Since 1948 the American Public Health Association has adopted numerous resolutions and policy statements that address school health. This position paper seeks to update several existing APHA policy statements1 and provide a contemporary, science-based school health program model for promoting healthy children, families and communities.
I. The Role of the Education System in Promoting Public Health Goals
According to Healthy People 2010, schools have more influence on the lives of young people than any other social institution except the family and provide a setting in which friendship networks develop, socialization occurs and behavioral norms are developed and reinforced.2 Of the 107 Healthy People 2010 objectives related to adolescents and young adults, 10 focus on the role of schools in improving the health of young people.3
Adult health status is directly associated with higher educational levels, regardless of income.4 Children who do not learn to read in the first few grades, who read poorly, or who are retained in grade more than once are more likely than their peers to be drawn into a pattern of risky behaviors.5 People who acquire more education not only are healthier and practice fewer health risk behaviors, but their children also are healthier and practice fewer health risk behaviors.6 Increasing the high school completion rate, a major goal of the education system, is also fittingly a health objective for the nation (objective 7.1).2
Preventable health risk behaviors that are often formed in childhood, persist into adulthood and are frequently interrelated include poor dietary choices; inadequate physical activity; behaviors that can result in violence or unintentional injuries; engaging in sexual behaviors that can cause HIV infection, other sexually transmitted diseases and unintended pregnancies; and the use of tobacco, alcohol and other harmful drugs.7 Certain risk behaviors are more likely to occur among particular subpopulations of students defined by sex, race/ethnicity and grade.7 These behaviors can lead to serious health problems and disabilities that are costly burdens on individuals, families, and the nation.2 For example, annual hospital costs for obesity-related conditions among youth aged 6 to 17 increased from $35 million to $127 million from 1979 to 2000.8
Well-prepared and supported school staff can provide credible health information and direction on forming healthy attitudes, beliefs and habits. Students who participate in health education classes that use effective curricula have been found to increase their health knowledge and improve their health skills and behaviors.9 School-based programs have proven effective in significantly reducing student binge drinking,10 tobacco use,11-13 physical inactivity,14 unhealthy dietary patterns15 and obesity.16 For many young people, schools might be the only place they ever receive accurate information and guidance to prevent workplace injuries and other adult health problems.
Elementary and secondary schools are also valuable settings for the provision of public health services. The 53.8 million students and 3.6 million staff members in nearly 129,000 public and private elementary and secondary schools comprise 20 percent of the U.S. population.17 More than 95 percent of children ages 5-6, 98 percent of children ages 7-15, and 93 percent of children ages 16-17 are enrolled in school17 and thus in easy reach of public health agencies. Schools often provide services that might not be available elsewhere. For example, schools provide most of the mental health services provided to children.18 Many agencies work with schools to help provide critical health services,19,20 particularly for students with disabilities21 and those from families in poverty.22
II. The Central Role of Health in Promoting Education Goals
It has long been clear that education and health are inextricably intertwined.23
Schools cannot achieve national educational goals if students and staff are not healthy and fit physically, mentally and socially.5,
24 As the U.S. Department of Education has acknowledged, "Too many of our children start school unready to meet the challenges of learning, and are adversely influenced by...drug use and alcohol abuse, random violence, adolescent pregnancy, AIDS, and the rest."25
Student learning and academic achievement can be inhibited by poor nutritional status,26-28 poor indoor air and environmental quality,29-30 uncontrolled asthma31 and other chronic health conditions, undiagnosed and untreated vision and hearing problems, injuries, unaddressed social and mental health troubles, early pregnancy, alcohol and drug use and other health problems.30,31 Educational institutions at all levels are coping with increasing prevalence of chronic health conditions that require ongoing monitoring and care by trained health professionals.32 One child in four has been estimated to be at risk of failure in school because of social, emotional and health problems.33
School health programs can improve education outcomes.31,34,35 For example, a school health program designed to teach low-income elementary school students and their parents how to better manage asthma significantly increased effective asthma management behaviors, reduced asthma episodes and improved school grades.36 School-based mental health services provided in partnership with community organizations can help elementary and secondary students succeed in school.34 Parents and the general public consistently demonstrate strong support for promoting health37,38 and fitness39 goals in schools.
III. The Coordinated School Health Program Model
The twin goals of education and health inspire the Coordinated School Health Program (CSHP) model, which is designed to purposefully integrate the efforts and resources of education, health and social service agencies to provide a full set of programs and services without fragmentation or wasteful duplication.5,31,40 The CSHP model, which is more comprehensive than prior approaches to school health,40 provides a practical, systematic and cost-efficient31 approach to the provision of prevention education and services. Staff interviewed from schools with a coordinated approach to school health associated this approach with higher test scores, more alert students, more positive attitudes, skill development, and readiness to learn.41
The CSHP model involves the active coordination of the following eight components such that each component reinforces the other:42
1. A Healthy School Environment: School buildings and the area surrounding them are safe, secure and free of tobacco and biological and chemical agents that are detrimental to health; physical conditions including noise, lighting, temperature and air quality are conducive to learning; the psychosocial climate and culture of the school promotes academic achievement and overall well-being while preventing violence and bullying; and the school facilitates and actively promotes physical activity, healthy eating and other lifelong health habits.
2. Comprehensive Health Education: A planned, sequential, PreK-12 curriculum taught by qualified, proficient teachers addresses the physical, mental, emotional and social dimensions of health and allows students to develop and demonstrate increasingly sophisticated health-related knowledge, attitudes, skills and practices. The curriculum is consistent with the National Health Education Standards43 and incorporates 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, tobacco-use prevention and substance abuse prevention.
3. Physical Education: A planned, sequential PreK-12 curriculum taught by qualified, proficient teachers provides cognitive content and learning experiences 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. A quality physical education program is consistent with the National Physical Education Standards,44 promotes each student’s optimum physical, mental, emotional, and social development, and involves activities and sports that all students enjoy and can pursue throughout their lives.
4. School Health Services: Services provided for students at school or in school-linked clinics by qualified professionals such as school nurses, physicians, dentists, health educators, optometrists and other allied health personnel are designed to ensure access or referral to primary health care services, conduct diagnostic screening, manage chronic health conditions, provide emergency care for illness or injury, prevent and control communicable disease and other health problems and provide educational and confidential counseling opportunities.
5. School Nutrition Services: Qualified child nutrition professionals provide access to a variety of nutritious and appealing meals that accommodate the health and nutrition needs of all students and are provided in pleasant settings with adequate time to eat and socialize. All foods and beverages sold or served at school reflect the U.S. Dietary Guidelines for Americans and other criteria to assure nutrition integrity. Also included are classroom nutrition and health education to foster lifelong habits of healthy eating, and linkages with nutrition-related community services.
6. School Counseling and Psychological Services: Professionals such as certified school counselors, psychologists and social workers provide services to improve students’ mental, emotional, and social health and remove barriers to students’ academic success, through such means as individual and group assessments, interventions, referrals, tobacco cessation programs and consultation with other school staff members.
7. Health Promotion for School Staff: Opportunities are provided for school staff to improve their health status and morale through such activities as health assessments, health education, tobacco cessation and health-related fitness activities so as to reduce health care costs and motivate staff to model a healthy lifestyle to students.
8. Family and Community Involvement: The school health program is enhanced with an integrated school, family and community approach through such means as school health advisory councils, the active solicitation of parent involvement, and the engagement of health-related community resources and services such as after-school recreation programs.
The CSHP model provides an organizational framework for school districts and state education and health agencies to use in planning, coordinating and evaluating school health initiatives, synchronizing comparable public health and school health programs, and efficiently using multiple funding sources to improve the health and education of young people.3
The CSHP model also addresses the national goal of eliminating health disparities in youth by addressing unmet needs in infectious and chronic health conditions as well as mental health.
Further, it informs the professional preparation and continuing education of teachers and other school health program professionals. For example, the National Council for Accreditation of Teacher Education (NCATE), in cooperation with the American Association of Health Education (AAHE) and the National Association for Sport and Physical Education (NASPE), has developed program standards for health education45
and physical education teacher preparation programs.
In recent years, a growing number of states including Arkansas, California, Florida, Kentucky, Maine, Maryland, Michigan, New Mexico, New York, North Carolina, Oregon, Rhode Island, Tennessee, West Virginia, and Wisconsin have adopted the CSHP model and actively promote it. Numerous scientifically rigorous, practical resources have been developed by the Division of Adolescent and School Health (DASH) within the Centers for Disease Control and Prevention (CDC),46
state education and health agencies,47
and health and education professional organizations (48) to guide the establishment of CSHPs. Such resources can prove valuable to schools that already provide some of the components of the CSHP model, though perhaps with insufficient scope, quality or coordination.
IV. Recommendations for Implementing Coordinated School Health Programs
APHA supports the implementation of effective coordinated school health programs in every public and private elementary, middle, and high school across the nation and gives the following recommendations:
1. Establish support infrastructure: Each state and school district should adopt policies, employ a qualified school health coordinator, provide guidance and assistance, and assure adequate financial resources for the establishment of a coordinated school health program in each school that is managed by a school health team or individual coordinator.
2. Conduct needs assessments: Education administrators should conduct needs assessments to identify undiagnosed health conditions or other unmet health or mental health needs that inhibit student academic success.
3. Tailor the CSHP to the local community: Every school should ensure that its school health program addresses the identified needs of students, is consistent with community values, is hospitable to the cultures and languages of the school population, and builds on community assets.
4. Establish school health councils: Each state, school district and school should establish and support a school health council comprised of school health program staff members, public health officials, parent representatives and members of the community to assist with the oversight, management, planning and evaluation of school health policies and programs.
5. Increase Federal resources: The federal government should expand support for school health coordinator positions in each state health and education agency to facilitate communication and coordination of programs among key players; coordinate state-level data-gathering and data-analysis for evaluation, public health surveillance and research; and provide technical assistance, professional development and other forms of support for the widespread implementation of CSHP.
6. Improve coordination among Federal agencies: The U.S. Departments of Education, Health and Human Services, Agriculture and Justice should strengthen collaboration on integrating funding streams, collecting and analyzing data, and sponsoring research on best practices to support the widespread adoption of CSHP.
7. Improve coordination among voluntary, health professional, and educational organizations in support of CSHP.
1. Policy statements 4802, 4809, 5406, 6204, 6305, 6701, 6917, 7223, 7436(PP), 7835, 7905, 8705, 8905, 9302, and 9309.
2. U.S. Department of Health and Human Services. Healthy People 2010: Volume I, 2nd ed. Washington, DC: U.S. Government Printing Office. Nov 2000. Online: http://www.health.gov/healthypeople/.
3. Fisher C, Hunt P, Kann L, Kolbe L, Patterson B, Wechsler H. Building a healthier future through school health programs, in Centers for Disease Control and Prevention. Promising Practices in Chronic Disease Prevention and Control: A Public Health Framework for Action. Atlanta, GA: Department of Health and Human Services. 2003. Online: http://www.cdc.gov/nccdphp/promising_practices/school_health.
4. National Center for Education Statistics, Office of Educational Research and Improvement, U.S. Department of Education. The Condition of Education 2002. NCES 2002–025, Washington, DC: U.S. Government Printing Office. May 31, 2002. Online: http://nces.ed.gov/pubs2002/2002025.pdf.
5. Tyson H. Kappan special report--A load off the teachers’ backs: Coordinated school health programs. Phi Delta Kappan. Jan 1999:K-1. Online: http://www.pdkintl.org/kappan/ktys9901.htm.
6. Lowry R, Kann L, Collins J, Kolbe L. The effect of socioeconomic status on chronic disease risk behaviors among U.S. adolescents. JAMA 1996;276:792-97.
7. Centers for Disease Control and Prevention. Youth risk behavior surveillance--United States, 2003. Surveillance Summaries. MMWR May 21, 2004;53(SS-2):1-100. Online: http://www.cdc.gov/mmwr/PDF/SS/SS5302.pdf.
8. Wang G, Dietz WH. Economic burden of obesity in youths aged 6 to 17 years: 1979-1999. Pediatrics May 2002;109:E81-1.
9. Connell D, Turner R, Mason E. Summary of findings of the school health education evaluation: health promotion effectiveness, implementation, and costs. J School Health 1985;55:316-321.
10. Botvin GJ, Griffin KW, Diaz T, Ifill-Williams M. Preventing binge drinking during early adolescence: one-and two-year follow-up of a school-based preventive intervention. Psychol Addict Behav 2001;15(4):360-365.
11. Dent C, Sussman S, Stacy A, Craig S, Burton D, Flay B. Two year behavior outcomes of project towards no tobacco use. J Consulting Clin Psychol 1995(4);63:676-677.
12. Flynn BS, Worden JK, Secker-Walker RH, Badger GJ, Geller BM, Costanza MC. Prevention of cigarette smoking through mass media intervention and school programs. Am J Public Health 1992;82:827-834.
13. Botvin GJ, Baker E, Dusenbary L, Botvin E, Diaz T, Long-term follow-up results of a randomized drug abuse prevention trial in a white middle-class population. JAMA 1995;273:1106-1112.
14. Centers for Disease Control and Prevention. Increasing physical activity: a report on recommendations of the task force on community preventive services. MMWR 2001;50(RR18):1-16.
15. Luepker R, Perry C, McKinlay S, Perry CL, Nader PR, Parcell GS, Stone EJ, Webber LS, Elder JP, Fledman HA, Johnson CC, Kelders SH, Wu M. Outcomes of a field trial to improve children’s dietary patterns and physical activity: the Child and Adolescent Trial for Cardiovascular Health. JAMA 1996;275:768-776.
16. Gortmaker SL, Peterson K, Wiecha J, Sobol AM, Dixit S, Fox MK, Laird N. Reducing obesity via a school-based interdisciplinary intervention among youth. Arch Pediatr Adolesc Med 1999;153(4):409-418.
17. U.S. Census Bureau, Administrative and Customer Services Division, Statistical Compendia Branch. 2003 Statistical Abstract of the United States (online). Washington, DC: U.S. Government Printing Office. Last revised: May 21, 2004. Online: http://www.census.gov/prod/www/statistical-abstract-03.html.
18. Office of the Surgeon General of the U.S. Public Health Service, U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General. Washington, DC: U.S. Government Printing Office. 1999. Online: http://www.surgeongeneral.gov/
19. Brener ND, Burstein GR, DuShaw ML, Vernon ME, Wheeler L, Robinson J. Health services: results from the School Health Policies and Programs Study 2000. J School Health 2001;71(7):294-304.
20. National Assembly on School-Based Health Care. Creative Financing for School-Based Health Centers: A Tool Kit. Washington, DC: National Assembly on School-Based Health Care. 1999.
21. U.S. Department of Education, Office of Special Education and Rehabilitative Services. A New Era: Revitalizing Special Education for Children and Their Families. Washington, DC: U.S. Government Printing Office. 2002.
22. Health Care Financing Administration and Department of Health and Human Services. Medicaid and School Health. Washington, DC: U.S. Government Printing Office. 1997.
23. National Commission on the Role of the School and Community in Improving Adolescent Health. Code Blue: Uniting for Healthier Youth. Alexandria, VA: National Association of State Boards of Education. 1990.
24. Novello AC, Degraw C, Kleinman D. Healthy children ready to learn: an essential collaboration between health and education. Public Health Reports. 1992;107(1):3-15.
25. U.S. Department of Education. America 2000: An Education Strategy Sourcebook. Washington, DC: U.S. Government Printing Office. 1991:16-17.
26. Meyers AF, Sampson AE, Weitzman M, Rogers BL, Kayne H. School breakfast program and school performance. American Journal of Diseases of Children Oct 1989;143:1234-39.
27. Murphy JM, Pagano ME, Nachmani J, Sperling P, Kane S, Kleinman RE. The relationship of school breakfast to psychosocial and academic functioning: Cross-sectional and longitudinal observations in an inner-city school sample. Arch Pediatr Adolesc Med 1998;152:899-907. Online: http://archpedi.ama-assn.org/issues/v152n9/abs/pnu7508.html#aainfo.
28. Pollitt E, Liebel RL, Greenfield D. Brief fasting, stress, and cognition in children. Am J Clin Nutrition 1981;34:1526-33.
29. Fowler MG, Davenport MG, Garg R. School functioning of U.S. children with asthma. Pediatrics 1992;90(6):939-44.
30. Wolford-Symons C. Bridging student health risks and academic achievement through comprehensive school health programs. J School Health 1997;67:224.
31. Kolbe LJ. Education reform and the goals of modern school health programs: How school health programs can help students achieve success. State Education Standard. Autumn 2002;3(4):4-11. Online: http://www.nasbe.org/Standard/11_Autumn2002/Education_Reform.pdf.
32. Newacheck PW, Halfon N. Prevalence, impact, and trends in childhood disability due to asthma. Arch Pediatr Adolesc Med 2000;154(3):287-93.
33. Dryfoos JG. Full Service Schools: A Revolution in Health and Social Services for Children, Youth, and Families. San Francisco: Jossey-Bass. 1994.
34. Center for Health Promotion and Prevention Research, University of Texas School of Public Health, The University of North Carolina Center for Health Promotion and Disease Prevention, University of New Mexico Prevention Research Center. Student achievement through better health. Demonstrated Benefits of Coordinated School Health Programming. 26 September 2000. Online: http://www.learnnc.org/dpi/instserv.nsf/ID/Student_Achieveètter_Health/$file/Student_Achieveètter_Health.doc.
35. Murray NG, Schuler KE, Lopez SD, Low B, Kelder SH, Parcel GS. School Connections: Schools Connecting Health and Success. Houston, TX: Center for Health Promotion and Prevention Research. 2001.
36. Evans D, Clark NM, Feldman CH, Rips JL, Kaplan KL, Levison MJ, Wasilewski Y, Levin B, Mellins RB. A school asthma health education program for children aged 8-11 years. Health Edu Q. 1987;14:267-289.
37. Gallup Organization. National Telephone Survey of 1,003 Parents of Adolescents Enrolled in U.S. Public Schools. Atlanta, GA: American Cancer Society. 1993.
38. Marzano RJ, Kendall JS, Cicchinelli LF. What Americans Believe Students Should Know: A Survey of U.S. Adults. Aurora, CO: Mid-continent Regional Educational Laborator. Sep 1998. Online: http:
39. American Alliance for Health, Physical Education, Recreation, and Dance. Public Attitudes Toward Physical Education. Are Schools Providing What the Public Wants? Princeton, NJ: Opinion Research Corporation International. 2000.
40. Allensworth DD, Kolbe, LJ. The comprehensive school health program: Exploring an expanded concept. J School Health 1987;57(10):409-411.
41. Siegel M, Doner L. Marketing Public Health: Strategies to Promote Social Change. Gaithersberg, MD: Aspen Publishers. 1998:296-302.
42. Marx E, Wooley SF, Northrop D. Health Is Academic: A Guide to Coordinated School Health Programs. New York: Teachers College Press. 1998.
43. American Cancer Society. Health for Success: The National Health Education Standards. Atlanta, GA: American Cancer Society. 1995.
44. National Association for Sport and Physical Education. Moving into the Future: National Standards for Physical Education. Reston, VA: National Association for Sport and Physical Education. 1995.
45. National Council for Accreditation of Teacher Education. Standards for Health Education Programs. 2001. Online: http://www.ncate.org/standard/programstds.htm.
46. Dozens of guidance publications are listed at http://www.cdc.gov/HealthyYouth/publications/index.htm.
47. For example: School Work Group. Building Infrastructure for Coordinated School Health: California’s Blueprint. Sacramento, CA: California Department of Education. 2000. Online: http://www.cde.ca.gov/ls/he/cs/documents/blueprintfinal.pdf; Maine School Management Association. State of Maine Guidelines for Coordinating School Health Programs. Augusta, ME: Maine School Management Association. 2002.
48. For example: Bogden JF. Fit, Health, and Ready to Learn: A School Health Policy Guide. Alexandria, VA: National Association of State Boards of Education. 2000; Council of Chief State School Officers, CCSSO and the Association of State and Territorial Health Officials. School Health Starter Kit. Washington, DC: Council of Chief State School Officers. 2003.