsured or lack coverage for even the most basic preventive services. Each community must devise appropriate strategies to ensure that all of its students have access to these basic preventive and primary care services.

Even if many students in a community already have access to private care, certain preventive and primary care services might be more efficiently and effectively delivered at the school site, either by school personnel (school nurses, nurse practitioners, psychologists, counselors, or social workers) or community providers, rather than at scattered locations throughout the community. Studies have found that school-based health centers increase access to health care and provide some services more easily and appropriately than other kinds of providers, particularly for adolescents (U.S. Department of Health and Human Services, 1993; U.S. General Accounting Office, 1994b). As discussed in Chapter 4, some of the American Medical Association's Guidelines for Adolescent Preventive Services (GAPS) recommendations might be efficiently and appropriately carried out in schools by school personnel.

Lack of stable and adequate funding appears to be a major obstacle to the development of school-based services, as noted in Chapter 4. Although barriers to cooperation between school health providers and private sector providers are large (Davis et al., 1995; U.S. Department of Health and Human Services, 1993; U.S. General Accounting Office, 1994a, 1994b), some progress is beginning to occur. Examples include the Health Start program in St. Paul, Minnesota (Zimmerman and Reif, 1995), and the program conducted by the Baltimore City Health Department, both of which have negotiated with managed care plans to support the delivery of school-based services. As described in Chapter 4, the Florida legislature has added provisions to the insurance code allowing school districts to become large grouping mechanisms for the purchase of health coverage for students and their families. The state has established a quasi-

public, nonprofit corporation (Healthy Kids Corporation) that subsidizes the payment of premiums where necessary and acts as an intermediary between school districts and the insurance community. The Florida program has been effective in negotiating managed care coverage for tens of thousands of children in rural and urban areas. Although such examples of progress exist, school or private sector collaboration and third-party reimbursement for school-based services are still critical issues requiring further study and analysis.

The committee believes that although dedication and cooperation will be required, the goal of a comprehensive school health program is attainable, and the situation is not so complicated that, even today, local communities could not begin working toward this vision. The process itself—mobilizing the various stakeholders in a community to give greater attention to the needs of its children and families—may have significant benefits that extend beyond the school health program.

Recently, a group of more than 100 distinguished professionals, representing a wide range of child health and related perspectives, came together over a four-year period to develop scientifically based child health supervision guidelines to meet the health promotion and disease prevention needs of children and families into the twenty-first century. The resulting document, Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (Green, 1994), has been widely accepted and endorsed by a broad range of individuals and national organizations concerned with the health and welfare of children and youth.

Bright Futures emphasizes that the "linear model of prevention"—which worked well in the past, as in the case of developing and distributing vaccines that provide immunity—is no longer adequate. Health, educational, and social issues are strongly interrelated and cannot be addressed in isolation from each other. Child health supervision in the future will require a partnership between health professionals and families, attention to the social and cultural context in which children live, and the support of a range of community institutions.

As a basis for preparing the Bright Futures guidelines, the study participants adopted the following Children's Health Charter shown in Box 7-1.

The committee believes that this document represents a consensus view of what we owe to our children and young people; the committee also suggests that a comprehensive school health program can make a critical contribution to achieving each of the charter's goals. A CSHP can help all students reach their full potential, assist them in becoming eco-

nomically productive citizens, allow them take personal charge of their own health, and enable them to become informed participants in the health system in the future. A CSHP also represents an investment in the future because, as today's children mature and have their own children, future generations will be affected.

The committee's one overwhelming finding is that most people think school health programs are an important and a good thing. School health is the focus of many governmental and nongovernmental initiatives and the subject of numerous reports and policy statements, some of which have proposed ambitious recommendations and standards. Yet the committee has found a wide gap between rhetoric and action, between theory and practice. For programs to reach their potential and promise, concerted action and departure from "business as usual" will be needed to coordinate scattered activities, improve the quality and consistency of implementation, engage the participation of crucial stakeholders, and provide adequate and stable funding.

Perhaps the term "comprehensive school health program" does not do justice to these programs, and a different name might better convey their true nature and importance to the general public. Comprehensive school health programs may not be "comprehensive" in and of themselves, but they serve as a critical link to ensure that the broader community health and social services system is comprehensive. The word "school" belies the fact that programs are not the sole responsibility of the school, and the school alone can do very little without the support of families and the community. The term "health" is often regarded in its narrowest sense as the absence of disease, whereas its meaning here involves complete physical, emotional, and social well-being and fulfillment of one's maximum potential. Some observers have suggested that the term "coordinated school health program'' might give a better sense of the interdisciplinary and interagency collaboration required. Although the term comprehensive school health program seems firmly entrenched in the vocabulary of those close to these programs, the question remains of whether a different name would give a better sense of the true nature of these programs and more readily capture the attention from the general public that these programs deserve.

Whatever the name given to these programs, this report has underscored their importance for all students, affluent or poor, high achievers or those at risk of dropping out. 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.

Collins, J.L., Small, M.L., Kann, L., Pateman, B.C., Gold, R.S., and Kolbe, L.J. 1995. School health education. Journal of School Health 65(8):302–311.

Davis, M., Fryer, G.E., White, S., and Igoe, J.B. 1995. A Closer Look: A Report of Select Findings from the National School Health Survey 1993–1994. Denver: Office of School Health, University of Colorado Health Sciences Center.

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.

Pate, R.R., Small, M.L., Ross., J.G., Young, J.C., Flint, K.H., and Warren, C.W. 1995. School physical education. Journal of School Health 65(8):312–318.

Pateman, B.C., McKinney, P., Kann, L., Small, M.L., Warren, C.W., and Collins, J.L. 1995. School food service. Journal of School Health 65(8):327–332.

Ross, J.G., Einhaus, K.E., Hohenemser, L.K., Greene, B.Z., Kann, L., and Gold R.S. 1995. School health policies prohibiting tobacco use, alcohol and other drug use, and violence. Journal of School Health 65(8):333–338.

Small, M.L., Majer, L.S., Allensworth, D.D., Farquhar, B.K., Kann, L., and Pateman, B.C. 1995. School health services. Journal of School Health 65(8):319–326.

U.S. Department of Health and Human Services. 1993. School-Based Health Centers and Managed Care. Washington, D.C.: U.S. Department of Health and Human Services, Office of the Inspector General.

U.S. General Accounting Office. 1994a. School-Based Health Centers Can Promote Access to Care. Pub. No. GAO/HEHS-94-166. Washington, D.C.: U.S. General Accounting Office, May.

U.S. General Accounting Office. 1994b. School-Based Health Centers Can Expand Access for Children. Pub. No. GAO/HEHS-95-35. Washington, D.C.: U.S. General Accounting Office, December.

Zimmerman, D.J., and Reif, C.J. 1995. School-based health centers and managed care health plans: Partners in primary care. Journal of Public Health Management Practice 1(1):33–39.