2
Evolution of School Health Programs

HISTORICAL OVERVIEW

Schools have been the focus of numerous and varied efforts to promote and secure the health of American children and young people since the colonial era. In its interim statement, the committee reviewed some of the historical aspects of school health programming to provide a context for its definition of a comprehensive school health program (CSHP) and a background for identifying issues to be examined in the committee's study. The following section extends that review. An understanding of the evolution of school health programs gives insight into how educational, political, and societal issues—as well as health issues—have influenced these programs over the years and provides lessons for the future development of school health programs.

School Health Through the Early Twentieth Century

During the colonial period, only limited attention was paid to any aspect of school health. Benjamin Franklin advocated a "healthful situation" and promoted physical exercise as one of the primary subjects in the schools that were developing during his time. Samuel Moody, headmaster of the Dummer Grammar School, which opened in 1763 as the first private boarding school, taught the value of exercise and participated in it himself. Prior to the mid-1800s, however, public education was still in a formative stage and efforts to introduce health into the schools were iso-



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 33
School & Health: Our Nation's Investment 2 Evolution of School Health Programs HISTORICAL OVERVIEW Schools have been the focus of numerous and varied efforts to promote and secure the health of American children and young people since the colonial era. In its interim statement, the committee reviewed some of the historical aspects of school health programming to provide a context for its definition of a comprehensive school health program (CSHP) and a background for identifying issues to be examined in the committee's study. The following section extends that review. An understanding of the evolution of school health programs gives insight into how educational, political, and societal issues—as well as health issues—have influenced these programs over the years and provides lessons for the future development of school health programs. School Health Through the Early Twentieth Century During the colonial period, only limited attention was paid to any aspect of school health. Benjamin Franklin advocated a "healthful situation" and promoted physical exercise as one of the primary subjects in the schools that were developing during his time. Samuel Moody, headmaster of the Dummer Grammar School, which opened in 1763 as the first private boarding school, taught the value of exercise and participated in it himself. Prior to the mid-1800s, however, public education was still in a formative stage and efforts to introduce health into the schools were iso-

OCR for page 33
School & Health: Our Nation's Investment lated and sparse. It was not until 1840 that Rhode Island passed legislation to make education compulsory, and other states soon followed (Means, 1975). School health professionals often state that the ''modern school health era" began in 1850 (Pigg, 1992). In that year, the Sanitary Commission of Massachusetts, headed by Lemuel Shattuck, produced a report that had a significant impact on school health and has become a classic in the field of public health. Shattuck served as a teacher in Detroit and as a member of the school committee in Concord, Massachusetts, where he helped reorganize the public school system. His background led to school programs receiving major attention as a means to promote public health and prevent disease (Means, 1975). The report states the following: Every child should be taught early in life, that, to preserve his own life and his own health and the lives and health of others, is one of the most important and constantly abiding duties. By obeying certain laws or performing certain acts, his life and health may be preserved; by disobedience, or performing certain other acts, they will both be destroyed. By knowing and avoiding the causes of disease, disease itself will be avoided, and he may enjoy health and live; by ignorance of these causes and exposure to them, he may contract disease, ruin his health, and die. Everything connected with wealth, happiness and long life depends upon health; and even the great duties of morals and religion are performed more acceptably in a healthy than a sickly condition. Soon after the release of the Shattuck report, the medical and public health sectors began to recognize the role that schools could play in controlling communicable disease with their "captive audience" of children and young people. For example, even though a vaccine had been developed years earlier, smallpox continued to strike well into the latter half of the nineteenth century, due to the constant influx of new immigrants and the mobility of the population. When New York City was faced with an outbreak of smallpox in the 1860s, no mechanism was in place to provide free vaccinations to those who needed them, so the Board of Health turned to the schools. Education officials agreed to permit inspection of school children to determine whether or not they had been vaccinated, and in 1870, smallpox vaccination became a prerequisite to school attendance (Duffy, 1974). Although the schools of this period had the potential to confront and control communicable disease, no doubt they also contributed to the spread of disease. In the late 1860s and early 1870s, the New York City Board of Health instituted a program of sanitary inspections of all public school twice a year. These inspections revealed a filthy environment and excessive crowding. Modern plumbing was nonexistent, and schools were sometimes overrun by rats. Frequently, more than 100 students occupied

OCR for page 33
School & Health: Our Nation's Investment a single small classroom, with two or three children sitting at the same desk. Classrooms lacked ventilation and fresh air, a problem exacerbated by using stoves for heating and gaslights for illumination. These problems continued in New York City even into the early twentieth century, and no doubt the situation was not unique to New York (Duffy, 1974). The era of school "medical inspection" began in earnest at the end of the nineteenth century (Means, 1975). In 1894, Boston appointed 50 "medical visitors" to visit schools and examine children thought to be "ailing." By 1897, Chicago, Philadelphia, and New York had all started comparable programs, and most of the participating medical personnel provided their services without compensation. The success of these early programs developed into more formalized medical inspection. In 1899, Connecticut made examination of school children for vision problems compulsory. In 1902, New York City provided for the routine inspection of all students to detect contagious eye and skin diseases, and employed school nurses to help the students' families seek and follow through with treatment. In 1906, Massachusetts made medical inspection compulsory in all public schools, a step that ushered in broad-based programs of medical inspections in which school nurses and physicians participated. Legislative mandates became the means of ensuring medical inspections, and legislation continues to this day to be the basis for many elements of school health programs. Around the turn of the century, the role and advantages of school nurses began to be recognized. In 1902, Lillian Wald demonstrated in New York City that nurses working in schools could reduce absenteeism due to contagious diseases by 50 percent in a matter of weeks (Lynch, 1977). For minor conditions, nurses treated students in school and instructed them in self-care. For major illnesses, nurses visited the homes of children who had been excluded from school because of illness or infection, educated parents on their child's condition, provided information on available medical and financial resources, and urged the parents to have their child treated and returned to school. School nurses began to assume a major role in the daily medical inspection of students, treatment of minor conditions, and referral of major problems to physicians. By 1911, there were 102 cities employing cadres of school nurses. In 1913, New York City alone had 176 school nurses (Means, 1975). This expansion of the role of school nurses freed physicians to spend more time in conducting medical inspections of individual students with recognized needs rather than in inspecting entire classes. Medical inspections in the early part of the century were no doubt perfunctory and superficial. For example, in New York City in 1904, it was reported that 8,261,733 examinations were given and 515,505 students were treated by school nurses and physicians, yet the total number

OCR for page 33
School & Health: Our Nation's Investment of medical inspectors was only 50! Another factor reducing the effectiveness of medical inspections was the Victorian attitude toward exposing the body. As late as 1914, school inspectors were not allowed to touch children, and inspections were done with children fully clothed. In 1915, the New York Board of Education introduced a new requirement that all children entering school must undergo a physical examination without clothing. This requirement met some resistance, with critics declaring it immoral to strip children for medical purposes and asserting that school physical examinations were an intrusion and a "violation of personal liberty, and hence contrary to the principles of a free government" (Duffy, 1974). The prevalence of tuberculosis in the United States had a significant impact on school health during the early part of the century. Particularly notable was the development and spread of "open-air classrooms"—wide open to the outside air, even in the middle of winter—in all major cities, under the supervision of both medical and education personnel. In 1915, the National Tuberculosis Association enlisted school children in the Christmas Seal drive. A child who bought or sold 10 cents worth of seals was enrolled as a "Modern Health Crusader" and received a certificate with four "health rules." Crusaders also kept a personal record of how well they carried out 11 daily "health chores.''1 In the first year of the program, 100,000 children became "crusaders," and the drive was endorsed by the National Education Association and the National Congress of Parents and Teachers (Means, 1975). Throughout the late nineteenth century and early twentieth century, the temperance movement also had an influence on school health programs, stressing that children should learn about the effects of alcohol, tobacco, and narcotics on the human system. As a result of this effort, a 1   The list of these health chores gives a revealing look at what were considered to be significant health issues for children in that era. These daily chores were as follows: 1. Wash hands before each meal; clean fingernails. 2. Brush teeth after breakfast and the evening meal. 3. Carry handkerchief and use it to protect others when coughing or sneezing. 4. Avoid accidents; look both ways when crossing the street. 5. Drink four glasses of water, but no tea, coffee, or any harmful drink. 6. Eat three wholesome meals; drink milk. 7. Eat some cereal or bread, green (watery) vegetable and fruit, but no candy or "sweets" unless at the end of the meal. 8. Go to the toilet at regular times. 9. Sit and stand straight. 10. Spend 11 hours in bed, with windows open. 11. Have a complete bath and rub yourself dry.

OCR for page 33
School & Health: Our Nation's Investment majority of states passed legislation mandating such instruction, which was often incorporated into the physiology and hygiene curricula. Physical training—commonly called "gymnastics"—also began to be introduced into schools during this period. The early leaders in the physical education movement had medical degrees, and there was much discussion about the new profession of physical education being a blend of the medical and educational fields. Physical training was often associated with instruction in temperance and hygiene; other topics of focus in the early years of physical education included anthropometrical measurement, gymnastic systems, athletics, folk dancing, and military drill—although military activities fell out of favor around the turn of the century (Lee and Bennett, 1985). The range of school-linked health services was broad in the early twentieth century, and school-based medical and dental clinics sprang up to provide services, especially to indigent students. These services were sometimes overpromised and touted as a panacea for eliminating school failure and delinquency, providing equal educational opportunity, and reaching parents to make them more responsible citizens. Although free school clinics were frequently denounced by the medical establishment as socialized medicine, dentists tended to support free school dental clinics. Many dentists considered children to be "troublesome patients; moreover, parents demanded lower fees for children's care, and they often refused to pay the dentist's bill for that care" (Tyack, 1992). The extent of the medical services provided was so broad that sometimes even minor surgery was performed in schools. For example, in New York City in 1906, when the parents of large numbers of children who needed their tonsils and adenoids removed could not afford carfare to the nearest dispensary, several volunteer physicians performed this surgery on 83 children at Public School 75. Unfortunately, a rumor subsequently spread that "school doctors were slitting the throats of school children as a prelude to a general massacre of the Jews," and several riots resulted. These riots were found to be instigated by the "snip doctors," private physicians who performed the same surgery for a fee and resented the schools doing the work for free (Duffy, 1974). In the period between the 1890s and World War I, the impetus for many health and social services in education came from outside the schools. In the 1890s, schools in Boston and Philadelphia were early pioneers in establishing cooperative programs with philanthropic organizations to provide school lunches to fight malnutrition and hunger and their consequent effect on learning. In many cities, women's clubs provided school meals, transportation, and special classes for sickly or handicapped children, as well as education and recreation programs during the sum-

OCR for page 33
School & Health: Our Nation's Investment mer and out-of-school hours. Settlement-house workers developed model programs for social work and for vocational counseling, generally staffed by volunteers or supported by charitable contributions. Visiting teachers, the forerunner of school social workers, worked with families—especially immigrant families—to help them adjust and to find needed resources and worked with educators to help them deal with the greater diversity of students coming into the classroom. Vocational guidance counselors, the forerunners of school guidance counselors, attempted to link students with jobs and to connect the school with the overall economy (Tyack, 1992). School Health from World War I to the 1960s World War I marked a turning point in the history of school health programs. Prior to this period, programs had a narrow focus emphasizing inspection, hygiene, negative messages, and didactic instruction about anatomy and physiology. However, the advent of the war made the problems of poverty more visible: malnutrition, poor physical condition, and the abysmal state of the health and welfare of many of the country's children. New health promotion philosophies and movements began to spring up to replace the outmoded methods; these new approaches were based on using motivational psychology and an understanding of behavior. During the years immediately following World War I, the image of modern school health programs began to emerge. The Influence of Reports and Publications Following World War I, the Child Health Organization was one of the most active groups devoted to the health of children, and the organization conducted "a nationwide campaign to raise the health standard of the American School Child." This distinguished group began as an outgrowth of the Committee on War Time Problems of Childhood, and its members were leaders in the fields of medicine, education, public health, psychology, and other arts and sciences. The organization's primary focus was on the development of improved health practices, and its approach was enlightened and progressive. Recognizing the motivating effect of stimulating students' interest, the organization promoted a positive approach to health and influencing behavior. It printed and distributed teaching materials for students, provided speakers, and published a large volume of material on school health. In 1922, in collaboration with the U.S. Department of the Interior and the Bureau of Education, the organi-

OCR for page 33
School & Health: Our Nation's Investment zation published and widely distributed The Rules of the Health Game 2 (Means, 1975). In 1918, the Commission on the Reorganization of Secondary Education of the National Education Association (NEA) published the pivotal report The Cardinal Principles of Secondary Education. This report established a new framework for contemporary secondary education in the United States and listed seven main objectives of education: health, command of fundamental processes, worthy home membership, vocation, citizenship, use of leisure, and ethical character (Commission on the Reorganization of Secondary Education, 1981). The NEA had also joined with the American Medical Association (AMA) in 1911 to sponsor what would be for more than a half century one of the most influential groups in the development of school health: the Joint Committee on Health Problems of the National Education Association and the American Medical Association. Prior to 1920, this group published the report Minimum Health Requirements for Rural Schools. The Joint Committee strongly promoted the emerging concept of coordinated effort for health in schools. In a 1927 paper, Health Supervision and Medical Inspection of Schools, the group declared (Means, 1975): As yet, states have been slow in providing for coordination between the medical service or supervision, the physical education, and health education programs. Such a step is necessary for the proper functioning of any program of health supervision. It is ironic that almost 70 years later, coordination of these programs is still considered lacking. Early in the 1920s, the NEA–AMA Joint Committee on Health Problems in Education reported the results of a nationwide survey of the status of health education in 341 city schools. The findings are particularly interesting in light of the current U.S. Public Health Service's Healthy People 2000, which calls for this goal: "Increase to at least 75 percent the 2    Despite the progressive tone to the publication, the "rules" still seem antiquated by modern standards. The "rules" are as follows: 1 . Take a full bath more than once a week. 2 . Brush the teeth at least once every day. 3 . Sleep long hours with windows open. 4 . Drink as much milk as possible, but no coffee or tea. 5 . Eat some vegetables or fruit every day. 6 . Drink at least four glasses of water a day. 7 . Play part of every day out of doors. 8 . Have a bowel movement every morning.

OCR for page 33
School & Health: Our Nation's Investment proportion of the nation's elementary and secondary schools that provide planned and sequential kindergarten through grade 12 quality school health education" (U.S. Department of Health and Human Services, 1991). In the 1920s, more than 73 percent of the surveyed schools taught health directly under the name of "health" or "hygiene,'' while 108 cities reported correlating content in their health curriculum to such other subjects as language, civics, reading, physical education, general science, and art. Daily inspection for health habits was reported by 69 percent of the 341 cities, and nearly 30 percent of elementary schools reported having organized student clubs for the promotion of health (Means, 1975). In 1928, the Sixth Yearbook of the Department of Superintendents of the National Education Association outlined the following content guidelines for health education (Means, 1975): Mental hygiene must be emphasized and protected. The establishment of health habits depends upon the pupil's understanding something of the function of his own body. A discussion of the causes of disease merits a place in the secondary school program. A thorough study of nutrition should be placed in the upper grades. Posture should be emphasized. The hygiene of the home should be taught. Sex hygiene cannot be overlooked. School health became the focus of a variety of agencies and professional organizations between the 1930s and 1960s, and many important documents emphasizing a range of health issues were published during this period. Nationally and at state levels, maternal and child health agencies sponsored numerous conferences to improve school health services by linking them to other community health efforts. Particularly significant health education reports include Suggested School Health Policies, published by the National Committee on School Health Policies of the National Conference for Cooperation in Health Education, and Health Appraisal of School Children, published by the NEA–AMA Joint Committee on Health Problems in Education. Other agencies and organizations publishing important reports on school health during this period included the U.S. Public Health Service, the U.S. Office of Education, the American Association of School Administrators, and various affiliates of the National Education Association (Means, 1975). School health services research was also under way during this period and resulted in the publication of reports on such topics as staffing patterns for school health services, effective strategies for referral and

OCR for page 33
School & Health: Our Nation's Investment follow-up of students with positive screening results, and the beneficial impact of nursing services on school attendance. The Nature of School Health Programs from World War I to the 1960s Between 1918 and 1921, almost every state enacted laws related to health education and physical education for school children (Kort, 1984). During the following decades, the health education curriculum became stabilized and more fully developed. Topics such as nutrition, personal health habits, diseases, exercise, alcohol and tobacco, family health, and sex education became common. The importance of the cooperation of schools with other community agencies and of parental involvement became increasingly acknowledged. The significance of the health of the teaching force became recognized, both so that the teachers would be able to cope with the demands of the job and so that they could better serve as role models of health and vigor for the students (Means, 1975). Safety problems and conditions that surfaced during World War I stimulated the scientific study of safety and the introduction of safety into the school environment and curriculum. Fire drills began to be prescribed, and safety instruction included such topics as fire prevention, traffic safety, and bicycle safety. Increasingly, safety education became integrated into classroom health education (with the exception of driver training, which developed later and is often organized and staffed separately). When many of the World War I draftees failed their physical examinations, there was a move to require physical education "without military features" in schools in an attempt to improve the physical condition of children and young people (Lee and Bennett, 1985). Similarly, when many World War II draftees were found to suffer from nutritional deficiencies, the federal government in 1946 passed the National School Lunch Act to provide funds and surplus agricultural commodities to assist schools in serving nutritious hot lunches to school children. It was not until 1966, however, that a pilot school breakfast program was established, and the program was not made permanent until 1975. School-based medical inspections and screening continued into the 1930s, but typically there was a lack of follow-up to correct defects. In an attempt to remedy the situation, in 1936, in New York City Board of Education set aside a day as Health Day, during which teachers checked children's height, weight, vision, hearing, and teeth. Teachers then had the responsibility for trying to get any defects corrected (Duffy, 1974). Unfortunately, the teachers' work duplicated the efforts of the Health Department. In response, New York City devised the Astoria Plan, an experimental program designed to coordinate all school health services and eliminate duplication; this plan is discussed in the next section.

OCR for page 33
School & Health: Our Nation's Investment During this period, the NEA–AMA collaboration defined the role of schools in providing health services. Health services should focus on the prevention of health problems through conducting screening activities, establishing a healthful environment, providing for immediate care in the instance of problems, and referring children to professionals and facilities that could handle more complex health problems. Many school systems had physicians coordinating the health service programs. It was assumed that most students had family doctors for primary care services, and the appropriate role of schools was to inform parents of problems and advise them when it was necessary to take their children to the doctor. Although collaboration between the medical and educational sectors occurred throughout this period, clearly boundaries were also being established to limit the range of health services that should be available in schools (Lynch, 1977; Walker et al., 1990). This philosophy of discouraging the delivery of primary health services in the schools was the basis for the traditional configuration of school health services between the 1920s and the 1970s (Walker et al., 1990). Although health education was considered an important and legitimate function of the school, when it came to providing services the school acted primarily as a link between students and the community's health services resources. Typically, a school nurse and/or aide, sometimes under the supervision of a part-time physician, was responsible for first aid, immunization, screening, referral, recordkeeping, and follow-up. Over the years, these school-based health services became institutionalized into the educational bureaucracy and were often no longer under the purview of the medical community. As a result, school health policy and the responsibilities of school health personnel became increasingly prescribed by those with an education background rather than health training (Lynch, 1977). These decades saw a continual decline in the diagnostic and treatment aspect of school health services. A 1930 White House Conference on Child Health and Protection called for the elimination of treatment in schools and for school physicians and nurse supervisors to increase contact with physicians in private practice. School dentistry during this period changed from restorative treatment to dental health education and inspection. The 1948 National School Health Bill, which was designed to provide federal aid to school health, was defeated partly because of the opposition of the medical profession whose members feared that funds would be provided for services to students who would otherwise have paid private practitioners (Solloway et al., 1995). It was not until the 1960s that concern for the health and welfare of children and young people led to a reconsideration of the possibility of delivering diagnostic and treatment services at the school site. A classic report appearing in the 1970s

OCR for page 33
School & Health: Our Nation's Investment signified the return to more substantial health services in schools (Leeds et al., 1980). Research and Experimentation The period around World War I saw the beginning of many research studies and demonstration projects in school health (Means, 1975). One of the earliest was the Locust Point Demonstration, which was launched in 1914 in Locust Point, a highly underprivileged section of Baltimore, under the direction of a school physician, school nurse, and school principal. The program's team approach was successful in improving the health of children and teachers, and the project attracted visitors from near and far to learn about the new methods and approaches. Another early demonstration conducted in 1917 in Framingham, Massachusetts, was primarily concerned with tuberculosis prevention and resulted in increased school appropriations for health education and physical education; the project was financed by the Metropolitan Life Insurance Company and carried out by the National Tuberculosis Association. A number of school health demonstration projects and studies were carried out during the 1920s, 1930s, and 1940s. These included such examples as the School Health Study of the American Child Health Association (begun in 1926); the Ohio Research Study (1929–1932); the Cattaragus County Studies (begun in 1931); the School-Community Health Project, funded by the W.K. Kellogg Foundation (begun in 1942); and the California School-Community Health Project (launched in 1944). One of the most intensive research efforts was the Astoria Plan, carried out in the Astoria Health District of New York City from 1936 to 1940, which was supported by the American Child Health Association, Metropolitan Life Insurance Company, Milbank Memorial Fund, and the U.S. Children's Bureau. Directed by the public health leader Dorothy B. Nyswander, the study had five objectives: (1) to determine whether prevailing methods used to discover children needing medical or dental care were satisfactory and, if not, to find what methods could be substituted; (2) to make inquiries into the nature of the cumulative health records of the children examined; (3) to find out just how the teacher, nurse, and physician were working together; (4) to find out the ways in which the staff made use of its time; (5) and to find out how physicians and nurses, immured in old practices, could be educated to new ways of work and thought (Means, 1975). Under the Astoria Plan, services became more streamlined and efficient. Routine but cursory annual physical examinations were replaced by detailed examinations when the child first entered school and thereafter only when the conferring teacher and nurse deemed it necessary. The

OCR for page 33
School & Health: Our Nation's Investment subjects may seem abstract and remote.9 Science is a logical area to connect with health because most health practices and health problems have a scientific basis. The National Science Education Standards call for students to understand science in its personal and social perspectives, including science in health. These standards contain extensive references to health, including basic body functions, cardiovascular fitness, nutrition, sexuality, the scientific basis for disease, problems with substance abuse, accident prevention and safety, risks and personal decisionmaking (National Research Council, 1996). Science is not the only subject that can be enhanced and made more relevant using health topics. In mathematics, elementary students can collect and use the information on nutrition labels to devise a well-rounded diet for themselves, and secondary students can examine the mathematical models for the spread of contagious disease. Language arts classes can analyze the persuasive effects of the media on health behaviors or write letters to politicians and the media about student health concerns. Visual and performing arts classes, including dance, drama, music, and visual arts, can encourage students to enhance mental health through expression of personal feelings; awareness of health issues can be promoted through student expression and interpretation in these various art media. Social studies classes can explore how nutrition and disease shaped history, discuss the advantages and disadvantages of prohibition and current implications for controlling other substances, or debate the ethics of withholding health care and other benefits to those suffering from conditions caused by deliberately engaging in risky behavior. It should be emphasized that the inclusion of health topics in other curricular areas should enhance, but not replace, the health education curriculum. Services Presented below is a brief summary of the types of services typically found in school health programs. These services represent a complex area, and issues of concern include determining the appropriate range and configuration of school-based services, interaction between the school and other community providers, qualifications and training of service deliv- 9    In a related situation, the American Association for the Advancement of Science was recently concerned with increasing the scientific knowledge of low-literate adults. In surveys, these adults expressed a lack of interest in science but indicated that health was highly relevant to daily life. Consequently, materials were developed that taught scientific concepts through health topics, and these materials are currently in use in adult education centers throughout the country.

OCR for page 33
School & Health: Our Nation's Investment ery personnel, scientific validity of mandated services, financing, evaluation, and controversial aspects of certain services. Chapter 4 focuses on services, and these issues are discussed in greater depth there. Health Services. Health services are designed to evaluate, protect, and promote student health. SHPPS has described school health services as a "coordinated system that ensures a continuum of care from school to home to community health care provider and back" (Small et al., 1995). The goals and program elements of school health services vary at the state, community, school district, and individual school levels, but some common elements exist across the country. A recent national school health survey, A Closer Look, reported on the most frequently provided health services in schools (Davis et al., 1995). The results are shown in Table 4-1 (see Chapter 4). Two health services are provided almost universally by school districts—first aid and administration of medications. Other commonly provided services include screenings—height, weight, vision, and hearing—and services mandated by law for children with disabilities and special needs. School health services are provided by nurses, physicians, dentists, and other allied health personnel in settings ranging from a health aide's office in the school to a full-blown school-based clinic providing a wide range of primary care services. Depending on the community, certain basic health services may be considered the responsibility of the school system, such as the provision of school nurses or health aides. However, more extensive ventures—school-based clinics, for example—are often initiated and managed in cooperation with the school by groups outside education, such as a health department, community clinic, or hospital. Counseling, Psychological, and Social Services. These services promote the mental, emotional, and social health of students and deal with problems that interfere with teaching and learning. Services include individual or group assessment, interventions, and referrals. School staff and families of students may also receive these services, and services for special education students are an important focus. These services bridge the gap between the school's academic program and the mental and emotional health of students and their families. Professionals in these fields work closely with each other and with school health personnel, teachers and administrators, families, and community agencies. They frequently serve as brokers in linking community health and social service resources to the school site. In this era of emphasis on academic standards and limited financial resources, counseling, psychological, and social services are sometimes seen as outside the mainstream and are threatened by cutbacks. However,

OCR for page 33
School & Health: Our Nation's Investment these services address today's new social morbidities that prevent students from achieving at their highest potential, and the extent of the problems may not be recognized. It is estimated that 12 to 20 percent of our nation's children and adolescents suffer from one or more diagnosable mental disorders, and many others are at risk due to violent neighborhoods, parental abuse or neglect, and risky and dangerous behavior (IOM, 1994). In fact, it has been suggested that fully 40 percent of all students are in ''very bad educational shape" and "at risk of failing to fulfill their physical and mental promise" (Hodgkinson, 1993). It is also important to realize that all students—not simply low-income or low-achieving students—are vulnerable to mental and emotional problems. A recent national survey of high-achieving high school students indicated that more than 50 percent report violence at their school, 29 percent have considered committing suicide, 81 percent report that it is easy to get alcohol and 77 percent say alcohol is very common at parties, 25 percent have engaged in sexual intercourse, and 11 percent have tried marijuana. More than 30 percent of these high-achieving students say their home life is less than "happy and close most of the time" (Who's Who Among American High School Students, 1994). Given this context, it has been proposed that counseling, psychological, and social services receive increased emphasis in school reform and restructuring, as an essential "enabling" component to address factors that interfere with students' learning and performance (Adelman, in press). Nutrition and Foodservice. The school foodservice not only provides nutritious and appealing meals but also helps students develop lifelong healthful eating habits. Evidence shows that dietary behaviors tend to stay constant over time, and poor eating habits established in childhood tend to persist through adulthood (CDC, 1996). A poor diet contributes to the development of four of the nation's ten leading causes of death: coronary heart disease, stroke, diabetes, and certain types of cancer. Other detrimental conditions associated with diet are hypertension, obesity, osteoporosis, and poor oral health. Also, the number of overweight children and adults has increased significantly in the last decade, and eating disorders and unsafe weight loss methods have become more prevalent as well. Nutrition education is critical at all levels, even in early childhood and elementary schools, in order that students develop healthful dietary habits and understand the influence of nutrition on health. Nutrition education should be part of classroom health education, and nutrition should be introduced into other subjects such as science, physical education, and home economics. In providing a variety of nutritious and appealing meals, the school foodservice serves as a laboratory to reinforce the lessons learned in the classroom.

OCR for page 33
School & Health: Our Nation's Investment Research has shown that children's cognitive, behavioral, and physical performance are impaired by poor nutrition (Center on Hunger, Poverty, and Nutrition Policy, 1993; CDC, 1996). School meals that meet U.S. Department of Agriculture (USDA) dietary guidelines play a significant role in providing good nutrition. The School Nutrition Dietary Assessment Study (Burghart and Devaney, 1995) found that students who ate the school lunch had higher intakes of key nutrients than students who made other choices. A study of low-income elementary students found that participation in the school breakfast program led to increased standardized test scores and decreased absenteeism and tardiness (Meyers et al., 1989). The concept of foodservice is not limited to the reimbursable school meal program for which the USDA establishes nutrition standards. High-quality local standards are needed for all food available on the school campus—including food sold through vending machines and special events—and for the environment in which these foods are made available to students. Although the immediate goal of the school foodservice may be the provision of student meals, the ultimate goals are providing education and establishing lifelong healthful dietary habits. Comprehensive Family Services. Access may be provided through the school to a wide range of health and social services for students and their families, especially in disadvantaged communities. Examples of services include health and dental care, adult literacy programs, employment training, family counseling, child care, legal services, recreation and culture, and provision of basic needs in housing, food, and clothing. Providing access to services through the school does not necessarily require an increase in overall budgets for these services. Typically, many of these services already exist but in a fragmented manner, and families often find the system difficult to access and navigate. Collocating and coordinating comprehensive services through a familiar neighborhood institution such as the school has been found to improve access, increase efficiency, and facilitate follow-up (Wagner et al., 1994). Comprehensive school-affiliated family services are increasingly considered to be an important means for reaching families and for improving academic, health, and social outcomes for students10 (American Academy of Pediatrics, 1994a, 1994b; 10    As examples, the Goals 2000 legislation calls for states to involve parents and other community representatives in developing the state's educational improvement plan, which should include such strategies as increasing the access of all students to health and social services in convenient sites designed to provide "one-stop shopping" for parents and students. The Improving America's Schools Act, which reauthorizes the Elementary and Secondary Education Act (ESEA), allows local districts to set aside 5 percent of ESEA funds for the coordination of services.

OCR for page 33
School & Health: Our Nation's Investment Bruininks et al., 1994; U.S. Department of Education and U.S. Department of Health and Human Services, 1993; U.S. Department of Education, 1995). Although seeming ambitious, comprehensive school-affiliated family services are not a new idea; many schools were providing access to a similar range of services in poor urban and rural areas a century ago (Tyack, 1992). Integration of Comprehensive School Health Programs with Community Health Efforts Early in its study, the IOM committee sensed that school programs working in isolation are likely to have limited effect without community support and reinforcement. To examine this premise further, a paper on integrating school and community health efforts was commissioned; the paper is found in its entirety in Appendix A. (Note that in this paper the author uses the terminology "comprehensive school health education" to refer to what the committee has called a "comprehensive school health program.") The paper reviews the results of selected studies on school-based programs, community programs, and programs integrating the efforts of schools and communities. Examples of community participation and mechanisms for interfacing the school and community are also discussed. Results suggest that combined school-community programs yield higher levels of participation, implementation, and dissemination; greater effects on the more serious levels of health risk (e.g., on daily smoking compared to monthly smoking); and effects on parents as well as youth, perhaps longer effects than are currently obtainable from most school programs alone. The author notes that in the programs analyzed, the assumption of the need for integrating school and community efforts has usually been based on practical considerations and common wisdom rather than on theory or empirical evidence. The author also points out knowledge gaps and the limitations of existing studies, and suggests directions for future research. Integration of the Elements of a Comprehensive School Health Program Integration—the blending of program components into a unified whole—is an elusive concept. A single standard process for achieving and recognizing "integration of components" does not exist, because each situation is unique. Integration might be considered a topic that is "hard to define, but you recognize it when you see it." Consider the following simple example pertaining to nutrition that illustrates the practical meaning of the term integration: Lessons on nutrition in the health education classroom are supported

OCR for page 33
School & Health: Our Nation's Investment by a school foodservice that serves healthful, well-balanced meals and labels the nutritional content of cafeteria selections to increase nutrition awareness. Classroom lessons are also strengthened by school policies requiring that foods available through vending machines, special events, and fund-raising drives meet a high standard of nutrition. School nurses and counselors promote awareness about weight management and eating disorders, and provide assistance for students and staff with problems in this area. Students with special conditions, such as diabetes, have dietary provisions prescribed by a physician and arranged by the school nurse and foodservice or by a community dietitian if the school lacks the required expertise. Physical education instructors help students understand the relationship between caloric intake and energy expenditure and between nutrition quality and physical stamina and performance. Nutrition-related topics also enhance instruction in other subject matter areas, such as science, mathematics, and social studies. Community-wide campaigns promote nutrition awareness so that healthy eating habits acquired in school will be reinforced outside school; restaurant and fast-food outlets promote healthful choices, and grocery stores publicize healthful selections and provide recipes and tips for healthful family meal planning. The conventional wisdom is that when the various elements of a CSHP are integrated, they will mutually reinforce and support each other and produce a whole that is greater than the sum of its separate parts. The concept and desired outcomes of integration are simple to recite, but integration is a difficult and sophisticated process to implement and measure—"the reality lags far behind the vision" (Education Development Center, 1995). While exemplary individual program components exist in many schools and various states and communities are making progress in establishing CSHPs, truly comprehensive and integrated programs do not yet appear to be widespread.11 Although individual program components have been studied separately and many are reasonably well understood, the committee could find no record of systematic research on the integration of multicomponent programs. There is a dearth of scientific analysis of what exactly constitutes integration of components, whether integration actually enhances the effects of separate components, and what the most effective strategies are for achieving integration and measuring its impact. This lack of evidence is not surprising, given the scarcity and complexity of programs and limited program resources. Research 11    The committee did not attempt to carry out a national search for comprehensive school health programs. However, informal feedback from the Infrastructure States—demonstration sites for comprehensive school health programs sponsored by DASH/CDC—indicates that progress is being made, but CSHPs are not yet a widespread institutionalized phenomenon.

OCR for page 33
School & Health: Our Nation's Investment on the process and effectiveness of individual components—a particular health education curriculum, health services intervention, or modification of school environment—is difficult enough; even more so is the study of any synergism among them. Since individual programs are idiosyncratic and not easily replicable, research and evaluation that attempt to detect the effects of integration per se or to detect the specific contribution of individual or various combinations of factors to the overall program are not likely to be fruitful. The pragmatic approach to integration of program components at the local level is to make certain that each individual component is designed to address identified needs and implemented according to effective practices, and that systematic and regular communication occurs among all stakeholders. Then, if indicators are moving in the right direction at the desired rate, this should be sufficient evidence for a community to declare that its program is effective. Additional issues and dilemmas involved in evaluating comprehensive integrated programs are discussed further in Chapter 6. SUMMARY Schools have a long history of providing health education, services, and outreach to families. A vision of what schools might be able to do to promote health, education, and family well-being has led to the concept of a CSHP. Although exemplary individual program components exist in many schools, truly comprehensive and integrated programs are not yet widespread. Various models for CSHPs exist, but most of the basic elements or components tend to be similar. There is no "best" model or standard algorithm for establishing a program—it must be specifically tailored to fit each particular community. Active community involvement is key, and the integration of school programs with other community efforts appears to produce more positive results than school or community programs operating in isolation. REFERENCES Adelman, H.S. In press. Restructuring Education Support Services: Toward the Concept of the Enabling Component. Kent, Ohio: American School Health Association. Adolescent Medicine. 1995. 20(10):1–4. Allensworth, D.D. 1993. Expansion of comprehensive school health: What works. Paper presented at the Institute of Medicine Workshop, Integrating Comprehensive School Health Programs in Grades K-12, Washington, D.C., May. Allensworth, D.D., and Kolbe, L.J. 1987. The comprehensive school health program: Exploring an expanded concept. Journal of School Health 57(10):409–411.

OCR for page 33
School & Health: Our Nation's Investment Allensworth, D.D., Wolford Symons, C., and Olds, R.S. 1994. Healthy Students 2000: An Agenda for Continuous Improvement in America's Schools. Kent, Ohio: American School Health Association. American Academy of Pediatrics, Committee on School Health. 1993. School Health: Policy and Practice. Elk Grove Village, Ill.: American Academy of Pediatrics. American Academy of Pediatrics. 1994a. Principles to Link By: Integrating Education, Health, and Human Services for Children, Youth, and Families . Report of the Consensus Conference. Washington, D.C. American Academy of Pediatrics. 1994b. Statement by the Task Force on Integrated School Health Services. Pediatrics 94(3):400–402. American Medical Association. 1992. Guidelines for Adolescent Preventive Services. Chicago: American Medical Association, Department of Adolescent Medicine. American School Food Service Association. 1995. Keys to Excellence: Standards of Practice for School Food Service and Nutrition. Alexandria, Va.: American School Food Service Association. American School Health Association. 1994. Guidelines for Comprehensive School Health Programs. Kent, Ohio: American School Health Association. Belcastro, A., and Gold, R. 1984. Teacher stress and burnout: Implications for school health personnel. Journal of School Health 53(7)404–407. Bruininks, R.H., Frenzel, M., and Kelly, A. 1994. Integrating services: The case for better links to schools. Journal of School Health 64(6):242–248. Burghart, J., and Devaney, B., eds. 1995. The school nutrition dietary assessment study. American Journal of Clinical Nutrition 61:1(Suppl.). Carnegie Council on Adolescent Development. 1989. Turning Points: Preparing American Youth for the 21st Century. Washington, D.C.: Carnegie Corporation. Carnegie Council on Adolescent Development. 1995. Personal communication with Turning Points Evaluator. Center on Hunger, Poverty, and Nutrition Policy. 1993. Statement on the Link between Nutrition and Cognitive Development in Children. Medford, Mass.: Tufts University School of Nutrition. Centers for Disease Control and Prevention. 1994. Guidelines for school health programs to prevent tobacco use and addiction. Morbidity and Mortality Weekly Report 43(RR–2):1–18. Centers for Disease Control and Prevention. 1997. Guidelines for school and community health programs to promote physical activity among youth. Morbidity and Mortality Weekly Report. Centers for Disease Control and Prevention. 1996. Guidelines for school health programs to promote healthy eating. Morbidity and Mortality Weekly Report 45(RR-9). 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. Comer, J.P. 1984. Improving American Education: Roles for Parents. Hearing Before the Select Committee on Children, Youth, and Families. Washington, D.C.: U.S. Government Printing Office. Comer, J.P. 1988. Educating poor minority children. Scientific American 259(5):42–48. Commission on the Reorganization of Secondary Education. 1981. Cardinal Principles of Secondary Education. Bulletin #35. Washington, D.C.: Bureau of Education. Cortese, P., and Middleton, K., eds. 1994. The Comprehensive School Health Challenge. Santa Cruz, Calif.: Education, Training, and Research Associates. 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, Colo.: Office of School Health, University of Colorado Health Sciences Center.

OCR for page 33
School & Health: Our Nation's Investment Dryfoos, J.G. 1994. Full-Service Schools: A Revolution in Health and Social Services for Children, Youth, and Families. San Francisco, Calif.: Jossey-Bass. Duffy, J. 1974. A History of Public Health in New York City, 1866–1966 . New York: Russell Sage Foundation. Education Development Center. 1995. The Status of School Health: Annex 1 to the Working Paper of the World Health Organization Expert Committee on Comprehensive School Health Education and Promotion. Newton, Mass.: Education Development Center. Edwards, L.H. 1992. Organizational models for school health. In Principles and Practices of Student Health, Volume Two: School Health, H.M. Wallace, K. Patrick, G.S. Parcel, and J.B. Igoe, eds. Oakland, Calif.: Third Party Publishing. Falck, V., and Kilcoyne, M. 1984. A health promotion program for school personnel. Journal of School Health 54(6):239–242. Goldberg, M., and James, H. 1983. A nation at risk: the report of the National Commission on Excellence in Education. Phi Delta Kappan 65(1):14–18. Hilmar, N.S., and McAtee, P. 1973. The school nurse practitioner and her practice: A study of nurses in elementary schools . Journal of School Health 43(7):431–441. Hirsch, D. 1995. Health-Promoting Schools: From Ideas to Action. Frontiers in Education: Schools as Health Promoting Environments. Review of conference held in Geneva, Switzerland, February, 1995, jointly sponsored by the Johann Jacobs Foundation and the Carnegie Corporation. Hodgkinson, H.L. 1993. American education: The good, the bad, and the task. Phi Delta Kappan 74:619–623. Institute of Medicine. 1994. Reducing Risks for Mental Disorders. Washington, D.C.: National Academy Press. Institute of Medicine. 1995. Defining a Comprehensive School Health Program: An Interim Statement. Washington, D.C.: National Academy Press. Jamison, J. 1993. Health education in schools: A survey of policy and implementation. Health Education Journal 52(2):59–62. Joint Committee on Health Education Terminology. 1991. Report of the 1990 Joint Committee on Health Education Terminology. Journal of Health Education 22(2):99–108. Joint Committee on National Health Education Standards. 1995. National Health Education Standards: Achieving Health Literacy. Atlanta, Ga.: American Cancer Society. Kohn, M.A. 1979. School Health Services and Nurse Practitioners: A Survey of State Laws. Washington, D.C.: Center for Law and Social Policy. Kolbe, L.J. 1986. Increasing the impact of school health promotion programs: Emerging research perspectives. Journal of Health Education 17(5):47–52. Kort, M. 1984. The delivery of primary health care in American public schools, 1890–1980. Journal of School Health 54(11):453–457. Lavin, A.T., Shapiro, G.R., and Weill, K.S. eds. 1992. Creating an Agenda for School-Based Health Promotion: A Review of Selected Reports . Boston: Harvard School of Public Health. Lee, M., and Bennett, B. 1985. Centennial articles. Journal of Physical Education, Recreation and Dance Centennial Issue 56(4):19–27. Leeds, S., Heneson-Walling, R., and Shwab, J. eds. 1980. EPSDT: A Guide for Educational Programs. Washington, D.C.: U.S. Government Printing Office. Lynch, A. 1977. Evaluating school health programs. In Health Services: The Local Perspective, A. Levin, ed. New York: Academy of Political Science; Proceedings of the Academy of Political Science 32(3):89–105. Maysey, D.L. 1988. School worksite wellness programs: A strategy for achieving the 1990 goals for a healthier America. Health Education Quarterly 15(1):53–62. McGinnis, J.M., and DeGraw, C. 1991. Healthy Schools 2000: Creating partnerships for the decade. Journal of School Health 61(7):292–297.

OCR for page 33
School & Health: Our Nation's Investment Means, R.K. 1975. Historical Perspectives on School Health. Thorofare, N.J.: Charles B. Slack. Meyers, A.F., Sampson, A.D., Weitzman, M., Rogers, B.L., and Kayne, H. 1989. School breakfast program and school performance. American Journal of Diseases and Children 143:1234. Nader, P.N. 1990. The concept of comprehensiveness in the design and implementation of school health programs. Journal of School Health 60(4):133–138. National Association for Sport and Physical Education. 1995. Moving into the Future: National Standards for Physical Education: A Guide to Content and Assessment. St. Louis, Mo.: Mosby. National Commission on Children. 1991. Beyond Rhetoric: A New American Agenda for Children and Families. Washington, D.C.: U.S. Government Printing Office. National Education Goals Panel. 1993. The National Education Goals Report: Building a Nation of Learners, Volume One: The National Report . Washington, D.C.: U.S. Government Printing Office. National Education Goals Panel. 1994. The National Education Goals Report: Building a Nation of Learners. Washington, D.C.: U.S. Government Printing Office. National Nursing Coalition for School Health. 1995. School health nursing services: Exploring national issues and priorities. Journal of School Health 65(9):370–389. National Research Council. 1996. National Science Education Standards . Washington, D.C.: National Academy Press. Office of Technology Assessment, Congress of the United States. 1995. Risks to Students in School. OTA–ENV–633. Washington, D.C.: U.S. Government Printing Office, September. 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. Pigg, R.M. 1992. The school health program: Historical perspectives and future prospects . In Principles and Practices of Student Health, Volume Two: School Health, H.M. Wallace, K. Patrick, G.S. Parcel, and J.B. Igoe, eds. Oakland, Calif.: Third Party Publishing. Proctor, S.T., Lordi, S.L., and Zarger, D.S. 1993. School Nursing Practice Roles and Standards. Scarborough, Maine: National Association for School Nurses. 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. Silver, H.K., Igoe, J.B., and McAtee, P. 1976. The school nurse practitioner: Providing improved health care to children. Pediatrics 58(4):580–584. Simons-Morton, B.G. 1992. Health-related physical education. In Principles and Practices of Student Health, Volume Two: School Health, H.M. Wallace, K. Patrick, G.S. Parcel, and J.B. Igoe, eds. Oakland, Calif.: Third Party Publishing. Slavin, R.E., Madden, N.A., Karweit, N.L., Dolan, L.J., and Wasik, B.A. 1992. Success for All: A Relentless Approach to Prevention and Early Intervention in Elementary Schools. Arlington, Va.: Educational Research Service. Sliepcevich, E. 1964. School Health Education Study: A Summary Report. Washington, D.C.: School Health Education Study. 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. Solloway, M.R., Pine, Y., and Anderson, E. 1995. Health supervision and school health services for children. In Child Health Supervision , M.R. Solloway and P.P. Budetti, eds. Arlington, Va.: National Center for Education in Maternal and Child Health.

OCR for page 33
School & Health: Our Nation's Investment Stone, E.J. 1990. ACCESS: Keystones for school health promotion. Journal of School Health (60)7:298–300. Tyack, D. 1992. Health and social services in public schools: Historical perspectives. The Future of Children: School Linked Services, R.E. Behrman, ed. Los Altos, Calif.: Center for the Future of Children, David and Lucille Packard Foundation 2(1):19-31. U.S. Department of Education. 1995. School-Linked Comprehensive Services for Children and Families: What We Know and What We Need to Know. Washington, D.C.: U.S. Department of Education, SAI 9503025. U.S. Department of Education and U.S. Department of Health and Human Services. 1993. Together We Can: A Guide for Crafting a Profamily System of Education and Human Services. Washington, D.C.: U.S. Government Printing Office. 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. University of Colorado Health Sciences Center, Office of School Health. 1991. The Community Health Nurse in the Schools. Denver, Colo.: University of Colorado Health Sciences Center. Wagner, M., Golan, S., Shaver, D., Newman, L., Wechsler, M., Kelley, F. 1994. A Healthy Start for California's Children and Families: Early Findings from a Statewide Evaluation of School-Linked Services . Menlo Park. Calif.: SRI International. Walker, D.K., Butler, J.A., and Bender, A. 1990. Children's health care and the schools. In Children in a Changing Health System: Assessments and Proposals for Reform, M.J. Schlesinger and L. Eisenberg, eds. Baltimore: Johns Hopkins University Press. Wallace, H.M., Patrick, K., Parcel, G.S., and Igoe, J.B., eds. 1992. Principles and Practices of Student Health, Volume Two: School Health . Oakland, Calif.: Third Party Publishing. Who's Who Among American High School Students. 1994. Twenty-Fifth Annual Survey of High Achievers. Views on Education, Social and Sexual Issues, Drugs. Lake Forest, Ill.: Educational Communications. Health, State of New Mexico.