Health Services

SCHOOL
Kerry Redican
Charles Baffi

COLLEGES AND UNIVERSITIES
Molly Black Duesterhaus

SCHOOL

Provision of public school health services in the United States has been sporadic, reflecting the tenor of the times, and influenced by pressure groups, vested interests, and resistance to change by those in administrative positions.

The initial justification for provision of school-based health services was primarily to control communicable diseases in order to cut down on school absenteeism. At the turn of the twentieth century, physicians were appointed as public school health officers. The first school nurse was employed by the New York City Board of Education in 1902, for the express purpose of controlling communicable diseases, particularly infectious skin diseases. Even though the number of physicians who were employed by schools outnumbered the number of nurses employed by schools by approximately three to one, school nurses were the main providers of school health services. Because of prevailing social mores, hygiene instruction in the late 1800s and early 1900s centered on a physiological and anatomical study of the negative effects of alcohol, tea, coffee, and tobacco.

Administrative responsibility for health services was often assigned to a specifically established department within the school, which was often under the direction of a local physician who was accountable to a school superintendent. In other instances, the responsibility for this service was assumed by a community health agency under the direction of a local health officer. These remained accepted practices even into the twenty-first century.

As new scientific knowledge emerged, new movements for improved personal and community health became popular. Addressing health problems of children and youth required a multidimensional approach. School health services only focused on medical related services, not environment or education. It became clear that the school needed to be concerned about not only school health services but also about the school environment and health education. Further, school health services, provision of a healthful school environment, and health education needed to function in a coordinated context in order to be effective. This set the foundation for the development of the school health program.

The original school health program model consisted of school health services, healthful school living, and health education. The goal of the school health program was to provide opportunities for every child to reach their full potential as a student as well as a contributing member of society. The major objective of the school health program was the promotion of physical, mental, social, and emotional well being. This model prevailed for years.

School health services as a part of the overall school health program provided health and medical services to students. These services tended to be one of three types: basic, expanded, or comprehensive. Basic health services include such things as immunizations, hearing and vision screenings, scoliosis screening, sports physicals, health counseling, and nutritional screenings. Expanded health services included health promotion/disease prevention, mental health counseling, substance abuse counseling, family life/sex education, and care of special needs children. Finally, comprehensive health included reproductive health care, primary care, chronic illness management, and prenatal care.

CDC Model

The services, environment, instruction focused model of the school health program worked well but still was not inclusive or comprehensive enough to meet the needs and interests of students. A more comprehensive model was needed. The concept of the Centers for Disease Control and Prevention (CDC) comprehensive school health programs model was first proposed in a landmark work published by Diane Allensworth and Lloyd Kolbe in 1987. The model employed the use of eight components. These include the following:

1. Health education: classroom instruction addressing physical, mental, and social dimensions of health; developing health knowledge, attitudes, and skills; and tailored to each age level. Designed to motivate and assist students in maintaining and improving their health, prevent disease, and reduce the number of health-related problem behaviors they exhibit.
2. Physical education: planned, sequential instruction that promotes lifelong physical activity. Designed to develop basic movement skills, sports skills, and physical fitness as well as to enhance mental, social, and emotional abilities.
3. School health services: preventive services, education, emergency care, referral, and management of acute and chronic health conditions. Designed to promote the health of students, identify and prevent health problems and injuries, and ensure care for students.
4. School nutrition services: integration of nutritious, affordable, and appealing meals; nutrition education; and an environment that promotes healthy eating behaviors for all children. Designed to maximize each child's education and health potential for a lifetime.
5. School counseling, psychological, and social services: activities that focus on cognitive, emotional, behavioral, and social needs of individuals, groups, and families. Designed to prevent and address problems, facilitate positive learning and healthy behavior, and enhance healthy development.
6. Healthy school environment: the physical, social, and emotional climate of the school. Designed to provide a safe physical plant, as well as a healthy and supportive environment that fosters learning.
7. School-site health promotion for staff: assessment, education, and fitness activities for school faculty and staff. Designed to maintain and improve the health and well-being of school staff, who serve as role models for students.
8. Family and community involvement in school health: partnerships among schools, families, community groups, and individuals. Designed to share and maximize resources and expertise in addressing the healthy development of children, youth, and their families.

Components to School Health Services

Every current comprehensive approach to school health includes at least the eight components of the CDC model. The School Health Services component is generally structured around preventive services, education, referral, emergency care, and management of acute and chronic conditions.

Preventive services. Activities typically included in preventive services are educating teachers on the signs and symptoms of health problems of students and health screenings. Teachers are in a unique position to observe health problems among students. They have an advantage in that they can compare students and notice differences that might indicate a potential health problem. Even parents do not have this strategic advantage. It requires that teachers be trained to identify health related issues that may be noticeable during their daily observations of students. This training is often included in a pre-professional course or through in-service instruction offered by the school or school district. The goal of teacher observation is not diagnosis but referral.

Preventive services also include health screenings of students. The most common health screenings conducted in schools include vision, hearing, growth and development, blood pressure, cholesterol, and dental health screenings. Often the school will establish a partnership with a local public health department. The health department's professional staff is responsible for conducting the screenings. The purpose of screening is not to diagnose but to identify a potential health problem and refer the student for a more complete evaluation.

Referral and follow-up represent the culmination of teacher observation and screening. The referral process is initiated in one of two ways: First, a teacher makes an observation that indicates a student might have a health problem, and refers the student to the school nurse or the person in the school responsible for health concerns. Second, if a student does not pass a particular health screening, the student is referred again to the school nurse or the person in the school responsible for health concerns. What follows is a series of conferences, such as teacher/nurse, nurse/parent, and student/nurse.

Emergency care. Unintentional injuries are the leading cause of death in children and youth ages one through twenty-one; for every childhood death caused by injury, there are approximately 34 hospitalizations, 1,000 emergency room visits, and many more visits to private physicians. Because of the magnitude of injuries to children and youth, and because many injuries occur in the school, it is important that schools as a part of health services address safety and emergency care.

Safety and emergency care is normally addressed in two ways: written policies including legal aspects and preparations for handling emergencies. All schools should have written policies, which reflect a sound philosophy of safety and emergency care and specific procedures for school personnel to follow in both prevention of accidents and the protocol in dealing with accidents and emergencies.

Management of acute and chronic conditions.

School health services are concerned with both acute and chronic health conditions of students. Acute conditions are normally communicable diseases and chronic conditions are such things as diabetes, asthma, and juvenile arthritis.

It is extremely difficult if not impossible to prevent the spread of common communicable diseases in school settings. Such illnesses as colds and influenza will run their epidemiologic course. School health services must include policies on how to handle communicable diseases; in other words, when to allow students back in school or sending students home who are sick. Further, schools health services must have documentation that students are up-to-date on immunizations. Schools will typically partner with local public health departments to receive guidance in how to handle communicable disease in the school setting.

Education and universal precautions are two important pieces in the management of acute conditions. Spread of communicable disease can be prevented through sound health practices, even as simple as washing hands. Schools must educate both personnel and students on the importance of sound health practices.

At times, a student will have an injury, perhaps resulting in their bleeding or vomiting. Both blood and vomit, as well as other body fluids, can contain pathogens and disease can be transmitted. Blood can contain HIV and the viruses responsible for viral hepatitis. Following universal precautions will limit the likelihood of transmission of disease through exposure to body fluids. Universal precautions are those activities designed to deal with body fluids and include use of gloves, masks, and proper receptacles for placing materials used to clean up body fluids. School are required to have an exposure control plan and have materials readily available for use when dealing with body fluids.

Issues and Trends

Numerous health problems that were once largely family and community problems now impact the school. Violence, drug use, teen pregnancy, sexually transmitted diseases, and poverty all have tremendous implications for school health services, yet because of the political and economic environment, there is, in general, less funding for programs to deal with these issues. Further, the complexity of the health problems and issues makes citizens question what the exact role of the school is in trying to solve or manage problems that are a result of powerful cultural influences. There seem to be two major perspectives, both with political implications. One is that the role of the school is to teach basic skills, such as reading, writing, math, and history, and health-related issues are a family problem or at best a community problem. The opposite perspective is that the government and by extension the school should play a major role with regard to student health problems and work closely with students in any way possible.

Perhaps the most controversial trend is the implementation of school-based health centers or clinics located in the school. School-based health centers were first established in the early 1970s. They were implemented as a response to health problems such as sexually transmitted diseases, unplanned teenage pregnancy, and substance abuse.

Funded by the federal government and private foundations, school-based health centers are located in forty-five states and the District of Columbia. As of 2000, approximately one-half of the health centers are located in high schools, one-quarter are located in elementary schools, and the remainder are located in other settings. The majority of the centers are located in poor urban and rural areas where coordinated medical and social services are lacking or where there are many uninsured children/parents, making access to services difficult.

Services provided by school-based health centers include but are not limited to primary care (diagnosis and treatment of simple illness), primary prevention (health education programs, vaccinations), and secondary prevention (early detection). These services range from diagnosing such maladies as colds, flu, and sexually transmitted diseases to substance abuse counseling. Services offered vary among communities and from community to community.

School-based health centers face an uncertain future primarily because they rely so heavily on external funding. As the nation grapples with the issue of providing access to health care for all Americans, school-based health centers need to be well positioned to meet the care and prevention needs of children and youth.

Given the political, cultural, and economic climate of the United States two future scenarios emerge. First, with the increasing emphasis on providing access to health care to all Americans it is possible that there will be a greater role for the school in providing health services to students, especially in medically underserved areas. Second, with the increasing shift to managed care it may prove more cost-effective for third-party payers to underwrite health services delivered in a school setting rather than in a community private sector setting.

College health-service programs provide low-cost, primary medical care for students on college campuses. Kevin Patrick estimated in 1988 that 80 percent of America's more than fourteen million college students received primary health care from campus health programs. Just as modern medicine has changed, so too has the scope of services college health centers provide. Medical developments allow for most injuries and illnesses to be treated by ambulatory clinics, and this same trend is seen in most college health centers. These centers often provide care for acute illnesses and injuries on an outpatient basis, while also meeting the needs of students with continued and chronic illnesses and providing wellness education to the campus community.

In addition to meeting the basic and most common needs of the students they serve, campus health-service programs also act as referral agents for students to connect with medical providers, as needed, in the local community. College health services are continually evolving and changing in order to best provide treatment and education for the campuses they serve.

Staffing

College health-service staffs vary widely in the range and level of services they provide. Once directed mainly by full-time medical doctors, most college health centers are now lead by Licensed Nurse Practitioners (LPNs), Registered Nurses (RNs) or Physician Assistants (PAs). Some health centers continue to have full-time physicians on staff (particularly at larger universities and institutions with medical centers), while others maintain part-time relationships with local doctors to staff particular hours each week. Health centers with less comprehensive services (usually at smaller, private colleges) often act as a link to services in the immediate community.

Services

College health-service programs tend to have three primary areas of responsibility: physical, mental, and educational. Medical services range from basic care in the form of treatment for colds, viruses, and minor injuries at less comprehensive centers to thorough lab tests, X rays, specialists, and pharmacies at the most comprehensive centers. Many college health programs also provide counseling services. Some counseling services are limited to basic intervention and referral for long-term care, while others provide extensive and long-term psychotherapy.

The most common, and a primary focus of college health-service programs, is that of intervention and health, or wellness, education. Although all student health centers concern themselves with the immediate healing of ill students, most will also work to educate students about approaches to healthier lifestyles in order to prevent future illness or injury. Wellness themes exhibited on many college campuses are health and nutrition, stress management, eating disorder awareness, smoking cessation and prevention, time management, alcohol abuse prevention, strategies to avoid depression, and issues around sexually transmitted diseases and their prevention. Some colleges maintain twenty-four-hour care for students; however, most colleges maintain regular weekly hours during the academic year with a system for emergency assistance when needed.

Payment

Many college health centers are funded through fees students pay to the college or university and subsidized with institutional resources. Sometimes these fees are included within the tuition charges of a college or university, while other institutions may charge a separate student health fee in addition to the college tuition. Prepayment for student health services ensures that students have access to the treatment and services needed while at school. At many colleges, basic and most common services are offered to full-time students at little or no charge. Many college health centers will provide, as needed, over the counter medications free of charge; however, they will charge for, or send students to a pharmacy for, prescription medications. Students will usually incur charges for lab work, other diagnostic tests, and services provided by referrals made to outside physicians and specialists. Most colleges and universities require students to have and maintain health insurance. Although many students may continue on their parent's health insurance plans, other students may need to purchase individual health insurance, and can usually do so through programs offered at their college or university.

Requirements

Most, if not all, colleges and universities require that undergraduate students complete health history forms prior to their arrival on campus. This information assists health center staff to prepare for any special needs identified on the form and to have a recorded history in case information is needed to properly treat a student. In addition to the form, all students are required to have current immunizations per state law and institution policy. Documentation of these immunizations must be provided in order to attend the institution.

Confidentiality

Services provided by college health centers are deemed confidential. Health center staff work in partnership with students to get well, make good choices, and develop healthy living habits. The responsibility of informing parents falls to the student in most cases. Only when a condition warrants notification will health services staff break the confidence of the relationship, usually with the permission of the student unless there is concern about harm to self or others.