Creating an agenda for school-based health promotion: a review of 25 selected reports.

Articles Creating an Agenda for School-Based Health Promotion: A Review of 25 Selected Reports Alison T. Lavin, Gail R. Shapiro, Kenneth S. Weill

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n 1990, the Harvard School Health Education Project initiated a national policy analysis related to schoolbased health promotion. The Project was established at the Harvard School of Public Health to raise public and professional awareness of school health promotion issues, to contribute to comprehensive school health education theory, policy, practice, and evaluation, and to examine the role of the nation’s colleges and universities in working with state and local departments of education, departments of health, and with other agencies and organizations to implement and improve comprehensive school health education programs. As a preliminary step, the project examined recent reports from national commissions, federal and state agencies, and other sources. This paper summarizes and synthesizes 25 reports, each of which was published between 1989 and 1991, addresses the interconnectedness of children’s health and education, and incorporates a comprehensive approach to health, rather than focusing on a single categorical concern. The project reviewed a variety of publications, including government documents, commercial books, and reports produced independently by private and professional organizations. Their authors include individual researchers, congressional staff, state and federal executive agency staff, professional panels, and others. Some emphasize public health concerns, while others reflect an education perspective. Several reports focus on a specific age range, such as early childhood or adolescence. Some studies are comprised primarily of survey data. Some examine the effectiveness of intervention programs. Several incorporate a substantial body of epidemiologic and demographic data as the basis for their conclusions. Most discuss policy options and recommendations. Thus, substantial variation exists with respect to such factors as level of detail, use of research data, intended audience, and political viewpoint. The 25 reports reflect a growing consensus about the critical issues, the urgency of these concerns, and potential strategies for action. Given the diversity of author~

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Alison T, Lavin, Gail R. Shapiro, Kenneth S. Weill, Harvard School Health Education Project, Dept. of Health and Social Behavior, Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115. The project was supported under a cooperative agreement from the Centers for Disease Control (Division of Adolescent and School Health) and the Association of Schools of Public Health.

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ship and purpose, the commonalities are remarkable. When viewed collectively, five themes emerge from the ~~~

25 Reports American Association of School Administrators. Healthy Kids for the Year 2000: An Action Plan for Schools American Medical Association. America’s Adolescents: How Healthy Are They?

American School Health Association, Association for the Advancement of Health Education, Society for Public Health Education, Inc. National Adolescent Student Health Survey

Arnerlcan School Health Association, Southwest Center for Prevention Research. School Health in America: An Assessment of State Policies to Protect and Improve the Health of Students, 5th ed Carnegie Council on Adolescent Development. Turning Points: Preparing American Youth for the 27st Century

Center for the Study of Social Policy. Kids Count Data Book - State Profiles of Child Well-Being Children’s Defense Fund. The State of America‘s Children 1991 Congress of the U.S., Office of Technology Assessment. Adolescent Health Volume 1. Summary and Policy Options Council of Chief State School Officers. Beyond the Health Room Dryfoos JG. Adolescents at Risk: Prevalence and Prevention Hewlett SA. When the Bough Breaks: The Cost of Neglecting Our

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Massachusetts Dept of Education. Educating the Whole Student: The School’s Role in the Physical, Intellectual, Social, and Emotional Development of Children Michigan Model for Comprehensive School Health Education: Implementation Plan for Year 1997 National Commission for Drug-Free Schools. Toward a Drug-Free Generation: A Nation ’s Responsibility National Commission on Children. Beyond Rhetoric: A New American Agenda for Children and Families

National Commission on the Role of the School and the Community in Improving Adolescent Health, convened by National Association of State Boards of Education and American Medical Association. Code Blue: Uniting for Healthier Youth

National Education Goals Panel. Building a Nation of Learners: The National Education Goals Report

National Forum on the Future of Children and Families. Social Policy for Children and Families: Creating an Agenda

National HealthIEducation Consortium. Crossing the Boundaries Between Health and Education

National School Boards Association. School Health: Helping Children Learn

Newman L, Buka SL. Every Child a Learner: Reducing Risks of Learning Impairment During Pregnancy and Infancy

Schorr LB, Schorr D. Within Our Reach: Breaking the Cycle of Disadvantage U.S. Dept of Education. America 2000: An Education Strategy U S . Dept of Health and Human Services, Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives West Virginia Task Force on School Health. Building a Healthy Future.

reports: Education and health are interrelated. Children who suffer from violence, hunger, substance abuse, tooearly pregnancy, depression, or hopelessness are not healthy children. Unhealthy children are children with impaired learning. Education can contribute substantially to improving health. Conversely, a child’s health status constitutes a major determinant of educational achievement. To improve academic achievement, schools and other institutions must devote more attention to health concerns. The biggest threats to health are “socialmorbidities.” National statistics reflect the increasing impact of health problems on youth. These problems, many of which are preventable, are strongly influenced by social environment and specific behaviors, which often are established during youth and extend into adulthood. A more comprehensive, integrated approach is needed. Professionals know enough about what works and what does not - in addressing child health problems to implement more effective programs. Many programs have been successful, though some have been fragmented; they target categorical symptoms rather than their common antecedents. More collaborative programs and policies should address the underlying causes of problems. Health promotion and education efforts should be centered in and around schools. Most children attend school. Elementary and secondary schools constitute the “workplace” for nearly one-fifth of the U.S. population (children and adults). Schools possess the unique capacity to affect the lives of students, staff, parents, and entire communities. Components of comprehensive school health programs include health instruction at all grade levels, health services, a healthful, safe, and nurturing environment, physical education, food services, guidance and counseling, interaction with families and community organizations, and worksite wellness programs for school employees. In addition, school buildings can provide sites for community health promotion programs which need not be administered by the schools themselves. As community institutions, schools must play a larger role in addressing the health and social problems that limit not only academic achievement, but the nation’s public health and economic productivity. Prevention efforts are cost-effective: the social and economic costs of inaction are too high and still escalating. School failure, underachievement, and related health and social problems produce serious repercussions not only for children and their families, but for their communities and ultimately for the nation’s economic and social systems as well. THE FIVE COMMON THEMES Education and Health are Interrelated

History acknowledges the positive impact of education on health. Knowledge of health and the etiology of disease can influence both behavior and susceptibilityto disease for cultures and societies as well as individuals. Education affects health . . . Health professionals know that education can promote good health . . . The reverse is also true: ignorance can put even a healthy child at risk. (National Health/Education Consortium, p 8)

Only recently has the U.S. recognized the extent to which the converse is true: health affects education. Health affects education. Teachers know that learning comes easier to a healthy child. Any health problem - hunger, poor vision or hearing, increased blood lead levels, dental caries and child abuse - can interfere with learning. Physical and mental health problems cause children to miss school, lack energy, be distracted, or have other problems which impair their ability to learn. (National Health/Education Consortium, p 8) Efforts to improve school performance that ignore health are ill-conceived, as are health improvement efforts that ignore education. This means that increasing academic achievement will require attending to health in the broadest sense. (National Commission on the Role of the School and the Community in Improving Adolescent Health, p 9) This understanding can be attributed largely to recent research involving infants and young children. In a report published by the Education Commission of the States, Newman and Buka synthesized findings from several major studies which document the role of preventable conditions in the development of learning impairment in children from birth to age five. They identify seven major preventable factors: low birthweight, prenatal alcohol exposure, maternal smoking, prenatal exposure to drugs, lead poisoning, child abuse and neglect, and malnutrition. These data sound the alarm for state and federal policy makers in education, health and the environment. Health, environmental and poverty -based hazards are compromising many children’s ability to learn. (Newman and Buka, p vii) New evidence indicates that by school age a troubling 12% of children - more than 450,000 additional children each year - suffer damage that prevents them from learning as well as their natural endowment would allow. (Newman and Buka, p I ) Many of these children experience the cumulative impact of more than one risk factor. Problems may be exacerbated by social problems such as poverty or lack of insurance. The National Education Goals address this challenge by specifying: Goal I: By the year 2000, all children in America will start school ready to learn. Objectives: . . .Children will receive the nutrition and health care needed to arrive at school with healthy minds and bodies, and the number of low-birthweight babies will be significantly reduced through enhanced prenatal health systems. (National Education Goals Panel, p 32) This objective is echoed by the National Commission on Children: Traditionally, society’s responsibility for educating children began when they entered schod. Growing knowledge of child development, however, compels us as individuals and as a society to


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place far greater emphasis on children’s early development to ensure that every child is prepared for school. Therefore, the National Commission on Children recommends that all children, from the prenatal period through the first years of life, receive the care and support they need to enter school ready to learn - namely, good health care, nurturing environments, and experiences that enhance their development. (National Commission on Children, p 187). The relationship between health and education also has been emphasized in a number of reports that focus on adolescence. Many problem behaviors of young adolescents appear to be interrelated. Young people who smoke and drink often experiment with illegal The Harvard School Health Education ProJecl The Harvard School Health Education Project was initiated in 1989 at the Harvard School of Public Health to raise public and professional awareness of school health promotion issues; to contribute to comprehensive school health education theory, policy, practice, and evaluation; and to examine the role of the nation’s colleges and universities in working with state and local departments of education, departments of health, and with other agencies and organizations to implement and improve comprehensive school health education programs. By maintaining a locus for school health education, the Project is working to channel the multidisciplinary resources of the University toward advocacy and action for improved health promotion through our nation’s schools. With the support of Dean Harvey V. Fineberg, MD, PhD, the Project has convened an ongoing faculty Seminar whose participants include members of the faculty of Harvard’s undergraduate, graduate, and professional schools and teaching hospitals; staff members of both the Massachusetts Department of Public Health and the Massachusetts Department of Education; teachers and administrators in local school systems; and others in government and community agencies whose work and interests are particularly relevant. With input and guidance from a broad range of professions, academic disciplines, and government agencies, the seminar is examining substantive issues related to program effectiveness, implementation, legislative and legal factors, and collaborative models for systemwide change. Particular aftention is being given to strategies for encouraging greater interaction between state and local departments of education and of health; between corresponding university and governmental departments of education or of health; as well as intrauniversity interaction among faculties of education. public health, medicine, dentistry, law, business, and others with respect to school health. Project staff are preparing discussion papers and planning a conference which will focus on the unique role of the nation ’s colleges and universities in helping to forge stronger links between public health and public education, through professional preparation programs; school/college partnerships; research and evaluation; and collaboration with government and community groups to implement and improve school health programs. When the Project initiated its national policy analysis related to school-based health promotion, a preliminary step was the examination of selected reports of national commissions, federal and state agencies, and others. Creating an Agenda for School-Based Health Promotion: A Review of Selected Reports constitutes a synthesis of 25 of these reoorts.

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drugs and early, unprotected sex as well. These same young people are also prone to school failure . . . The risks that all young people face are compounded for those who are poor, members of racial or ethnic minorities, or recent immigrants. These youth generally attend the weakest schools, have access to the least adequate health services, and have the fewest clearly visible paths to opportunities in the mainstream. (Carnegie Council on Adolescent Development, p 25) According to Code Blue: Uniting for Healthier Youth: At the same time that health problems have multiplied, student performance has also been discouraging: -An unacceptably large proportion of adolescents fail to complete high school, and -Even more young people are unable to achieve the high level of math, science, and communications skills that will be required to function effectively in the technological world of the twenty-first century. . . . These health and educationfindings are closely related. The Commission finds that education and health are inextricably intertwined. (National Commission on the Role of the School and the Community in Improving Adolescent Health, pp 4-5) Unhealthy teenagers - those who are alienated or depressed, who feel that nobody cares, who are distracted by family or emotional problems, who are drinking or using drugs, who are sick or hungry or abused or feel they have no chance to succeed in this world - are unlikely to attain the high levels of education achievement required for success in the 21st century. And thousands of these young people will experience school failure, which for many will be a precursor to an adult life of crime, unemployment, or welfare dependency. (National Commission on the Role of the School and the Community in Improving Adolbscent Health, Executive Summary) In her detailed economic analysis on the “cost of neglecting our children,” Hewlett summarizes a 1985 report on business and the public schools by the Committee for Economic Development: No matter how much money you pump into schools, no matter how well you pay the teachers, fine-tune the curricula, or enrich the programs, you do not address the critical needs of a substantial segment of students unless you also concern yourself with nutrition, health care, housing, and family functioning - the factors that determine the early development of the child. If children are hungry or abused, if their minds are paralyzed by fear, or if they live in cramped squalid tenements, it is unlikely they will do well in school. (Hewlett, pp 219-220) Thus, a growing consensus continues to emerge: Good health is a prerequisite to a good education. Effective education complements and supports the health and social services needed to overcome the conditions that put a young person at educational

risk. (Council of Chief State School Offcers, P 41) The Biggest Threats to Health are “Social Morbidities”

The American Medical Association defines “social morbidities” as threats to health that “are primarily the result of social environment and or behavior.” They account for a growing proportion of the morbidity and mortality among children and youth. The health profile of American children has shifted markedly in the past 40 years. Once dominated by the threat of major infectious diseases, such as polio, scarlet fever, pneumonia, measles, and whooping cough, today, widespread immunization has virtually eliminated many of these diseases. Others are in steep decline . . . The leading cause of death in childhood - unintentional injuries - not only accountsfor the most deaths but also is among the most preventable. Other major, preventable problems include homicide, suicide, child abuse and neglect, developmental problems, and lead poisoning. (U.S. Dept. of Health and Human Services, pp 12-13). During the past decade, national mortality rates for infants and young children have improved. However: Our nation’s children are at greater risk today than at the beginning of the 1980s. Child poverty increased and persists. Births to unmarried teens rose. The chances that a teenager would die a violent death by accident, suicide or murder also increased over the decade. On other key measures of child well-being, our nation has stalled. (Center for the Study of Social Policy, p 2) Again, health risks in infancy and early childhood often are preventable: - About 6.9% - 260,000 children each year are born at below-normal weights. - About 40,000a year are born with alcohol-related impairments. - Drug abuse during pregnancy affects 11% of newborns each year - more than 425,000infants in 1988. - About 1.5 million children have been physically, sexually or mentally abused or neglected, most of them under age 5. (Newman and Buka, p I ) Among children ages 1-14, half of all deaths result from unintentional injuries. Of these, half result from motor vehicle crashes, and most of the remainder from drownings and fires. In addition, poisonings and falls often result in non-fatal injuries which have long-term consequences. Among adolescents and young adults ages 15-24,as in the younger group, half of all deaths result from unintentional injuries. In this age group, three-quarters of deaths due to unintentional injuries occur in motor vehicle crashes, and half of these involve alcohol. The next leading cause of death is homicide. About half of the cases involve alcohol use, and most involve firearms. For Black youth, homicide represents the number one cause of death. For all youth, suicide ranks just behind homicide as the third leading cause of death. (U.S.Dept. of Health and Human Services, pp 12-17)

For young people overall, 70% of mortality can be attributed to four causes: motor vehicle crashes (35%), other unintentional injuries (IS%), homicide (lo%), and suicide (10%). The Code Blue report observes: For the first time in the history of this country, young people are less healthy and less prepared to take their places in society than were their parents. (National Commission on the Role of the School and the Community in Improving Adolescent Health, Executive Summary) Though illicit drug use appears to have declined, prevalence of alcohol use remains high, and tobacco and alcohol use begins at younger ages. More than 77% of eighth grade students and 88% of ninth grade students report having consumed alcohol: 26% of eighth grade students and 38% of 10th grade students reported consuming more than five drinks on one occasion in the past two weeks. (National Adolescent Student Health Survey, p 76) By age 15, approximately 27% of girls and 33% of boys engage in sexual intercourse. By age 17, the proportions rise to 50% of girls and 66% of boys, and by age 20, approximately 78% of girls and 86% of boys. Each year, this age group experiences approximately 1.1. million pregnancies, and 2.5 million cases of sexually transmitted diseases (STDs), including HIV. Although serious, chronic medical and psychiatric disorders affect approximately 2 million adolescents (6% of the adolescent population), many more adolescents today are at risk for death and other poor health outcomes that are not primarily biomedical in origin. Contemporary threats to adolescent health, the so-called “social morbidities, ” are primarily the result of social environment and/or behavior. Social morbidities include suicide, homicide, substance abuse, sexually transmitted diseases (STDs), unintended pregnancy, and the human immunodeficiency virus (HIV) infection that can lead to acquired imrnunodeficiency syndrome (AIDS). (American Medical Association, p x) Consequences from these “social morbidities” can be immediate or delayed: life-ending, life-threatening, or chronic. Yet, the consequences remain largely preventable. The years from I5 through 24 are a time of changing health hazards. Caught up in change and experimentation, young people also develop behaviors that may become permanent. Attitudes and patterns related to diet, physical activity, tobacco use, safety, and sexual behavior may persist from adolescence into adulthood. The dominant preventable health problems of adolescents and young adults fall into two major categories: injuries and violence that kill and disable many before they reach age 25 and emerging lifestyles that affect their health many years later. (U.S. Dept. of Health and Human Services, p 16) Dryfoos.presents statistical data and commentary on the prevalence of delinquency, substance abuse, adolescent pregnancy, and school failure and dropping out, as well


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as discussion of the overlap in high-risk behaviors. She concludes: Of the 28 million girls and boys aged I0 to 17, it is estimated that I in 10 (almost 3 million) are in critical situations. Another group of 4 million (I5%) have excessively high prevalence rates for some but not all of the high-risk behaviors. Thus the future of 7 million youth - one in four in this country - is in jeopardy unless major and immediate changes are made in their school experiences, in their access to opportunitiesfor healthy adolescent development, and in the quality of life in their communities . . . Another 25 percent of youth (7 million) are at moderate risk, because of school problems, minor delinquencies, light substance use, and early, but protected, intercourse . . . About harf the nation’s youth (14 million) experiencefew problems and are probably at low risk of negative consequences from their behavior, but they too require general preventive services and health promotion programs. And, of course, effective schools are a social necessity for everyone. (Dryfoos, p 115) A More Comprehensive, Integrated Approach is Needed

The reports agree much has been learned about effectiveness of interventions in health, social services, and education. There is currently enough evidence about “what works ’’ to design strategies and programs that will improve the health and life chances of individual teens. Many programs around the country have been evaluated and have demonstrated that they are helping adolescents make wise choices about their health and their education, avoid health risking behaviors, and make a successful transition to responsible adulthood. We need substantialpublic and private investment in these kinds ofprograms. (National Commission on the Role of the School and the Community in Improving Adolescent Health, p 7) Information on about 100 different successful programs has been compiled from the fields of delinquency, substance use, teen pregnancy, and educational remediation . . . The level of consensus bet ween the different disciplines about what works to prevent high-risk behavior is remarkable . . . It should be clear by now that, despite shortcomings in program evaluation, enough is known to greatly improve the potential life course for high-risk children in the United States. (Dryfoos, pp 241. 243) For every suggested cause of learning impairment, there are successful programs of prevention. There is, however, no coordinated effort under way nationally or in individual states to deal with these problems. (Newman and Buka, p. vii) Many reports cite fragmentation of programs and services as a major barrier to effectiveness. Whether it be medical care, social services, or education, when those in greatest need do receive

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services, they are most likely to be too fragmented and too meager to accomplish their purpose . . . What it comes down to is that, for the children of the shadows, rotten outcomes - even risk factors - cannot be prevented by simplistic, one-pronged approaches any more . . . Many interventions have turned out to be ineffective not because seriously disadvantagedfamilies are beyond help, but because we have tried to attack complex, deeply rooted tangles of troubles with isolated fragments of help, with help rendered grudgingly in one-shot forays, with help designed less to meet the needs of beneficiaries than to conform to professional or bureaucratic convenience, with help that may be useful to middle class families but is often irrelevant to families struggling to survive. (Schorr, pp 260, 262, 263-164)

The Commission finds that fragmentation in the delivery of services to adolescents is seriously reducing their effectiveness. The origin of this problem lies in unintended effects of public policies that create separate programs to address specificproblems. . . The Commissionrecognizes the important contributions that these specific programs make, but sees the failure to connect various programs as preventing or limiting individual program success. (National Commission on the Role of the School and the Community in Improving Adolescent Health, p 11) An urgent and compelling need exists for more comprehensive and coordinated policies, programs and services. Given the relationship between health and learning, addressing any single issue in isolation is rarely enough. Effective school strategies need to look beyond academics to the often unmet and interrelated health needs that limit school performance. (Council of Chief State School Officers, p 12) System changes are needed. That health and education are related seems obvious, and now a solid and rapidly growing body of research documents the connections and their importance to the development of young children. But public policy as yet does not fully recognize this fact; instead policy decisions often increase the divisions between health and education, causing them inadvertently to work at cross-purposes. Changes are needed in the way health and education programs are funded, professionals are trained, and how each system relates to the other. (National Health/Education Commission, p 9)

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The Commission believes both that (a) there must be better collaboration among problem-specific programs, and (b) problem-specific programs must be complemented by activities that address underlying problems and place them in a broader perspective. (National Commission on the Role of the School and the Community in Improving Adolescent Health, p 11)

Health Promotion and Education Efforts Should be Centered in and Around Schools

Debate abounds concerning the proper role for schools. Educators protest that schools are not social service agencies, so schools should not be expected to remedy the nation’s social ills. Yet, a growing understanding suggests: In today’s world, schools can only accomplish their education mission i f they attend to students’ emotional, social, and physical problems. (National Commission on the Role of the School and the Community in Improving Adolescent Health, p 38) Schools are society’s vehicle for providing young people with the tools for successful adulthood. Perhaps no tool is more essential than good health. (Council of Chief State School Officers, P 4) School systems are not responsible for meeting every need of their students. But where the need directly affects learning, the school must meet the challenge. So it is with health. (Carnegie Council on Adolescent Development, p 61) Children spend most of their time at school. “Every school day, nearly 47 million students attend elementary and secondary schools in the U.S.; about 6 million professional and non-professional workers staff those schools. Thus, schools constitute the center of work activity for nearly one-fifth of the U.S. population.”’ These numbers increase with inclusion of daycare and preschool settings, and institutions of higher education. The prevention strategy that emerges from this analysis is centered in schools for many reasons: educational failure appears to be a significant common marker for many behavioral problems (and it is a problem in itselfl. Children are located in school, at least nominally, and therefore interventions can be targeted more readily. Community agencies are being allowed to bring their services into schools, especially in needy areas. (Dryfoos, p 267) Because children with unattended health or family problems are unlikely to perform at their best, schools can help children achieve academically by making sure that such supports as health care, child protective services, and mental health services are accessible to students and their families. As the one community institution that serves every family with children, a school is the natural hub for collaborative service delivery systems. (Children’s Defense Fund, p 78) Middle grade schools -junior high, intermediate, and middle schools - are potentially society’s most powerful force to recapture millions of youth adrift, and help every young person thrive during early adolescence. (Carnegie Council on Adolescent Development, p 8) Much of the attention - and the funding - directed toward schools with respect to health education has focused on categorical topics, most notably drug use and HIV/AIDS prevention. This analysis deliberately

excluded many reports with a categorical focus. However, escalating concerns about drug abuse and AIDS catalyzed a broader understanding about the role of schools in improving public health, and implicitly recognized the influence of health on educational achievement. In its final report, the National Commission on Drug-Free Schools: Calls on states, local communities, and the private sector to increase funding for drug prevention programs in the schools . . . [and/ calls for all schools and colleges to provide moral leadership in the war on drugs and to include, either as part of their drug education program or separately, the principles of civic and individual values and responsibilitiessuch as honesty, loyalty, integrity, compassion, hard work, citizenship, and respect for others. (National Commission on Drug-Free ~chools,p viii) The report specifies a number of objectives to be met by all schools: AN schools, colleges, and universities should: - Develop comprehensiveprevention and education programs, addressing the most critical needs first. - Coordinate services of community agencies and organizations involved in law enforcement and in drug education, prevention, and treatment. Develop written agreements that outline prevention roles and responsibilities for schools and community groups. - With help from the community and the private sector, keep the school open after hours and during the summer as a community resource. - Develop strategies to improve instruction and students’ academic performance, and to train all teachers, administrators, and other school employees in drug prevention. (National Commission on Drug-Free Schools, pp xii-xiii) This emphasis on drug prevention, to the exclusion of other health-related concerns, typifies the policies and programs of current and previous federal administrations and of the U.S. Dept. of Education. However, a growing consensus recognizes that categorical topics may be addressed most effectively within a broader health context. For example, the National Education Goals include: Goal 6: By the year 2000, every school in America will be free of drugs and violence and will offer a disciplined environment conducive to learning. Significantly, one objective for achieving Goal 6 indicates: Every school district will develop a comprehensive K-12 drug and alcohol prevention education program. Drug and alcohol curriculum should be taught as an integral part of health education. (National Education Goals Panel, p 70) The U.S.Dept. of Health and Human Services proposes a more comprehensive approach: Schools offer a natural locus for the provision of crosscutting educational interventions in health, and studies have shown that school health educa-



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tion is an effective means of helping children improve their health knowledge and develop attitudes that facilitate healthier behaviors. Yet only 25 States currently mandate comprehensiveschool health education programs, and implementation is spotty even in these States. (US.Dept. of Health and Human Services, p 62) Of the 300 National Health Promotion and Disease Prevention Objectives for the Year 2000, more than 100 address the health-related behavior of school-age children and youth. Many of the objectives can be achieved, directly or indirectly, through schools. One of the more ambitious objectives proposes: Increase to at least 75 percent the proportion of the Nation 3 elementary and secondary schools that provide planned and sequential kindergarten through 12th grade quality school health education. (Objective 8.4, US. Dept. of Health and Human Services, p 102) Other objectives that can be attained directly by schools include: Increase to at least 75 percent the proportion of the Nation’s schools that provide nutrition education from preschool through 12th grade, preferably as part of quality school health education. (Objective 2.19) Establish tobacco-free environments and include tobacco use prevention in the curricula of all elementary, middle, and secondary schools, preferably as part of quality school health education. (Objective 3.10) Provide to children in all school districts and private schoolsprimary and secondary school educational programs on alcohol and other drugs, preferably as part of quality school health education. (Objective 4.13) Increase to at least 50 percent the proportion of elementary and secondary schools that teach nonviolent conflict resolution skills, preferably aspart of quality school health education. (Objective 7.16)

Provide academic instruction on injury prevention and control, preferably as part of quality school health education, in at least 50 percent of public school systems (grades K through 12). (Objective 9.18)

Increase to at least 95 percent the proportion of schools that have age-appropriate HIV education curricula for students in 4th through 12th grade, preferably as part of quality school health education. (Objective 18.10) Include instruction in sexually transmitted disease transmission prevention in the curricula of all middle and secondary schools, preferably as part of quality school health education. (Objective 19.12)

Increase to at least 50 percent the proportion of children and adolescents in 1st through 12th grade who participate in daily school physical education. (Objective 1.8)

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Increase the high school graduation rate to at least 90 percent, thereby reducing risks for multiple problem behaviors and poor mental and physical health. (Objective 8.2) (U.S. Dept. of Health and Human Services, pp 91-125) The national health promotion and disease prevention objectives for the year 2000 emphasize the critical role of school health education programs in promoting child and adolescent health. Other reports cite the importance of health services. Turning Points calls on middle grade schools to: Improve academic performance through fostering the health and fitness of young adolescents, by providing a health coordinator in every middle grade school, access to health care and counseling services, and a health-promoting school environment. (Carnegie Council on Adolescent Development, p 9) The National Commission on the Role of the School and the Community in Improving Adolescent Health issued four major recommendations. The first follows: Recommendation I: Guarantee all adolescents access to health services regardless of ability to pay. (National Commission on the Role of the School and the Community in Improving Adolescent Health, p 18) The Commission specifies that services not only should include medical care, but family support services and psycho-social services. Furthermore, the Commission: recommends that adolescent health centers be established in each community, particularly in underserved communities . . . Adolescent health centers can be located in schools or other convenient locations. They can be organized by public health agencies, schools, community health agencies, hospitals, or independent organizations. (National Commission on the Role of the School and the Community in Improving Adolescent Health, p 21) According to the Office of Technology Assessment, U.S.Congress: The most promising recent innovation to address the health and related needs of adolescents is the school-linked health or youth services center. (Office of Technology Assessment, p 1-31) This approach entails more than administering occasional first aid. Because poor health leads to poor learning, school health programs today must go beyond simply providing a health room and a part-time nurse, or offering a semester of health education. (Council of Chief State School Officers, front cover) Health education and health services represent but two aspects of health promotion for school-aged children and youth. Traditionally, school health programs encompassed three complementary emphases: health education (classroom instruction), health services (school nursing, screenings, immunizations), and healthful environment (physical safety, nurturing climate). Many reports reflect an expanded concept of comprehensive school health promotion’ which includes eight components:

1) planned, sequential school health instruction at all levels, K-12. 2) school health services, which may include school-linked clinics or coordinated referral systems and collaboration with community resources, 3) a safe, nurturing, healthful school environment, 4) school physical education, 5) school food services, 6) school guidance and psychologial services, 7) integrated school and community health promotion efforts, and 8) schoolsite health promotion for faculty and staff. (West Virginia Task Force on School Health, p 3; American School Health Association, p 8) Until recently, school health program advocates were found primarily in health-related professions, organizations, and agencies. Now, they have been joined by a broad range of education organizations. Reports reviewed here include those from the American Association of School Administrators, the National Association of State Boards of Education, the Council of Chief State School Officers, and the National School Boards Association. Schools are in a prime position to help ensure that children and youth get the healthiest start possible and have the tools they need to be healthy adults. (Council of Chief State School Officers, p 41) Code Blue, issued by the National Commission on the Role of the School and the Community in Improving Adolescent Health, resulted essentially from the combined efforts of the American Medical Association and the National Association of State Boards of Education. Code Blue presents detailed discussion of four major recommendations, one of which was cited previously. Another follows: Recommendation IV: Urgeschools toplay a much stronger role in improving adolescent health. The American Association of School Administrators convened two task forces composed of educational leaders, to consider options for improving child health and to promote Healthy People 2000: National Health Promotion and Disease Prevention Objectives. The final product, Healthy Kids for the Year 2000: A n Action Plan for Schools, offers a 12-step plan for developing a comprehensive health education program. The first two steps are: I . Make the health of students and staff apriority for your schools; 2. Make a policy commitment to comprehensive school health education. (American Association of School Administrators, p 6) More professional organizations, government agencies, and individuals in the health and education professions are adding their voices as advocates of comprehensive school health promotion programs.

Prevention Efforts are Cost-Effective The Social and Economic Costs of Inaction are Too High and Still Escalating

The Children’s Defense Fund summarizes findings from a broad body of research:

Investing in children’s health also saves money . . Every dollar spent on prenatal care saves more than $3 in the child3first year of life alone by reducing the need for costly remedial care. Every dollar spent to immunize a child saves more than $10 by reducing childhood illness and death from diseme. Every dollar spent to give food supplements to a pregnant woman enrolled in Medicaid saves $2 in the baby’sfirst 60 days of life alone by reducing the likelihood of low birthweight. And poor children who have comprehensive primary and preventive health care have been shown to have annual health care costs nearly 10 percent lower than children who do not receive such care. (Children’s Defense Fund, p 55) Turning Points cites evidence from other studies to estimate costs of preventable problems. For example: - Each year’s class of dropouts will, over their lvetime, cost the nation about $260 billion in lost earnings and foregone taxes. -Each added year of secondary education reduces the probability of public werfare dependency in adulthood by 35 percent. - The United States spent more than $19 billion in 1987 in payments for income maintenance, health care, and nutrition to support families begun by teenagers. - Of teens who give birth, 46percent will go on wevare within four years; of unmarried teens who give birth, 73 percent will be on werfare within four years. - Alcohol and drug abuse in the United States cost more than $136 billion in 1980 in reducedproductivity, treatment, crime, and related costs. (Carnegie Council on Adolescent Development, p 29) Code Blue focuses on costs resulting from the crisis in adolescent health: It is abundantly clear from well-documented studies that without appropriate programs, large numbers of adolescents willfail educationally,fail as effective parents, and fail as productive members of the economy. Many will have chronic health problems. Many will die prematurely. Over time, such problems will require unacceptably high public expenditures . . , If this nation is to avoid thesefuture costs, we must act immediately, using the abundant information now available to guide our investments. (National Commission on the Role of the School and the Community in Improving Adolescent Health, pp 7-8) If we cannot quantify all the costs, we can seek to understand the stake that society has in reducing the numbers of adolescents who commit crimes, drop out of school, and bear children. For only by confronting fully the magnitude of our current failures and their consequences, can we develop the impetus to take the actions that can change the future. (Schorr, p 3)

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From the perspective of an economist, Hewlett provides a compelling analysis of the “cost of neglecting our children.” She describes recent initiatives by large compan-


August 1992. Vol. 62. No. 6

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ies in such areas as family support policies, investments in education, and community involvement. She cites signs of hope in the private sector: A significant chunk of corporate America has come to believe that a better family support system is necessary for economic survival . . . Improving the prospects for infants and children through better prenatal care and early childhood education, for example, is not an expense but an excellent investment, one that can be postponed only at great cost to society. (Hewlett, p 24) The final consideration, ultimately, involves commitment of resources: Enough is known about the lives of disadvantaged high-risk youth to mount an intensive campaign to alter the trajectories of these children. Enough has been documented about the inability of fragmented programs to produce the necessary changes to proceed toward more comprehensive and holistic approachs. Enough is known about the inadequacies of the educational system to give the highest priority to school reform. The comprehensive multicomponent framework appears to make sense, linking educational enhancement with social supports of all kinds. Money and commitment are the bottom lines. The funds have to be located and redirected toward a giant rescue operation. (Dryfoos, p 268) Hewlett underscores the high stakes involved: The argument builds logically, cumulatively, and remorselessly, leaving us with the overwhelming conviction that each and every citizen has an enormous stake in avoiding damage to children . . . We all live in fear of crime in our homes and on our streets. We are all diminished when large numbers of parents are incapable of nurturing their young . . . r f we fail to save our children we will pay through the nose - and put our own lives on the line. (Hewlett, p 274)

CREATING A N AGENDA FOR CHANGE The 25 reports share a sense of urgency and a compelling need for immediate action. What is intolerable in the present crisis is our paralysis in dealing with adolescent health issues . . . We have access to afull measure of promising strategies. Now, we must act. (National Commission on the Role of the School and the Community in Improving Adolescent Health, p 8) The reports establish cleary the challenge to: Work toward building a national will to more effectively integrate the health and education servicesprovided to children . . . Children must become a priority at every level of government federal, state and local and throughout the nation. (National Health/Education Consortium, p 20) Convince a critical mass of citizens and leaders that the growth of child poverty, drug abuse, violence, and family and neighborhood disintegration poses as much of a threat to American

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prosperity, security, competitiveness, and moral leadership in the new decade as any other enemy outside or inside our borders; . . . [and to] push Americans in all walks of life to confront and clarify their values and commitment to working for rather than just talking about protecting and nurturing children. (Children’s Defense Fund, pp 7-9)

If current knowledge is to be harnessed to change outcomes for children growing up at risk, more Americans must become aware of the high stake that all of us have in what happens to these children, and more Americans must become convinced that we know what needs to be done and how to do it. (Schorr, p xix) The biggest single need is for a far broader base of understanding among all Americans of what can be done, and what must be done. (Schorr, p 283) The task of building a “national will” to make children’s health and education a priority requires active participation of individual citizens, as well as organizations and government agencies. That “will” then must be channeled into specific strategies. A comprehensive program to improve the health of America’s youth will require active involvement and commitment by all sectors of society. A first step in this direction is for organizations representing medical and health professionals, educators, and volunteer groups working with adolescents to develop an active agenda in adolescent health for their membership. (American Medical Association, p 75) The challenge involved in developing such an agenda derives from the need for comprehensiveness, for programs that cut across traditional boundaries of disciplines and professions, and require active collaboration among previously independent or distant groups. Educators and health professionals typically operate in distinct spheres, with little overlap between them. They belong to separate professional organizations, read different journals and research literature and, in essence, speak different languages. Yet, they must communicate more effectively, and draw others into the discussion and the agenda-setting process. Improving the health of American children requires a wide range of social and economic interventions. For example, more and better preschool education for disadvantaged children and children with disabilities could help to detect and prevent developmental problems. Educational and support programs for parents in high-risk environments hold promise for reducing child abuse and other health problems, such as lead poisoning. The complex developmental problems besetting children in these environments demand concerted efforts by many different sectors of society. Primary health care providers, social service professionals, health educators, housing officials, community groups, and concerned individuals can each make a difference in the health of American children. (US. Dept. of Health and Human Services, p 15) The Children’s Defense Fund recognizes that:

As the one community institution that serves every family with children, a school is the natural hub for collaborative service delivery systems. Developing these systems will depend, however, on the willingness of school districts to lower the bureaucratic walls that have discouraged collaboration in the past. (Children’s Defense Fund, p 76) Some professional education organizations are urging their members to take the lead in advocating change: State education agencies can be catalysts to help communities make the critical link between health and education - and move beyond the confines of the health room to discuss the role of schools in meeting the health needs of young people . . . Providing good health programsfor young people requires new partnerships among schools, parents, and community agencies and organizations. (Council of Chief State School Officers, pp 2, 64) A number of states and school districts already have moved to develop and implement comprehensiveschool health programs. The 25 reports reviewed here include as examples three recent state-level documents: a task force report from West Virginia, a position paper from Massachusetts, and an implementation plan from Michigan. The West Virginia Task Force on School Health, appointed in 1990 by Governor Caperton, recognized: West Virginia and the rest of our nation arefacing an unprecedented crisis in the area of health. And nowhere is that crisis more apparent than in the health and well-being of children , We cannot allow our greatest resource, our children, to fall victim to such a plight . . . West Virginia is not alone in this health crisis; we do not lead the nation in alarming statistics. However, we do lead the nation in one important regard. West Virginia is taking the lead by taking solid, proactive steps to do something about this problem. (West Virginia Task Force on School Health, p I ) The Task Force advocated development of a comprehensive West Virginia School Health program, and issued recommendations in eight areas: school health education, including development of a prekindergarten-12th grade comprehensive health education curriculum; school health services, including establishment of school-based health centers also available for community health education; healthful school environment; child nutrition; physical education, including periodic fitness testing in conjunction with complete health appraisals; counseling; schooVcommunity collaboration; and teacher and staff wellness. A newly established West Virginia School Health Committee is charged with planning, implementing, and evaluating the program. The Committee, which includes government and nongovernment representatives from education, health, and business, reports to the governor through the Cabinet on Children and Families. A policy paper of the Massachusetts Dept. of Education, Educating the Whole Student, discusses the school’s role in the physical, intellectual, social, and emotional development of children. . . . unless the school is involved in the physical,

. .

social, and emotional development of the child, students will not learn, will not achieve, and will not become productive citizens in our democratic society. In a time of limited resources, . .schools must work with the entire community to restructure and reorganize existing resources to provide children with a sense of serf worth, high expectation and commitment to their community. (Massachusetts Dept. of Education, Introduction) The Massachusetts Board of Education identified a primary goal: Education should contribute to the learner’s physical and emotional well-being and development, in an environment that fosters self-esteem. (Massachusetts Dept. of Education, p 1) The paper identifies criteria for achieving that goal, such as increased parent involvement and quality school health and counseling programs. Individual districts are urged to consider a variety of strategies, including development of an early childhood program, implementation of a health education curriculum (prekindergarten-12th grade, a physical education program that nurtures self-esteem and promotes lifetime fitness and health, and active partnerships with community agencies. The report includes an extensive list of resource people who can provide technical assistance in specific program areas. The Michigan Model for Comprehensive School Health Education has evolved for more than a decade, The Michigan Dept. of Education established performance objectives for health education in 1974. In 1980, the State Board of Education adopted a position statement regarding the Comprehensive School Health Program specifically to avoid fragmentation and misinterpretation by the growing number of agencies and organizations developing materials and resources for school health. (Michigan Dept. of Education et al, p 3) According to the Michigan Board of Education: The School Health Program is a composite of learning activities and experiences within the school setting that are directed toward developing an environment that protects and promotes the health of the students and the school personnel. A comprehensive school health program includes health education, health services, and a healthful environment . , . School health education has as its goal the provision of a planned, sequential K-12 arrangement of learning activities that are designed to influence health attitudes, practices, and cognitive skills. (MichiganDept. of Education et al, p 3) In 1983, five state agencies jointly proposed establishment of support for a single comprehensive school health education curriculum. The proposal was included in the executive budget and became an important component of the Governor’s Health Care Cost Containment program, receiving legislative endorsement and appropriations. The program is coordinated at the state level by a State Interagency Steering Committee composed of the Dept. of Education (lead agency for implementation),



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the Depts. of Mental Health, Public Health, Social Services, State Police, Management and Budget, and Office of Substance Abuse Services. Local coordination is provided within each of 26 regions by “Michigan Model Coordinator” who facilitates a local steering committee and serves as liaison for local school districts, classroom teachers, community resource agencies, individuals who provide extensive inservice training, and the Dept. of Education. The state provides funding for curriculum materials, teacher training, school employee wellness programs, and hiring the local 26 coordinators. The curriculum itself is a composite of several validated comprehensive school health curricula. It is periodically evaluated and updated. Having a single comprehensive health education package has many advantages for the State, schools, and for students. By joining the resources of cooperating state agencies, the quality of the product is much greater than could be achieved otherwise. When new health issues (such as AIDS or anabolic steroids) arise, a mechanism is in place for developing and delivering pertinent education materials and for training teachers to implement them in the classroom. (Michigan Dept. of Education et al, p 5) Other examples of innovative programs are cited or reviewed within the 25 reports. The New York City schools, in collaboration with the New York Academy of Medicine, implemented comprehensive health education curricula (Growing Healthy and Being Healthy) in elementary and middle schools. New Jersey established a number of school-based youth service centers. Other statewide initiatives include Missouri, New Mexico, “Healthy Kids, Healthy California” and “Healthy Me, Healthy Maine.” The list continues to grow. Some form of health instruction is mandated by law in 36 states; 43 states have established a legal basis for health education through educational codes or other legislation. Actual requirements vary: 32 states require that health education be taught at some time during grades K-12; 19 states require health education some-

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time during grades one-six; 22 states require it either in grade seven or eight; and 25 states require a course in health education for high school graduation. School Health in America provides information about state policies related to health instruction, health services, health environment, physical education, food and nutrition services, guidance and counseling, and school psychology. CONCLUSION The past few years witnessed a dramatic increase in public concern about the health and education of the nation’s young people. Consequently, programs in health/education have expanded dramatically in nature and scope. Evidence from each of the 25 reports is compelling; collectively, they demand innovative social strategies. Where do we go from here? Moving ahead will not be easy. People in both the public and private sectors will need to understand the extent of the problem, and the comprehensive nature of the solutions. Families, neighborhoods, the health community, and the public and private sectors will need to forge new partnerships to address the interconnected health and education problems our young people are experiencing. The people of this country must renew their commitment to the health of young people. This will take resources, time, and most of all thepolitical will to make it happen. (National Commission on the Role of the School and the Community in Improving Adolescent Health, p 41) The common themes from the 25 reports are clear. The next step involves mobilization - making the health and education of children a real national priority. References 1. Green LW, Kreuter MW. Health Promotion Planning: An educational and environmental approach. New York, NY: Mayfield Publishing Company; 1991:350. 2. Allensworth DD, Kolbe LJ. The comprehensive school health program: Exploring an expanded concept. J Sch Health. 1987;57(10): 409-412.

Figure 1 Synopsis of Major Reports and Publications Title/ Date

Focus

Summary

Contact

Healthy Kids tor the Year 2000: An Action Plan tor Schools ( 1990)

Comprehensive school health education: action plan, legislative goals

12-step action plan for developing comprehensive health education program: Make health of students and staff a school priority. Make policy commitment to comprehensive school health education. Form school health education advisory committee or task force. Assess health, attitudes, behavlors, values, and needs. Set goals, objectives, evaluation criteria. Decide on curricula. Appoint health coordinator. Invest in staff wellness program. Provide staff development to ensure winning teaching methods. Seek long-term funding and commitment. Foster sustained community involvement. Ensure evaluation and accountability.

American Association of School Administrators, 1801 N. Moore St.. Arlington, VA 22209 703/528-0700

Adolescent health issues; Q&A, statistics

1) Improving adolescent health is complex because health problems are linked with educational performance, family relationships, poverty, and lifestyle. 2) Health problems affect adolescents at Increasingly younger ages. 3) 25% adolescents lead “high risk” lifestyles. 4) Lack of services places adolescents at greater risk. 5) Biggest health threats are not biomedlcal, but “social morbidities” (suicide, homicide, substance abuse, pregnancy, STDs, HIV). resulting from social envlronment and/or behavior. We need to promote healthy behavior by strengthening families, schools, communities, and environment. We need to improve adolescents’ access to health care services. We need an active agenda in adolescent health and involvement and commitment by all sectors of society.

Dept. of Adolescent Health, Profiles NL012690, Amerlcan Medical Association 535 N. Dearborn St., Chicago, IL 60610 800.621-8335 $10 (AMA members) $12 (non-members)

National survey of eighth and 10th grade students: assessed knowledge, attitudes, behavior in eight critical health areas

Detailed tabulation of survey data on substance use, injury prevention, nutrition, violence, suicide, AIDS, and consumer skllls. Contains survey data; implications and recommendations: Health must have higher priority in school curriculum and public policy. Planned, sequential health instructlon (K-12), supported by other school health promotion components. is essential. Providing information alone is not enough; instruction should develop skills in coping, stress management, decision-making. More attention to health Instruction Is needed in elementary grades. Curriculum development, successful school health programs result from collaborative efforts by school personnel, parents, community groups, state agencies, businesses. Gender, ethnic, and religious differences should be considered during health instruction. On-going health Instruction assessment is critical.

American School Health Association P.O. Box 708 Kent, OH 44240 216/678-1601 $12.50 (ASHA member) $14.50 (non-member)

Producer: American Association of School Administrators (AASA)

America ’s Adolescents: How Healthy Are They? ( 1990) Producer: American Medical Association (AM4

National Adolescent Student Health Survey ( 1989) Producers: American School Health Association, (ASHA), Association for the Advancement of Health Education, (AAHE), and Society for Public Health Education, Inc. (SOPHE)

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School Health in America: An Assessment of State policies to Protect and lmprove the Health of Students, 5th ed ( 1989)

State policies for school health promotion

Turning Points: Preparing American Youth for the 21st Century ( 1989)

Early-adolescent well-being: risks, strategies

Summarizes state policies for school health services, education, environments, food services, physical education, guidance and counseling, and school psychology. In each area, speclflc requirements are tabulated by state, with additional information on programs and personnel. Schools provide focal point for influencing students’ health more Producer: American School than any other community setting. Comprehensive program should include multidisciplinary team Health Association approach to meet student needs, (ASHA) and University Worksite health promotion programs for school personnel, of Texas Health integrated programming and between schools and community Science Center at agencies. Houston

Producer: Carnegie Council on Adolescent Development, Task Force on Education of Young Adolescents

1) One-fourth of the adolescents ages 10 - 17 may be vulnerable to multiple hlgh-risk behaviors like school failure, substance abuse, early unprotected Intercourse. 2) Middle schools should: Improve academic performance by fostering health and fitness of youth. provide health coordinator In every school. provide access to health care and counseling services. connect with communities to share responsibility, establish partnerships, use resources, and ensure student access to health services and activities. ~~


American School Health Association P.O. Box 708, Kent, OH 44240-0708 216/678-1601 $15 (member) $18 (non-member)

Carnegie Council on Adolescent Development, P.O. Box 753, Waldorf, MD 20604 2021429-7979 $9.95

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Figure 1 Synopsis of Major Reports and Publications Tle/Oate

Focus

Summary

Kids Count Data Book: State Profiles of Child Well-Being (1991)

Annual, statistical, state-by-state profile of child well-being in America

1) Data on eight indicators organized to provide U S . minority, and state profiles. 2) Major conclusions: Children are at greater risk today than at beginning of 1980s. Child poverty has increased and persists. 0 Births to unmarried teen-agers rose. Chances that teen-agers wlll die by accident, suicide, or murder increased over the decade.

The Center for the Study of Social Policy, 1250 I St., NW. Suite 503, Washington, DC 20005 2021371-1565 $12.50

Annual overview of status of American children’s well-being: statistics, trends, strategies, current CDF legislation

1) Current status in child care, education, health, housing, employment poses threat to nation. 2) Need to create political will, crusade for well-being of American children. 3) Chlldren with unattended health/family problems unlikely to perform at their best. 4) School can help students achieve by ensuring accessibility of supports like health care, child protective services, and mental health services. 5) School is natural hub for collaboratlve servlce dellvery systems. 6) Developing these systems will depend on willingness of school districts and social service agencies to lower bureaucratic walls.

Children’s Defense Fund, 122 C St., NW, Washington, DC 20001 202162a-a7a7 $14.95

Adolescent Health -Volume I:Summary and Policy Options -Volume /I: Background and the Effectivness of Selected Prevention and Treatment Programs -Volume 111: Crosscutting lssues in the Delivery of Health and Related Services (1991)

Physical, emotional, behavioral health status of American adolescents; statistical charts, major findings, strategies for Congress

1) Suggests three policy options to Congress: take steps to improve adolescents’ access to appropriate health and related services; take steps to restructure, invigorate federal government’s efforts to Improve adolescents’ health; support efforts to improve adolescents’ environments. 2) For each major policy option, several specific strategies are discussed. 3) Specific findings relate to roles of families, schools, federal agencies; financial and legal access to health services. 4) Parents, schools, health care workers and systems, and adolescents themselves are given little guidance and few resources to enable them to be supportive of adolescents. 5) A more sympathetic, supportive approach to adolescents is needed.

Superintendent of Documents, Government Printing Off ice, Washington, DC 20402-9325 2021783-3238 Volume I SIN 052-003-01234-1, $9.50; Volume II; S I N 052-003-01235-9 $30; Volume 111 SIN 052-003-01236-7, $13

Beyond the Health Room (1991) Producer: Council of Chief State School Officers (CCSSO)

Youth health needs, comprehensive school health programs, and HIV infection

1) Because health and learning are interrelated, school health is being discussed in context of school reform. 2) State education agencies can be catalysts to help communities make the critical link between health and education, and to discuss the role of schools in meeting youths’ health needs. 3) Effective school strategies must look beyond academics to health deficits that limlt school performance.

Resource Center on Educational Equity, Council of Chief State School Officers, Suite 379 400 N. Capitol St.. NW Washington, DC 20001 2021393-8159 $1 0

Adolescents at Risk: Prevalence and Prevention ( 1990)

Summary of prevalence: overview of programs to prevent adolescent pregnancy , delinquency, substance abuse, school failure

1) Of youth ages 10-17, 7 million (‘14) are at high risk for encountering serious problems; another 7 million are borderline high-risk. 2) Schools should be focal institution in prevention to assure academic achievement and to provide social support and health programs. 3) Two common aspects of many successful programs: intensive individualized attention. communitywlde multiagency collaborative approach. 4) More research is not necessary to take action, mount campaign. 5) Money and commitment are bottom lines. 6) Strategy for assisting high-risk youth is based on: interrelatedness of problems. need for early, sustained intervention. Importance of one-on-one intensive education. 0 importance of basic educational skills, social skills, and experientlal education to function in adult world.

Oxford University Press 200 Madison Ave., New York. NY 10016 800/451-7556 $29.95 $14.95 paperback

Producer: Center for the Study of Social Policy, with support from the Annie E. Casey Foundation The State of America’s Children 1991 (1991)

Producer: Children’s Defense Fund (CDF)

Producer: Joy G. Dryfoos

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Producer: Congress of the U.S. Office of Technology Assessment (OTA)


August 1992, Vol. 62. No. 6

Contact

I

Figure 1 Synopsls of Major Reports and PubUcaUons Tltle/Date

Focus

Summary

Contact

When the Bough Breaks: The Cost Of Neglecting Our Children (1991)

Plight of America's children; national economic impact of neglect, devaluation of children's health and well-being; call to action

1) Such factors as misallocation of national resources and dearth of parenting (due to divorce and working parents) have led to child neglect on a massive scale. 2) This child neglect, in turn, has caused an increasingly violent society with an underprepared labor force and a threatened national economy. 3) Multi-faceted action plan includes issues of parenting leave, chiid care, tax-reform, family-friendly workplace, volunteerism. 4) Describes cost-effective private programs for children which are key to our economic survival. 5) Neglecting children is not just issue of economics, but also humanity - we must reach beyond our self-Interest to do the right thing. 6) Among 10 key policy initiatives to Improve life-chances of children is "Educational Reform:" We need significant new money for programs that target disadvantaged youth. We need to spend relatively more In the early years, where society gets relatively high rate of return.

BaslcBooks, division of HarperCollins publishers, 10 E. 53rd St., New York, NY 212/207-7057 $22.95

School involvement in student development; strategies, recommendations

1) School must work with whole community to ensure optimal physical, social, emotional development of all children and access to needed prevention, intervention services. 2) Student's self-esteem and academic achievement are interdependent. 3) Each school district needs to: maximize parent involvement. offer flexibility in curricula to meet needs of all students. create opportunities for all students to develop a positive relationship with adult or older student. reinforce responsible student decision-making, positive behavior change. offer on-going staff training, support. ensure active role for school counseling personnel. develop partnerships with community agencles.

Massachusetts Dept. of Education, Bureau of Student Development and Health, 1385 Hancock St., Quincy, MA 02169 617/770-7580 publication 16,215 Free

Background, present status, future objectives and plans for Michigan Model; summary data of implementation (including funding and support issues); focus on substance abuse component

1) Overview of rationale, development, and implementation of state "weilness curriculum," administered by State Interagency Steering Committee through regional coordinators. 2) Intent of the Michigan Model was to utilize the best features of existing curricula with adapted materials and to mobilize and coordinate federal, state, and local resources behind one curriculum. 3) Curriculum includes safety and first aid; nutrition; family, consumer, community, personal, emotional and mental health; growth and development; substance use and abuse; disease prevention and control.

Don Sweeney, Michigan Model, Center for Health Promotion, 3423 N. Logan, Lansing, MI 48909 517/335-8389 Free

Lists objectives and makes recommendationsfor schools, colleges to be drug-free by year

Recommendations for schools, colleges, families, communities, government: Schools should provide drug prevention programs for all students K-12. Colleges should conduct mandatory drug education for all students. Schools should develop better linkages with community services. Communities should keep schools open after school hours and during summer as site for activities. Each community should establish a drug-prevention task force. Schools and colleges should provide moral leadership in war on drugs.

National Clearinghouse for Alcohol and Drug Information (NCADI), P.O. Box 2345, Rockville, MD 20852, 800/729-6686 Free

Producer: Sylvia Ann Hewlett

Educating the Whole Student: The School's Role in the Physical, Intellectual, Social, and Emotional Development of Children ( 1990) Producer: Massachusetts Dept. of Education

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Michigan Model for Comprehensive School Health Education: lmplementation Plan for Year 1991 ( 1990) Producers: Michigan Depts. of Education, Mental Health, Public Health, Social Services, and State Police; Office of Highway Safety Planning; Off ice of Substance Abuse Services Toward a Drug-Free Generation: A Nation's Responsibility ( 1990)

2000.

Producer: National Commission for DrugFree Schools

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Figure 1 Synopsis of Major Reports and Publications Title/Date

Focus

Summary

Contact

Beyond Rhetoric: A New American Agenda for Children and families (1991)

Findings, recommendations, blueprint of a national policy for American children and families; tables, cost projections, funding options

1) Commission’s agenda includes ensuring Income security, improving health, increasing educational achievement, supporting the transition to adulthood, strengthening and supporting families, protecting vulnerable children and their families, making policies and programs work, and creating a moral climate for children. 2) Echoes national education goals for year 2000 (see The National Education Goals Report, 1991). most notably the goal that all children will enter school ready to learn. 3) Health education programs in schools are important for helping children learn about risks and consequences of various unhealthful behaviors, as well as how to promote their own health. 4) The report includes dissenting views by group of nine commissioners. One conclusion they reach: Increase support of abstinence education to reduce spread of STDs and AIDS and rate of unwed teen-age pregnancies.

National Commission on Children, 1111 18th St. NW, Suite 810, Washington, DC 20036 202/254-3800 First copy free, additional copies: $5 each. Also available is the 100-page summary.

Health crisis of U.S. adolescents: background, recommendations

1) State of adolescent health in America constitutes a national emergency. 2) Health status and school performance are interrelated. 3) Four major recommendations: Guarantee all adolescents access to health care regardless of ability to pay. Make community frontline In battle for adolescent health. Organize services around people, not people around services. Urge schools to play stronger role in Improving adolescent health. 4) “Call to Action” suggests specific strategies for federal and state governments, educators, health and social services, businesses, media, religious and community groups, and individual citizens.

NASBE, 1012 Cameron St., Alexandria, VA 23314 703/684-4000 $13.50

Highlights current status in reaching National Education Goals; notes data gaps; summarizes proposals for creating more effective indicators.

Summarizes progress in achieving National Education Goals on both: federal and state levels. By the year 2000: 1) All children in America will start school ready to learn. 2) High school graduation rate will increase to at least 90%. 3) American students will leave grades four, eight, and 12 having demonstrated competency in challenging subject matter, Including English, mathematics, science, history, and geography: every school in America will ensure that all students learn to use their minds well so they may be prepared for responsible citizenship, further learning, and productive employment in our modern economy. 4) U.S. students will be first in the world in science and mathematics achievement. 5) Every adult American will be literate and will possess the knowledge and skills necessary to compete In a global economy and exercise the rights and responsibilities of citizenship. 6) Every school in America will be free of drugs and vlolence and will offer a disciplined environment conducive to learning.

National Education Goals Panel, 1850 M St., NW, Suite 270, Washington, DC 20036; 202/632-0953 Free

1) Five major themes emerged: interrelatedness of the problems. need for additional resources. economic, demographic imperatives. role of private sector. cost-effectiveness of prevention. 2) Five “next steps” suggested: set priorities for children and families. plan staging of pollcies and activities. provide effective delivery systems. finance the solutions. ensure quality and accountability.

National Forum on the Future of Children and Families, 2101 Constitution Ave., NW, Washington, DC 20418 202/334-1935

Producer: National Commission on Children

Code Blue: Uniting for Healthier Youth ( 1990)

Producer: National Commission on the Role of the School and the Community in Improving Adolescent Health, convened by National Association of State Boards of Education (NASBE) and American Medical Association (AMA)

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Building a Nation of Learners: The National Education Goals Report (1991)

Producer: National Education Goals Panel

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Social Policy for Children and families: Creating an Agenda (1989)

Review of 22 recent reports on health status of children and families; policy recommendations

Producers: National Forum on the Future of Children and Families, institute of Medicine, National Research Council, National Academy of Sciences

226



Figure 1 Synopsis of Major Reports and Publlcatlons Focus

TIe/Date ~~

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Crossing the Boundaries Between Health and Education

Relationship between education and health

(1990) Producer: National Health/ Education Consortium, convened by the National Commission to Prevent Infant Mortality and the Institute for Educational Leadership School Health: Helping Children Learn

(1991) Producer: National School Boards Association (NSBA)

€very Child a Learner: Reducing Risks of Learning Impairment During Pregnancy and lniancy (1990)

Producer: Lucille Newman and Stephen L. Buka; Education Commission of the States

Within Our Reach: Breaking the Cycle of Disadvantage

(1989) Producer: Lisbeth 8. Schorr with Daniel Schorr

School leader’s guide to comprehensive school health programs: rationale, implementation plan, checklists, case studies

Contact

Summary ~~~

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1) Six key points: Health affects education. Education affects health. Technological advances are not enough. Families have critical role. ‘At risk” does not mean “doomed.” System changes are needed. 2) Health and education systems often work in isolation from each other; need more collaboration. 3) Need reorganization, integration of health and education policies and programs. 4) Need to build national will to make children a priority at federal, state, and local levels.

1) Documents the need for school health programs.

2) Analyzes extent to which 100 school distrlcts incorporated four broad components of comprehensive school health programs (program philosophy, health instruction, health services, and healthy school environment) into their programs. 3) Discusses specific policies, costs, training, and evaluation. 4) Outlines 10-step planning, implementation process of school health program: Determine priority of health and well-being within community. Commit school board and administration to supporting school health program. Assess needs, wants of community. Enlist community support, establish School Health Advisory Committee. Assign school health program coordinator. Choose right curriculum. Train teachers and school staff members. Link instruction and health services. Concentrate on healthy school environment. Plan for evaluation and accountability.

National COmmiSSiOfl to Prevent Infant Mortality, Switzer Bldg., Room 2014, 330 C St., SW, Washington, DC

20201 2021472-1364 $9

National School Boards Association, 1680 Duke St., Alexandria, VA 22314

7wa38-6722 $15 plus shipping and handling

Synthesis of major research studies; identification of primary preventable conditions associated with development of learning impairment in children birth to age five

1) School-age health education is Important to emphasize benefits of health promotion and to reduce behaviors that put young women and their future babies at risk. 2) School health education assists young people in their role as students and later as parents themselves. 3) It is important to concentrate on cognitive development of youth, coupled with familial support, in order to lessen some disadvantages of poverty and low birthweight and to avoid some intellectual impairment. 4) Prevention strategies specific to education: provide vigorous K-12 health education, including self-care, nutrition, substance abuse, and sex education. provide reproductlve health with self-esteem. decision-making, and accessible contraception educatlon. expand comprehensive, community-based early childhood programs in compliance with Education of Handicapped Act Amendment (1963).

Education Commission of the States Distribution Center, 707 17th St., Suite 2700, Denver, CO

Successful programs to improve well-being of the disadvantaged

1) Documents child and adolescent troubles and the “hight cost of rotten outcomes.” 2) Reviews a braod range of effective intervention programs. 3) Enough research has been done to plan effective programs. 4) Many relevant parties are not aware of newly merging insights, especially from outside thelr fields. 5) Biggest single need Is for broader base of understanding of what can and should be done. 6) Successful programs are: Intensive. comprehensive. flexible, family- and community-orlented, and conducted by staff with time and skills to develop relationships of resped and collaboration.

Anchor Books, Doubleday , New York, NY;


80202-3427 303/299-3692 $5

800/223-6834x9479 $9.95 or $2.50 bulk rate, $4.50 for UPS ground S8lviCE


227

Figure 1 Synopsis of Major Reports and Publications Tltle/Date

Focus

Summary

Contact

America 2000: An Education Strategy (1991)

Action plan to achieve six national education goals

Four strategies to move toward President’s and governors’ six national education goals to be reached by year 2000 (see Building a Nation of Learners: The National Education Goals Report. 1991): 1) “Radically improve” and make more accountable today’s schools. 2) Invent a “New Generation of American Schools,” funded by businesses and other donors; 535 by 1996, thousands by 2000. 3) Those in workforce must continue to learn so that a “Nation at Risk” can become a “Nation of Students.” 4) Communities must become committed to their schools and create an environment conducive to learning.

U.S.Dept. of

Producer: U.S.Dept. of Education

Healthy People 2000; National Health Promotion and Disease Prevention Objectives ( 1990)

Strategy for improving nation’s health during 1990s

1) Presents 300 specific, measurable, objectives, including: “Increase to at least 75% proportion of elementary and secondary schools that provide planned, sequential K-12 quality school health education.” 2) Age-appropriate health education curricula can change attitudes, behavior. 3) Schools can be used to facilitate chlldren’s access to basic health services. 4) School health education can foster healthful behaviors and help prevent hazardous ones, especially smoking, nutrition, and physical activity. 5) In partnership wlth parents and community groups, schools can create health programs, enhance health education curricula, and serve as resource to adults of community.

New statewide plan: Comprehensive school health issues, programs, implementation, recommendations

1) Develop K-12 comprehensive school health education curriculum and teacher’s guide, incorporating concepts, activities from best existing guides. 2) Establish school-based health centers with community linkages to ensure student access to multiple health services. 3) Make centers available for Community health education. 4) Increase number of school nurses. 5) County board of education, with school improvement councils, will periodically devise and review plans to ensure healthy school climate. 6) School food services should reflect Dietary Guidelines for Americans; food providers should collaborate with educators. 7) Establish state coordinator and other trained coordinators for physical education. 8) Conduct periodic fitness testing with complete health appraisals for every child in K-12. 9) Establish effective personal/psychological counseling programs at all grade levels, particularly elementary. 10) After obtaining information from school improvement councils, county board of education should work wlth community medical providers, health education resources, and labor leaders to address health needs of whole community, especially children. 11) Establish wellness programs for school personnel.

Producer: U.S.Dept. of Health and Human Services, Public Health Service

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Building a Healthy Future ( 1990) Producer: West Virginia Task Force on School Health

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Education, America 2000. 400 Maryland Ave.,

sw,

Washington DC 20202-0498 BOO/USA-LEARN; Free Superintendent of Documents, U.S. Government Printing Office. Washington, DC 20402 DHHS Publication # (PHS) 91-50213 202/783-3238 Summary Report: S/N 017-001-00473-1 $9 Full Report: S/N 017-001-00474-0 $31

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Lenore Zedosky, West Virginia Dept. of Education, 1900 Kenewli Blvd., Room 6309, Capital Complex, Charlestown, WVA 25305

Health in post 2015 development agenda: deliver on health promotion.

Agenda Setting for Health Promotion: Exploring an Adapted Model for the Social Media Era.

Time to move forward: an agenda for campus sexual health promotion in the next decade.

Should pain be on the health promotion agenda?

Should health promotion be on the pain agenda?

Health promotion research in the United Nations' post-2015 agenda.

[Creating a "Health Promotion Checklist for Residents" Attempt to promote healthy activities].

Workplace health promotion for older workers: a systematic literature review.

Geriatric psychopathology: an American perspective on a selected agenda for research.

A new agenda for health in Europe.

An agenda for public health in the 1990s.

Global health in the European Union--a review from an agenda-setting perspective.

Weight loss maintenance: an agenda for health psychology.

Nutrition, food production and health - an agenda also for cardiologists.

Ensuring an inclusive global health agenda for transgender people.

Germany and global health: an unfinished agenda?

Germany and global health: an unfinished agenda?

An agenda for action.

Health promotion: an ethical analysis.

Smartphones and health promotion: a review of the evidence.

[Health promotion: Mental health promotion].

Building an Australasian paramedicine research agenda: a narrative review.

Public health: An agenda to promote Hispanic cardiovascular health.

Assessing environmental assets for health promotion program planning: a practical framework for health promotion practitioners.