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Introduction

PURPOSE OF THIS INTERIM STATEMENT

The Institute of Medicine has convened a committee to study the potentiality of comprehensive school health programs (CSHPs) in grades K–12. These programs propose to combine health education, health promotion and disease prevention, and access to health and social services, at the school site. While earlier generations of school health programs were predominantly concerned with stemming the threat of infectious disease, such problems have now to a large extent been superseded by the “new morbidities”—injuries, violence, substance abuse, risky sexual behaviors, psychological and emotional disorders, problems due to poverty—and by concerns about many students' lack of access to reliable health information and health care (Dryfoos, 1994). Comprehensive school health programs may be a promising approach for addressing many of the health-related problems of today's children and young people (Allensworth and Kolbe, 1987; Nader, 1990; Lavin et al., 1992; American Academy of Pediatrics, 1993, 1994a).

During the course its study, the committee will examine what constitutes a CSHP, how its components fit together, the desirable and feasible health and education outcomes of these programs, and program configurations to produce optimal outcomes. The committee will also assess the current status of CSHPs and, if appropriate, recommend strategies for their wider implementation. A full report will be produced at the end of the study presenting the committee's findings and recommendations.



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Defining a Comprehensive School Health Program: An Interim Statement 1 Introduction PURPOSE OF THIS INTERIM STATEMENT The Institute of Medicine has convened a committee to study the potentiality of comprehensive school health programs (CSHPs) in grades K–12. These programs propose to combine health education, health promotion and disease prevention, and access to health and social services, at the school site. While earlier generations of school health programs were predominantly concerned with stemming the threat of infectious disease, such problems have now to a large extent been superseded by the “new morbidities”—injuries, violence, substance abuse, risky sexual behaviors, psychological and emotional disorders, problems due to poverty—and by concerns about many students' lack of access to reliable health information and health care (Dryfoos, 1994). Comprehensive school health programs may be a promising approach for addressing many of the health-related problems of today's children and young people (Allensworth and Kolbe, 1987; Nader, 1990; Lavin et al., 1992; American Academy of Pediatrics, 1993, 1994a). During the course its study, the committee will examine what constitutes a CSHP, how its components fit together, the desirable and feasible health and education outcomes of these programs, and program configurations to produce optimal outcomes. The committee will also assess the current status of CSHPs and, if appropriate, recommend strategies for their wider implementation. A full report will be produced at the end of the study presenting the committee's findings and recommendations.

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Defining a Comprehensive School Health Program: An Interim Statement At the onset of the committee's work, it became evident that a broad range of constituencies has become interested and involved in CSHPs, and a variety of conceptions exist about what these programs are and do. The committee itself represents a diversity of backgrounds and experiences, and determined that it would be useful to establish its own working definition of the term, “comprehensive school health program.” This interim statement sets forth the committee's definition; it is intended to serve as a guide for the rest of the committee's work and to stimulate discussion among those involved in the field. WHY THE COMMITTEE NEEDED TO ESTABLISH ITS DEFINITION The structure and operation of a comprehensive school health program have been contemplated, but few, if any, truly comprehensive programs have actually been implemented and institutionalized. The vision of what constitutes a comprehensive school health program continues to evolve, and several models and definitions for these programs have been proposed. Some definitions are conceptual and focus on the desired goals for these programs; others are operational and emphasize essential program processes or components. The committee acknowledges the contributions these various models and definitions have made and uses them as the starting point for its own definition. The committee believes that its definition—and the elaboration of key terms in its definition—will further clarify the nature and essential elements of these programs. Through this interim statement, the committee is also attempting to generate discussion in the education, health, and social services fields and to suggest a common language that might facilitate interactions across these fields. THE CONTEMPORARY CONTEXT FOR THE DEFINITION Interest in the education, health,1 and welfare of our nation's children and youth has reached a new level (National Commission on Children, 1991). Economically, children are the poorest segment of our citizenry,2 and infant 1   The term “health” is used throughout this interim report in a broad sense to include optimal physical, mental, social, and emotional function, not just the absence of disease. 2 The following poverty rates existed in 1992: children under age 18, 21.9%; adults 18–64, 11.7%; adults 65 and older, 12.9% (National Research Council, 1995).

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Defining a Comprehensive School Health Program: An Interim Statement mortality rates in some parts of the country are as high as those in many developing countries.3 The greatest threats to child and adolescent health—injuries, violence, substance abuse, risky sexual behavior, poor dietary and physical activity habits—can be attributed to conditions and behaviors that are preventable. In addition, the major causes of chronic disease and death among adults—cancer, heart disease, injury, stroke, liver and lung disease—can be influenced by health behaviors and lifestyles established during childhood and youth (U.S. Department of Health and Human Services, 1990). To improve the health of all age groups, the U.S. Public Health Service, in partnership with practitioners and private organizations, developed the Healthy People 2000 initiative, a set of nearly 300 national health promotion and disease prevention objectives to be achieved by the year 2000. An examination shows that one-third of these objectives can be influenced significantly or achieved in or through the schools (McGinnis and DeGraw, 1991). Concern about students' academic performance has led to a national education reform movement and national standards in core academic subjects. The relationship between academic achievement and student health status has been acknowledged by the National Education Goals, a bipartisan effort that began at a national governors' summit convened by President Bush in 1989. Among its directives, the National Education Goals call for (National Education Goals Panel, 1994): Students to start school with the healthy minds, bodies, and mental alertness necessary for learning. Safe, disciplined, alcohol- and drug-free school environments. Access for all students to physical education and health education to ensure that students are healthy and fit. Increased parental partnerships with schools in order to promote the social, emotional, and academic growth of children. Although the prospects for future federal health care legislation are uncertain, the reform of the health care delivery system is a topic receiving intense attention. Many states are passing their own legislation to reform health care at the state level; this legislation will affect the quality and equity of care for children as access to care is beginning to differ from state to state. Increasingly greater numbers of individuals participate in managed health care arrangements, which emphasize prevention and early detection of health problems in order to maximize the effectiveness and contain the costs of care. 3 For example, the infant mortality rate for U.S. blacks ranks 40th when compared with other countries' overall rates; countries ranking higher include Jamaica, Costa Rica, Malaysia, and Sri Lanka (Children 's Defense Fund, 1994).

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Defining a Comprehensive School Health Program: An Interim Statement Against this backdrop of health and academic concerns, our nation 's schools stand out as those community institutions that touch all children and families. The school may, in fact, be the public institution that is most familiar, convenient, and welcoming to families, especially families in disadvantaged communities who have the greatest needs and the most limited access to services. Comprehensive school health programs are intended to take advantage of the pivotal position of the school by making the school the location of a set of integrated programs and services to enhance the education, health, and welfare of children and their families. These programs may not only improve health and educational outcomes for students but also reduce overall health care costs by emphasizing prevention and early identification of health problems and by providing easy access to care. CRITICAL ASSUMPTIONS Given today's education and health care environment, the committee began its work with the following fundamental assumptions: The primary goal of schools is education. Education and health are linked; academic performance is related to health status.4 Efforts to promote student health and prevent disease are an essential component of a school's education program. With regard to the last assumption, the committee recognizes the many demands that have been placed upon the schools. Even before beginning its study, the committee agreed that although the school may be the site for programs to promote student health and prevent disease, these programs are not the sole responsibility of the schools but of the entire community,5including the health care and social services sectors. In fact, to emphasize that the responsibility for these programs must be shared, some have suggested that the title “comprehensive school health program ” be reworded or even that the 4   The nature and extent of this linkage will be examined further in the committee's full report. 5 The term “community” will be explained in Chapter 3 as part of the discussion of terms in the definition. However, since the term is frequently used prior to that section, a brief explanation here is in order. The term “community” refers to the wide range of stakeholders at the particular site where the program will be implemented, including parents, students, educators, health and social service personnel, insurers, and business and political leaders.

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Defining a Comprehensive School Health Program: An Interim Statement word “school” be eliminated, lest it be assumed that the burden lies only on the schools. That may not be practical, given the widespread use of the phrase and the fact that the schools do provide the focus and target site for these programs. However, it is likely to be useful in the committee's further work to distinguish the various levels of school responsibility and involvement as follows: Programs/services that schools have the responsibility to deliver, such as classroom instruction. Programs/services that schools have the responsibility to arrange, such as clinical services. Programs/services with which schools should affiliate to benefit students, such as family protective services or public safety campaigns. Programs/services that schools should promote, such as youth services and agencies or church-based programs. In any event, the roles and responsibilities of others beyond the education sector will be closely examined during the rest of the committee's study. ORGANIZATION OF THE REMAINDER OF THE INTERIM STATEMENT Chapter 2 describes the historical background and evolution of health programming in the schools, proposes goals and optimal outcomes for comprehensive school health programs, and reviews previous definitions and models of school health programs. Chapter 3 gives the committee's provisional definition of a comprehensive school health program, with an explanation of terms. This definition may be subject to revision or expansion, based on findings from the committee's study. Chapter 4 sets forth a set of questions and issues that the committee intends to examine in its full report.