4. Thoreau HD: Walden or, Life in the Woods. Boston, Houghton Mifflin, 1893. 5. Durant W: The Lessons o/ History. New York, Simon and Schuster, 1968. 6. Fuchs V: Who Shall Live? New York, Basic Books Inc, 1975. 7. Dunn HL: High Level Wellness.Arlington,Va, RW Beatty, 1972. 8. Barnes SE, Fors SW: Who are Wednesday's children? J Sch Health 46:37-39. 1976. 9. Spencer H: Education: Intellectual, Moral, Physical. New York,
EL KellOM, 1892. 10. Salk J: Speech presented at the 46th Annual Convention of the American School Health Association, San Diego, Calif, October 1972.
s. E~~~~~Barnes,
is Chairman and Professor, Department of Health and Sqfety, University of Southern Mississippi, Hattiesburg, MS 39401. p
~
J
Closing the Gaps in School Health Services Louise Blruvelt, RN, BS, MA In 1972, I was appointed Supervisor of Health Services, Health Education, and Safety in a small but growing county in the state of Maryland. My previous assignment in school work focused primarily on health education. Although my undergraduate degree was in nursing, I felt a need for additional direction in order to plan and implement a more effective health services program. I turned to the State Department of Education for assistance. That was when I first became aware of the gaps in school health services. Each county school system (24 in all) was offering its own concept of school health services with little state leadership and minimal guidelines. Research disclosed that Article 77, Section 85, of The Public School Laws of Maryland had been adopted in July 1969. It provided that: Each county board of education with the assistance of the county health department shall provide adequate school health services, instruction in health education, and healthful school environment. The State Department of Education and the State Health Department. shall develop jointly public standards and guidelines for school health programs and offer assistance to county boards of education and health departments in their implementation.
Following passage of this law, the Maryland State School Health Council, functioning as an advisory body to the Maryland State Department of Education and the Maryland State Department of Health and Mental Hygiene, assumed the task of drafting guidelines for a total school health program. This task was to consume seven years. During this period, a public school system in the state wanting to establish a health services program could *Now Maryland State Department of Health and Mental Hygiene
422
THE JOURNAL OF SCHOOL HEALTH
find no overall health services standards to provide a framework. Although a health education curriculum guide was being finalized for publication, the only health services guidelines that had been developed by 1972 pertained to first aid in schools. This situation offered a challenge to me as a supervisor. Being engaged in graduate studies at the time, a thesis topic was born. As the investigation took form, the focus centered on school personnel in secondary health rooms, since elementary schools did not demonstrate enough staffing for study. Personnel included both nurses and non-nurses. Since it was a well-known fact that organizations representing education and health had been recommending professional nurses in schools for over 50 years, some questions relating to activities of the various personnel began to emergeWhat were they doing? What did they think they should be doing? What did their supervisors think they should be doing? What did their principals want them to do? What did national school health leaders think health room personnel should be doing? Was there any agreement among these groups? The purpose of this study, conducted in the spring of 1974, was to determine what functions health room personnel (including nurses and non-nurses) in the Maryland public secondary schools were performing and what functions principals, supervisors, national leaders, and health room personnel thought they should be performing. The survey instrument requested the respondent to indicate the appropriateness of health room functions by selecting (1) most appropriate, (2) very appropriate, SEPTEMBER 1977
(3) somewhat appropriate, (4) not very appropriate, or (5) inappropriate. An additional section for health room personnel only requested the respondent to indicate in order of importance the functions performed in the health room. The same 16 functions were ranked as (1) most important, (2) very important, (3) somewhat important, (4) not very importadt, or (5) unimportant. The functions that were selected for reaction by these groups were a compilation of recommendations of the National Education Association, American Medical Association, American Nurse’s Association, American School Health Association, and American Association for Health, Physical Education and Recreation. They included: Planning the budget for your school program, Evaluating your school health program, Planning policy for immunization program, Developing health education curriculum, Teaching health education in the classroom, Providing resource materials for the classroom teacher, Serving on faculty committees. Referring the student and/or family to community agencies, Counseling students about health interests and problems, Maintaining daily records of health room visits, Maintaining cumulative health records on students, Administering first aid, Conducting vision and hearing examinations, Assisting in immunization clinics, Referring safety hazards in school environment to the appropriate person, and Administering medication.
Final returns consisted of replies from 206 health room personnel (78Vo), 194 principals (75%), 28 supervisors (WVo), and six national leaders (100%). Within the limitations of this study the following findings were confirmed: 1. There was no significant level of agreement on the relative appropriateness of 16 selected functions that should be performed by school health room personnel between: nurses and non-nurses, principals and nurses, principals and non-nurses, supervisors and nurses, supervisors and non-nurses, and national panel and non-nurses. 2. There was a significant level of agreement between nurses and national leaders on what functions should be performed in the school health room. 3. Nurses were not performing the functions they thought should be performed. 4. Non-nurses were performing the functions they thought should be performed. 5. Neither nurses nor non-nurses were performing the functions that supervisors felt were most appropriate. 6. There was no significant level of agreement between what principals thought should be done in school hcalth rooms and what the nurses or non-nurses assigned to those rooms were actually doing. SEPTEMBER 1977
7. There was no significant level of agreement between what the national panel thought should be done and what both nurses and non-nurses were actually doing in their assigned health rooms. Recommendations based on the findings included the need for state guidelines for school health room functions to be developed and distributed to all local education agencies. They encouraged the establishment of basic criteria for school health room personnel in the state of Maryland with strong consideration given to the national recommendations for professional preparation. Also, a strong recommendation was made that there be conducted an appraisal of elementary school health services. Although the researcher found the results significant to school health programs in Maryland, there was no immediate response from appropriate health personnel across the state. Seeking wider dissemination, the results were presented at the American School Health Association conference in Denver, Colorado, in October 1975. A copy of that presentation was forwarded to the Maryland State Department of Education, to the attention of the Assistant Superintendent responsible for Public Services. In the absence of a health services specialist, the specialist in guidance was designated to convene a committee to study the need for standards for health services. At the recommendation of the guidance specialist who met with the committee, the Assistant Superintendent appointed an (official) Ad Hoc Committee on Health Services composed of representatives of the State Department of Education, State Department of Health and Mental Hygiene, local education agencies, and county health officers. The chairperson, appointed by the Assistant Superintendent, was to coordinate the efforts by working at the State Department several days a month. The committee’s charge was to draft standards to comply with Article 77, Section 85. The date was December 1975, just six and one-half years after the school health law was adopted. In February 1976, a resolution was introduced in the state legislature concerning emergency first aid services in the public schools. Prompted by a group of concerned elementary principals and supported by the state organization of elementary principals, the resolution directed that the State Board of Education conduct a survey to determine the provision of emergency first aid services in all public schools in Maryland. The Ad Hoc Committee on Health Services was immediately directed to respond to this resolution forcing a temporary halt to the work on the development of standards. Although the mandate was to survey emergency first aid services, the committee saw an opportunity to THE JOURNAL OF SCHOOL HEALTH
423
enlarge the task and gain new information about health services, in general. Two separate questionnaires were designed as instruments to gather the necessary data. One questionnaire was distributed to the superintendent of each local educational agency and the other was sent to the principal of each of the 1,321 schools. Principal responses to the questionnaire included 953 elementary schools (86%) and 300 secondary schools (92%). One hundred percent of the superintendents responded to their questionnaire. The responses included the following data: 1. Ninety percent of the responding elementary and 95% of the responding secondary schools offered emergency first aid service to all students and staff during regular school hours. 2. A wide variation was noted in the quality of service rendered since 41070 of all elementary schools reporting utilized personnel who did not hold a valid first aid certificate and 2% had no one assigned to provide coverage. Twenty-eight percent of the personnel assigned responsibility for first aid in the secondary schools did not hold a valid certificate and 8% of the schools had no one assigned to provide coverage. 3. Forty-one percent of the superintendents indicated that they did not have written policies and procedures for their school system to cover emergency first aid services. 4. The principals responding indicated that 25% of the elementary and 29% of the secondary schools had no written policies and procedures to cover emergency first aid services. 5. Fifty-nine percent of the elementary and 63% of the secondary schools reporting had analyzed records of emergency first aid services for the purposes of instructional programming for accident prevention. 6. The secretary was given responsibility most frequently for keeping pupil and staff emergency information cards up to date in the elementary schools (86%). Sixty-eight percent of the secondary schools responding utilized the secretary, while 54% utilized the school health room personnel. 7. Eight-nine percent of the elementary and 87% of the secondary schools reporting had a separate area designated as the school health room. 8. First aid training for bus drivers did not appear to be a priority since the majority of superintendents responding reported less than 50% of their bus drivers had first aid training. The final report was presented to the General Assembly in January 1977. Almost two years after the first survey related to school health services was conducted, this second effort demonstrated continuing variability. This led to these most recent recommendations: 424
THE JOURNAL OF SCHOOL HEALTH
1. A person currently certified in both Standard First Aid and Cardio-Pulmonary Resuscitation should be available on site during the regular school day, and during practice and participation in school sponsored athletic events. 2. A bus driver or bus aide certified in both Standard First Aid and Cardio-Pulmonary Resuscitation will be on the bus whenever students are transported. 3. A guide for emergency care management will be adopted by the local education agency (scope of which is not less than that in the First Aid Procedures for Maryland Schools, 1976. Copies of such guide should be available in the health room and library. 4. Orientation on emergency first aid services will be conducted annually for parents, students, and staff to inform them of current procedures. 5. Individual health records shall be kept current and be accessible only to appropriate personnel. 6. Every school must establish and equip a physical facility in close proximity to the administrative suite for the provision of health services as recommended in the First Aid Procedures for Maryland Schools, 1976.
Obviously, these recommendations represent simple, first steps in establishing some standardization of school health services across the state. They will be incorporated into the standards the Ad Hoc Committee is developing following the report to the state legislature. The State School Health Manual has now been published. Although it is partially outdated already and written in general terms, it provides a basis for referral. With the survey results available, the committee members are working with renewed enthusiasm on the task. Obviously, the need is great! And the time is now! The purpose of this synopsis of one state’s efforts to close the gaps in school health services is not to downgrade that state but to encourage participants in this national school health conference to learn from such an experience. You are urged to examine the process as it unfolded. Be aware of the impact of a few people who sought to draw attention to what they perceived to be service of a quality less than they could accept. Recapping the events as they unfolded, begin with the school law in 1969, representing in itself a less than significant impact on health services at the time. Spring of 1974 brought a fairly narrow study focusing on health room personnel but raising issues of standardization of both personnel and service in secondary school health rooms. Only when directed to a specific staff member at the State Department of Education did it elicit response. And, in conjunction with elementary principals’ concerns leading to legislation, the ball really started to roll. Those committee members currently involved believe that the survey results, as published in January of this year, will make a difference. SEPTEMBER 1977
The standards that are almost completed will provide guidelines for county superintendents concerned about the survey results from their schools. And the fervent hope is that the State Department staff will include a specialist in health services in the very near future who can spearhead implementation of state standards. Note that the time frame from adoption of school health law to the present represents almost eight years. But most of the progress occurred in the space of one and one-half years. The strongest identifiable factor for change would have to be the state legislature, for they
School Health
passed the resolution. It must be noted, however, that state legislators don’t move unless there is a demand for change. In this case, the demand came from educators and health professionals. Together they formed a team and together they are closing the gaps in school health services in the state of Maryland.
Louise Blauvelt, RN, BS, MA, i s Supervisor of Health Services, Prince George’s County Public Schools, Upper Marlboro, MD 20870.
- 1977
Georgia P. Macdonougb, RN, MA It has been a very long journey for school health from the early 1900s when Miss Lina Rogers of the Henry Street Nursing Association engaged in a one month’s demonstration project to prove the worth of a nurse in the school. In those days, pupils were excluded from school because of communicable and “nuisance” diseases. Rogers was able to show, through nursing follow-up, that children could return to school instead of wandering around the streets of New York. Today, school health, although still concerned with communicable disease control, has encompassed many additional services, which are constantly changing to meet society’s needs. I have been asked to prepare this paper, discussing school health on the national, state, and local levels, as I see the picture. I will give an overview of priorities, discuss some gaps, and suggest one or more approaches to some challenging situations. On the national level, the goals and priorities for school health, for the most part, emanate from the Bureau of Community Health Services Regional Workplan Guidance. The Department of Health, Education, and Welfare designates the regional offices to carry out work activities to ensure the meeting of program objectives. Since Arizona is served by Region I X headquarters in San Francisco, much of my information comes from communication with the Maternal and Child Health staff there. One of the national program objectives is to increase the number of children receiving appropriate preventive SEPTEMBER 1977
health care services (including health education), particularly junior and senior high school students. One activity supporting this objective is the stimulation and funding of research projects to obtain cost effectiveness data regarding preventative child health services. Another national priority is to implement a strategy to identify more children, prior to their entering school, who have a vision or hearing loss. Still another objective is to develop and disseminate guidance materials on nutritional disorders of children (screening, diagnosis, and follow-up). On the national level, a great deal of emphasis has been given to increasing the levels of immunization for both preschool and school-age children. For a few years, October has been designated “Immunization Action Month.” In June 1976, a national conference was held in St. Louis to mobilize voluntary and official agencies in a concerted effort to immunize “every child by 76/77.” Unfortunately, the impetus was interrupted by the Swine Flu program. Most of the costs of these immunization programs, in terms of provision of low-cost vaccine, is defrayed by the Center for Disease Control in Atlanta. A new major program has been recently proposed called Comprehensive Health Assessments and Primary Care for Children (CHAP). This program would constitute an expansion of Early Periodic Screening, Detection, and Treatment (EPSDT). President Carter has recommended amendments to Medicaid that would increase EPSDT funding from $137 million in 1977 to $345 million in 1978. THE JOURNAL OF SCHOOL HEALTH
425
EL KellOM, 1892. 10. Salk J: Speech presented at the 46th Annual Convention of the American School Health Association, San Diego, Calif, October 1972.
s. E~~~~~Barnes,
is Chairman and Professor, Department of Health and Sqfety, University of Southern Mississippi, Hattiesburg, MS 39401. p
~
J
Closing the Gaps in School Health Services Louise Blruvelt, RN, BS, MA In 1972, I was appointed Supervisor of Health Services, Health Education, and Safety in a small but growing county in the state of Maryland. My previous assignment in school work focused primarily on health education. Although my undergraduate degree was in nursing, I felt a need for additional direction in order to plan and implement a more effective health services program. I turned to the State Department of Education for assistance. That was when I first became aware of the gaps in school health services. Each county school system (24 in all) was offering its own concept of school health services with little state leadership and minimal guidelines. Research disclosed that Article 77, Section 85, of The Public School Laws of Maryland had been adopted in July 1969. It provided that: Each county board of education with the assistance of the county health department shall provide adequate school health services, instruction in health education, and healthful school environment. The State Department of Education and the State Health Department. shall develop jointly public standards and guidelines for school health programs and offer assistance to county boards of education and health departments in their implementation.
Following passage of this law, the Maryland State School Health Council, functioning as an advisory body to the Maryland State Department of Education and the Maryland State Department of Health and Mental Hygiene, assumed the task of drafting guidelines for a total school health program. This task was to consume seven years. During this period, a public school system in the state wanting to establish a health services program could *Now Maryland State Department of Health and Mental Hygiene
422
THE JOURNAL OF SCHOOL HEALTH
find no overall health services standards to provide a framework. Although a health education curriculum guide was being finalized for publication, the only health services guidelines that had been developed by 1972 pertained to first aid in schools. This situation offered a challenge to me as a supervisor. Being engaged in graduate studies at the time, a thesis topic was born. As the investigation took form, the focus centered on school personnel in secondary health rooms, since elementary schools did not demonstrate enough staffing for study. Personnel included both nurses and non-nurses. Since it was a well-known fact that organizations representing education and health had been recommending professional nurses in schools for over 50 years, some questions relating to activities of the various personnel began to emergeWhat were they doing? What did they think they should be doing? What did their supervisors think they should be doing? What did their principals want them to do? What did national school health leaders think health room personnel should be doing? Was there any agreement among these groups? The purpose of this study, conducted in the spring of 1974, was to determine what functions health room personnel (including nurses and non-nurses) in the Maryland public secondary schools were performing and what functions principals, supervisors, national leaders, and health room personnel thought they should be performing. The survey instrument requested the respondent to indicate the appropriateness of health room functions by selecting (1) most appropriate, (2) very appropriate, SEPTEMBER 1977
(3) somewhat appropriate, (4) not very appropriate, or (5) inappropriate. An additional section for health room personnel only requested the respondent to indicate in order of importance the functions performed in the health room. The same 16 functions were ranked as (1) most important, (2) very important, (3) somewhat important, (4) not very importadt, or (5) unimportant. The functions that were selected for reaction by these groups were a compilation of recommendations of the National Education Association, American Medical Association, American Nurse’s Association, American School Health Association, and American Association for Health, Physical Education and Recreation. They included: Planning the budget for your school program, Evaluating your school health program, Planning policy for immunization program, Developing health education curriculum, Teaching health education in the classroom, Providing resource materials for the classroom teacher, Serving on faculty committees. Referring the student and/or family to community agencies, Counseling students about health interests and problems, Maintaining daily records of health room visits, Maintaining cumulative health records on students, Administering first aid, Conducting vision and hearing examinations, Assisting in immunization clinics, Referring safety hazards in school environment to the appropriate person, and Administering medication.
Final returns consisted of replies from 206 health room personnel (78Vo), 194 principals (75%), 28 supervisors (WVo), and six national leaders (100%). Within the limitations of this study the following findings were confirmed: 1. There was no significant level of agreement on the relative appropriateness of 16 selected functions that should be performed by school health room personnel between: nurses and non-nurses, principals and nurses, principals and non-nurses, supervisors and nurses, supervisors and non-nurses, and national panel and non-nurses. 2. There was a significant level of agreement between nurses and national leaders on what functions should be performed in the school health room. 3. Nurses were not performing the functions they thought should be performed. 4. Non-nurses were performing the functions they thought should be performed. 5. Neither nurses nor non-nurses were performing the functions that supervisors felt were most appropriate. 6. There was no significant level of agreement between what principals thought should be done in school hcalth rooms and what the nurses or non-nurses assigned to those rooms were actually doing. SEPTEMBER 1977
7. There was no significant level of agreement between what the national panel thought should be done and what both nurses and non-nurses were actually doing in their assigned health rooms. Recommendations based on the findings included the need for state guidelines for school health room functions to be developed and distributed to all local education agencies. They encouraged the establishment of basic criteria for school health room personnel in the state of Maryland with strong consideration given to the national recommendations for professional preparation. Also, a strong recommendation was made that there be conducted an appraisal of elementary school health services. Although the researcher found the results significant to school health programs in Maryland, there was no immediate response from appropriate health personnel across the state. Seeking wider dissemination, the results were presented at the American School Health Association conference in Denver, Colorado, in October 1975. A copy of that presentation was forwarded to the Maryland State Department of Education, to the attention of the Assistant Superintendent responsible for Public Services. In the absence of a health services specialist, the specialist in guidance was designated to convene a committee to study the need for standards for health services. At the recommendation of the guidance specialist who met with the committee, the Assistant Superintendent appointed an (official) Ad Hoc Committee on Health Services composed of representatives of the State Department of Education, State Department of Health and Mental Hygiene, local education agencies, and county health officers. The chairperson, appointed by the Assistant Superintendent, was to coordinate the efforts by working at the State Department several days a month. The committee’s charge was to draft standards to comply with Article 77, Section 85. The date was December 1975, just six and one-half years after the school health law was adopted. In February 1976, a resolution was introduced in the state legislature concerning emergency first aid services in the public schools. Prompted by a group of concerned elementary principals and supported by the state organization of elementary principals, the resolution directed that the State Board of Education conduct a survey to determine the provision of emergency first aid services in all public schools in Maryland. The Ad Hoc Committee on Health Services was immediately directed to respond to this resolution forcing a temporary halt to the work on the development of standards. Although the mandate was to survey emergency first aid services, the committee saw an opportunity to THE JOURNAL OF SCHOOL HEALTH
423
enlarge the task and gain new information about health services, in general. Two separate questionnaires were designed as instruments to gather the necessary data. One questionnaire was distributed to the superintendent of each local educational agency and the other was sent to the principal of each of the 1,321 schools. Principal responses to the questionnaire included 953 elementary schools (86%) and 300 secondary schools (92%). One hundred percent of the superintendents responded to their questionnaire. The responses included the following data: 1. Ninety percent of the responding elementary and 95% of the responding secondary schools offered emergency first aid service to all students and staff during regular school hours. 2. A wide variation was noted in the quality of service rendered since 41070 of all elementary schools reporting utilized personnel who did not hold a valid first aid certificate and 2% had no one assigned to provide coverage. Twenty-eight percent of the personnel assigned responsibility for first aid in the secondary schools did not hold a valid certificate and 8% of the schools had no one assigned to provide coverage. 3. Forty-one percent of the superintendents indicated that they did not have written policies and procedures for their school system to cover emergency first aid services. 4. The principals responding indicated that 25% of the elementary and 29% of the secondary schools had no written policies and procedures to cover emergency first aid services. 5. Fifty-nine percent of the elementary and 63% of the secondary schools reporting had analyzed records of emergency first aid services for the purposes of instructional programming for accident prevention. 6. The secretary was given responsibility most frequently for keeping pupil and staff emergency information cards up to date in the elementary schools (86%). Sixty-eight percent of the secondary schools responding utilized the secretary, while 54% utilized the school health room personnel. 7. Eight-nine percent of the elementary and 87% of the secondary schools reporting had a separate area designated as the school health room. 8. First aid training for bus drivers did not appear to be a priority since the majority of superintendents responding reported less than 50% of their bus drivers had first aid training. The final report was presented to the General Assembly in January 1977. Almost two years after the first survey related to school health services was conducted, this second effort demonstrated continuing variability. This led to these most recent recommendations: 424
THE JOURNAL OF SCHOOL HEALTH
1. A person currently certified in both Standard First Aid and Cardio-Pulmonary Resuscitation should be available on site during the regular school day, and during practice and participation in school sponsored athletic events. 2. A bus driver or bus aide certified in both Standard First Aid and Cardio-Pulmonary Resuscitation will be on the bus whenever students are transported. 3. A guide for emergency care management will be adopted by the local education agency (scope of which is not less than that in the First Aid Procedures for Maryland Schools, 1976. Copies of such guide should be available in the health room and library. 4. Orientation on emergency first aid services will be conducted annually for parents, students, and staff to inform them of current procedures. 5. Individual health records shall be kept current and be accessible only to appropriate personnel. 6. Every school must establish and equip a physical facility in close proximity to the administrative suite for the provision of health services as recommended in the First Aid Procedures for Maryland Schools, 1976.
Obviously, these recommendations represent simple, first steps in establishing some standardization of school health services across the state. They will be incorporated into the standards the Ad Hoc Committee is developing following the report to the state legislature. The State School Health Manual has now been published. Although it is partially outdated already and written in general terms, it provides a basis for referral. With the survey results available, the committee members are working with renewed enthusiasm on the task. Obviously, the need is great! And the time is now! The purpose of this synopsis of one state’s efforts to close the gaps in school health services is not to downgrade that state but to encourage participants in this national school health conference to learn from such an experience. You are urged to examine the process as it unfolded. Be aware of the impact of a few people who sought to draw attention to what they perceived to be service of a quality less than they could accept. Recapping the events as they unfolded, begin with the school law in 1969, representing in itself a less than significant impact on health services at the time. Spring of 1974 brought a fairly narrow study focusing on health room personnel but raising issues of standardization of both personnel and service in secondary school health rooms. Only when directed to a specific staff member at the State Department of Education did it elicit response. And, in conjunction with elementary principals’ concerns leading to legislation, the ball really started to roll. Those committee members currently involved believe that the survey results, as published in January of this year, will make a difference. SEPTEMBER 1977
The standards that are almost completed will provide guidelines for county superintendents concerned about the survey results from their schools. And the fervent hope is that the State Department staff will include a specialist in health services in the very near future who can spearhead implementation of state standards. Note that the time frame from adoption of school health law to the present represents almost eight years. But most of the progress occurred in the space of one and one-half years. The strongest identifiable factor for change would have to be the state legislature, for they
School Health
passed the resolution. It must be noted, however, that state legislators don’t move unless there is a demand for change. In this case, the demand came from educators and health professionals. Together they formed a team and together they are closing the gaps in school health services in the state of Maryland.
Louise Blauvelt, RN, BS, MA, i s Supervisor of Health Services, Prince George’s County Public Schools, Upper Marlboro, MD 20870.
- 1977
Georgia P. Macdonougb, RN, MA It has been a very long journey for school health from the early 1900s when Miss Lina Rogers of the Henry Street Nursing Association engaged in a one month’s demonstration project to prove the worth of a nurse in the school. In those days, pupils were excluded from school because of communicable and “nuisance” diseases. Rogers was able to show, through nursing follow-up, that children could return to school instead of wandering around the streets of New York. Today, school health, although still concerned with communicable disease control, has encompassed many additional services, which are constantly changing to meet society’s needs. I have been asked to prepare this paper, discussing school health on the national, state, and local levels, as I see the picture. I will give an overview of priorities, discuss some gaps, and suggest one or more approaches to some challenging situations. On the national level, the goals and priorities for school health, for the most part, emanate from the Bureau of Community Health Services Regional Workplan Guidance. The Department of Health, Education, and Welfare designates the regional offices to carry out work activities to ensure the meeting of program objectives. Since Arizona is served by Region I X headquarters in San Francisco, much of my information comes from communication with the Maternal and Child Health staff there. One of the national program objectives is to increase the number of children receiving appropriate preventive SEPTEMBER 1977
health care services (including health education), particularly junior and senior high school students. One activity supporting this objective is the stimulation and funding of research projects to obtain cost effectiveness data regarding preventative child health services. Another national priority is to implement a strategy to identify more children, prior to their entering school, who have a vision or hearing loss. Still another objective is to develop and disseminate guidance materials on nutritional disorders of children (screening, diagnosis, and follow-up). On the national level, a great deal of emphasis has been given to increasing the levels of immunization for both preschool and school-age children. For a few years, October has been designated “Immunization Action Month.” In June 1976, a national conference was held in St. Louis to mobilize voluntary and official agencies in a concerted effort to immunize “every child by 76/77.” Unfortunately, the impetus was interrupted by the Swine Flu program. Most of the costs of these immunization programs, in terms of provision of low-cost vaccine, is defrayed by the Center for Disease Control in Atlanta. A new major program has been recently proposed called Comprehensive Health Assessments and Primary Care for Children (CHAP). This program would constitute an expansion of Early Periodic Screening, Detection, and Treatment (EPSDT). President Carter has recommended amendments to Medicaid that would increase EPSDT funding from $137 million in 1977 to $345 million in 1978. THE JOURNAL OF SCHOOL HEALTH
425
