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The Evolution of School Health Programs

HISTORICAL OVERVIEW OF SCHOOL HEALTH 6

Numerous public health initiatives, reports, studies, organizations, and professional societies have promoted the development of school health since the colonial American era. In fact, 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. However, prior to the mid-1800s, efforts to introduce health into the schools were isolated and sparse. It was not until 1840 that Rhode Island passed the first legislation to make health education mandatory, and other states soon adopted this concept.

In 1850, the Sanitary Commission of Massachusetts, headed by Lemuel Shattuck, produced a report that has become a classic in the field of public health and had a significant influence on school health. Shattuck served as a teacher in Detroit and member of the school committee in Concord, Massachusetts, where he helped reorganize the public school system of the town. This background led to school programs receiving major attention as a means to promote public health and prevent disease. The report states that

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Much of the information in this synopsis has been excerpted from the book entitled, Historical Perspectives on School Health, by Richard Means, Ed.D. (Means, 1975). The reader is encouraged to refer to this source book for a more complete understanding of the history of school health in the United States prior to 1975.



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Defining a Comprehensive School Health Program: An Interim Statement 2 The Evolution of School Health Programs HISTORICAL OVERVIEW OF SCHOOL HEALTH 6 Numerous public health initiatives, reports, studies, organizations, and professional societies have promoted the development of school health since the colonial American era. In fact, 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. However, prior to the mid-1800s, efforts to introduce health into the schools were isolated and sparse. It was not until 1840 that Rhode Island passed the first legislation to make health education mandatory, and other states soon adopted this concept. In 1850, the Sanitary Commission of Massachusetts, headed by Lemuel Shattuck, produced a report that has become a classic in the field of public health and had a significant influence on school health. Shattuck served as a teacher in Detroit and member of the school committee in Concord, Massachusetts, where he helped reorganize the public school system of the town. This background led to school programs receiving major attention as a means to promote public health and prevent disease. The report states that 6 Much of the information in this synopsis has been excerpted from the book entitled, Historical Perspectives on School Health, by Richard Means, Ed.D. (Means, 1975). The reader is encouraged to refer to this source book for a more complete understanding of the history of school health in the United States prior to 1975.

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Defining a Comprehensive School Health Program: An Interim Statement good health is the basis for wealth, happiness, and long life and that all children should be taught that preserving their health and the health of others is one of their most important duties. Knowledge leads to good health, while ignorance leads to poor health and disease. Between the late 1800s and 1950, many social concerns and public health issues focused on the role of schools in promoting and maintaining health. 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. The era of “medical inspection” in schools started at the end of the nineteenth century in response to problems of urbanization and immigration. In 1894, 50 “medical visitors” were appointed in Boston 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 visual defects 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 their families seek and follow through with treatment. In 1906, Massachusetts made medical inspection compulsory in all public schools and this ushered in broad-based programs of medical inspections in which school nurses and physicians participated. By 1911, there were 102 cities employing cadres of school nurses. In 1913, New York City alone had 176 school nurses. A great deal of the nurses' time was spent in home visits to families with children who had been excluded from school because of illness or infection, encouraging these families to have their children treated and returned to school. During this period the prevalence of tuberculosis in the United States also had a dramatic impact on school health with the development and spread of “open-air classrooms” in all major cities under the supervision of both medical and educational personnel. One of the most influential groups in the development of school health was the Joint Committee on Health Problems and Education, which was jointly sponsored by the American Medical Association (AMA) and the National Education Association (NEA). Prior to 1920, the committee published the report Minimum Health Requirements for Rural Schools. Their 1927 paper Health Supervision and Medical Inspection of Schools strongly promoted the emerging concept of coordination among the medical services, the physical education, and the health education programs in schools. Early in the 1920s, the AMA/NEA Joint Committee on Health Problems and Education reported the results of a nationwide survey on the status of health education in 341 city schools. The findings are particularly interesting

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Defining a Comprehensive School Health Program: An Interim Statement in light of the current U.S. Public Health Service's Healthy People 2000, which calls for an “increase to at least 75 percent the 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, 1990). In the 1920s, over 73 percent of the surveyed schools taught health directly under the name of “health” or “hygiene.” Correlating content in their health curriculum to other subjects such as language, civics, reading, physical education, general science, and art was reported by 108 cities. Daily inspection for health habits was reported by 69 percent of the 341 cities and nearly 30 percent reported having organized student health clubs for the promotion of health in the elementary schools. School health became the focus of a variety of organizations during the 1930s. The May 1938 issue of the Journal of Educational Sociology was exclusively devoted to the subject under the theme “Health Education.” At the end of the decade, the Educational Policies Commission of the NEA issued a report, Social Services and the Schools. The report dealt with administrative guidelines for health examination, medical attention, communicable disease control, mental health, health instruction, the healthful environment and regimen, and health supervision of teachers and employees. The focus on school health continued throughout the next several decades. In 1940, the U.S. Public Health Service published a 100-page pamphlet titled High Schools and Sex Education. In 1940, the Eighteenth Yearbook of the American Association of School Administrators was titled Safety Education. In 1942, the Twentieth Yearbook was Health in Schools. When many World War II draftees were found to suffer from nutritional deficiencies, the school was considered the place to focus on a solution; the National School Lunch Act was passed in 1946 to provide federal funds and surplus agricultural commodities to assist local schools in providing a nutritious hot lunch to school children. In 1950, the Twenty-Ninth Yearbook of the Department of Elementary School Principals of the NEA was titled Health in the Elementary School. The February 1960 issue of The National Elementary Principal also featured elementary school health programs including health services, health instruction, and health administration. The AMA/NEA Joint Committee on Health Problems in Education issued three editions of a publication titled Health Appraisal of School Children. This booklet established “standards for determining the health status of school children, through the cooperation of parents, teachers, physicians, nurses, dentists, and others.” The most significant school health education initiative of the 1960s was the School Health Education Study (SHES). This study defined health as a dynamic, multidimensional entity and outlined 10 conceptual areas of focus that over the years have often been translated into 10 instructional content

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Defining a Comprehensive School Health Program: An Interim Statement areas. These conceptual areas include such themes as human growth and development, personal health practices, accidents and disease, food and nutrition, mood-altering substances, and the role of the family in fulfilling health needs. The primary publication from this initiative was titled School Health Education Study: A Summary Report, which provided the basis for most of the current legislation on school health education (Sliepcevich, 1964). Numerous additional publications resulted from nearly 10 years of this activity, including curriculum designs and teacher–student resource guides addressing the 10 instructional content areas of health education across all grade levels. Several important school health services initiatives also took place in the 1960s, including the U.S. Public Health Service's study of school health services and the Title I provision of the Elementary and Secondary Education Act, which tripled the number of school nurses. Another significant event was the development of the school nurse practitioner role in the late 1960s. At this time, issues of diagnosis and treatment in nontraditional health facilities surfaced, and the prevailing belief was that such activities were not permissible by any primary care provider, including physicians in the school. However, by 1972, a state-by-state survey sponsored by the Robert Wood Johnson Foundation failed to uncover any legislation that would prohibit the delivery of these services in schools, and working in close collaboration with physicians, the clinical functions of school nurses were expanded to include primary care services. The introduction of school nurse practitioners into schools resulted in reaching students in need of primary care, an increase in problem resolution rates, and greater accuracy in excluding students from school for illness and injury (Hilmar and McAtee, 1973; Kohn, 1979; Silver et al., 1976). During the twentieth century, several White House conferences have been convened that relate directly to school health issues. One of the most important was the White House Conference on Children and Youth, which had a session in December 1970 on children under age 13 and a session in February 1971 on young people over age 13. Each of the landmark conferences resulted in specific recommendations and suggested programs related to school health services, health instruction, and a healthy school environment. Many additional developments in school health have taken place in recent years. Examples include: the establishment and funding of school health initiatives through the Centers for Disease Control and Prevention; the creation of a Federal Interagency Committee on School Health, chaired by the assistant secretaries of health and of elementary and secondary education, and a National Coordinating Committee on School Health; and the Robert Wood Johnson Foundation school-based clinic initiative, which catalyzed the rapid proliferation of school-based clinics.

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Defining a Comprehensive School Health Program: An Interim Statement The committee will revisit some of these historical developments in its full report in order to understand the lessons learned and the bases for current programs. However, it is clear from this brief overview that for many decades, health and education professionals have joined together to establish, implement, and evaluate school health programs in response to societal needs. The history of these school health programs provides perspective and a valuable resource of information for understanding current programs and for designing and improving programs in the future. THE COMPREHENSIVE SCHOOL HEALTH PROGRAM Today, school health has evolved into what is termed a comprehensive school health program (CSHP). The committee believes that the general goal of a CSHP is to establish a system of home, school, and community support to assure that students are provided with a planned sequential program of study, appropriate services, and a nurturing environment that promotes the development of healthy, well-educated, productive citizens. At this preliminary stage, the committee has proposed a set of optimal outcomes for CSHPs—a vision of what these programs ought to be and what they might be able to do. The feasibility of these outcomes and possible strategies for achieving them will be examined in the committee's full report. The optimal outcomes can be categorized into three general areas: student outcomes, programmatic and organizational outcomes, and community outcomes. Student Outcomes Students will assume personal responsibility for avoiding social, emotional, and physical health-compromising behaviors and for engaging in health-promoting behaviors. Students' health needs—preventative, emergency, acute, and chronic—will be addressed to allow students to reach the highest possible level of educational achievement and personal health. Particular attention will be given to the health component of Individual Education Plans of students with special health care needs who require special education and related services.

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Defining a Comprehensive School Health Program: An Interim Statement Programmatic and Organizational Outcomes The relationship between health status and educational achievement will be evident in the policies and programs of the school. The school 's health emphasis will be integrated across all activities. Linkages among program components, disciplines, and participating agencies will be clearly defined and regularly evaluated. Individual and group health problems will be identified and managed with appropriate prevention, assessment, intervention or referral, and follow-up measures. Services will be organized to provide appropriate and timely responses to emergency, acute, and chronic health problems. The school's education and health programs will be continually reexamined and reformed as necessary to enhance student health, performance, and achievement. Community Outcomes The community will be actively involved in determining the design of a school health program and in supporting and reinforcing the goals of the program. This design will include assurance that schools are safe, with an environment conducive to learning and health promotion, and that policies and procedures are in place to enhance the use of schools as a community resource for health. All health-related programs delivered by the school and by community members through the schools will enhance the health status of the students and result in an improvement of the health and quality of life of the community. PREVIOUS DEFINITIONS AND MODELS OF SCHOOL HEALTH PROGRAMS The Three-Component Model The three-component model is considered the traditional model of school health programs. Originating in the early 1900s and evolving through the 1980s, this model defines a school health program as consisting of the following three basic components: Health instruction is accomplished through a comprehensive health education curriculum that focuses on increasing student understanding of health principles and modifying health-related behaviors.

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Defining a Comprehensive School Health Program: An Interim Statement Health services includes prevention and early identification and remediation of student health problems. A healthful environment is concerned with the physical and the psychosocial setting and such issues as safety, nutrition, food service, and a positive learning atmosphere. The Eight-Component Model In the 1980s, the three-component model was expanded to include additional components (Kolbe, 1986; Allensworth and Kolbe, 1987). According to this model, a comprehensive school health program contains the following eight essential components: Health education consists of a planned, sequential, K–12 curriculum that addresses the physical, mental, emotional, and social dimensions of health. Physical education is a planned, sequential, K–12 curriculum promoting physical fitness and activities that all students could enjoy and pursue throughout their lives. Health services focuses on prevention and early intervention, including the provision of emergency care, primary care, access and referral to community health services, and management of chronic health conditions. Services are provided to students as individuals and in groups. Nutrition services provides access to a variety of nutritious and appealing meals, an environment that promotes healthful food choices, and support for nutrition instruction in the classroom and cafeteria. Health promotion for staff provides health assessments, education, and fitness activities for faculty and staff, and encourages their greater commitment to promoting students' health by becoming positive role models. Counseling, psychological, and social services include school-based interventions and referrals to community providers. Healthy school environment addresses both the physical and psychosocial climate of the school. Parent and community involvement engages a wide range of resources and support to enhance the health and well-being of students. The Division of Adolescent and School Health of the Centers for Disease Control and Prevention has promoted the eight-component model, and it has received widespread attention and adoption by many states in recent years.

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Defining a Comprehensive School Health Program: An Interim Statement Joint Committee on Health Education Terminology In 1990, the Association for the Advancement of Health Education convened a committee of delegates from the Coalition of National Health Organizations7 and the American Academy of Pediatrics. The charge to this Joint Committee on Health Education Terminology was to review and update earlier terminology and to provide definitions for new terms currently used in the health education field. The Joint Committee defined a CSHP as follows (Joint Committee on Health Education Terminology, 1991): A comprehensive school health program is 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, healthful school environment, and health education. It should also include, but not be limited to, guidance and counseling, physical education, food service, social work, psychological services, and employee health promotion. Related Models and Definitions In recent years, additional models, definitions and descriptions have emerged that build upon previous models. Several examples are discussed below. Nader (1990) has proposed that the school is one locus of a broad range of health and educational activities, carried out by a diverse group of health and educational personnel based both in the community and in the school. The model emphasizes that the school, community, and family/friends are the three important systems supporting children 's health status and educational achievement. Further, the media—including educational, electronic, and print media—play a prominent role as part of the community system in influencing health-related behaviors. According to this model, the first steps in developing a CSHP are to establish community linkages and carry out a community needs and resources assessment. These steps will then lead to the implementation and 7 Members of the Coalition are: American Public Health Association, School Health Education and Services Section and the Public Health Education and Health Promotion Section; American College Health Association; American School Health Association; Association for the Advancement of Health Education; American Alliance for Health, Physical Education, Recreation and Dance; Association of State and Territorial Directors of Public Health Education; Society for Public Health Education, Inc.; and the Society of State Directors of Health, Physical Education and Recreation.

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Defining a Comprehensive School Health Program: An Interim Statement expansion of school health services, school health education, and a healthful school environment. Allensworth (1993) has described a CSHP by what it does, rather than by listing what it contains. According to this model, a comprehensive school health program: Focuses on priority behaviors that interfere with learning and long-term well-being. Fosters the development of a supportive foundation of family, friends, and community. Coordinates multiple programs within the school and community. Uses interdisciplinary and interagency teams to coordinate the program. Uses multiple intervention strategies to attain programmatic goals. Promotes active student involvement· Solicits active family involvement. Provides staff development. Accomplishes health promotional goals via a program planning process. The Illinois Department of Health has recently developed a model of a CSHP as part of their long-range plan for school health (Wallace et al., 1992). This model consists of six critical elements: management, health promotion and education, school health services, healthy and safe environment, integration of school and community programs, and specialized services for students with special needs. The distinguishing characteristics of this model include the importance of the management role in coordinating and integrating the other critical elements, and the emphasis on students with special health care needs. International models often include the school health program as an element of a country's primary health care system (Wallace, et al., 1992). Although each country's approach to primary health care may vary, school programs throughout the world typically include components of preventive, promotive, curative, and rehabilitative services. Another prominent feature in many countries is the strong collaboration between the school nurse and physician, with both health professionals often available to the school, either on a full- or part-time basis.

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Defining a Comprehensive School Health Program: An Interim Statement Full-Service Schools Previous definitions and models have culminated in the full-service schools model (Dryfoos, 1994). A full-service school is the center for collocating a wide range of health, mental health, social, and/or family services into a one-stop, seamless institution. The exact nature and configuration of services and resources offered will vary from place to place, but services should thoroughly address the unique needs of each particular school and community—hence the title “full-service schools. ” According to this model, a full-service school provides a quality education for students that includes individualized instruction, team teaching, cooperative learning, a healthy school climate, alternatives to tracking, parental involvement, and effective discipline. The school and/or community agencies provide comprehensive health education, health promotion, social skills training, and preparation for the world of work. A distinguishing feature of this model is the broad spectrum of services to be provided at the school site by community agencies. Some examples of these various services include: Health services: health and dental screening, nutrition, and weight management. Mental health services: individual counseling, crisis intervention, and substance abuse treatment and follow-up. Family welfare and social services: family planning; child care; parent literacy; employment training; legal services; basic services for housing, food, and clothing; and recreation and cultural activities. SUMMARY The preceding discussion of definitions and models is not intended to be exhaustive. Other worthy definitions and models may exist, and any exclusion from this discussion is not intended to minimize their importance. Instead, the purpose of the preceding discussion is to illustrate the diversity of definitions that exist and to emphasize that as these models and definitions have evolved, they tend to become more complex and appear to demand more from the schools and community.