Defining a Comprehensive School Health Program: An Interim Statement (1995)

The provisional definition of a comprehensive school health program (CSHP) adopted by the Committee on Comprehensive School Health Programs in Grades K–12 follows:

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

The committee recognizes that many widely used definitions of CSHPs list a set of essential program components. The committee acknowledges that there are undoubtedly certain basic key components of these programs but decided not to define a CSHP in terms of these components at this initial stage of deliberation. During its study, the committee will examine evidence about the impact and interrelationship of various program components, and in its full report the committee will likely make recommendations about the importance and necessity of particular components. Since communities' needs and resources vary, perhaps the components—or the relative emphasis on various components—may be different from one community to the next. Thus, the committee chose to adopt a preliminary definition that would be compatible

with existing definitions but not confine or constrain the committee 's study. The committee's definition emphasizes the unique features of these programs—family and community involvement, multiple interventions, integration of program elements, and collaboration across disciplines. Each italicized term or phrase in the definition is explained in the following discussion.

The term comprehensive means inclusive, covering completely and broadly, and refers to a broad range of health and education components. Thus CSHPs are a broad set of school-based and community-based components involving a wide range of professionals. Examples of components include health education, health services, physical education, counseling and psychological services, nutrition and food programs, a healthful and supportive school environment, work-site health promotion for school faculty and staff, and integration of school programs with a wide range of community health and social programs. These components provide educational, social, and health care interventions assisting students and families in preventing disease, promoting and protecting health, minimizing the complications of health problems, and managing chronic conditions.

While comprehensive implies broad and complete coverage, it should be emphasized that programs and services actually delivered at the school site may not provide complete coverage by themselves. Instead, school-site programs and services are intended to work with and complement the efforts of families, primary sources of health care, and other health and social service resources in the community to produce a continuous and complete system to promote and protect students' health.

Integrated means to form, coordinate, or blend into a functioning or unified whole, to unite. When the various elements of CSHPs are integrated, they mutually reinforce and support each other, and produce a whole that is greater than the sum of its separate parts, in meeting the health needs of students and fostering student health literacy.

As an example, consider how the various elements of a CSHP might be integrated in the area of nutrition. Lessons on nutrition in the health education classroom can be supported by a school food service that serves healthful, well-balanced meals and labels the nutritional content of cafeteria selections.

Classroom lessons can also be strengthened by school policies requiring that foods available through vending machines and fundraising drives meet a high standard of nutrition. School nurses and counselors can promote awareness about weight management and eating disorders and provide assistance for students with problems in this area. Physical education instructors can help students understand the relationship between nutrition and physical stamina and performance, and nutrition-related topics can enhance instruction in other subject matter areas, such as science, mathematics, and social studies. Community-wide campaigns can promote nutrition awareness so that healthy eating habits acquired in school will be reinforced in the home.

A single standard process for achieving integration does not exist, for each situation is unique. In general, however, an integrated program is characterized by a community-based approach to identify the needs and resources in the educational, health care, and social services areas, and to develop a delivery system that may more effectively and efficiently meet these needs (American Academy of Pediatrics, 1994b).

The term planned implies a deliberate design, a detailed formulation of a program of action. Planning involves developing an orderly arrangement of program strategies, activities, and services, after careful consideration of needs and resources, in order to meet the needs of students and their families. Comprehensive school health programs should include a planning process that involves a broad range of people—providers and recipients of programs and a cross section of community members. The planning process should begin by conducting a local needs and resources assessment and establishing desired local goals and outcomes. A program to achieve the goals must then be designed and implemented, with specific timelines and benchmarks. An essential component of the planning process is ongoing process and outcomes evaluation.

The term sequential implies a deliberate ordering or succession of program elements, so that each successive event builds upon previous student experience and is compatible with a student's developmental status. Health beliefs, behaviors, and needs of children change with age and experience. As children grow to full size and maturity, different physical, cognitive, social, personal, and sexual characteristics must be addressed. Early case finding must

identify and promptly confront any problems that would interfere with this process. A sound understanding of child development principles —including physical, cognitive, social, and emotional development—is required to design an effective sequence or ordering of program activities.

The term school-affiliated refers to activities that are school-based, school-linked, or have any other connection with the schools. School-affiliated activities generally represent a collaborative effort in which the school and community partners share in the planning and governance responsibilities. Examples include health services, environmental health and safety measures, counseling programs, and social services. School-affiliated activities may be provided on-site at the school (school-based) or off-site but coordinated with the school (school-linked). School-based services may be provided by school personnel or by community agency personnel working on-site at the school. Generally, school personnel do not provide services outside the school, although community outreach and home visits by school personnel are often utilized in school-linked programs.

Strategies, activities, and services refer to approaches, methods, actions, and interventions for the purpose of accomplishing program goals and objectives. Strategies are the overall approach or network of related methods and processes, carefully designed to achieve desired goals. Examples include policy mandates, environmental change, media use, role modeling, and social support. Activities and services are those specific and concrete actions carried out as part of a strategy. Examples are classroom lessons in health education, fitness exercises in physical education, the provision of nutritious and appealing school meals, health screening, and psychological counseling. All strategies, activities, and services should be carried out in a culturally sensitive and competent manner. They should be designed to enhance student knowledge and skills, encourage desired behavior, promote appropriate use of professionals, and advance physical, mental, and emotional health.

Development refers to the process of growth, advancement, and maturation. Comprehensive school health programs provide age-appropriate activities, programs, and services that take into account students' developmental needs and help students achieve developmental milestones. Optimal development implies setting children on a course of growth and maturation that will lead to a healthy adulthood. The most important risk factors responsible for chronic disease and premature death among adults can be attributed to unhealthy habits and lifestyles, and the foundations for these behaviors are established in childhood and adolescence (U.S. Department of Health and Human Services, 1990). During the formative developmental years, children and young people spend a significant proportion of their time in schools. Schools can be pivotal in promoting health-enhancing behaviors, detecting health-threatening conditions, and contributing to development of the next generation of productive healthy adults.

Involves means to engage as a participant, to include. Supportive implies help, assistance, advocacy—to hold up or serve as a foundation. Family is defined here in its broadest context. A family includes one or more children plus one or two parents, a legal guardian, or an adult acting as a care provider. In the absence of any of these arrangements, a designated adult or group residence may take responsibility for a child.

Family involvement implies that the family has knowledge of the CSHP—and participates in community deliberations to determine the needs and the activities, strategies, and services that are to be offered. Adult family members serve on the advisory committee for school-based health centers and work with teachers or school boards in the design and delivery of health education and health promotion curricula and services. Parental consent for services is based on laws specific to each state, and families are informed about the confidentiality policies that govern school-based health programs.

Comprehensive school health programs provide support to families in many different forms. Primary health services may be available on-site in the school or made more accessible through better linkages with community health care providers. Access to services for the entire family, including siblings and parents, may be facilitated. Family visiting, consultations, and counseling may be provided in conjunction with social and mental health services. Other school-affiliated activities and services of CSHPs that involve families may include: parenting education, nutrition education, provision of meals, physical

activity and aerobics programs, and community use of school facilities for sports.

If families are closely involved in the program and program developers are sensitive to community concerns, CSHPs will support, not supplant, the role of the family in developing the health of children and improving the quality of life in the community.

Determined means to come to a decision by investigation, reasoning, or calculation, to settle or decide by choosing among altematives or possibilities. The local community refers to the wide range of stakeholders—parents, students, educators, health and social service personnel, insurers, business and political leaders, and so forth—at the particular site where the program will be implemented. The form and structure of a CSHP should not be perceived as being imposed on the local community by some outside mandate but should be determined through a deliberative process by those who will be involved in and affected by the program.

Although local autonomy is important for community involvement, commitment and support, it is important to recognize in advance that tensions may arise. Conflicting views within a community will need to be resolved so that differences do not lead to gridlock. Program standards proposed by the community must satisfy the quality standards of those professions involved in school health in order to ensure program quality, safety, and effectiveness. In fact, professional standards can function as basic unifying forces from one school system to another.

The term needs refers to the lack of something desirable or useful and to conditions requiring relief or remediation. An important step for a community in establishing a CSHP is to conduct a comprehensive needsassessment to determine the health status of its children and young people, recognize health promotion and education opportunities, and identify existing conditions that require help and relief. Resources refer to the strengths and sources of relief or recovery within the community—the ability of the community to meet and handle the situation. The components of a CSHP should be based upon documented needs, fill gaps in education and services, and draw from community strengths and available resources.

Standards and requirements refer both to professional and legal criteria and to community ethics, mores, and values. School health programs are currently influenced by state laws and regulations mandating certain procedures. These legal mandates influence to a great degree the distribution and nature of staff and services that can be provided. Certainly in designing a CSHP, a community must conduct a careful evaluation of existing statutory requirements. In addition, program design must consider and be sensitive to the cultures, values, and moral standards of the community.

Coordinate means to bring into combined action, to cause separate elements to function in a smooth concerted manner. Multidisciplinary teams involve individuals with different backgrounds, skills, and knowledge working together. Coordination implies a formal relationship, mutual understanding of mission, planning and division of roles, and open communication channels; however, the coordinating partners can still retain their identity and affiliation to their profession.

In today's terminology, coordination and integration of services entail going beyond merely working together in a harmonious fashion; in newer models of integrated service programs, it is expected that the usual professional roles and responsibilities will be shared and less distinct. At the institutional level, it means more effective collaboration among agencies, joint funding, relaxation of bureaucratic barriers and regulations, simplification of procedures, involvement of both the public and private sector, and transfer of power and decision-making to the local community.

The use of the term multidisciplinary team reflects the committee's opinion that a distinguishing feature of a CSHP is the involvement of individuals with varied skills and knowledge. Even in a small or isolated school, it should be possible to find two or more individuals with different disciplinary backgrounds to coordinate the program, link it to the community, and see that the separate program elements function in a smooth concerted manner.

Accountable means responsible, answerable. Accountable refers to the planners, coordinators, and implementers of a CSHP. These individuals are responsible to the community in which the program operates to assure that the program has a high degree of excellence and produces the desired results—that

there is a sustained partnership with the community, including ongoing interaction during the planning, implementation, and evaluation of the program. Accountability includes making process and outcome measurements, providing this information to allow for informed decision-making, and financial responsibility.

Quality refers to the degree of excellence; effectiveness has to do with producing the desired result. Judgements about quality contain subjective elements, while measures of effectiveness tend to be more objective. Quality and effectiveness are interrelated in CSHPs—the existence of one implies the presence of the other.

Quality reflects the degree to which the program is consistent with current professional knowledge and standards, is delivered by competent personnel in a manner that respects and protects the dignity of the recipients (students, families, communities), and is delivered within an accountable system in which resources are used efficiently with minimal waste and cost. Effectiveness is the degree to which the program improves desired outcomes—health, developmental, and educational. Effective programs carefully match needs with appropriate and necessary interventions. They ensure the proper use of and access to needed interventions and avoid unnecessary or inappropriate interventions that can waste resources and increase the risk of harmful side effects. An implicit component of a high-quality, effective program is the presence of an ongoing feedback system that monitors processes and outcomes, and continually adjusts processes to optimize outcomes.