School Health Education

School health programs are said to be one of the most efficient strategies that a nation might use to prevent major health and social problems. Next to the family, schools are the major institution for providing the instruction and experiences that prepare young people for their roles as healthy, productive adults. Schools can–and invariably do–play a powerful role in influencing students' health-related behaviors. Elementary, middle, and secondary schools are therefore prime settings for public health programming: in 1999, nearly 99 percent of young people ages seven through thirteen and 96 percent of those between fourteen and seventeen were enrolled in school in the United States. Appropriate school interventions can foster effective education, prevent destructive behavior, and promote enduring health practices. For many young people in their formative years, school may, in fact, be the only nurturing and supportive place where they learn health information and have positive behavior consistently reinforced.

In addition, health and success in school are inextricably intertwined. Good health facilitates children's growth, development, and optimal learning, while education contributes to children's knowledge about being healthy. Studies of young people have found that health-risk behaviors negatively affect:(1) education outcomes, including graduation rates, class grades, and performance on standardized tests;(2) education behaviors, including attendance, dropout rates, behavioral problems, and degree of involvement in school activities such as homework and extracurricular pursuits; and (3) student attitudes, including aspirations for postsecondary education, feelings about safety at school, and positive personal attitudes.

Schools cannot achieve their primary mission of education if students and staff are not healthy and fit physically, mentally, and socially. Children who are sick, hungry, abused, using drugs, who feel that nobody cares, or who may be distracted by family problems are unlikely to learn well. One child's lack of progress can impede the learning of the other children in the classroom as well. Education reform efforts are bound to be of limited effectiveness unless health-related barriers to learning are directly addressed. As Harriet Tyson writes, "First among those barriers are poor physical and mental health conditions that prevent students from showing up for school, paying attention in class, restraining their anger, quieting their self-destructive impulses, and refraining from dropping out" (p. 2). When surveyed, most parents and members of the general public consistently rate health as an important topic that schools should address.

Although reliable data on the implementation of school health programs are lacking, there are indications that few schools operate comprehensive, coordinated programs designed to systematically address the nation's major health risks. For example, 71 percent of high school students surveyed in 1999 did not attend a daily physical education class, and 44 percent were not even enrolled in a physical education class. Only 72 percent of the nation's schools participated in the federal School Breakfast Program during the 1999–2000 school year, despite the well-documented health and educational benefits of doing so. In 1994 health education staff were involved in joint activities or projects with staff from other components of the school health program in only 65 percent of middle and high schools. Health services facilities were not available in 32 percent of all middle and high schools in 1994. During the 1998–1999 school year, 76 percent of public high schools and 55 percent of public middle schools operated vending machines, most of which were located in or near the cafeteria. The most common types of food offered in school vending machines are soft drinks, chips, desserts, and candy. Few schools are known to sponsor health promotion activities for staff.

Educators should work to ensure that every elementary, middle, and high school establishes and maintains comprehensive, well-coordinated school health programs. The American Public Health Association (APHA) supports the definition offered by the Institute of Medicine: "A comprehensive school health program is an integrated set of planned, sequential, school-affiliated strategies, activities, and services designed to promote the optimal physical, emotional, social, and educational development of students. The program involves and is supportive of families and is determined by the local community, based on community needs, resources, standards, and requirements. It is coordinated by a multi-disciplinary team and accountable to the community for program quality and effectiveness …." (p. 2). There is no single 'best' comprehensive school health program model that will work in every community. Programs must be designed locally, and collaboration among all stakeholders in the community is essential if programs are to be accepted and effective.

Characteristics of Effective Programs

There are eight elements that characterize high-quality school health programs. These elements are described below.

1. A focus on priority behaviors that affect health and learning. School health programs were initiated early in the twentieth century, in large part to address the numerous infectious diseases afflicting children. At the beginning of the twenty-first century, the etiology of health risks facing young people–and the adults they will become–are most often social or behavioral. The Division of Adolescent and School Health (DASH) of the Centers for Disease Control and Prevention (CDC) documents that six health-risk behaviors account for nearly two-thirds of the morbidity and mortality in adolescents. These behaviors are tobacco use; unhealthful dietary behaviors; inadequate physical activity; alcohol and other drug use; sexual behaviors that may result in HIV infection, other sexually transmitted diseases, or unintended pregnancy; and behaviors that may result in intentional injuries (i.e., violence and suicide) and unintentional injuries (e.g., motor vehicle crashes).

The leading causes of death among adults–including cardiovascular disease, cancer, and diabetes–are closely linked to these health-risk behaviors. In addition, these behaviors tend to co-occur, they tend to be established in youth, and they are preventable. Children and adolescents need to learn, and to practice, making health-enhancing choices before health-damaging behaviors are initiated or become ingrained.

CDC's Youth Risk Behavior Surveillance System provides reliable national data on the prevalence of specified behaviors. Most states, and some large cities, also conduct the Youth Risk Behavior Survey. Results from these state and city surveys, and other available state and local data from education and health agencies, can be used to plan school health program activities.

2. A foundation of support for every child and adolescent. Whether a student engages in health-debilitating or health-enhancing behaviors depends on the interplay of assets and deficits in the influential support systems surrounding the student, including friends, peers, family, community, and schools. Three protective factors have been found to frequently help young people overcome stress and adversity to become healthy competent adults with a sense of purpose: (1) caring and supportive relationships, (2) high expectations for success, and (3) active participation in school and community activities. For example, the ongoing National Longitudinal Study of Adolescent Health has found that students who feel "connected" to schools are more likely to adopt health-enhancing behaviors (respectful and caring teachers are among the factors related to students feeling connected). Applying a "positive youth development" approach, schools should aim to develop a full range of "life competencies" among students–not only academic and vocational competencies but also healthful living skills, personal and social skills, ethics, and citizenship.

3. A complete set of program components. Many national organizations and membership associations, as well as CDC's DASH, promote a school health program model consisting of eight mutually reinforcing components that communities can shape to fit their needs and circumstances. These eight basic components are health education; school health services; a healthy school environment; physical education; school nutrition services; counseling, psychological, and social services; health-promotion programs for staff; and family and community involvement.

Health education consists of a planned, sequential curriculum taught daily in every grade (prekindergarten through twelve) that addresses the physical, mental, emotional, social, and spiritual dimensions of health and is designed to motivate and help students maintain and improve their health, prevent disease, and avoid health-related risk behaviors. A quality curriculum allows students to develop and demonstrate increasingly sophisticated health-related knowledge, attitudes, skills, and practices while addressing a variety of topics, including personal health, family health, community health, consumer health, environmental health, sexuality education, mental and emotional health, injury prevention and safety, nutrition, prevention and control of disease, and substance use and abuse. The National Health Education Standards, jointly developed in 1995 by APHA, the American Cancer Society (ACS), the American School Health Association (ASHA), the American Association for Health Education (AAHE), and the Society of State Directors of Health, Physical Education and Recreation (SSDHPER), provide useful guidance for curriculum development, instruction, and assessment of student performance. Well-implemented health education has been shown to improve the adoption of health enhancing behaviors and school achievement.

School health services are provided for students and are designed to appraise, protect, and promote health. These services are designed to ensure access and/or referral to primary health care services, foster appropriate use of primary health care services, prevent and control communicable diseases and other health problems, provide emergency care for illness or injury, promote and provide optimum sanitary conditions for safe school facilities and environments, and provide educational and counseling opportunities for the promotion and maintenance of individual, family, and community health. Services should be provided by qualified professionals such as physicians, nurses, dentists, and other allied health personnel. Health services via school-based clinics that are linked with enhanced academic services have been associated with reduced absenteeism, improved academic achievement, and improved health status.

Although only 53 percent of states required schools to offer school nurse services in 1994, nearly every school had provisions for administering first aid (99%), administering medications (97%), and conducting vision, hearing, and height/weight screenings (89%). However, fewer schools provided less traditional services, such as mental health counseling (56%) or conducting health-risk appraisals to help students determine their lifestyle practices (36%). School-based or school-linked health centers are becoming more common, however, and many of these centers offer a wide range of physical and mental health services. A national survey identified a total of 1,157 school-based health centers that provided in-school care to children during the 1997–1998 school year. Thirty-seven percent were housed in high schools, 16 percent in middle schools, 34 percent in elementary schools, and the remainder were off-site.

A healthy school environment attends to the physical and aesthetic surroundings and to the school's psychosocial climate and culture, thus protecting the health and safety of students and staff and promoting health-enhancing behaviors. Physical environmental concerns include indoor and outdoor safety hazards, biological or chemical agents that might be detrimental to health, air temperature and quality, water quality, sanitation, precautions for infection control, lighting, noise levels, and access for persons with disabling conditions. The psychological environment includes the interrelated physical, emotional, and social conditions that affect the well-being and productivity of students and staff, including physical and psychological safety, positive inter-personal relationships, recognition of needs and successes of the individual, and support for building self-esteem in students and staff. In considering the school environment, there are things that both large and small schools can implement. In fact, a large body of research in the affective and social realms overwhelmingly affirms the superiority of schools with small enrollments.

Bullying and harassment can have damaging effects on students' health and well-being. Those who manage school environments also need to actively encourage health-enhancing behaviors by assuring that nutritious foods are available as an affordable option whenever food is served or sold, providing convenient and appealing opportunities for physical activity, enforcing tobacco-free policies, and conducting educational campaigns to promote positive health behaviors.

Physical education is a planned, sequential curriculum and program of physical activity taught daily in every grade. Cognitive content and learning experiences should be provided in a variety of activity areas, such as basic movement skills; physical fitness, rhythms and dance; games; team, dual, and individual sports; tumbling and gymnastics; and aquatics. Quality physical education should promote lifetime activities and sports that students can enjoy and pursue throughout their lives. The National Standards for Physical Education developed by the National Association for Sport and Physical Education (NASPE) provide useful guidance for curriculum development, instruction, and appropriate assessment of student performance.

Physical education needs to be taught by qualified teachers. Studies have found that well-prepared physical education specialists teach longer and higher-quality lessons than those not professionally prepared in physical education. Elementary schools also need to provide daily periods of supervised recess, and middle schools and high schools should provide multiple opportunities for all students to voluntarily participate in intramural programs, sports and recreation clubs, and interscholastic athletics. Links with community-based sports, recreation, and fitness programs should also be sought and fostered.

Studies among adolescents have demonstrated that physical activity is consistently related to higher self-esteem and to reduced levels of anxiety and stress. Conversely, low levels of physical activity are associated with high-risk behaviors such as cigarette smoking and marijuana use. Studies have found that students who participate in extracurricular programs tend to have higher grade point averages, better attendance records, lower dropout rates, and fewer discipline problems than students generally.

School nutrition services promote the health and education of students through access to a variety of nutritious and appealing meals, nutrition education, and a school environment that encourages students to make healthy food choices. The school food-service program can provide opportunities for students to practice healthful eating on a daily basis–more than half of the young people in the United States get one of their three major meals from school food programs, and 10 percent get two of their three main meals at school.

Sound school food-service programs reflect the current U.S. Dietary Guidelines for Americans (DGA) and other quality criteria necessary to achieve nutrition integrity. These programs provide pleasant eating areas for students and staff with adequate time for unhurried eating, offer opportunities for students to experience learning laboratories for classroom nutrition and health education, and serve as resources for linkages with nutrition-related community services.

Services should be provided by qualified child nutrition professionals. Studies have shown that chronically undernourished children attain lower scores on standardized achievement tests, especially tests of language ability. These children are also more likely than other children to become sick, to miss school, and to fall behind in class. Undernourished students are often irritable, have difficulty concentrating, and have low energy. School nutrition services have been associated with increases in learning, and studies of low-income elementary school students have shown that students who participate in the federal School Breakfast Program have greater improvements in standardized test scores and math grades, and reduced rates of absence, tardiness, and psychosocial problems, than children who qualify for the program but do not participate.

Counseling, psychological, and social services provide broad-based individual and group assessments, interventions, and referrals that attend to the mental, emotional, and social health of students in a range of school and community settings. Organizational assessment and consultation skills of counselors and psychologists contribute to the overall health of students, and to the health of the school environment. Services are provided by professionals, such as certified school counselors, psychologists, and social workers.

One in five visits to school-based health centers is related to mental health. In a 1999 report on mental health, the U.S. Surgeon General estimated that 21 percent of U.S. children ages nine through seventeen have a diagnosable mental or addictive disorder, yet studies indicate that approximately 70 percent of children and adolescents in need of treatment do not receive mental health services. Of those young people who do receive mental health services, about 70 percent receive services offered in school settings, compared to 40 percent using mental health specialists and 11 percent using the health sector (a young person might access more than one resource). The report also acknowledges that private and public health insurance coverage for such services is often lacking. Schools can make efforts to enter into collaborative relationships with other service providers for help with the resource burden.

Some of the burdens students face include inadequate basic resources, such as food, clothing, housing; and a sense of security at home, at school, and in the neighborhood. Psychosocial problems include difficult relationships at home and at school; emotional upset; language problems; sexual, emotional, or physical abuse; substance abuse; delinquent or gang-related behavior; and psychopathology. Additional stressful situations, such as being unable to meet the demands made at school or at home, inadequate support systems, and hostile conditions at school or in the neighborhood, have also been identified. In addition, crises and emergencies such as the death of a classmate or relative, a shooting at school, or natural disasters such as earthquakes, floods, or tornadoes are becoming commonplace. Life transitions, such as the onset of puberty, entering a new school, and changes in life circumstances (moving, immigration, loss of a parent through divorce or death) also affect the health of the student.

Health promotion programs for staff are designed to promote the physical, emotional, and mental health of school employees through health assessments, health education, health-related fitness activities, and employee assistance programs. Evaluations have found that participation in staff health-promotion programs can increase morale, improve absenteeism rates, increase participation in vigorous activity, improve physical fitness, facilitate weight loss, lower blood pressure, and improve stress-management skills. Teachers who become interested in their own health have been found to take a greater interest in the health of their students and become more effective teachers of health.

Staff can influence student behaviors by being powerful role models for healthy lifestyles. Private industry has found that staff health-promotion programs can improve productivity, improve morale, reduce health insurance costs, and are usually well worth the cost: More than 81 percent of U.S. businesses with fifty or more employees have some form of health promotion program.

Family and community involvement promotes an integrated school, family, and community approach that establishes a dynamic partnership to enhance the health and well-being of students. Involving family members and the community has been linked with improvements in students' health knowledge and behaviors. Numerous studies link parent/family involvement to their children's achievement, academic standing, and decreased school failure and grade repetition, and a number of studies have shown that involving families enhances the effects of school health-promotion efforts. School health programs should be designed to actively solicit family involvement and assist and support families to effectively reinforce children's healthful habits and behaviors. The National PTA has developed the National Standards for Parent/Family Involvement Programs, which provide PTAs, schools, and communities with voluntary guidelines and quality indicators for effective parent/family involvement programs.

Schools should be encouraged to engage community resources and services to respond more effectively to the health-related needs of students. State and local government agencies, private businesses, youth-serving organizations, and other organizations in the community can be valuable additions to school health programs by serving as resources for student learning, offering opportunities for student service, coordinating community health-promotion efforts with school programs, raising funds to support specific activities, and providing expert advice and assistance to school health program planners. The full-service school model involves locating a variety of family and youth services at school to improve families' access to the services. New Jersey and Kentucky have pioneered statewide programs of linking schools with community agencies. Providing these kinds of services does not necessarily require an increase in the school's budget: typically, many of these services already exist, but in a fragmented manner that some families find difficult to use.

4. Multiple interventions. As the Carnegie Corporation has stated, "Given the complex influences on adolescents, the essential requirements for ensuring healthy development must be met through the joint efforts of a set of pivotal institutions that powerfully shape adolescents' experiences. These pivotal institutions must begin with the family and include schools, health care institutions, a wide array of neighborhood and community organizations, and the mass media" (p. 23).

Because the health problems facing students have a multifactorial etiology, a single health message delivered by one teacher during the year, particularly when there are so many competing messages from friends, family, and the media, is rarely sufficient to promote the adoption or maintenance of health-enhancing behaviors. Consistent and repeated messages delivered by several teachers, school staff, peers, and families are more effective.

A health promotion model that uses a variety of interventions in addition to instruction to promote the adoption of health-enhancing behaviors among children and youth is needed. Interventions that have been successful include policy mandates, environmental changes, direct interventions (screening, referral, and treatment), social support/role modeling, and media. The number of interventions necessary to address any one problem is unknown. Larry Green and Marshall Kreuter suggest that a minimum of three interventions be employed for each behavior that is targeted, and John Elder states that "true progress will be realized by using multi-component packages which include multilevel and multiple-channel generalization efforts and appropriate evaluation criteria" (p. 31).

5. Program coordination and oversight. The value of a coordinated approach has been noted by numerous individuals. A variety of options have been proposed to implement and manage a coordinated school health program, including school health coordinators, school health advisory councils, interdisciplinary work committees and work teams, and interagency coordinating councils or networks. Health-program coordination can help reduce ambiguity about responsibilities and tasks, which often impedes program implementation, and can help ensure that the various program components are mutually reinforcing each other's efforts. School health advisory councils can involve a variety of health and education professionals, parents, and other community members who can mobilize community resources, represent the diverse interests within the community, provide school personnel and families with a sense of program ownership, and provide guidance to the school board. A 1994 national survey found that 33 percent of school districts and 19 percent of secondary schools had such councils.

Others advise that a more formalized structure, such as a coordinating council, is inherently more effective than an advisory group, as committed leadership has been found to be critical to the success of school-linked comprehensive services. In 2000 the American Cancer Society began conducting a national leadership program designed to train individuals to become school health coordinators, including the development of school health councils, and to replicate the training program in their respective regions of the nation. Responsibilities of a coordinating council can include assessing needs and resources, establishing program goals, developing a community plan, coordinating school programs with community programs and resources, providing leadership and assistance for local schools, and assuring continuous improvement through evaluation quality assurance mechanisms. The Institute of Medicine (IOM) recommends that a school health coordinator and a coordinating council are an integral part of the infrastructure needed to support a coordinated school health program.

6. Systematic program planning. Every organizational group that is part of the school health program (e.g., school work teams, school health committee, school-community coordinating council) needs to use a programming process to assure continuous improvements in programming. Included in the process is the need to involve all stakeholders, define the problem from a local perspective (a needs assessment), set realistic goals and objectives, identify priority strategies to be used in the action plan to attain goals and objectives, implement the plan, evaluate the results, and use the results to start the process over again. DASH has produced the School Health Index for Physical Activity and Healthy Eating: A Self-Assessment and Planning Guide, which schools can use to improve school health programs. Differences in health status among distinct regions and groups argue for the need to base policies on local data that might be available from public health departments. Planners should conduct needs assessments with community input; adapt activities to the interests and preferences of different ethnic, religious, and social groups; and foster effective school-community collaboration.

7. Ongoing staff development. To assure effective programming, there is a need for staff development programs. Many teachers received their training at a time when the problems and issues facing students were much different. Staff development increasingly is approached as the day-to-day fostering of continuous improvement in one's professional practice, and not as a workshop that occurs in isolation. Phyllis Gingiss has identified five concepts that those planning staff development need to consider:

• Teachers respond to innovations in developmental stages.
• A multiphase approach to staff development is necessary to assist teachers during each stage.
• Staff development requires opportunities for teacher collaboration.
• Approaches to staff development must fit the stage of teacher development.
• The organizational context for staff development is critical to its success.

Critical organizational and environmental factors that must be addressed before providing staff development programs include a positive school climate, administrative support, and supportive policies. Those schools that encourage teacher experimentation enhance the willingness of teachers to try new methods and programs. A meta-analysis of staff-development training revealed that the utilization of theory, demonstration, practice, and feedback produced meaningful differences in the faculty's acquisition attitudes, knowledge, and skills. However, for meaningful differences to occur in the transfer of training to the practitioners' practice in the classroom, peer coaching had to be added to the above mix of effective interventions. Without peer follow-up and peer coaching after training, transfer effects are negative to minimal.

The National Council for Accreditation of Teacher Education (NCATE) has developed various sets of standards for teacher preparation programs, in association with numerous professional organizations, including the American Association for Health Education (AAHE), the National Association for Sport and Physical Education (NASPE), and the National Association of School Psychologists (NASP). Many states and professional preparation programs have adopted or adapted the NCATE standards.

To ensure that students are taught by well-prepared and well-qualified teachers, health education and physical education professional associations suggest that state licensure agencies should: (1) establish separate teaching licenses for health education and physical education; (2) offer licenses for different levels (e.g., preschool and early elementary school, elementary school, middle school, high school); (3) require that all generalist teachers (pre-school, elementary school, middle school) pass courses or demonstrate their competence at applying the skills required to effectively teach health education; and (4) allow schools to assign teachers to courses they are not properly certified to teach only when a licensed teacher cannot be found and only on a temporary basis with the stipulation that such teachers receive the necessary training if they are to continue teaching the class.

8. Active student involvement. Peer instruction has proven effective in disseminating knowledge and changing behaviors. Students are more likely to turn to peers for advice, and change is more likely to occur, if someone similar to them recommends the change. In addition, peer instruction has been effective in improving decision-making and problem-solving skills, which may be prerequisites for implementing behavior change. Role modeling and peer support systems represent additional benefits of peer-education programs.

Peer involvement may occur in a variety of ways, such as peer counseling, peer instruction, peer theater, youth service, and cross-age mentoring. The elements of a successful peer program include positive interdependence, face-to-face interaction, individual accountability, training in social skills, time for group processing, heterogeneous composition, having each child be a helper, adequate duration, and involvement of participants in program implementation.

Conclusion

Because the health of students is inextricably linked to educational achievement, it is critical that schools promote health. Schools can provide the nurture and support needed to facilitate the adoption of health-enhancing behaviors. This helps assure that the educational gains achieved by a student will be maximized by a long and healthy life as an adult. A comprehensive, well-coordinated school health program can promote the optimal physical, emotional, social, and educational development of students.