The Role of the Federal Government in Promoting Health Through the Schools: Report from the National School Health Education Coalition Statement of Maureen Corry, MPH, Chair, National School Health Education Coalition, before the Subcommittee on Oversight of Government Management, Committee on Governmental Affairs. U.S. Senate, November 14, 1991.
T
he National School Health Education Coalition (NaSHEC) includes more than 60 national organizations, associations, voluntary health agencies, corporations and federal agencies working together to improve the health of our nation’s youth. Established in 1982, NaSHEC’s goal is to ensure that every student in grades K-12 receives a comprehensive health education experience. NaSHEC exists because members believe in the value of a “comprehensive” versus a “categorical” approach to school health education in helping children establish healthy attitudes, beliefs, and habits that last a lifetime. While the member organizations hold various categorical and professional interests, a common bond unites members in the realization that our nation’s children must receive quality comprehensive school health education in grades K-12. The National School Health Education Coalition, Inc. believes comprehensive health education is essential to ensuring that our children achieve their full health potential. Delivery and coordination of federal health education programs is vital to ensuring a comprehensive approach to health education. We urge the Committee to require federal agencies to coordinate such funds through comprehensive health education programs, and we recommend that an Office of Comprehensive School Health Education be created to oversee systematic coordination among federal agencies, state and local departments of education, and departments of health. Comprehensive school health education is based on sound scientific principles of health promotion and disease prevention. It provides a well-organized, planned, sequential series of learning experiences that address and integrate education about a range of categorical health problems and issues. It is skills-based and includes experiential learning. Instruction is provided by health education specialists or teachers trained t o teach the subject in a prescribed amount of time at each grade level. Evaluations of several comprehensive health education curricula confirm that health education works by positively influencing student knowledge, attitudes, and behavior towards health. The amount of time allocated to instruction, amount of teacher inservice training, and level of support from administrators, teachers, and parents are critical to successful outcomes. Unfortunately, comprehensive health education is not Maureen Corry, MPH, Chair, National School Health Education Coalition, 1000 Vermont Ave., NW, Suite 400, Washington, DC 20005.
offered in most American schools. An estimated 95% of schools deliver piecemeal, crisis-driven categorical health education, an approach not only expensive, but ultimately not as effective. A survey by the National Association of State Boards of Education and the Council of Chief State School Officers reported that 42 states require health education to be offered in schools; all but seven require it for both elementary and secondary school students. In addition, 28 of 42 states requiring health education specify that they require “comprehensive school health education.” How these states define and implement what they consider comprehensive school health education needs to be examined. We are not optimistic that genuine comprehensive health education actually is being implemented in these 28 states that require it. In 1989, the President and the nation’s governors established six National Education Goals with the hope of capturing the attention and resolve of Americans to restructure our schools and increase student performance. Goal six states that, by the year 2000, every school in America will be free of drugs and violence and will offer a disciplined environment conducive to learning. One objective required to achieve this goal states that every school district will develop a comprehensive K-12 drug education program and that drug and alcohol education be taught as an integral part of health education. Unfortunately, this objective does not mention drug education as an integral component of a comprehensive school health education curriculum. This omission is not surprising when a major funding source for drug education - the U.S. Dept. of Education’s Drug Free Schools and Community Program - discourages funds from being used for comprehensive health education. Rather, it encourages a “categorical” approach to drug education. This approach is unacceptable if one believes in the value of a comprehensive approach. Goal Six should be changed to read “Every school district will implement comprehensive health education in grades K-12 that includes drug education and violence prevention.” A fundamental problem with health education in schools relates to the nature of funding which tends to be “categorical” or focused on a specific problem. This approach incorporates essentially a “medical” model rather than an educational model. The medical model proves most useful in intervening with a particular ailment or illness needing treatment. Using highly precise interventions, medical professionals offer short-term palliatives to help restore such in-
Journal of School Health
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Aprll 1992, Vol. 62, No. 4
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143
dividuals to health. This same type of intervention has been applied to “cure” social ills such as drug abuse, smoking, reckless driving, and other problems resulting in a mushrooming of issue-specific programs in the nation’s schools and communities, as well as in the federal bureaucracy. An educational model, by comparison, is designed not as an intervention, but as a long-term effort to help young people become mature thinkers, literate in the fields that will best prepare them to participate in the American agenda. We expose young minds to math, science, literature, social studies, and other subjects so that after 12 years, graduates “get it.” That is, they possess utilitarian knowledge as well as positive attitudes that enable them to join the adult world and make a contribution. Just as graduates from sound educational programs possess the fundamentals of thinking in math, literature, and science, so too should they be knowledgeable about health. If we expect adults to lead healthy, vibrant, energetic, and productive lives, then health education should be continuous throughout their formative years. Without long-term exposure, they have little chance to “get it” regarding their own health, nor find the health of their future children.
CURRENT STATUS A N D FUTURE PROSPECTS An Historical Perspective In 1972, President Nixon’s Commission on Health
Education issued its report on the importance of health education. Rather than ignoring the report, suppose the nation’s schools had responded positively and included comprehensive health education in the curriculum. Perhaps an entire generation of Americans now having their own children would be healthier and wiser as consumers of medical goods and services. Perhaps we would not have 1 million teen-age pregnancies each year, because we would have healthy literate parents able to speak knowledgeably to their daughters and sons about sexuality. Perhaps we would not have thousands of babies born each year exposed prenatally to drugs. Perhaps we would not have 30,000 deaths per years from guns, many of these deaths related to drug violence. Perhaps if we had invested in comprehensive health education in 1972, we would not face a health care crisis in 1992 caused by Americans so dependent on a medical system that demand has pushed costs to astronomical levels. We missed an opportunity in 1972 to produce a far healthier nation in 1992 than we have today. We could have helped avert the crisis our medical system faces if we had acted in 1972 and focused on prevention and education. Yet, we have opportunities in 1992 to build a stronger, healthier nation in 2002 and 2012. By those dates, two more generations of children will pass through the nation’s schools. Will they love and accept themselves and be adequately educated to lead robust, healthy, adult lives. Or will they have minuscule exposure to whatever the “hot topic” happened to be when they took their mandatory half-credit in health sometime in the ninth or 10th grade? NaSHEC is optimistic about the future and will work diligently to ensure that all children have access to comprehensive rather than crisis-driven school health
144
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April 1992, Vol. 62, No. 4
education. NaSHEC’s strength lies in the ability of national member organizations to mobilize their affiliates at the state and local levels to promote comprehensive school health education. NaSHEC members work together to encourage creation of state and local coalitions and activities in the public and private sectors to promote comprehensive school health education; provide strategic and tactical support to such coalitions by providing technical assistance; elevate the public’s perception of education at all levels; cooperate and share information among member organizations; and encourage member organizations to provide leadership and take action to facilitate accomplishment of this work. Current Initiatives
NaSHEC believes that all levels of government involved in funding education should encourage comprehensive health education. The federal government must coordinate its own widely scattered efforts to foster health education. Currently, seven federal agencies operate school health programs with no formal coordination or focal point within the U.S. Dept. of Education. Yet, some success stories exist at the federal level. The Centers for Disease Control’s Division of Adolescent and School Health (DASH), and efforts of the Office of Disease Prevention and Health Promotion at the U.S. Dept. of Health and Human Services, provide two examples of successful federal health promotion and disease prevention programs. DASH administers a successful program of comprehensive school health education with an emphasis on adolescent health issues. CDC identified priority health risks among adolescent populations, including behaviors that result in elevated risk for development of cardiovascular diseases and cancer, transmission of HIV/AIDS, or that result in mortality, morbidity, and disability either during adolescence or adulthood. After these health risks were identified, CDC developed, evaluated, and disseminated interventions to reduce highpriority health risks among adolescent populations. DASH also administers a program of cooperative agreements and grants to state education agencies and local education agencies, colleges, and related educational organizations to promote and disseminate effective school health education about HIVIAIDS prevention. The Office of Disease Prevention and Health Promotion developed Healthy People 2000, national health promotion and disease prevention objectives for the year 2000.These objectives, developed by the Public Health Service through a national process involving all state and territorial health departments and some 300 national membership organizations, recognize that planned and sequential comprehensive school health education programs must be a key element in prevention strategies to improve the health of all Americans. These programs, which illustrate how modest federal funding and coordination can work with schools and national organizations, promoted exemplary comprehensive school health education curricula to benefit our young children. Whereas other federal initiatives that offer categorical health education programs, such as the U.S. Dept. of Education’s Drug Free Schools and Communities Program, limit use of their funds t o specific
purposes rather than a broad-based comprehensive school curriculum. Legislative Action
NaSHEC believes the focal point for comprehensive school health education should be an Office of Comprehensive School Health Education. This office would coordinate divergent activities of federal agencies in the school health arena and award grants to organizations prepared to take innovative approaches to providing comprehensive school health education. In 1978, the “Health Education Act” (Public Law 95-561) directed the Commissioner of Education at the U.S. Dept. of Health, Education, and Welfare to consult with the Public Health Service and the Surgeon General to “assure coordination and prevent duplication of effort” in all school health programs. In 1979, HEW responded by establishing an Office of Comprehensive School Health. Until abolished by the Reagan Administration in 1981, the Office served an important function coordinating the federal government’s health education programs. Since that time, the U.S. Dept. of Education has offered no visible effort to coordinate federal health education efforts. In the 1988 Hawkins-Stafford Elementary Education Improvement Act, Congress reauthorized an Office of Comprehensive School Health Education within the U.S. Dept. of Education and requested the Secretary of Education to make grants to state and local education agencies to establish or strengthen comprehensive school health education programs. While the U.S. Dept. of Education proceeded to implement the school health grant program through the Office of the Fund for Improvement and Reform in School and Teaching (FIRST), they decided not to formally establish an Office of Comprehensive School Health Education. Despite repeated Congressional inquiries and statements of intent that an Office of Comprehensive School Health Education was needed not only to run the school health grant program, but to perform the crucial coordinating function, the Department’s position remained firm. Based on experience with other programs, the Department believed establishment of an Office was not necessary to work cooperatively with other federal agencies to coordinate the Department’s school health education programs and activities. However, NaSHEC still believes significant benefits would result if such an office were established. NaSHEC also advocated funding for the school health education grant program as well as for greater flexibility
in use of federal funds designated for specific programs. The school health education grant program received $3 million to start the grant program in 1988, and the first round of grant awards was made in 1989. Eighty applications, totalling $19.3 million from 35 state and local education agencies were received. Because of budgetary constraints, only 18 projects in 10 states received awards. This same scenario has been repeated year after year. Comprehensive school health education grants have been over-subscribed significantly since their creation. In the Fiscal Year 1992 Labor, DHHS, and Education Appropriations Bill, Congress appropriated $4.5 million to continue the school health grant program. These grant awards demonstrated and performed two important goals. First, the need to address quality health education programs in schools to confront problems of teen-age pregnancy, smoking, alcohol abuse, poor nutrition habits, and lack of physical education. Second, successful collaborative partnerships were established between state education agencies, local education agencies, communitybased health organizations, and the corporate community in fostering health promotion and disease prevention in the nation’s schools.
CONCLUSION It is extraordinary how many major health issues and decisions our children and youth face daily. Statistics confirm the sobering fact that one in five of today’s 31 million adolescents has at least one serious health problem. Nearly three-quarters of deaths among adolescents occur due to social causes, many of which could be prevented. Someone said, “Statistics are people with the tears washed off.” Tears are shed by millions of children and families in America whose lives are negatively influenced by poor health status and practice of high-risk behavior. We must do more for our children. We must educate them about the importance of good health and the practice of healthy lifestyle behaviors. Thus, NaSHEC offers three recommendations: First, federal agencies need greater clarity concerning their role in improving school health education and sufficient resources to implement comprehensive health education programs; second, federal agencies must coordinate health education funds through comprehensive health education programs; and third, an Office of Comprehensive School Health Education should be created to oversee coordination between federal agencies, state and local departments of education and departments of health.
Journal of School Health
April 1992, Vol. 62, No. 4
145
T
he National School Health Education Coalition (NaSHEC) includes more than 60 national organizations, associations, voluntary health agencies, corporations and federal agencies working together to improve the health of our nation’s youth. Established in 1982, NaSHEC’s goal is to ensure that every student in grades K-12 receives a comprehensive health education experience. NaSHEC exists because members believe in the value of a “comprehensive” versus a “categorical” approach to school health education in helping children establish healthy attitudes, beliefs, and habits that last a lifetime. While the member organizations hold various categorical and professional interests, a common bond unites members in the realization that our nation’s children must receive quality comprehensive school health education in grades K-12. The National School Health Education Coalition, Inc. believes comprehensive health education is essential to ensuring that our children achieve their full health potential. Delivery and coordination of federal health education programs is vital to ensuring a comprehensive approach to health education. We urge the Committee to require federal agencies to coordinate such funds through comprehensive health education programs, and we recommend that an Office of Comprehensive School Health Education be created to oversee systematic coordination among federal agencies, state and local departments of education, and departments of health. Comprehensive school health education is based on sound scientific principles of health promotion and disease prevention. It provides a well-organized, planned, sequential series of learning experiences that address and integrate education about a range of categorical health problems and issues. It is skills-based and includes experiential learning. Instruction is provided by health education specialists or teachers trained t o teach the subject in a prescribed amount of time at each grade level. Evaluations of several comprehensive health education curricula confirm that health education works by positively influencing student knowledge, attitudes, and behavior towards health. The amount of time allocated to instruction, amount of teacher inservice training, and level of support from administrators, teachers, and parents are critical to successful outcomes. Unfortunately, comprehensive health education is not Maureen Corry, MPH, Chair, National School Health Education Coalition, 1000 Vermont Ave., NW, Suite 400, Washington, DC 20005.
offered in most American schools. An estimated 95% of schools deliver piecemeal, crisis-driven categorical health education, an approach not only expensive, but ultimately not as effective. A survey by the National Association of State Boards of Education and the Council of Chief State School Officers reported that 42 states require health education to be offered in schools; all but seven require it for both elementary and secondary school students. In addition, 28 of 42 states requiring health education specify that they require “comprehensive school health education.” How these states define and implement what they consider comprehensive school health education needs to be examined. We are not optimistic that genuine comprehensive health education actually is being implemented in these 28 states that require it. In 1989, the President and the nation’s governors established six National Education Goals with the hope of capturing the attention and resolve of Americans to restructure our schools and increase student performance. Goal six states that, by the year 2000, every school in America will be free of drugs and violence and will offer a disciplined environment conducive to learning. One objective required to achieve this goal states that every school district will develop a comprehensive K-12 drug education program and that drug and alcohol education be taught as an integral part of health education. Unfortunately, this objective does not mention drug education as an integral component of a comprehensive school health education curriculum. This omission is not surprising when a major funding source for drug education - the U.S. Dept. of Education’s Drug Free Schools and Community Program - discourages funds from being used for comprehensive health education. Rather, it encourages a “categorical” approach to drug education. This approach is unacceptable if one believes in the value of a comprehensive approach. Goal Six should be changed to read “Every school district will implement comprehensive health education in grades K-12 that includes drug education and violence prevention.” A fundamental problem with health education in schools relates to the nature of funding which tends to be “categorical” or focused on a specific problem. This approach incorporates essentially a “medical” model rather than an educational model. The medical model proves most useful in intervening with a particular ailment or illness needing treatment. Using highly precise interventions, medical professionals offer short-term palliatives to help restore such in-
Journal of School Health
.
Aprll 1992, Vol. 62, No. 4
*
143
dividuals to health. This same type of intervention has been applied to “cure” social ills such as drug abuse, smoking, reckless driving, and other problems resulting in a mushrooming of issue-specific programs in the nation’s schools and communities, as well as in the federal bureaucracy. An educational model, by comparison, is designed not as an intervention, but as a long-term effort to help young people become mature thinkers, literate in the fields that will best prepare them to participate in the American agenda. We expose young minds to math, science, literature, social studies, and other subjects so that after 12 years, graduates “get it.” That is, they possess utilitarian knowledge as well as positive attitudes that enable them to join the adult world and make a contribution. Just as graduates from sound educational programs possess the fundamentals of thinking in math, literature, and science, so too should they be knowledgeable about health. If we expect adults to lead healthy, vibrant, energetic, and productive lives, then health education should be continuous throughout their formative years. Without long-term exposure, they have little chance to “get it” regarding their own health, nor find the health of their future children.
CURRENT STATUS A N D FUTURE PROSPECTS An Historical Perspective In 1972, President Nixon’s Commission on Health
Education issued its report on the importance of health education. Rather than ignoring the report, suppose the nation’s schools had responded positively and included comprehensive health education in the curriculum. Perhaps an entire generation of Americans now having their own children would be healthier and wiser as consumers of medical goods and services. Perhaps we would not have 1 million teen-age pregnancies each year, because we would have healthy literate parents able to speak knowledgeably to their daughters and sons about sexuality. Perhaps we would not have thousands of babies born each year exposed prenatally to drugs. Perhaps we would not have 30,000 deaths per years from guns, many of these deaths related to drug violence. Perhaps if we had invested in comprehensive health education in 1972, we would not face a health care crisis in 1992 caused by Americans so dependent on a medical system that demand has pushed costs to astronomical levels. We missed an opportunity in 1972 to produce a far healthier nation in 1992 than we have today. We could have helped avert the crisis our medical system faces if we had acted in 1972 and focused on prevention and education. Yet, we have opportunities in 1992 to build a stronger, healthier nation in 2002 and 2012. By those dates, two more generations of children will pass through the nation’s schools. Will they love and accept themselves and be adequately educated to lead robust, healthy, adult lives. Or will they have minuscule exposure to whatever the “hot topic” happened to be when they took their mandatory half-credit in health sometime in the ninth or 10th grade? NaSHEC is optimistic about the future and will work diligently to ensure that all children have access to comprehensive rather than crisis-driven school health
144
Journal of School Health
April 1992, Vol. 62, No. 4
education. NaSHEC’s strength lies in the ability of national member organizations to mobilize their affiliates at the state and local levels to promote comprehensive school health education. NaSHEC members work together to encourage creation of state and local coalitions and activities in the public and private sectors to promote comprehensive school health education; provide strategic and tactical support to such coalitions by providing technical assistance; elevate the public’s perception of education at all levels; cooperate and share information among member organizations; and encourage member organizations to provide leadership and take action to facilitate accomplishment of this work. Current Initiatives
NaSHEC believes that all levels of government involved in funding education should encourage comprehensive health education. The federal government must coordinate its own widely scattered efforts to foster health education. Currently, seven federal agencies operate school health programs with no formal coordination or focal point within the U.S. Dept. of Education. Yet, some success stories exist at the federal level. The Centers for Disease Control’s Division of Adolescent and School Health (DASH), and efforts of the Office of Disease Prevention and Health Promotion at the U.S. Dept. of Health and Human Services, provide two examples of successful federal health promotion and disease prevention programs. DASH administers a successful program of comprehensive school health education with an emphasis on adolescent health issues. CDC identified priority health risks among adolescent populations, including behaviors that result in elevated risk for development of cardiovascular diseases and cancer, transmission of HIV/AIDS, or that result in mortality, morbidity, and disability either during adolescence or adulthood. After these health risks were identified, CDC developed, evaluated, and disseminated interventions to reduce highpriority health risks among adolescent populations. DASH also administers a program of cooperative agreements and grants to state education agencies and local education agencies, colleges, and related educational organizations to promote and disseminate effective school health education about HIVIAIDS prevention. The Office of Disease Prevention and Health Promotion developed Healthy People 2000, national health promotion and disease prevention objectives for the year 2000.These objectives, developed by the Public Health Service through a national process involving all state and territorial health departments and some 300 national membership organizations, recognize that planned and sequential comprehensive school health education programs must be a key element in prevention strategies to improve the health of all Americans. These programs, which illustrate how modest federal funding and coordination can work with schools and national organizations, promoted exemplary comprehensive school health education curricula to benefit our young children. Whereas other federal initiatives that offer categorical health education programs, such as the U.S. Dept. of Education’s Drug Free Schools and Communities Program, limit use of their funds t o specific
purposes rather than a broad-based comprehensive school curriculum. Legislative Action
NaSHEC believes the focal point for comprehensive school health education should be an Office of Comprehensive School Health Education. This office would coordinate divergent activities of federal agencies in the school health arena and award grants to organizations prepared to take innovative approaches to providing comprehensive school health education. In 1978, the “Health Education Act” (Public Law 95-561) directed the Commissioner of Education at the U.S. Dept. of Health, Education, and Welfare to consult with the Public Health Service and the Surgeon General to “assure coordination and prevent duplication of effort” in all school health programs. In 1979, HEW responded by establishing an Office of Comprehensive School Health. Until abolished by the Reagan Administration in 1981, the Office served an important function coordinating the federal government’s health education programs. Since that time, the U.S. Dept. of Education has offered no visible effort to coordinate federal health education efforts. In the 1988 Hawkins-Stafford Elementary Education Improvement Act, Congress reauthorized an Office of Comprehensive School Health Education within the U.S. Dept. of Education and requested the Secretary of Education to make grants to state and local education agencies to establish or strengthen comprehensive school health education programs. While the U.S. Dept. of Education proceeded to implement the school health grant program through the Office of the Fund for Improvement and Reform in School and Teaching (FIRST), they decided not to formally establish an Office of Comprehensive School Health Education. Despite repeated Congressional inquiries and statements of intent that an Office of Comprehensive School Health Education was needed not only to run the school health grant program, but to perform the crucial coordinating function, the Department’s position remained firm. Based on experience with other programs, the Department believed establishment of an Office was not necessary to work cooperatively with other federal agencies to coordinate the Department’s school health education programs and activities. However, NaSHEC still believes significant benefits would result if such an office were established. NaSHEC also advocated funding for the school health education grant program as well as for greater flexibility
in use of federal funds designated for specific programs. The school health education grant program received $3 million to start the grant program in 1988, and the first round of grant awards was made in 1989. Eighty applications, totalling $19.3 million from 35 state and local education agencies were received. Because of budgetary constraints, only 18 projects in 10 states received awards. This same scenario has been repeated year after year. Comprehensive school health education grants have been over-subscribed significantly since their creation. In the Fiscal Year 1992 Labor, DHHS, and Education Appropriations Bill, Congress appropriated $4.5 million to continue the school health grant program. These grant awards demonstrated and performed two important goals. First, the need to address quality health education programs in schools to confront problems of teen-age pregnancy, smoking, alcohol abuse, poor nutrition habits, and lack of physical education. Second, successful collaborative partnerships were established between state education agencies, local education agencies, communitybased health organizations, and the corporate community in fostering health promotion and disease prevention in the nation’s schools.
CONCLUSION It is extraordinary how many major health issues and decisions our children and youth face daily. Statistics confirm the sobering fact that one in five of today’s 31 million adolescents has at least one serious health problem. Nearly three-quarters of deaths among adolescents occur due to social causes, many of which could be prevented. Someone said, “Statistics are people with the tears washed off.” Tears are shed by millions of children and families in America whose lives are negatively influenced by poor health status and practice of high-risk behavior. We must do more for our children. We must educate them about the importance of good health and the practice of healthy lifestyle behaviors. Thus, NaSHEC offers three recommendations: First, federal agencies need greater clarity concerning their role in improving school health education and sufficient resources to implement comprehensive health education programs; second, federal agencies must coordinate health education funds through comprehensive health education programs; and third, an Office of Comprehensive School Health Education should be created to oversee coordination between federal agencies, state and local departments of education and departments of health.
Journal of School Health
April 1992, Vol. 62, No. 4
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