School Health

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For more than 150 years, schools in the United States have addressed the health and safety needs of their students. Prior to the mid-1800s, public education was still in a formative state, and efforts to introduce health into the schools were isolated and sparse. In 1840, Rhode Island became the first state in the nation to require children to attend school, and other states adopted compulsory education soon afterwards. The foundation for school health programs is often credited to Lemuel Shattuck's report in 1850 for the Sanitary Commission of Massachusetts. Among other recommendations, the report described the value of using schools to control communicable diseases. Shattuck's report is applicable to current health problems, which often have their etiology in health risk behaviors established during childhood. According to the report: "Every child should be taught early in life, that, to preserve his own life and his own health and the lives and health of others, is one of the most important and constantly abiding duties." By the late 1860s, the New York City Board of Health had established sanitary inspections for communicable diseases in schools. By the end of the nineteenth century, the era of medical inspection in schools became institutionalized, with school nurses gradually replacing medical inspectors.

In 1918, the Commission on the Reorganization of Secondary Education published a landmark report identifying the desired outcomes of education. Health was the first of seven cardinal outcome objectives, the other objectives were command of fundamental processes, worthy home membership, vocation, citizenship, use of leisure, and ethical character. As a result of the temperance movement of the late nineteenth and early twentieth centuries, schools incorporated lessons on the effects of alcohol, tobacco, and narcotics into the hygiene curricula. Physical education was also introduced into the school curricula during this time period.

Between 1918 and 1921, many U.S. states enacted laws requiring health education and physical education for school children. However, as a result of a report issued by the National Education Association and the American Medical Association, primary health care services were gradually replaced with preventive health care by school nurses. This report defined the role of schools in screening for health problems and referring students with problems to health professionals. By the 1970s, there was a reemergence of primary health care in schools, with the establishment of school-based clinics centered around the unique physical, emotional, and developmental needs of students. By 1999, there were over 1,100 school-based or school-linked health centers in forty-five states.

From the early 1900s through the 1980s, school health programs had three components: health education, health services, and a healthy school environment. In 1987, D. D. Allensworth and L. J. Kolbe proposed an eight-component model that included the original three components, but added physical education; nutrition and food services; counseling, psychological, and social services; health promotion for staff; and family and community involvement.

Health education consists of a planned, sequential, K-12 curriculum that addresses the physical, mental, emotional, and social dimensions of health. Health services are provided to students to appraise, protect, and promote health. These services include the provision of emergency and primary care, access and referral to community health services, and management of chronic health conditions. A healthy school environment attends to the physical and aesthetic surroundings, and to a psycho-social climate and culture that maximizes the health of students and staff. Physical education is a planned, sequential, K-12 curriculum that provides cognitive content and learning experiences from a variety of activities that students can enjoy all their lives, such as basic movement skills; physical fitness, rhythms and dance; games; and sports. School nutrition and food services promote the health and education of students through access to a variety of nutritious meals, an environment that promotes healthful food choices, and support for nutrition instruction in the classroom and cafeteria. Counseling, psychological, and social services provide broad-based individual and group assessments, interventions, and referrals that attend to the mental, emotional, and social health of students. Health promotion for staff provides health assessments, health education, and health-related fitness activities. These programs also encourage staff to become positive role models. Family and community involvement promotes an integrated school, parent, and community approach that establishes a dynamic partnership to enhance the health and well-being of students, with schools being encouraged to actively solicit parent involvement and engage community resources and services.

These eight components interact best when they focus on the behaviors that interfere with learning and long-term well-being; and when they foster support of family, friends, and community; use interdisciplinary and interagency teams to plan and coordinate the program; use multiple intervention strategies; promote student involvement; and provide staff development.

The eight-component model forms the basis of a coordinated school health program (CSHP), currently defined as "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 resources, standards and requirements. It is coordinated by a multidisciplinary team and accountable to the community for program quality and effectiveness" (Allensworth, 1997).

While no studies have evaluated the efficacy of the CSHP, there have been numerous studies that have evaluated the components individually and in combination with each other. These studies have shown that health education can improve the adoption of health-enhancing behaviors (Connell et al., 1985; Resnicow et al., 1991) and school achievement (Hawkins et al., 1999); and that nutrition services, and particularly school breakfast programs, have increased learning (Meyers et al., 1991; Powell et al., 1998). Health services have been associated with reduced absenteeism, academic achievement, and improved health status(U.S. General Accounting Office, 1983). Physical education has been shown to improve physical fitness, reduce stress, and enhanced student's self image (Dwyer, 1983; Pate et al., 1995). Involving family members and the community have been linked with improving health knowledge and behaviors (Pentz, 1997), and health promotion for faculty and staff have improved absenteeism rates for staff as well as improved their health status (Blair et al., 1984).

Public support is strong for health-related services and education in schools. According to a Gallup survey of U.S. adults in 1998, health ranked the highest of fifteen subject areas that were "definitely necessary" for schools to teach (Marzano et al., 1998). Business leaders are concerned about the "employability" of graduates and want schools to help provide a healthy, productive workforce. Voluntary health organizations and insurance companies support school health programs in order to prevent future chronic health conditions that lead to increased medical care costs.

During the 1990s in Europe, the concept of a health-promoting school has emerged, which incorporates policies, curriculum, psycho-social and physical environment, health services, and formal and informal partnerships between schools, parents, the health sector, and the local community to maximize successful outcomes in youth. With the support of the World Health Organizations, the European Network for Health Promoting Schools now has thirty-eight countries involved. WHO's Expert Committee on Comprehensive School Health Education and Promotion has identified principles and priorities for actions to improve global school health, acknowledging that theories and frameworks for a coordinated and integrated approach to school health are relatively sophisticated, so application and adaptability to different nations and cultures may be far less developed. The WHO notes that school health policies, intersectoral collaboration, program implementations, financial support and administrative support could be enhanced in many countries.

Schools alone cannot be expected to solve the most serious health and social problems. However, schools can provide an ideal setting in which families, health professionals, and community agencies can work together to improve the well-being of young people.

Diane D. Allensworth

Linda S. Crossett

(see also: Child Care, Daycare; Child Health Services; Community Health; School Health Educational Media )


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