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Defining a Comprehensive School Health Program: An Interim Statement 4 Issues to Be Addressed in the Full Report In the remainder of its study, the committee will examine the structure and functioning of comprehensive school health programs (CSHPs), consider evidence for the effectiveness of these programs and possible approaches for restructuring programs to increase effectiveness, and, if appropriate, recommend strategies for wider implementation of effective programs. In order to carry out these tasks, the committee has identified, at this preliminary stage, some questions that are important to the further study of CSHPs. The committee recognizes that an extensive analysis has already been carried out on some of these questions by others, and in these cases the committee will review existing work. In other cases, no simple answers may exist. In some of those situations, the committee may propose an answer, based on a consensus reached through the knowledge and expertise of its members. In cases where insufficient evidence exists or no consensus can be reached, the committee will seek to point out the knowledge gaps and recommend how they might be addressed. The committee also recognizes that it may not be feasible to answer all of these questions, but they may provide the basis for future studies. The committee has organized its preliminary questions into the following categories: fundamental understandings, program outcomes, comprehensive programming, health education, health-related services,
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Defining a Comprehensive School Health Program: An Interim Statement research and evaluation, funding, local, state, and federal policy, personnel and training issues, and obstacles and opportunities. FUNDAMENTAL UNDERSTANDINGS In order to understand how comprehensive school health programs may possibly affect student health and education outcomes and future health literacy, the committee will examine the following questions: What are the basic health needs of children and young people? What are the role and responsibility of the school in meeting these needs? What lessons have been learned from the 150-year history of health programming in schools? What are appropriate measures of health status? Of educational achievement? What is known about the nature and extent of the linkage between health status and educational achievement? How, to what extent, and for what duration, might CSHPs influence health and education outcomes and future health literacy? PROGRAM OUTCOMES Some of the optimal outcomes of CSHPs described earlier may not be feasible to achieve or measure. Yet in order to establish criteria for determining the effectiveness of these programs, realistic and measurable program outcomes must be identified. Therefore, the committee will seek answers to these questions: What are the realistic and measurable student, teacher, parent, organizational, and community outcomes that can be expected from comprehensive school health programming? What are the similarities or differences in expected student outcomes, depending on developmental and grade level? Are changes in health knowledge and attitudes sufficient endpoints for measuring the effectiveness of CSHPs, or should programs be considered ineffective unless there is an impact on related health behavior and health problems are adequately and appropriately addressed? What changes in health status should be considered meaningful endpoints for CSHPs?
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Defining a Comprehensive School Health Program: An Interim Statement What should be the evaluation standards in order to attribute improved health and education outcomes to CSHPs? Can realistic and measurable outcomes be achieved at reasonable cost? COMPREHENSIVE PROGRAMMING The distinguishing feature of the committee's provisional definition of a comprehensive school health program is that many separate elements work in harmony in an “integrated” fashion. Questions about the specific nature of these programs and how schools and communities can provide such intensive programming are: To what extent have CSHPs been implemented and evaluated? What are the findings? What role should the various program components (e.g. health education, physical education, health services, nutrition services, counseling and psychological services, social services, staff work-site health promotion, and healthy school environment) play in a CSHP? What does “integration” of program components mean in practice? How can the impact of integration be measured? Are student outcomes enhanced when program components are integrated? How does organization of the school affect the integration of the components of a CSHP? What is considered the state-of-the-art CSHP? What factors appear to predict success (or lack of success) of a program? What is the best process for establishing and implementing a CSHP? HEALTH EDUCATION Health education is considered an important component of CSHPs, yet the role and organization of health instruction within our education agenda is unclear. From this uncertainty arise obstacles in incorporating health education as a credible and critical part of a student's overall education. To address these issues, the committee will consider the following: Where in the school curriculum does health education best fit? How can health education best articulate with other subjects? What are the nature and extent of the preparation of health education teachers? How do the quality and quantity of teacher preparation influence the effectiveness of health education?
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Defining a Comprehensive School Health Program: An Interim Statement Should there be a standardized curriculum for school health? Should there be a national standardized assessment of student health knowledge? Which health problems or health risk behaviors should be given priority in health instruction? How would this vary by grade level? Are there advantages—or possible disadvantages—of incorporating health topics into other curricular areas? Of incorporating other curricular areas into health education? Are there advantages—or possible disadvantages—of integrating health education into the delivery of health services to individuals and groups? What evidence exists about the effectiveness of various health education modalities, such as skills training, fear messages, and peer interventions? Is there sufficient evidence to recommend a minimum “dose” of health education, within and across developmental stages? Does an increased dose of health education produce more lasting effects? Is there evidence of a synergistic effect between health education and the other components of a CSHP? Which statistically significant health education outcomes have actual public health significance? HEALTH-RELATED SERVICES Communities are exploring new ways to provide equitable, efficient, and effective health care for children. Since schools are “where the children are,” the school is receiving increased attention as the site for access to health-related services. To determine how best to provide these services, the committee will ask: What is the range of school-affiliated health-related services? What health-related services are school districts currently mandated to provide? Are these mandates scientifically sound? What are the principal sources of health services and health information for students? Are these sources adequate? If not, why not? How would the situation be different if school-affiliated services were more widely available? What should be the role of educators and administrators in providing health-related services? To what degree should school-based health and social services be integrated into the total school program? What are the advantages—and possible disadvantages—of the schools, rather than other community institutions, serving as the site for primary health care?
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Defining a Comprehensive School Health Program: An Interim Statement How might the range and types of needed school-affiliated services vary depending on community demographic and socioeconomic characteristics? What are the mechanisms to coordinate school health services with health services in the community? RESEARCH AND EVALUATION Comprehensive school health programs have not been implemented to a sufficient extent to provide a broad knowledge base about these programs. Research and evaluation of varying quality have been done in categorical areas, both in instruction and in services, but typically programs have not been studied comprehensively. The committee will make recommendations about conducting research on comprehensive school health programs and criteria for judging effectiveness by first examining: What kinds of research and evaluation studies have already been done? What research and evaluation studies are needed to measure the impact of CSHPs? What should be the criteria for declaring a program successful or effective? What existing databases can be utilized in research and evaluation of CSHPs? How might the effects of programs delivered in “real-world” settings differ from those of programs delivered under experimental or research conditions? Is a meta-analysis of CSHP evaluations useful and feasible? If so, what criteria should be used in selecting studies? What is the receptivity to the CSHP concept by teachers, administrators, school board members, families, and the community? What is the level of understanding of the CSHP concept of these groups? How does the level of understanding relate to receptivity? FUNDING For many years, free and appropriate public education has been a standard entitlement in this country. In these days of increasing needs, financial constraints make the provision of quality education problematic. The inclusion of school-affiliated health and social service delivery adds a new dimension to this tension, so the committee will ask:
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Defining a Comprehensive School Health Program: An Interim Statement What is known about the costs and benefits of CSHPs, especially at particular grade and developmental levels? What is the current public perception about the importance and cost/benefits of CSHPs? Are current priorities and investments in school health programming consistent with cost/benefit analyses? What should be the role of federal, state, or local governments in providing financial support for CSHPs? The private sector? What kinds of administrative and fiscal relationships at federal, state, and local levels appear to work best? Should the fiscal “ lead agency” at the local level be the school system or some other community agency(ies)? How might the school system's participation be influenced if it is not the lead agency? Should health services be considered part of the guarantee of free and appropriate education? LOCAL, STATE, AND FEDERAL POLICIES Local control of education has been a tradition in this country. Furthermore, most experts believe that successful school health programs require the active involvement of the community in which the children live. However, with the diversity of mores, values, and needs in each community, stimulating and maintaining the community's participation in and support of the school health program is likely to be a challenge. While the local context is crucial, state and federal policies may also play an important role in fostering or inhibiting the success of these programs. To assess the impact of these factors, the committee will examine: What is the proper balance between prescriptive program standards and local autonomy? Who should take the lead at the community level? Is there an optimum model for governance and administration? How should a community's needs be assessed? How can disagreements and conflicting views be resolved? How might community institutions—such as businesses, institutions of higher education, and academic health centers—become involved in CSHPs? How might state and federal policies enhance or inhibit the success of local programs? What data are needed by various constituencies in order to make policy decisions?
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Defining a Comprehensive School Health Program: An Interim Statement PERSONNEL AND TRAINING ISSUES Funding for schools and public health is constrained and many community agencies are undergoing restructuring; however, the scope of school health programs continues to broaden. As a result, new roles may emerge for personnel working in the area of school health, requiring new kinds of preservice and inservice training. Questions relating to training issues are: What kinds of educators and health care providers will be required in the future? How might the reorganization or blending of traditional roles produce new careers, and possibly new disciplines, in the field of child and adolescent health? Who should delineate the various roles of community and school personnel in the CSHP? Who should coordinate the efforts of consolidating and integrating the diverse components of a CSHP? What should be the qualifications of a classroom teacher of health education? What are the issues involved in delegation of health care from the primary care practitioner to school personnel? What changes might be required in preservice and inservice training to produce the personnel needed for CSHPs? How might training and personnel recommendations differ in primary and secondary grades? OBSTACLES AND OPPORTUNITIES Once a community is committed to establishing a comprehensive school health program, many barriers and obstacles still make implementation of such programs difficult at best. The committee will ask: What are the principal barriers and obstacles—are they legal, regulatory, political, territorial, technological, time demands, or labor intensiveness? What are the core changes that must be made to overcome or modify these barriers?
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Defining a Comprehensive School Health Program: An Interim Statement SUMMARY As mentioned earlier, a review of the existing literature may provide concrete answers to some of these questions. In other cases, the committee may attempt to arrive at an answer through consensus based on the knowledge and expertise of members, or may simply point out those areas that require more research before an answer can be obtained. The committee also realizes that it may not be feasible to address all of these questions in this study, but they may provide the basis for future studies. The committee has charted an ambitious course for its work but trusts that its full report will be of vital interest to families, educators, health service providers, and policymakers —in short, to everyone concerned with the health, education, and quality of life of our nation's children and young people.
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