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

Adapted from the American School Health Association

Kent, Ohio

Second Edition, November 1994

''What is very clear, is that education and health for children are inextricably entwined. A student who is not healthy, who suffers from an undetected vision or hearing deficit, or who is hungry, or who is impaired by drugs or alcohol, is not a student who will profit optimally from the educational process. Likewise, an individual who has not been provided assistance in the shaping of healthy attitudes, beliefs and habits early in life, will be more likely to suffer the consequences of reduced productivity in later years."

—J. Michael McGinnis, Director

Disease Prevention and Health Promotion

U.S. Public Health Service

School can be one of the primary sites through which children and youth learn about the factors that influence their health. It also can be the site that provides or coordinates some or all of the needed health care services. It has been said that youth are one-third of our population and all of our future. As such, their care and nurture within the school setting is of concern to the American School Health Association (ASHA).

These guidelines address the eight separate components of the comprehensive school health program: school environment; health education; health services; physical education; counseling, guidance and mental health; school food and nutrition services; worksite health promotion; and integration of school and community health activities. Developed

by the American School Health Association, the guidelines provide an operational set of practices and outcomes that may serve local school districts as the basis for developing needs assessment tools, defining staff development needs, improving program planning and evaluating the efficacy of local comprehensive school health programs. The guidelines are descriptive rather than prescriptive. They will be re-examined periodically by the ASHA Board of Directors and updated as appropriate.

—Rosemary K. Gerrans

Past President

American School Health Association

The health and well-being of children and youth must be a fundamental value of society. Urgent health and social problems have underscored the need for collaboration among families, schools, agencies, communities and governments in taking a comprehensive approach to school-based health promotion.

Health scientists have established that 50 percent of premature illness, injury and death is due to an unhealthy lifestyle. Experience and research evidence suggest that a comprehensive school health approach can improve the health-related knowledge, attitudes and behaviors of students.

It is also recognized, however, that other major determinants of health status such as genetics, the health care delivery system and socioeconomic, cultural and environmental factors require a multifaceted approach to the maintenance and improvement of health status.

A comprehensive school health approach includes a broad spectrum of activities and services which take place in schools and their surrounding communities that enable children and youth to enhance their health, develop to their fullest potential and establish productive and satisfying relationships in their present and future lives. The goals of a comprehensive approach are to:

• promote health and wellness.

• prevent specific diseases, disorders and injury.

• prevent high risk social behaviors.

• intervene to assist children and youth who are in need or at risk.

• help support those who are already exhibiting special health care needs.

• promote positive health and safety behaviors.

Attainment of these goals requires an integrated approach that coordinates multiple programs and provides multiple strategies. Work teams in collaboration with a coordinating council should involve families, students and community members in the program planning process. Further, professional staff development is necessary to effectively address specific health-related issues. A comprehensive school health program focuses on priority behaviors that contribute to the health, safety and well-being of students, staff and families, while assuring a supportive and health environment that nurtures academic growth and development. The successful implementation of this comprehensive approach necessitates leadership from health and education agencies and elected and appointed officials, adequate funding, trained personnel, administrative support, appropriate policy, quantitative and qualitative evaluation, legislation and regulations.¹

• District policies and administrative guidelines reflect a commitment to maintaining an open and positive psychosocial climate and a healthy physical environment that are conductive to high student achievement and the long-term health of students and staff.

• Policies, rules and regulations are consistently enforced.

• The chief administrator, the school board and the school health coordinating council receive, at least annually, a report on the psychosocial climate of the school and a report on the physical environment, along with an action plan for continuous improvement of the school environment.

• A uniform process for reporting injuries and health problems in the school environment should be in place and analyzed for the purpose of monitoring risk factors, trends and patterns and suggesting possible preventive measures.

• Effort should be made to compare the progress in the psychosocial and physical health arenas with relevant educational goals.

• Policies that assure safe transport of students to and from school (e.g., bus, bicycle, walking) are enforced.

• Administrative support for a healthy psychosocial environment is evidenced by district and campus policies and procedures.

• The school environment is friendly, nurturing, respectful of differ-

ences, physically and emotionally safe and conducive to learning with high expectations for academic success.

• School climate problems are addressed directly, in a timely manner and discussed openly within the limits of privacy.

• Effective instructional plans and techniques are used with all students to foster learning, self worth and mental health.

• Students, families and staff work as a team in planning and implementing programs and activities to affirm all cultural, linguistic and socioeconomic backgrounds.

• Students, families and staff are regarded as valuable and are involved in school governance.

• Students are empowered to take a leadership role in the development and implementation of programs to promote a healthy school.

• Focus is placed on people's feelings and needs as well as tasks and duties.

• Strong encouragement is given for students and staff to cooperatively solve problems and resolve conflict in an open and respectful manner.

• A crisis response system has been established to support students and staff in the event of violence, suicide, unintentional injury, death and other school-site incidents.

• Family involvement and support is encouraged.

• The quality of air, water and other environmental elements is monitored to ensure the safety and well-being of students and staff.

• The district/school has a tobacco-free, drug-free and violence-free policy for students, staff and visitors on all school-owned property and vehicles.

• The structure of, or adaptations to, school buildings ensure access by persons with disabilities.

• District and school emergency disaster plans are established and emergency drills held periodically.

• Staff and students are trained in and practice emergency, first aid and infection control procedures including universal precautions.

• All schools have and maintain equipment and supplies needed to implement first aid and universal precautions for infection control.

• Buildings, equipment, playgrounds and athletic fields are clean, kept in good repair, free of hazards and meet all safety standards.

• Student and staff comfort is maintained by adherence to appropriate standards for heating, cooling, ventilation, lighting, space, safety glass and noise.

• The cafeteria facility creates an environment that encourages students to participate in the meal service.

• Safe, clean, appropriately equipped bathrooms, including facilities for hand washing, are available.

• District policies and administrative guidelines reflect a commitment to attain desired student outcomes essential to optimal physical and mental health.

• The chief administrator, the school board and the school health coordinating council receive, at least annually, reports on actions taken and results achieved related to desired student outcomes, along with the action plan for continuous improvement in health education.

• At the intermediate and secondary level, certified health education specialists with teacher certification teach the health courses. Coordination and team teaching with related professionals is encouraged.

• At the elementary level, teachers have professional preparation in elementary health education.

• Educators are given opportunities for effective professional training when implementing a new curriculum.

• District/school goals and objectives for health education are clear, based on assessed needs and stated in terms of student outcomes expected at each grade level and for each course.

• Entry and exit-level performances are defined for each grade level or health education course along with adaptations for students with special needs.

• Formative evaluations are conducted to monitor the implementation process and to determine the response of administrators, teachers, other staff, families and students to the curricular materials.

• Summative evaluations are conducted to measure changes in students' knowledge, attitudes, behaviors, skills and social action related to health.

• Congruence exists between the evaluation measures used, the

district's health education curriculum, teaching strategies and the critical health objectives for student learning.

• Students demonstrate competence in essential health education objectives established for each grade level or course.

• Health education curriculum content is targeted at priority areas appropriate for developmental stage and potential risks.

• Health education includes integration of the physical, intellectual, social, emotional and spiritual dimensions of health as a basis of study in the ten content areas suggested by the 1990 Joint Committee on Health Education Terminology: community health, consumer health, environmental health, family life, growth and development, nutritional health, personal health, prevention and control of disease, safety and injury prevention and substance use and abuse.

• Health education occurs as a regularly scheduled component of the curriculum at each grade level. The successful completion of health education is required for graduation.

• Health and safety issues are infused regularly into the curriculum of various subject areas (e.g., home economics, science, language arts, social studies, vocational education).

• Healthy decision making and psychosocial health are reinforced through guidance and counseling curricula and other pupil services prevention plans. Health-enhancing messages are promoted via the media, social clubs, community service, extra-curricular activities and all school programming, including school nutrition services.

• Opportunities to practice generic personal and social skills (e.g., problem solving, decision making, communication) are provided to students at all levels.

• Appropriate instructional strategies are chosen to achieve instructional goals.

• Peer instruction is used to solicit active student involvement in instruction.

• Active family involvement with health lessons is planned and implemented.

• Current, research-based, instructional materials for regular and

special needs students as well as for students with limited English proficiency are available to teachers.

• Health education resources from appropriate agencies and organizations are coordinated and used (e.g., state, county or city health departments, state departments of education, American Cancer Society, American Heart Association, American Lung Association, American Red Cross).

Responsibilities and competencies for those providing health and safety education include:²

• Assessing individual and community needs for health education.

• Planning effective health education programs.

• Implementing health education programs.

• Evaluating effectiveness of health education programs.

• Coordinating provision of health education services and acting as a resource person in health education.

• Communicating health and health education needs, concerns and resources.

• Teachers are involved in: (1) identifying staff-development needs and (2) working with school leaders to implement staff-development programs to ensure achievement of standards.

• Staff development and inservice programs related to current health and safety issues and instructional strategies are provided at the district level and from professional organizations.

• Policies and administrative guidelines promote, protect and improve the health and safety of students, staff and the community.

• Policies and administrative guidelines reflect quality assurance and accountability for an effective health services component.

• A plan exists to coordinate health services with other school and community programs.

• The chief administrator, the school board and the school health coordinating council review, at least annually, reports on actions taken and results achieved by the health services component, along with an

action plan for continuous improvement in the delivery of health services.

• The director of the school health services may be a physician trained in school or child/adolescent health or a registered nurse with a minimum of a baccalaureate degree in nursing (BSN) and relevant experience in school, child/adolescent or community health.

• The planning, management and delivery of school health services are provided by a school health professional (e.g., at least a registered nurse or physician).

• School nurses are registered nurses with a baccalaureate degree who have met specific school nurse requirements.

• Goals and objectives for the health services component are clear, based on assessed needs and stated in terms of expected outcomes.

• All school health services are conducted as required by law or as defined by the school health services plan (e.g., dental, hearing, vision and spinal screenings, sports participation physicals).

• School nurses assess the health status of students, plan appropriate interventions and evaluate the care provided.

• Nursing interventions include case finding, direct care, health counseling, health education, referral and follow up.

• School nurses provide students with direct, one-on-one health instruction as needed and deliver classroom instruction in collaboration with teachers and administrators.

• Students with special health care needs have a written, individualized health care plan and, when appropriate, the plan is incorporated into the individualized education plan (IEP), 504 modification plan or individual family service plan (IFSP).

• The minimum standards for ratios of school nurses to students are:

  • 1:750 for the general school population.

  • 1:225 for special needs students mainstreamed within the general school population.

  • 1:125 for severely/profoundly disabled students.

    (Students with complex medical needs may require lower ratios and must be decided on a case-by-case basis.)

• According to state law and district policy, and upon proper medical authorization, the delegation of nursing activities to other school per-

sonnel requires that the school nurse provide training and ongoing supervision for the designated personnel regarding the delegated care.

• Educational programs that empower students and families to effectively access and utilize health care services are provided.

• All school health records are maintained as required by law or as defined by the school health services plan.

• School policies include provisions for the protection of confidential health/mental health records as defined by federal and state law.

• School illness, injury and violence reports are analyzed to facilitate prevention.

• Services are provided in each school in a health room or clinic with appropriate facilities and adequate equipment and supplies.

• School health services are coordinated with related in-school professionals and with students' primary care providers, as well as with community, city, county and state agencies and organizations.

• School health services make use of available school-based resources and community-based resources including professional and volunteer health organizations.

• The director collaborates with community primary care providers to ensure that every student has continuous access to comprehensive primary health care services.

• The plan to coordinate health services with other school programs is monitored by the district school health coordinating council.

• A qualified consulting physician is available to consult with school health professionals and the school administration.

• The school health physician is familiar with laws, regulations, policies and programs (e.g., federal, state and local) related to comprehensive school health programs.

• The school physician assures efficient linkages and liaisons with the medical community; provides timely medical consultation on individual students, health procedures, curriculum and program issues; and regularly reports on consultation activities to the district administration.

The health services component employs standards of school nursing practice.³ Accordingly, the school nurse:

• Utilizes a distinct clinical knowledge base for decision making in nursing practice.

• Uses a systematic approach to problem solving in nursing practice.

• Contributes to the education of the student with special health needs by assessing the student, planning and providing appropriate nursing care and evaluating the identified outcomes of care.

• Uses effective written, verbal and nonverbal communication skills.

• Establishes and maintains a comprehensive school health program.

• Collaborates with other school professionals, families and caregivers to meet the health, developmental and educational needs of the students.

• Collaborates with members of the community in the delivery of health and social services and utilizes knowledge of community health systems and resources to function as a school-community liaison.

• Contributes to nursing and school health through innovations in practice and participation in research or research-related activities.

• Identifies, delineates and clarifies the nursing role; promotes quality of care; pursues continued professional enhancement; and demonstrates professional conduct.

• District policies and administrative guidelines reflect a commitment to students' physical development, motor skills acquisition and knowledge to support lifetime health and physical activity practices.

• The chief administrator, school board and the school health coordinating council review, at least annually, a report on the actions taken and results achieved in relation to students' physical fitness (muscular strength, cardiovascular endurance, body composition, muscular endurance and flexibility) and other desired outcomes as well as the action plan for continuous improvement in the physical education program.

• Certified teachers with specialization in physical education teach physical education at all levels.

• District/school goals and objectives for physical education, based on state frameworks and national standards, are clear, and are based on

assessed needs and stated in terms of student outcomes expected at each grade level.

• Supervision and positive role modeling occur during physical education activities.

• Entry and exit-level performances for physical development are defined for grade levels and physical education courses; adaptations are made for all students, particularly those with special physical, intellectual or emotional needs.⁴

• Evaluations are conducted to appropriately measure students' knowledge of physical development and physical activity skills, as well as the amount of participation in moderate to vigorous physical activity. ⁴

• Students demonstrate appropriate levels of health-related fitness (for age and development as defined by American Alliance for Health, Physical Education, Recreation and Dance, American College of Sports Medicine, etc.) and physical competence related to satisfying and safe physical activity participation.⁴

• Instruction includes integration of the intellectual, social and emotional dimensions of participation in physical activity and its relationship to physical health.

• Students are involved daily in quality, health-related physical activity and motor skills instruction at the elementary and secondary level taught by a qualified physical education specialist.

• The curriculum is developmentally and instructionally appropriate in that it is suitable for the specific students being served.

• The physical education program provides instruction in a variety of movement forms and devotes time to instruction about lifetime physical activities.

• The physical education program includes instruction relating to physiological and biomedical principles that support safe participation in physical activity to minimize the risk of injury.

• In addition to class time for skills instruction, the physical education program provides opportunities for all students to have a minimum of 60 minutes of moderate to vigorous health-related activity per week. Programs to promote development of muscular strength, endurance and flexibility are provided three times a week.

• Students in third grade and above participate annually in a health-related physical fitness testing program using an accepted set of measures

to test body composition, muscular strength and endurance, cardiorespiratory endurance and flexibility. Individualized exercise prescriptions are provided based upon the assessment.

• Athletic and playing fields are well maintained and free of hazards.

• Proper and correctly fitted equipment to prevent injury is worn or in place for all athletic practices and events (e.g., mouth guards, break away bases, mats on concrete gym walls, etc.).

• Injury data should be collected and reviewed regularly to identify remedial measures that could prevent future incidents and avoid litigation.

• A policy for transport of injured students should be developed with specific and appropriate guidelines for various types of injuries.

• Equipment for emergencies is accessible and available at practice and competitions.

• Coaches receive continuing education to upgrade their skills in recognizing, treating and preventing injuries.

• Congruence exists between state intramural and interscholastic association recommendations and the sports activities sponsored by the district in order to ensure safety of all players at practice and during competition.

• Effective teaching methods are used to achieve the desired student outcomes related to physical development and lifetime physical activity.

• Ongoing individual assessments of students are performed and serve as the basis for teacher decisions regarding individualization of instruction, curriculum planning, communication with families and evaluation of program effectiveness.

• Class size is equal to the size of other classes.

• The district level administration of physical education staff is involved in identifying staff-development needs and working with school leaders to implement goals that assure achievement of guidelines.

• Staff development provided for the physical education staff is ongoing and effective.

• All physical education staff are trained in appropriate emergency procedures.

• District policies and administrative guidelines reflect a commitment to and accountability for the social and psychological health of students.

• The chief administrator, school board and the school health coordinating council review, at least annually, status reports on the extent to which students demonstrate social and psychological growth and the extent to which identified student needs are met, along with action plans for continuous improvement in guidance, counseling, social and psychological services.

• School policies include provisions for the protection of confidential health/mental health records as defined by federal and state law.

• Mental health services must be directed by a certified or licensed school psychologist or school social worker with a minimum of an advanced professional degree and related national/state certificate.

• A plan to coordinate services with health and other school programs is monitored by the district and used to improve program effectiveness.

• Certified/licensed counselors, school psychologists and school social workers, along with school physicians and nurses, are available to meet the needs of students.

• The counseling and mental health staff is effective in achieving the program objectives.

• The goals of the counseling, guidance and mental health program are clear, based on assessed needs and stated in terms of student outcomes.

• The minimum standard for counselors to students is 1:250; school psychologists to students 1:1000; and school social workers to students is 1:800.

• Counseling, guidance and psychosocial service activities are provided to reduce inappropriate and unhealthy student behavior, promote optimal mental and emotional health and identify and address problems that impede learning.

• Programming with students promotes problem solving, social

skills, decisionmaking, self-esteem building, academic guidance and transitions.

• Peer programs are organized to address health, safety and social issues.

• Coordination of confidential health/mental health records is required.

• The counseling, guidance and mental health staff use available resources from health agencies and other community resources, including volunteers, to facilitate achievement of student and staff mental health needs.

• Effective in-service education is provided by and to the counseling, guidance and mental health staff addressing the multitude of mental health issues of children and adolescents (e.g., multicultural sensitivity, dysfunctional family systems, disability awareness, developmental learning, etc.).

• In-service programs are provided to assist with the implementation of experiences that promote interpersonal development in students.

• Consultation services are available to teachers, administrators, families and others on student and system levels to improve learning and psychosocial developmental outcomes.

• District policies reflect a commitment to meeting the nutritional needs of all students in an environment fostering positive attitudes and social skills.

• The chief administrator, the school board and the school health coordinating council, including the school food service professional, review at least annually, reports on the status of the food and nutrition services and progress toward achieving annual objectives, along with the action plan for continuous improvement of school nutrition.

• Nutrition education is an integral part of the cafeteria experience, complementing the classroom curriculum in comprehensive school health.

• The planning, management and delivery of the nutrition services are directed by a qualified food service/nutrition professional, preferably with a baccalaureate degree in food service systems management.

• The local food service manager has the appropriate training and experience in institutional food service management, including courses in nutrition.

• All food service staff are certified according to their level of practice, meeting state requirements or professional standards.

• Food items available to students during school hours (fund raisers, vending machines, snack bars) that compete for student monies or replace their consumption of regular school meals provide adequate nutrition.

• The goal of the school food and nutrition services is to provide nutritionally appropriate meals to students at a reasonable price in an environment that is pleasant, comfortable and conducive to the practice of positive nutrition behavior.

• School food and nutrition personnel support teachers and students by offering their services, technical expertise and resource materials to enhance nutrition and health education curricula and activities.

• Pleasant eating environments are provided. This includes adequate time and space to eat school meals, cafeterias that are well lighted, at comfortable temperature and sound levels; walls and ceilings in good repair; positive supervision; and role modeling at meal time.

• School staff are recognized as role models promoting nutrition and eating competence.

• Students are taught to make responsible, healthy choices in their meals at school.

• Students eligible for free or reduced-priced meals are receiving these at school. Confidentiality of status is maintained to protect the dignity of students.

• Students with special dietary needs have a written individualized food plan as part of their individualized education plan (IEP). Meals served at school are consistent with the nutritional goals established by the USDA [U.S. Department of Agriculture].

• Meals offered to students include a variety of foods, particularly fresh fruit, fresh vegetables and whole grain products.

• Meals served at school contain the appropriate levels of sodium, calcium and iron.

• Meals are planned with the goal of meeting the recommended 30

percent or less of total calories from fat; and 10 percent or less of total calories from saturated fat.

• Fund raisers, vending machines and sale of foods by organizations other than the school food and nutrition service offer foods that provide appropriate nutrition.

• Menu planning practices reflect the ethnic and cultural food preferences of students.

• Students and families are involved in menu planning, menu evaluation and taste testing.

• Nutrition messages are included on printed menus for students and families.

• Staff development programs are ongoing and effective.

• The staff development program includes training in food service management; the procurement, preparation, planning and promotion of foods/meals; and nutrition education to achieve the goal of providing nutritious meals.

• District policies and administrative guidelines reflect a philosophical and financial commitment to employee health and safety, including support for staff health promotion programs.

• At least annually, the worksite health promotion program is evaluated and a status report is compiled and presented to the chief administrator and the school health coordinating council, along with an action plan for continuous improvement in worksite health promotion for school employees.

• An individual with appropriate training and skills is designated to coordinate the worksite health promotion program and is provided administrative support, including decision-making authority and release time to coordinate the program.

• Staff are encouraged to model a healthy life-style.

• The goals and objectives of the district's staff health promotion program are clear, based on assessed needs and stated in terms of expected outcomes.

• The health promotion programs offered are based upon health assessment and employee preferences.

• Staff are provided access to health assessments, screenings, health education and appropriate referrals.

• School facilities are made available for health promotion activities during non-instructional time.

• Staff are given adequate opportunities and incentives to participate in health promotion activities.

• Health promotion activities offered to school employees include employee assistance programs, smoking cessation, nutrition education, weight management and aerobic activity.

• Confidentiality is maintained regarding all staff assessments.

• District policies and administrative guidelines reflect a commitment to effective school/community relationships.

• The goals and objectives of the school-community component of comprehensive school health are clear, based on assessed needs and stated in terms of intended outcomes.

• An interdisciplinary/interagency school health coordinating council that includes school staff, families who represent all segments of the community, students and community resource personnel is organized at the community level to coordinate programs among agencies that promote the health and safety of youth.

• Interdisciplinary school health teams (committees) that include teachers, families, students, school nurses, physicians, health educators, school psychologists, coaches, social workers/counselors and community resource personnel are organized at the school level to address priority school health and safety issues that interfere with the learning process.

• Interdisciplinary school health teams and the interdisciplinary/interagency coordinating council achieve identified goals by implement-

ing the program planning model (assessment; planning; setting of goals, objectives and strategies; implementation; and evaluation).

• A systematic means for sharing information and resources and coordinating programs is established

• Periodic meetings of the interdisciplinary/interagency coordinating council are held to assess needs, initiate recommendations and evaluate programs.

• Integrated efforts to eliminate illegal use of alcohol and other drugs, use of tobacco, motor vehicle injuries, sports injuries, sexually transmitted diseases, suicide, child abuse, violence, teen pregnancies and other health and safety-related concerns are implemented.

• Evaluations are conducted at least annually to assess the level of satisfaction with the comprehensive school health program.

• Continuing education programs are offered for families and community members.

• Efforts are made to encourage family and other community member attendance and involvement with school and academic programs (e.g., health education, child care, evening meetings, coordination with other school activities).

• A two-way communication system is established between school and homes to encourage maximum involvement in areas of mutual interest.

• Families, after receiving the results of health-related fitness tests, encourage their child to complete an individualized activity plan.

• Programs are provided to assist families and community members in building communication and other family skills, as well as understanding child growth and development.

• A state of complete physical, mental and social well-being and not merely the absence of disease, injury and infirmity.

• A quality of life involving dynamic interaction and independence among the individuals' well-being, their mental and emotional reactions and the social complex in which they exist.

• An integrated method of functioning which is oriented toward maximizing an individual's potential. It requires that the individual maintains a continuum of balance and purposeful direction with the environment where he or she is functioning.

• A set of health-enhancing behaviors, shaped by internally consistent values, attitudes, beliefs and external social and cultural forces.

• An organized set of policies, procedures and activities designed to protect and promote the health and well-being of students and staff which has traditionally included health services, health school environment and health education. It should also include, but not be limited to physical education; food and nutrition services; counseling, psychological and social services; health promotion for staff; and family/community involvement.

• An organization that supports and monitors the implementation of the comprehensive school health program. Members include families, students, teachers, school nurses, physicians, health educators, a child nutrition director and other school health and mental health professionals, as well as community members, including but not limited to representatives from the health district, social services, juvenile justice, voluntary health agencies, business and mental health agencies.