A comprehensive school health program to improve health and education

Health and learning are inextricably intertwined. Simply, a child who is sick cannot learn or learn to the extent of his or her potential. Schoolaged youth face significant challenges. These include violence, drug abuse, sexually transmitted diseases including HIV infection, unintended pregnancy, school dropout, and disrupted family and home situations. Ultimately they translate into significant problems in terms of mortality, morbidity, and social problems. Many of these problems are preventable. The opportunity costs of these behaviors are enormous. Addressing them would result in substantial improvements in health status and economic productivity throughout the entire population. A comprehensive school health program is a promising approach to address these concerns. Models and guidelines for a comprehensive school health program exist. However, the implementation is far from satisfactory. This article discusses the importance of a comprehensive school health program. While certainly no panacea, a comprehensive school health program is more than an expenditure. It is an investment in a most valuable resource, our youth, our future.

Promoting the health and well being of children and adolescents is a generally accepted value of our society. In part, this value stems from their vulnerability. They lack the resources, knowledge, and skills to function independently. Support also represents the realization that the children an adolescents of today are the leaders and citizens of tomorrow; they are our future. Schools can and should play an important role with respect to the health of this important population, and a comprehensive school health program can help achieve this goal.

The Importance of the School Setting Schools are a major institution which can influence the health and well being of our youth. Except for the family, schools have more influence on our youth than any other institution. In the United States more than 95% of those ages 5-17 are enrolled in school. This translates to about 48 million youth attending almost 110,000 elementary and secondary schools for about six hours of classroom time a day for approximately 180 days per year. At the federal level, the importance of the role that schools can play has been highlighted by Dr. Michael McGinnis (McGinnis, 1981), former Director of the U.S. Public Health Service Office of Disease Prevention and Health Promotion, who indicated that factors which shape our lifestyles and our environment play a dominant role in our health status. Also, he indicated that the nation's schools provide an appropriate and efficient medium for educating our children about the increasingly complex risks to health and about the ways in which individuals and society can control those risks. More recently this message was reinforced by the Centers for Disease Control and Prevention Director, Dr. David Satcher, (Satcher, 1995) who stated, "Schools are the only public institution that can reach nearly all youth; therefore schools are in a unique position to improve not only the educational status but also the health status of young people throughout the nation" (p. 289).

Health and learning are inextricably intertwined. Simply, a child who is sick cannot learn or learn to the extent of his or her potential (American Cancer Society, 1995). Similarly, most would agree that education is an important component in one's ability to function successfully in society. Health is an essential component of that equation. Those involved with education have long recognized the link between health and learning. In support of this relationship, Shane (Shane, 1976) cites the original 1918 Cardinal Principles of Secondary Education that indicate the health of the individual is essential to the vitality of the of the Nation. As such, health was place first with regards to the objectives of education. Additional support for this position is provided by McGinnis (1981), who points out, "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" (p. 13). This relationship between health and learning has been reinforced by the National Association of School Boards (NASB, 1991) who maintained that a combination of instruction, health services and the establishment of a safe and healthy school environment offer the most efficient means for improving academic achievement opportunities and solving behavior-related problems which are major steps toward meeting our national need for healthier and more productive citizens. They also indicate that comprehensive school health programs, can provide the means for addressing the plethora of health and safety issues that confront school districts-from absenteeism and AIDS to steriod use and suicide.

Health Status of Youth

Analyzing the health status of the school aged population is a classic case of a good news-bad news scenario. Compared to other age groups, school aged youth are among the healthiest segments of the population (Pickett, 1990). The overwhelming majority of them will not only survive to adulthood but well beyond the mystical age of three score and ten. However, there is substantial reason for serious concern (AAHPERD, 1988). This concern is highlighted by the National Commission on the Role of the School and the Community in Improving Adolescent Health (1990), which was a joint effort by the National Association of State Boards of Education (NASBE) and the American Medical Association (AMA). In their Commission Report, Code Blue: Uniting for Healthier Youth (1990), they stated, "First, never before has one generation of American teenagers been less healthy, less cared for, or less prepared for life than their parents were at the same age-yet in many respects that is the case for adolescents today" (p. 3).

Yes, school aged youth have always faced challenges but, unlike previous generations, never at such epidemic levels. These challenges include violence, drug abuse, sexually transmitted diseases including HIV infection, uninteded pregnancy, school dropout, low literacy, and disrupted family and home situations. Ultimately they translate into significant problems in terms of mortality, morbidity, and social problems. It is important to realize that these problems have implications beyond simply imperiling the immediate health of our youth. In the short term they impact educational achievement. In the longer term they have significant social and economic impact that affect future well-being and prospects for a fulfilling life. Ultimately, the implications are even broader than the individual student risk. As indicated in Code Blue:

"The crux of this emergency is simply that far too many of our teenagers have lost their way and are engaging in destructive behaviors that imperil their immediate health. This crisis is not, as some people believe, confined to communities that are suffering from poverty and crime: Indeed, it involves millions of teenagers in every neighborhood across the nation. Without a doubt, it will destroy many young lives. Yet it goes beyond a concern for individuals, for when so many of our young people are affected by poor health or are engaging in risky health behaviours, it is the country as a whole that is as risk" (p.3).

Many Health Problems Are Preventable

A relatively small number of preventable health problems account for the leading causes of mortality, morbidity and social problems among young people. For example, nearly three-fourths of deaths among those ages 5-24 are from motor vehicle crashes (30% of all deaths), other unintentional injuries (11%), homicides (19%), and suicides (11%) (Kochanek & Hudson, 1995). Many of these problem can be prevented. Additionally, many of the 1 million adolescent pregnancies (Hoffereth, 1987) and more than the ten million cases of sexually transmitted diseases among persons ages 15-29 (CDC,1991a) are preventable. Also preventable are the alcohol and other drug use that is associated with many with of these problems. Prevention is a concept useful for youth as they become adults. Among adults 25 and older, the three leading causes of all deaths and significant morbidity (heart disease, cancer and stroke) account for two-thirds of those deaths and significant morbidity (Kochanek & Hudson, 1995). Each of these is subject to significant reduction through prevention. For example, with specific reference to cancer, Dr. John Seffrin (Seffrin, 1994), executive vice president and chief staff officer of the American Cancer Society, has indicated that, "If everything we already know about primary and secondary cancer prevention were only taught and applied universally, we could reduce cancer deaths by 50% to 60%" (p. 398). The U.S. Centers for Disease Control and Prevention have identified six categories of behaviors that make major contributions to the leading causes of mortality and morbidity in the nation (Kann, Kolbe, & Collins, 1993). Many of these behaviors are established during youth and extend into adulthood. These categories are:

Behaviors, such as failure to use safety belts and weapon-carrying, that contribute to unintentional and intentional injuries,

Tobacco use,

Alcohol and other drug use, Sexual behaviors that contribute to unintended pregnancy and STD, including human immunodeficiency virus (HIV) infection,

Unhealthy dietary behaviors, and Physical inactivity.

The opportunity costs of these behaviors are enormous. Addressing them would result in substantial improvements in health and status and economic productivity throughout the entire population. It would also allow significant resources to be directed to other societal concerns. A promising approach to improve youth health status is known as the comprehensive school health program. By definition, a comprehensive school health program (Association for the Advancement of Health Education, 1990) 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" (p. 9).

It is important to note that a comprehensive school health program is far more than classroom health instruction and is not limited to students. Rather, it is multifaceted and includes the entire school. Allensworth and Kolbe (1987) have delineated the expanded concept of a comprehensive school program to include the following eight interactive components: health education, physical education and other physical activities, health services, food service, school counseling and social services, integrated school and community efforts, faculty staff promotion, and the school environment. Fortunately, through the efforts of the American School Health Association (1994), each of these components has been further delineated into specific guidelines including, as appropriate, such key areas as policy and administrative support, goals and objectives, program components, student outcomes, program outcomes, curriculum, teaching methods, nursing standards, physician standards, health educator standards, professional development and coordination of standards. This concise but detailed document is a must for administrators, teachers, school health nurses, social service and food service personnel, concerned parents and anyone else interested in improving the health and learning of the school aged population. A comprehensive school health program is consistent with achieving the nation's health goals as set forth in the document, Healthy People 2000: National Health Promotion and Disease Prevention Objectives (USDHHS, 1991). Recently, the Centers for Disease Control and Prevention (CDC) conducted a nationwide School Health Policies Programs Study (SHPPS) which assessed the status of school health programs (Kann et al., 1995). The results of this study indicate serious shortcomings of school health programs (Kolbe et al., 1995).

Putting the Comprehensive School Health Program Into Perspective

While a comprehensive school health program can make a difference, by no means should it be perceived as a panacea (Birch, 1995). By itself, it will not eradicate drug use, school violence, or unintended pregnancy. Rightfully so, Green (1979) has warned practitioners of the danger of expecting too much: "The potential of school health education programs for students living with scant financial resources, receiving little or no family support, and battling overwhelming negative community influences, is limited" (p. 55). However, as previously cited, a comprehensive school health program can make a difference not only for youth already at risk, but by enhancing health promotion; that is, helping people who are already basically healthy to de-elop lifestyles that can maintain and enhance their state of well-being (Christenson et al., 1985, CDC,1991b,1994a,1994b, USODPHP,1993, Kirby et al., 1994). As noted by O'Rourke (1985), even modest success on the part of comprehensive school health programs would save billions of dollars in expenditures and, more importantly, contribute significantly to the goal of longer, healthier, and more productive living by our citizenry" (p. 124). Simply, a comprehensive school health program is not just an expenditure, but an investment in a most valuable resource, our youth, our future.

References

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American Cancer Society. (1995). American Cancer Society 's Approach to Youth Education. Atlanta, GA: American Cancer Society.

American School Health Association. (1993). A healthy child: The key to the basics-Using a comprehensive school health program to promote health and learning. Kent, OH: American School Health Association. American School Health Association. (1994). Guidelines for Comprehensive School Health Programs. Kent,

OH: American School Health Association. Association for the Advancement of Health Education (AAHE). (1990). Report of the 1990 Joint Committee on Health Education Terminology, November 1, 1990, p. 9.

Birch, D. (1995). Promoting comprehensive school health education: Guidelines for advocacy. Journal of Wellness Perspectives. 12(1), 22-28. Centers for Disease Control and Prevention. (1991a). Division of STD/HIV Prevention Annual Report, 1990. Atlanta, GA: US Dept. of Health and Human Services, Public Health Service. Centers for Disease Control and Prevention. (1991b). Effectiveness of a health education curriculum for secondary school students-United States, 198 1989. Morbidity and Mortality Weekly Reports. 40(7),113-116.

Centers for Disease Control and Prevention. (1994a). Guidelines for school health programs to prevent tobacco use and addiction. Morbidity and Mortality Weekly Report. 43 (No. RR-2, i-17.

Centers for Disease Control and Prevention. (1994b). Preventing tobacco use among young people: A report of the surgeon general. Atlanta GA: Centers for Disease Control and Prevention. Christenson, G., et al. (Eds.). (1985). Results of the school health education evaluation. Journal of School Health. 55(8), 295-355.

Green, L. (1979). The misunderstanding and misuse of

health education. Journal of School Health. 49(1), 55. Hoffereth, S.L. (1987). Teenage pregnancy and its resolution. In S.L. Hoffereth & C.D. Hayes (Eds.). Risking the Future: Adolescent Sexuality, Pregnancy, and Childbearing. Washington, DC: National Academy Press, 174-206.

Kann, L., Kolbe, L.J., & Collins, J.L. (Eds.). (1993). Measuring the health behavior of adolescents: The Youth Risk Behavior Surveillance System and recent reports on high-risk adolescents. Public Health Reports, 108 (suppl 1), 1-67.

Kann, L. Collins, J.L., Pateman, B.C., Small, M.L., et al. (1995). The school health policies and programs study (SHPPS): Rationale for a nationwide status report on school health programs. Journal of School Health. 65(3), 291-294.

Kirby, D., et al. (1994). School-based programs to reduce sexual risk behaviors: A review of effectiveness. Public Health Reports. 109(3), 339-360.

Kochanek, K.D. & Hudson, B.L. (1995). Advance report of final mortality statistics, 1992. Monthly Ktal Statistics Report. 43(6-S). 1-74.

Kolbe, L.J., Kann, L., Collins, J.L., Small, M.L., Pateman, B.C., & Warren, C.W. (1995). The school health policies and program study (SHPPS): Context, methods, general findings, and future efforts. Journal of School Health. 65(8), 339-343. McGinnis J.M. (1981). Health problems of children and youth: A challenge for schools. Health Education Quarterly, 8(1), 11-14.

O'Rourke, T. (1885). Why school health education? The economical point of view. Health Education. April/May, 121-124.

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National Commision on the Role of the School & the Community in Improving Adolescent Health. (1990). Code Blue: Uniting for Healthier Youth. Alexandria, VA: National Association of State Boards of Education, p. 3.

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Seffrin, J. (1994). America's interest in comprehensive school health education. Journal of School Health. 64(10), 397-399.

Shane, H.G. (1976). The seven cardinal principles revisited. Today's Education. 65, 57-72. U.S. Department of Health and Human Services, Public Health Service (USDHHS) (1991). Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: DHHS Publication No. (PHS) 91-50210.

U.S. Office of Disease Prevention and Health Promotion (USODPHP). (1993). School health: Findings from evaluated programs. Washington, DC: USODPHP.

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