ASCD & Centers for Disease Control and Prevention. Whole School, Whole Community, Whole Child: A
collaborative approach to learning and health. Alexandria, VA: ASCD. 2014.
WHOLE SCHOOL
WHOLE COMMUNITY
WHOLE CHILD
A Collaborative Approach to Learning and Health
1703 North Beauregard St. • Alexandria, VA 22311-1714 USA
Phone: 1-800-933-2723 or 1-703-578-9600 • Fax: 1-703-575-5400
Website:www.ascd.org • E-mail: [email protected]
Gene R. Carter, Executive Director; Judy Seltz, Deputy Executive Director, Chief Constituent Services Officer; Sean
Slade, Director, Whole Child Programs; Theresa Lewallen, Senior Director, Constituent Programs; Klea Scharberg,
Whole Child Programs Specialist; Kristen Pekarek, Project Coordinator; Gary Bloom, Senior Creator Director; Reece
Quiñones, Art Director; Lindsey Heyl Smith, Graphic Designer; Greer Wymond, Graphic Designer; Mary Beth Nielsen,
Manager, Editorial Services; Mike Kalyan, Manager, Production Services; Kyle Steichen, Production Specialist
© 2014 by ASCD. All rights reserved. Printed in the United States of America.
ABOUT ASCD
ASCD is a global community dedicated to excellence in learning, teaching, and leading. Comprising 140,000 members—superintendents, principals, teachers, and advocates from more than 138 countries—the ASCD community
also includes 56 affiliate organizations. ASCD’s innovative solutions promote the success of each child. To learn more
about how ASCD supports educators as they learn, teach, and lead, visit www.ascd.org.
ABOUT ASCD’S WHOLE CHILD INITIATIVE
Launched in 2007, ASCD’s Whole Child Initiative is an effort to change the conversation about education from
a focus on narrowly defined academic achievement to one that promotes the long-term development and success of
children. Through the initiative, ASCD helps educators, families, community members, and policymakers move from
a vision about educating the whole child to sustainable, collaborative action. ASCD is joined in this effort by Whole
Child Partner organizations representing the education, arts, health, policy, and community sectors. Learn more at
www.ascd.org/wholechild.
ABOUT THE U.S. CENTERS FOR DISEASE CONTROL AND PREVENTION
CDC works 24/7 to protect America from health, safety, and security threats, both foreign and in the U.S. Whether
diseases start at home or abroad, are chronic or acute, curable or preventable, human error or deliberate attack, CDC
fights disease and supports communities and citizens to do the same. As the nation’s health protection agency, CDC
saves lives and protects people from health threats. To accomplish its mission, CDC conducts critical science and provides health information that protects our nation against expensive and dangerous health threats, and responds when
these arise. Learn more at www.cdc.gov.
The mark ‘CDC’ is owned by the U.S. Dept. of Health and Human Services and is used with permission. Use of this logo is not an
endorsement by HHS or CDC of any particular product, service, or enterprise.
WHOLE SCHOOL
WHOLE COMMUNITY
WHOLE CHILD
A Collaborative Approach to Learning and Health
03
Why We Need a Collaborative Approach to Learning and Health
05
The Need for a New Model
06
Expanded Components
09
Coordinating Policy, Process, and Practice
09
Whole School, Whole Community, Whole Child
10References
12
Core and Consultation Groups
13
The Whole School, Whole Community, Whole Child Model
HEALTH AND EDUCATION
AFFECT INDIVIDUALS,
SOCIETY, AND THE
ECONOMY AND, AS SUCH,
MUST WORK TOGETHER
WHENEVER POSSIBLE.
SCHOOLS ARE A PERFECT
SETTING FOR THIS
COLLABORATION.
WHY WE NEED A COLLABORATIVE APPROACH
TO LEARNING AND HEALTH
Health and well-being have, for too long, been put
into silos—separated both logistically and philosophically from education and learning.
youth attend school. At the same time, integrating health services and programs more deeply
into the day-to-day life of schools and students
represents an untapped tool for raising academic
achievement and improving learning.
In his meta-analysis Healthier Students Are Better Learners,1 Charles Basch called a renewed
focus on health the missing link in school reforms
to close the achievement gap.
In short, learning and health are interrelated.
Studies demonstrate that when children’s
basic nutritional and fitness needs are met,
they attain higher achievement levels.2–14
Similarly, the use of school-based and schoollinked health centers ensuring access to needed
physical, mental, and oral health care improves
attendance,15 behavior,16–21 and achievement.22–25
The development of connected and supportive
school environments benefits teaching and
learning, engages students, and enhances positive
No matter how well teachers are prepared to
teach, no matter what accountability measures are put in place, no matter what governing structures are established for schools,
educational progress will be profoundly limited if students are not motivated and able
to learn.
Yet in the same publication Basch stated,
Though rhetorical support is increasing,
school health is currently not a central part of
the fundamental mission of schools in America nor has it been well integrated into the
broader national strategy to reduce the gaps
in educational opportunity and outcomes.
For the purposes of this document, academic
achievement is defined as:
1. Academic performance (class grades,
standardized tests, and graduation rates);
2. Education behavior (attendance, dropout
rates, and behavioral problems at school);
and
Health and education affect individuals, society,
and the economy and, as such, must work together
whenever possible. Schools are a perfect setting for this collaboration. Schools are one of the
most efficient systems for reaching children and
youth to provide health services and programs, as
approximately 95 percent of all U.S. children and
3. Students’ cognitive skills and attitudes
(concentration, memory, and mood).
Source: Centers for Disease Control and Prevention. The association
between schoolbased physical activity, including physical education,
and academic performance. Atlanta (GA): US Department of Health
and Human Services; 2010.
3
It is time to truly align the sectors and place the child at
the center. Both public health and education serve the
same students, often in the same settings. We must do
more to work together and collaborate.
—WAYNE H. GILES, DIRECTOR, DIVISION OF POPULATION HEALTH,
NATIONAL CENTER FOR CHRONIC DISEASE
PREVENTION AND HEALTH PROMOTION, CDC
4
learning outcomes. The development of a positive
social and emotional climate increases academic
achievement, reduces stress, and improves
positive attitudes toward self and others.26, 27
whole child. Policy, practice, and resources
must be aligned to support not only academic
learning for each child, but also the experiences
that encourage development of a whole child—
one who is knowledgeable, healthy, motivated,
and engaged.42
In turn, academic achievement is an excellent
indicator for the overall well-being of youth and
a primary predictor and determinant of adult
health outcomes.28–29 Individuals with more education are likely to live longer; experience better
health outcomes; and practice health-promoting
behaviors such as exercising regularly, refraining from smoking, and obtaining timely health
care check-ups and screenings.32–34 These positive outcomes are why many of the nation’s leading educational organizations recognize the close
relationship between health35–37 and education, as
well as the need to foster health and well-being
within the educational environment for all students.38–41
Similar calls for collaboration have come from
the health sector, including the U. S. Centers for
Disease Control and Prevention (CDC).
In sum, if American schools do not coordinate
and modernize their school health programs
as a critical part of educational reform, our
children will continue to benefit at the margins from a wide disarray of otherwise unrelated, if not underdeveloped, efforts to improve
interdependent education, health, and social
outcomes. And, we will forfeit one of the most
appropriate and powerful means available to
improve student performance.43
THE NEED FOR A NEW MODEL
The traditional coordinated school health (CSH)
approach has been a mainstay of school health
in the United States since 1987. Promulgated by
the CDC, the CSH approach has provided a succinct and distinct framework for organizing a comprehensive approach to school health. In addition
to the CDC, many national health and education
organizations have supported the CSH approach.
However, it has been viewed by educators as
primarily a health initiative focused only on
health outcomes and has consequently gained
limited traction across the education sector at the
school level.
In 2007, ASCD called for an acknowledgement of
the interdependent nature of health and learning.
We call on communities—educators, parents,
businesses, health and social service providers,
arts professionals, recreation leaders, and policymakers at all levels—to forge a new compact
with our young people to ensure their whole
and healthy development. We ask communities to redefine learning to focus on the whole
person. We ask schools and communities to
lay aside perennial battles for resources and
instead align those resources in support of the
5
ASCD’s Whole Child Initiative is an effort to
change the conversation about education from a
focus on narrowly defined academic achievement
to one that promotes the long-term development
and success of the whole child. Through the initiative, ASCD helps educators, families, community
members, and policymakers move from a vision
about educating the whole child to sustainable,
collaborative action. However, this approach has
been viewed primarily as an education initiative
and has gained limited traction with the health
community.
The focus of the WSCC model is an ecological
approach that is directed at the whole school,
with the school in turn drawing its resources
and influences from the whole community
and serving to address the needs of the whole
child. ASCD and the CDC encourage use of
the model as a framework for improving
students’ learning and health in our nation’s
schools.
EXPANDED COMPONENTS
Whereas the traditional CSH approach contained eight components, this model contains 10,
expanding the original components of Healthy
and Safe School Environment and Family and
Community Involvement into four distinct
components. The expansion focuses additional attention on the effect of the Social and
Emotional Climate in addition to the Physical
Environment. Family and community involvement is divided into two separate components
to emphasize the role of community agencies,
businesses, and organizations as well as the
critical role of Family Engagement. This change
marks the need for greater emphasis on both the
psychosocial and physical environments as well
as the ever-expanding roles that community
agencies and families must play. Finally, this
new model also addresses the need to engage
students as active participants in their learning
and health.
The Whole School, Whole Community, Whole
Child (WSCC) model combines and builds on
elements of the traditional coordinated school
health approach and the whole child framework.
ASCD and the CDC developed this new model—
in collaboration with key leaders from the fields
of health, public health, education, and school
health—to strengthen a unified and collaborative
approach to learning and health.
The new model responds to the call for greater
alignment, integration, and collaboration
between education and health to improve each
child’s cognitive, physical, social, and emotional
development. It incorporates the components of
a coordinated school health program around the
tenets of a whole child approach to education
and provides a framework to address the symbiotic relationship between learning and health.
6
THE WSCC MODEL RESPONDS TO
THE CALL FOR GREATER ALIGNMENT,
INTEGRATION, AND COLLABORATION
BETWEEN HEALTH AND EDUCATION
TO IMPROVE EACH CHILD’S COGNITIVE,
PHYSICAL, SOCIAL, AND EMOTIONAL
DEVELOPMENT.
7
The Whole School, Whole Community,
Whole Child model developed by ASCD and
the CDC takes the call for greater collaboration
over the years and puts it firmly in place.
For too long, entities have talked about
collaboration without taking the necessary
steps. This model puts the process into action.
—DR. GENE R. CARTER, CEO & EXECUTIVE DIRECTOR, ASCD
8
COORDINATING POLICY,
PROCESS, AND PRACTICE
ject or sector. Rather than being an initiative
owned by one teacher, one nurse, department or
profession, this model outlines the whole school
approach, with every adult and every student
playing a role in the growth and development of
self, peers, and the school overall.
The key to moving from model to action is collaborative development of local school policies, processes,
and practices. The day-to-day practices within each
sector require examination and collaboration so
that they work in tandem, with appropriate complementary processes guiding each decision and
action. Developing joint and collaborative policy is
half the challenge; putting it into action and making
it routine completes the task.
Just as the whole school plays its part, the new
model outlines how the school, staff, and students
are placed within the local community. While the
school may be a hub, it remains a focal reflection
of its community and requires community input,
resources, and collaboration in order to support
its students. As with any relationship this works
both ways. Community strengths can boost the
role and potential of the school, but areas of need
in the community also become reflected in the
school, and as such must be addressed.
To develop joint or collaborative policies, processes, and practices, all parties involved should
start with a common understanding about the
interrelatedness of learning and health. From
this understanding, current and future systems
and actions can be adjusted, adapted, or crafted to
jointly achieve both learning and health outcomes.
Each child, in each school, in each of our communities deserves to be healthy, safe, engaged,
supported, and challenged. That’s what a whole
child approach to learning, teaching, and community engagement really is about. More than
merely a way to boost achievement or academics,
the whole child approach views the collaboration
between learning and health as fundamental. The
development of the whole child is more than the
acquisition of knowledge or skills, behavior or
character; it is all of these.
WHOLE SCHOOL, WHOLE
COMMUNITY, WHOLE CHILD
The new model redirects attention onto the
ultimate focus of the two sectors—the child. It
emphasizes a schoolwide approach rather than
one that is subject- or location-specific, and it
acknowledges the position of learning, health,
and the school as all being a part, and reflection,
of the local community.
The new model calls for a greater collaboration
across the community, across the school, and
across sectors to meet the needs and reach the
potential of each child.
The efforts to address the educational and health
needs of youth should be seen as a schoolwide
endeavor as opposed to being confined to a sub-
9
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11
CONSULTATION GROUP
Diane D. Allensworth, PhD
Professor Emeritus, Kent State University
CORE GROUP
Wayne Giles, MD, MS
Director, Division of Population Health,
National Center for Chronic Disease
Prevention and Health Promotion,
Centers for Disease Control and Prevention
Holly Hunt, MA
Branch Chief, School Health Branch,
Division of Population Health,
National Center for Chronic Disease
Prevention and Health Promotion,
Centers for Disease Control and Prevention
Theresa C. Lewallen, MA, CHES
Senior Director, Constituent Programs
ASCD
William Potts-Datema, MS
Acting Senior Advisor, Division of Adolescent
and School Health, Centers for Disease
Control and Prevention
Sean Slade, MEd
Director, Whole Child Programs
ASCD
Robert Balfanz, PhD
Co-Director of the Everyone Graduates Center
at the Center for Social Organization of
Schools, Johns Hopkins University’s School
of Education
Charles E. Basch, PhD
Richard March Hoe Professor of Health
and Education, Teachers College,
Columbia University
Mark Ginsberg, PhD
Professor and Dean of the College of
Education and Human Development,
George Mason University
Lloyd J. Kolbe, PhD
Emeritus Professor of Applied Health Science,
Indiana University School of Public Health—
Bloomington
Richard A. Lyons, MA
Superintendent of Schools,
Maine Regional School Unit #22
Laura Rooney, MPH
Adolescent Health Program Manager,
Ohio Department of Health
Susan K. Telljohann, HSD, CHES
Professor, Health Education, Department
of Health and Recreation Professions,
The University of Toledo
12
WHOLE SCHOOL
WHOLE COMMUNITY
WHOLE CHILD
A Collaborative Approach to Learning and Health
13
For more information on the Whole School, Whole Child, Whole
Community collaborative approach to learning and health, visit
www.ascd.org/learningandhealth.
Rasberry CN, Slade S, Lohrmann DK, Valois RF. Lessons learned from the whole child and coordinated
school health approaches. Journal of School Health. 2015; 85, 759-765.
GENERAL ARTICLE
Lessons Learned From the Whole Child and
Coordinated School Health Approaches
CATHERINE N. RASBERRY, PhD, MCHESa SEAN SLADE, MEd, BEdb DAVID K. LOHRMANN, PhD, MCHES, FASHA, FAAHEc
ROBERT F. VALOIS, MS, PhD, MPH, FASHA, FAAHB, FAAHEd
ABSTRACT
BACKGROUND: The new Whole School, Whole Community, Whole Child (WSCC) model, designed to depict links between
health and learning, is founded on concepts of coordinated school health (CSH) and a whole child approach to education.
METHODS: The existing literature, including scientific articles and key publications from national agencies and organizations,
was reviewed and synthesized to describe (1) the historical context for CSH and a whole child approach, and (2) lessons learned
from the implementation and evaluation of these approaches.
RESULTS: The literature revealed that interventions conducted in the context of CSH can improve health-related and academic
outcomes, as well as policies, programs, or partnerships. Several structural elements and processes have proved useful for
implementing CSH and a whole child approach in schools, including use of school health coordinators, school-level and
district-level councils or teams; systematic assessment and planning; strong leadership and administrative support, particularly
from school principals; integration of health-related goals into school improvement plans; and strong community collaborations.
CONCLUSIONS: Lessons learned from years of experience with CSH and the whole child approaches have applicability for
developing a better understanding of the WSCC model as well as maximizing and documenting its potential for impacting both
health and education outcomes.
Keywords: coordinated school health; whole child; education outcomes; child health; health outcomes; Whole School, Whole
Community, Whole Child (WSCC) model.
Citation: Rasberry CN, Slade S, Lohrmann DK, Valois RF. Lessons learned from the whole child and coordinated school health
approaches. J Sch Health. 2015; 85: 759-765.
Received on August 2, 2015
Accepted on August 3, 2015
I
n 2014, ASCD—formerly known as the Association
for Supervision and Curriculum Development—and
the US Centers for Disease Control and Prevention
(CDC) first unveiled the new Whole School, Whole
Community, Whole Child (WSCC) model, which
encompasses links between health and learning.
This model, based on foundational concepts of both
coordinated school health (CSH) and a whole child
approach, is designed to reflect decades of research,
practice, and lessons learned in a model that can have
broad-based appeal for both health professionals and
educators alike.
The purpose of this article is to provide the
history behind the foundational CSH and whole
child concepts that underlie the new WSCC model,
and to articulate many of the key lessons learned
from the implementation and evaluation of these
commonly used approaches. In addition, we describe
key implications for school health, with a focus on how
lessons learned from years of experience with CSH
and the whole child approach have applicability for
developing a better understanding of the WSCC model
as well as maximizing and documenting its potential
for impacting both health and education outcomes.
a
Health Scientist, ([email protected]), Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, TB Prevention, Division of Adolescent Health,
1600 Clifton Road, MS: E-75, Atlanta, GA 30329.
b
Director of Whole Child Programs, ([email protected]), ASCD, 1703 N. Beauregard Street, Alexandria, VA 22311-1714.
c
Professor and Chair, ([email protected]), Indiana University School of Public Health-Bloomington, Department of Applied Health Science, 1025 East Seventh St., SPH 116,
Bloomington, IN 47405.
dProfessor, ([email protected]), Department of Health Promotion, Education & Behavior, Arnold School of Public Health, University of South Carolina, 915 Green Street, Room 534A,
Columbia, SC 29208.
Address correspondence to: Catherine N. Rasberry, Health Scientist, ([email protected]), Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis,
STD, TB Prevention, Division of Adolescent Health, 1600 Clifton Road, MS: E-75, Atlanta, GA 30329.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Journal of School Health •
November 2015, Vol. 85, No. 11
• 759
© 2015 The Authors. Journal of School Health published by Wiley Periodicals, Inc. on behalf of American School Health Association.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and
reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.
LITERATURE REVIEW
History of CSH
The initial 8-component model of the CSH
approach was first introduced in 1987—then termed
‘‘comprehensive school health’’—via a special issue
of the Journal of School Health.1 Previously, school
health was conceptualized as a ‘‘3-legged stool’’
comprised of health education, health services, and
the healthy school environment.1 CSH involved both
implementation of programs and services within 8
high-quality components and systemic coordination
in order to eliminate gaps and overlaps and best use
available personnel, time and resources.1
The 8-components approach, and variants of it
adopted by some states,2,3 is an innovation that has
enjoyed an impressive dissemination and adoption
curve.4 This likely was facilitated by the decision
of CDC’s Division of Adolescent and School Health
to embrace the model.4 CDC, in collaboration with
other organizations including the American School
Health Association (ASHA), implemented a number
of actions in support of this new approach. For
example, CDC funded development of a book, Health Is
Academic: A Guide to Coordinated School Health Programs,5
that provided a broad delineation of CSH and its
components along with state and local dissemination
strategies.
In addition, CDC issued cooperative agreements to
national organizations and state education agencies for
the purpose of developing and disseminating policies
and programs in support of CSH.6,7 In 1992, 5 state
education agencies were initially selected to implement
CSH infrastructure such as funding and authorization,
personnel and organizational placement, communication and linkages, and resources8 internally and with
their sister state health agency over 5 years; under this
agreement, a CSH coordinator position was funded in
both the state-level education and health agencies and
a health education specialist was funded in the education agency. Their collective charge was to organize the
analogous 8 CSH components between their respective
agencies and, then, to instigate CSH adoption in local
education agencies/school districts via technical assistance and training.8 In the late 1990s, CDC shifted the
funding focus to encourage education agencies at both
the state and local levels to achieve specific healthrelated outcomes such as increased physical activity,
improved nutrition, prevention of tobacco use, and
reduction in sexual risk behaviors through use of the
CSH approach. To date, CDC continues to support
the tenets of CSH, now incorporated into the WSCC
model, as a foundation for improving health outcomes
of students in schools.
Along with the publication of the book Health
Is Academic,5 documents from the American Cancer Society emerged to provide detailed guidance for
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implementing the essential structures of CSH including
employment of a health coordinator,9 and differentiation of a system-wide CSH coordinating council10
from school building-level CSH teams. Thereafter,
the American Cancer Society, with funding from
CDC, conducted 2 sequential 18-month long School
Health Coordinator Leadership Institutes designed to
assist school districts’ adoption and implementation of
CSH.11 The initial Institute was inaugurated in 1999
for 50 participants from across the United States; these
participants subsequently were expected to assume
the role of CSH coordinator in their respective school
districts. The second Institute involved teams from 6
large urban school districts that enrolled hundreds of
thousands of pre-K-12 students. Thereafter, the CSH
Leadership Institute model was replicated regionally
by CDC-funded state education agencies, sometimes in
collaboration with American Cancer Society affiliates,
in the US northeast, mid-Atlantic, midwest, and southwest regions plus California. This strategy of supporting
school district coordinators and teams to implement
CSH was shown to be effective.12-16 In addition, the
American Cancer Society has worked with CDC in
more recent years to provide CSH-related trainings to
professionals teaching in higher education so that they
can better prepare their students for teaching school
health.
ASCD’s initial foray into CSH occurred in 2003
when the Robert Wood Johnson Foundation provided
funding to develop a tool that educators could use
to assess the status of CSH in schools. Following
an extended development process that involved an
expert panel review and conferences followed by field
testing,15,16 the assessment tool was published as an
ASCD book entitled Creating a Healthy School Using the
Healthy School Report Card.16 Thereafter, the tool was
used in several Leadership Institute replications,12,15,17
a Canadian version was disseminated,18 and an extensive evaluation was conducted at 11 funded schools
in both the United States and Canada. This evaluation, for the first time, documented the participation
of the school principal as essential to successful CSH
implementation.19,20 These activities aligned and supported ASCD’s subsequent development of a whole
child approach launched in 2006.
History of the Whole Child Approach
In 2006, ASCD convened the Commission on
the Whole Child. This Commission was composed
of leading thinkers, researchers, and practitioners
all drawn from a wide variety of sectors and was
charged with recasting the definition of a successful
learner from one whose achievement is measured
solely by academic tests, to one who is knowledgeable,
emotionally and physically healthy, civically inspired,
engaged in the arts, prepared for work and economic
© 2015 The Authors. Journal of School Health published by Wiley Periodicals, Inc. on behalf of American School Health Association.
self-sufficiency, and ready for the world beyond formal
schooling.
The Commission was convened to start a dialogue
to change what is meant by a successful school,
a successful education, and ultimately a successful
student. It was a discussion directly aimed at the
current educational landscape of 2007—dominated
by the No Child Left Behind Act of 2001—which was
moving the nation toward an ever greater focus on an
academics-above-all-else educational system.
The Commission began with a discussion of how
an ideal education—one that places the child at the
center—would look. It asked how resources, both
personnel and facilities, would be arranged if the
child was key in the equation. In 2007, Dr Gene
R. Carter, Executive Director of ASCD, summed this
up as follows: ‘‘If decisions about education policy and
practice started by asking what works for the child,
how would resources—time, space, and human—be
arrayed to ensure each child’s success? If the student
were truly at the center of the system, what could we
achieve?’’21(p4)
The Whole Child Initiative was borne out of
this discussion and this Commission. It established
5 tenets which provide the framework for what a
well-rounded, holistic, and effective education must
focus upon, ensuring that each child, in each school,
and in each community, is healthy, safe, engaged,
supported, and challenged. The tenets refer directly
back to Abraham Maslow’s Hierarchy of Needs which
was set out in the 1943 paper, ‘‘A Theory of Human
Motivation.’’22 The original hierarchy established the
foundational or base needs (physiological) at the
bottom of the pyramid, followed subsequently by
safety, love, and belongingness, esteem, and selfactualization. It established, via its pyramid structure,
the understanding that achieving certain needs was
possible only after others had been met.
Based on this structure, the whole child tenets were
arranged to demonstrate that health and then safety
were fundamental in establishing environments in
which students truly can be engaged, supported, and,
ultimately, challenged. By focusing initial attention
on ‘‘healthy,’’ the Whole Child Initiative actively
promoted the role of school health services and healthpromoting entities in the school and community. It
shined a light on the imperative need for schools
to consider not just the academic outcomes of the
students but their health and well-being, as well,
both as ways of improving educational outcomes
and for fostering the holistic development of the
individual child beyond the academic. It proposed that
districts and schools place additional initial attention
on the environment in which learning takes place
before embarking directly upon that learning. Again,
the Whole Child Initiative was borne out of an
understanding that students cannot learn if they are
not healthy and safe, and subsequently, will not learn
if they are not engaged, supported, and challenged.
The Whole School, Whole Community, Whole Child Model
In 2013, ASCD and CDC jointly convened a
group of leaders in school health, education, and
public health. These leaders sought to develop a
framework that would ‘‘strengthen a unified and
collaborative approach to learning and health’’23(p6)
building off the valuable tenets of both the Whole
Child Initiative, which was often viewed as primarily
education-focused, and the CSH approach, which was
often viewed as primarily health-focused.23 The result
was the Whole School, Whole Community, Whole
Child model—the next iteration in the evolution of
these 2 conceptual approaches merged into 1 unified
framework.
Lessons Learned From CSH and Whole Child Approaches
The use of CSH and whole child approaches
over time has provided many lessons learned. CSH,
from its inception, has provided education and
health professionals with a well-planned and easily
understood framework for addressing the healthrelated aspects of the whole child. In the original
model presented by Allensworth and Kolbe, 8
program components of CSH stretched across a
variety of student needs, and outcomes reflected
in the model extended beyond health behaviors to
include outcomes related to cognitive performance
and educational achievement, both of which are linked
to health.1 The innovation of the model was that it
brought to the forefront the interplay between varied
aspects of health and related school activities, and
highlighted the interdependence of each component
with the others. The CSH model provides a framework
for conceptualizing interventions to address a wide
spectrum of students’ needs that are often foundational
for both students’ health and ability to learn in school.
CSH is not simply a framework to inform and
support implementation of health-related interventions; research indicates that interventions conducted
in the context CSH can be successful. To date, most
research has investigated either health education or
health promotion interventions that focus on key topics within the CSH model such as physical education or
nutrition education24-27 or use of CSH processes and
structures to bring about improvements in policies,
programs, or partnerships.12,15,28,29 Researchers have
found evidence of effectiveness among several more
narrowly focused programs implemented in the context of CSH, including programs for physical activity,25
nutrition,26 and childhood obesity.24,27 The literature
also contains several examples of CSH approaches and
related infrastructure facilitating success in the implementation of program activities.15,24,29 In addition,
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researchers have provided some support for an association between CSH programs and outcomes related to
academic achievement.30,31
One challenge for CSH is that although CSH
provides a framework for addressing multiple aspects
of children’s health, research, and evaluation activities
that address student-level health and academic
outcomes have rarely reflected the comprehensive
nature of CSH. This may be part of the reason
that, even as far back as 1998, leaders in school
health described CSH as a program for which ‘‘the
promise . . . thus far outshines its practice.’’5(p10) Much
of the research on outcomes and effect of CSH has
been among the more narrowly defined programs
situated within the context of CSH, as described
above. Similarly, researchers have commented about
the challenges of sustainability and resulting change
from such narrowly focused and more programmaticoriented approaches to CSH.19 In a 2015 publication,
Valois et al discuss limitations of mere programmatic
change and suggest that, instead, health and school
improvement efforts can be enhanced and better
sustained when they are founded on systemic changes
within schools.20 Likewise, CDC has recently explored
CSH through the perspective of a systemic framework
in an attempt to better understand what makes the
strongest programs successful.32
Ultimately, schools are the domain of education
and, as such, any initiative must have educational
benefit to be successfully implemented and must be
aligned to processes in the existing educational setting.
One challenge for CSH has been that viewing it as a
health initiative, focused on health for health’s sake
only, has not required health and well-being to be
conceptualized as a core component of an effective
school and an effective educational system. Yet the
evidence supports the idea that health and education
are symbiotic—each benefits from the other.33,34 It is
why in 2002 the then Director of CDC’s Division of
Adolescent School Health, Lloyd Kolbe wrote,
In sum, if American schools do not coordinate and
modernize their school health programs as a critical part of
educational reform, our children will continue to benefit at
the margins from a wide disarray of otherwise unrelated,
if not underdeveloped, efforts to improve interdependent
education, health, and social outcomes. And, we will forfeit
one of the most appropriate and powerful means available
to improve student performance.35(p10)
Fortunately, several key lessons from CSH suggest
ways in which CSH and related whole child approaches
can be positioned in school settings. Across the
literature on CSH, one of the key lessons to
emerge is the critical nature of infrastructure within
the school and district to support health-related
activities. Although infrastructure may vary from
school to school and district to district, a few standard
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November 2015, Vol. 85, No. 11
infrastructure recommendations for supporting CSH
implementation have included the presence of a
school health coordinator, a district-level school health
advisory or coordinating council, and school-level
health teams or committees.36-41 District-level and
school-level councils/teams typically include school or
district representatives from all 8 components of CSH
as well as community members, parents, and students.
These teams, with leadership and guidance from a
school health coordinator, are typically responsible
for coordination between the 8 CSH components
and implementing activities to improve health within
schools.38
Once this infrastructure is in place, the use of a
systematic assessment and planning process can help
coordinators and councils/teams identify their school
or district’s specific health-related needs, prioritize
those needs, and develop plans to effectively address
them. This assessment and planning process can
take several different forms: some councils/teams
structure this around use of the School Health Index42
or the Healthy School Report Card.16,18 Regardless of
the tool or format used, this process can be most
effective when it is data-driven and includes defining
priorities, assessing existing and available resources,
developing clear and measurable goals and objectives,
and developing an action plan with a timeline for
reaching those goals and objectives.38,39
In addition to having key infrastructure in place, the
importance of having strong leaders/champions40,43
and administrative support and buy-in38 is well
supported by the literature about CSH.4,37,43 Leaders
and champions, from both within and outside of
schools, can build support for CSH in ways that
allow its proponents to overcome challenges and
barriers that might otherwise impede progress.40 In
particular, one recent study conducted for and released
by ASCD found that leadership from school principals
was critical for bringing about meaningful change in
schools.19,20 Administrative support and buy-in are
critical for ensuring sustained commitment to CSH and
health-related goals. This support may be evidenced
by incorporation of health-related goals into vision
and mission statements and/or school improvement
plans, assignment of staff to oversee school health, and
allocation of resources to address health-related needs.
The role of leadership and integration into school
improvement plans is further articulated in a 2011
report from ASCD that described findings from its
work in integrating a whole child approach with a
focus on health and well-being into the systems and
functions of the school.19 The report summarized key
actions schools had undertaken to ensure integration
and sustainability, and as a result, identified ‘‘9 levers’’
that mobilized change in school communities: (1) the
principal as leader; (2) active and engaged leadership;
(3) distributive leadership; (4) integration with the
© 2015 The Authors. Journal of School Health published by Wiley Periodicals, Inc. on behalf of American School Health Association.
school improvement plan; (5) effective use of data
for continuous school improvement; (6) ongoing and
embedded professional development; (7) authentic
and mutually beneficial community collaborations;
(8) stakeholder support of the local efforts; (9) the
creation or modification of school policy related to the
process.19,20
Of these 9 levers, 2 appeared particularly
influential—the principal as leader and integration
with the school improvement plan. These were particularly important for initiatives, especially ones that
may at first glance be viewed as superfluous to the
school’s primary mission, to be successfully implemented and sustained. The commonality across these
2 levers is that they establish an educational rationale to the process and the initiative. Having tangible
acceptance, commitment, and active engagement of
the principal as seminal to any health-related improvement initiative allows the school, staff, students, and
families to view that initiative as educationally beneficial. Subsequently they are more accepting and open
to seeing the connections between health, well-being,
safety, connectedness, and pedagogy; and any changes
or adaptations related to the initiative are more likely
to be integrated into the broader policies affecting the
school. By integrating the initiative or focus with the
school improvement plan, one additionally aligns it to
effective education and pedagogy, thereby allowing the
initiative to become a key part of what the administration and its teachers discuss and target annually, and
the initiative becomes further integrated into adjunct
policies. The school improvement plan provides the
direction for and purpose of the school, as well as the
implementation pathway.19,20
A whole child approach to education—one which
seeks to ensure that each child is healthy, safe,
engaged, supported, and challenged—appreciates
that, ‘‘children do not develop and learn in isolation,
but rather grow physically, socially, emotionally, ethically, expressively, and intellectually within networks
of families, schools, neighborhoods, communities, and
our larger society.’’21(p11) Initiatives to help address
these aspects of growth, whether framed as whole
child or CSH initiatives, can best gain footing when
those initiatives are aligned with the purpose of the
school—its mission, policies, and pedagogy.
Finally, from years of research and practice in CSH
and a whole child approach, the vital role of the
community has emerged. In a whole child approach,
‘‘authentic and mutually beneficial community
collaborations’’ have been identified as a key lever of
shifting a school’s culture,19 and in CSH, it has become
clear that community assets can be a lifeline for CSH
activities. Furthermore, CSH offers a framework by
which a school or district can harness community
assets. As other researchers have previously suggested,
the CSH approach may be best explained and
understood in the context of an ecological
framework,4,40 which can help account for the
context and influence of community on health. With
the integration of community members as stakeholders and participants in district-level councils and
school-level teams, CSH structures and processes offer
a natural opportunity for community organization and
community building that can help make key community resources available to students and staff and can
strengthen the overall community at the same time.
Although the appreciation of what constitutes an
effective education is changing and has changed since
both the introduction of No Child Left Behind44 and,
somewhat coincidentally with the introduction of the
Whole Child Initiative, there is still and likely always
will be a necessity to link any new initiative back
to the processes and functions of the school and its
educational outcomes whether these be academic,
cognitive, or developmental. As other researchers
have suggested, shifting the language and framing
of CSH and a whole child approach to reflect more
of a general school-improvement focus, one that can
meet the needs of the whole child and resonate with
both educators and community members outside of
the health profession, may enable health professionals
to better achieve the goal of healthy students.19,45
In a 2010 article, Hoyle et al went so far as to
say ‘‘insistence on alignment of programs under
the ‘health’ banner is detrimental to the purpose
and mission of both school health and school
improvement.’’45(p165) Instead, they suggested that
school health professionals could offer knowledge and
skills in the processes of developing, implementing,
and evaluating health-related interventions.45 These
processes, implemented through the foundational
infrastructure components used to support CSH and
seen in the 9 levers explored through the whole child
approach, can facilitate improvement in a variety of
student outcomes, including those related to health.
IMPLICATIONS FOR SCHOOL HEALTH
For school and education agency staff to be
motivated and able to successfully implement the CSH
and whole child tenants reflected in the WSCC model,
staff members likely need evidence-based suggestions
for the implementation process and articulation of
outcomes that can be reasonably expected. To provide
this information, we believe there are several key areas
of research that are warranted.
First, we recommend that researchers investigating
CSH and the whole child approach, as now reflected
in the WSCC model, continue to focus on the
ecological aspects of the model, particularly the
role of community. School staff involved in CSH
programs have reported that the CSH approach has
helped their schools develop new partnerships within
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their communities,12,46 and these partnerships can be
critical for meeting students’ needs. This vital role
of community is reflected in the new WSCC model
in both the community involvement component as
well as the positioning of all of the other CSHbased components within the context of community.23
To support school and district staff, we recommend
school health experts consider developing tools and
recommendations for how the WSCC model can best
be used to assess and harness community assets to
enable schools to meet the needs of the whole child.
Such tools and recommendations—developed using
language that can resonate with a broad range of
stakeholders including not only health professionals
but also educators and community members as
well—could serve as valuable resources to school
and district staff, particularly in an environment filled
with more and more demands on fewer and fewer
resources.
Second, we recommend that researchers exploring
the WSCC model seek to provide additional insight
into the ‘‘how’’ and not just the ‘‘what’’ of the model.
Specifically, the traditional 8-component CSH model
and now the WSCC model both provide a pragmatic
visual representation of the different aspects of
health that can be addressed through comprehensive
approaches. The WSCC model takes this a step
farther by presenting the role of ‘‘coordinating policy,
process, and practice’’ visually within the model.
However, neither model is designed to provide
school and health professionals with explanations
of how to do that coordination. Although many
professionals have sought to add to the ‘‘how’’
descriptions by delineating key infrastructure and
processes used in CSH,36-41,47 future researchers and
practitioners in school health can seek to provide
additional information and tools to help articulate
how such infrastructure pieces and key processes
can be coordinated and implemented effectively. To
the extent that the WSCC model functions as a
system connecting students, families, schools, and
communities, the literature on systems change may
offer insight into ways school health professionals can
better articulate how the ‘‘coordinated’’ aspect of the
model can be accomplished and strengthened.
Finally, we recommend research be conducted
about the WSCC model as a whole, not simply
individual components within the model, in order
to assess the cumulative effect that can result from a
comprehensive approach to addressing health and the
whole child. In the last several decades, researchers
have gathered additional evidence to support the use
of CSH, and importantly, to begin to understand
the structures and processes necessary to use CSH
effectively. What continues to remain largely missing
from the scientific literature is a holistic examination
of the full CSH model that assesses a broad range of
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Journal of School Health • November 2015, Vol. 85, No. 11
outcomes in 1 comprehensive evaluation. In theory,
the value of the CSH model comes from the synergistic
effect gained from coordinated interventions to address
multiple aspects of co-occurring needs. Examining the
new WSCC model, inclusive of foundational CSH
concepts, through research that is longitudinal in
nature and, ideally, designed to represent schools
and communities of various sizes48 may provide
researchers with the best opportunity to capture the
full impact of the model’s value for improving the
health and well-being of youth.
Human Subjects Approval Statement
Preparation of this paper did not include performing original research requiring inclusion of human
subjects.
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net/publication/267270095_Coordinated_school_health_as_a_
system_An_emerging_model. Accessed July 31, 2015.
Basch CE. Healthier students are better learners: high-quality,
strategically planned, and effectively coordinated school health
programs must be a fundamental mission of schools to help
close the achievement gap. J Sch Health. 2011;81(10):650-662.
Centers for Disease Control and Prevention (CDC). Health and
Academic Achievement. Atlanta, GA: US Department of Health
and Human Services, CDC, National Center for Chronic Disease
Prevention and Health Promotion; 2014.
Kolbe LJ. Education reform and the goals of modern school
health programs. State Educ Standard. 2002;3(4):4-11.
Allensworth D. Improving the health of youth through a coordinated school health programme. Promot Educ. 1997;1(4):42-47.
Fetro JV. Implementing coordinated school health programs in
local schools. In: Marx E, Wooley SF, Northrop D, eds. Health
Is Academic: A Guide to Coordinated School Health Programs. New
York, NY: Teachers College Press; 1998:15-42.
Centers for Disease Control and Prevention (CDC). How schools
can implement coordinated school health. 2013. Available at:
http://www.cdc.gov/healthyyouth/cshp/schools.htm. Accessed
December 1, 2014.
Fisher C, Hunt P, Kann L, Kolbe L, Patterson B, Wechsler H.
Building a healthier future through school health programs.
In: Promising Practices in Chronic Disease Prevention and Control: A
Public Health Framework for Action. Atlanta, GA: US Department
of Health and Human Services, Centers for Disease Control and
Prevention; 2003:9.2-9.25.
Lohrmann DK. A complementary ecological model of the
coordinated school health program. J Sch Health. 2010;
80(1):1-9.
Institute of Medicine (IOM). Schools and Health: Our Nation’s
Investment. Washington, DC: National Academy Press; 1997.
Centers for Disease Control and Prevention (CDC). School
Health Index. 2014. Available at: http://www.cdc.gov/
healthyyouth/shi/index.htm. Accessed January 8, 2015.
Valois RF, Hoyle TB. Formative evaluation results from the
Mariner Project: a coordinated school health pilot program. J
Sch Health. 2000;70(3):95-103.
US Department of Education. Elementary and Secondary
Education Act. 2015. Available at: http://www.ed.gov/esea.
Accessed February 6, 2015.
Hoyle TB, Bartee RT, Allensworth DD. Applying the process
of health promotion in schools: a commentary. J Sch Health.
2010;80(4):163-166.
Weiler RM, Pigg RM Jr, McDermott RJ. Evaluation of the Florida
coordinated school health program pilot schools project. J Sch
Health. 2003;73(1):3-8.
Centers for Disease Control and Prevention (CDC). How
states can support coordinated school health. 2013. Available at: http://www.cdc.gov/healthyyouth/cshp/states.htm.
Accessed December 1, 2014.
Valois RF. Promoting adolescent and school health: perspectives
and future directions. Am J Health Educ. 2003;34(6):314-328.
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Hunt P, Barrios L, Telljohann SK, Mazyck D. A whole school approach: Collaborative development of
school health policies, processes, and practices. Journal of School Health. 2015; 85, 802-809.
GENERAL ARTICLE
A Whole School Approach: Collaborative
Development of School Health Policies,
Processes, and Practices
PETE HUNT, MPH, MEda LISA BARRIOS, MPH, DrPHb SUSAN K. TELLJOHANN, HSD, CHESc DONNA MAZYCK, MS, RN, NCSNd
ABSTRACT
BACKGROUND: The Whole School, Whole Community, Whole Child (WSCC) model shows the interrelationship between
health and learning and the potential for improving educational outcomes by improving health outcomes. However, current
descriptions do not explain how to implement the model.
METHODS: The existing literature, including scientific articles, programmatic guidance, and publications by national agencies
and organizations, was reviewed and synthesized to describe an overview of interrelatedness of learning and health and the 10
components of the WSCC model.
RESULTS: The literature suggests potential benefits of applying the WSCC model at the district and school level. But, the model
lacks specific guidance as to how this might be made actionable. A collaborative approach to health and learning is suggested,
including a 10-step systematic process to help schools and districts develop an action plan for improving health and education
outcomes. Essential preliminary actions are suggested to minimize the impact of the challenges that commonly derail
systematic planning processes and program implementation, such as lack of readiness, personnel shortages, insufficient
resources, and competing priorities.
CONCLUSIONS: All new models require testing and evidence to confirm their value. District and schools will need to test this
model and put plans into action to show that significant, substantial, and sustainable health and academic outcomes can be
achieved.
Keywords: coordinated school health; whole child; academic achievement; health outcomes; Whole School, Whole Community,
Whole Child (WSCC) model.
Citation: Hunt P, Barrios L, Telljohann SK, Mazyck D. A whole school approach: collaborative development of school health
policies, processes, and practices. J Sch Health. 2015; 85: 802-809.
Received on August 2, 2015
Accepted on August 3, 2015
T
he Whole School, Whole Community, Whole
Child (WSCC) model was created to encourage
education and health organizations to work together to
improve student health and academic outcomes. The
model focuses on ‘‘what’’ should happen to improve
student health and academic outcomes, mainly by
describing the 10 school health components that
should be coordinated (health education; nutrition
environment and services; employee wellness; social
and emotional school climate; physical environment;
health services; counseling, psychological, and social
services; community involvement; family engagement;
and physical education and physical activity). The
purpose of this article is to describe how districts and
schools can use a systematic process to implement
the WSCC model and improve health and academic
outcomes.
The key to moving from model to action is collaborative development of local school policies, processes,
and practices. The day-to-day practices within each
a TeamLead Health Scientist, ([email protected]), Research Application and Evaluation Branch, Division of Adolescent and School Health, National Center for HIV/AIDS, Viral Hepatitis,
STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, NE, MS E-75, Atlanta, GA 30329.
Lead Health Scientist and Branch Chief, ([email protected]), Research Application and Evaluation Branch, Division of Adolescent and School Health, National Center for HIV/AIDS,
Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, NE, MS E-75, Atlanta, GA 30329.
c
Professor Emeritus, ([email protected]), The University of Toledo, Department of Health and Recreation Professions, 2801 W. Bancroft Dr., Toledo, OH 43606.
d
Executive Director, ([email protected]), National Association of School Nurses, 1201 16th Street, NW #216 Washington, DC 20036-3290.
b
Address correspondence to: Pete Hunt, Team Lead Health Scientist, ([email protected]), Research Application and Evaluation Branch, Division of Adolescent and School Health,
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, NE, MS E-75, Atlanta, GA 30329.
The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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© 2015 The Authors. Journal of School Health published by Wiley Periodicals, Inc. on behalf of American School Health Association.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and
reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.
WSCC component require examination and planning
so that they work in tandem, with appropriate
complementary processes guiding each decision and
action. Developing joint and collaborative policy is
half the challenge; putting it into action and making
it routine completes the task. To develop joint or collaborative policies, processes, and practices, all parties
involved should start with a common understanding
about the interrelatedness of learning and health.
From this understanding, current and future systems
and actions can be adjusted, adapted, or crafted to
achieve both learning and health outcomes.1
For several decades, various models have been
developed to describe the many pieces that make
up a school health program and how having
such pieces in place can lead to improvements in
health outcomes for young people.2-4 Although these
school health models have helped public health
and school officials understand the roles schools
can play in implementing health-related programs
and interventions, such efforts have not always
resulted in significant improvements in child and
adolescent health. Similarly, they have not led to
broader acknowledgement of the impact healthrelated interventions can have on academic outcomes.
As recently as 2011, Charles Basch pointed out that
‘‘school health is currently not a completely integrated
part of the fundamental mission of schools in America
nor has it been well integrated into the broader
national strategy to reduce the gaps in educational
opportunity and outcomes.’’5 Public health and
education sectors continue to remain isolated from
one another, and have not recognized the overlap and
advantages of working together to improve both health
and academic outcomes. The WSCC model is intended
to remedy this problem by focusing on both health
and academic outcomes. It is intended to bring health
and education professionals together with a common
purpose of helping the whole child.
LITERATURE REVIEW
Developing a Common Understanding of the
Interrelatedness of Learning and Health
Educational attainment is an excellent indicator
of future health: people who have more education
tend to have better health than those who have less
education.6 In fact, the US Community Preventive Services Task Force recently recommended interventions
intended to increase high school completion in order
to improve future health equity.7 At the same time,
health issues of students (for example, hunger and
chronic illness) can lead to poor school performance.
Health-risk behaviors such as early sexual initiation,
violence, unhealthy eating, and physical inactivity are
consistently linked to poor grades, test scores, and
lower educational attainment.8-11 Scientific reviews
have documented that school health programs can
have positive effects on academic outcomes, as well as
health-risk behaviors and health outcomes.5,12 Similarly, programs that are primarily designed to improve
academic achievement are increasingly recognized as
important public health interventions.6,13
The 10 Health Components
The ‘‘whole school’’ section of the WSCC model
lists sectors or components, of a school that are related
to school health. Although the individuals engaged in
these sectors might not recognize the contributions
of their actions toward creating a healthy school,
the model emphasizes that each plays a role toward
creating a healthy and safe school that supports the
health and academic achievement of students.
The 10 components included in the ‘‘whole school’’
section of the WSCC model are an expansion of
the 8 component coordinated school health (CSH)
approach described by the Centers for Disease Control and Prevention (CDC).14 The WSCC model splits
the CSH ‘‘Healthy and Safe School Environment’’
component into ‘‘Social and Emotional Climate’’ and
‘‘Physical Environment’’ components. Furthermore,
it divides CSH’s ‘‘Family/Community Involvement’’
into ‘‘Community Involvement’’ and ‘‘Family Engagement’’ components. This evolution meets the need for
greater emphasis on both the psychosocial and physical environment as well as the ever-increasing and
growing roles that community agencies and families
must play. The 10 final components are health education; nutrition environment and services; employee
wellness; social and emotional school climate; physical
environment; health services; counseling, psychological, and social services; community involvement;
family engagement; and physical education and physical activity. Table 1 presents a detailed description of
each component.
Some of the 10 components are easily recognizable
as important parts of school health, for example,
health education and health services. These components tend to have staffs, at both the district and school
level, who are devoted at least part-time to managing
or carrying out essential health-related functions.
They identify themselves, and others identify them,
as part of the school or district’s approach to school
health. On the other hand, they may not recognize
that the work in which they are engaged also impacts
academic achievement.
Staff engaged in other school services (for example,
nutrition services; physical education; counseling, psychological, or social services; and employee wellness)
might or might not recognize their relevance to school
health. However, these services are also provided
to meet health needs. Through nutrition services,
schools provide access to nutritious and appealing
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Table 1. Components of the Whole School, Whole Community, Whole Child (WSCC)∗
WSCC component
Description
Health Education
Formal, structured health education consists of any combination of planned learning experiences that provide the opportunity
to acquire information and the skills students need to make quality-health decisions. When provided by qualified, trained
teachers, health education helps students acquire the knowledge, attitudes, and skills they need for making
health-promoting decisions, achieving health literacy, adopting health-enhancing behaviors, and promoting the health of
others. Comprehensive school health education includes curricula and instruction for students in pre-K through grade 12 that
address a variety of topics such as alcohol and other drug use and abuse, healthy eating/nutrition, mental and emotional
health, personal health and wellness, physical activity, safety and injury prevention, sexual health, tobacco use, and violence
prevention. Health education curricula and instruction should address the National Health Education Standards (NHES) and
incorporate the characteristics of an effective health education curriculum. Health education, based on an assessment of
student health needs and planned in collaboration with the community, ensures reinforcement of health messages that are
relevant for students and meet community needs. Students might also acquire health information through education that
occurs as part of a patient visit with a school nurse, through posters or public service announcements, or through
conversations with family and peers.
The school nutrition environment provides students with opportunities to learn about and practice healthy eating through
available foods and beverages, nutrition education, and messages about food in the cafeteria and throughout the school
campus. Students may have access to foods and beverages in a variety of venues at school including the cafeteria, vending
machines, grab ‘n’ go kiosks, schools stores, concession stands, classroomrewards, classroomparties, school celebrations, and
fundraisers.
School nutrition services provide meals that meet federal nutrition standards for the National School Lunch and Breakfast
Programs, accommodate the health and nutrition needs of all students, and help ensure that foods and beverages sold
outside of the school meal programs (competitive foods) meet Smart Snacks in School nutrition standards. School nutrition
professionals should meet minimum education requirements and receive annual professional development and training to
ensure that they have the knowledge and skills to provide these services. All the individuals in the school community support
a healthy school nutrition environment by marketing and promoting healthier foods and beverages, encouraging
participation in the school meal programs, role-modeling healthy eating behaviors, and ensuring that students have access to
free drinking water throughout the school day.
Healthy eating has been linked in studies to improved learning outcomes and helps ensure that students are able to reach their
potential.
Schools are not only places of learning, but they are also worksites. Fostering school employees’ physical and mental health
protects school staff, and by doing so, helps to support students’ health and academic success. Healthy school
employees—including teachers, administrators, bus drivers, cafeteria and custodial staff, and contractors—are more
productive and less likely to be absent. They serve as powerful role models for students and may increase their attention to
students’ health. Schools can create work environments that support healthy eating, adopt active lifestyles, be tobacco free,
manage stress, and avoid injury and exposure to hazards (mold, asbestos). A comprehensive school employee wellness
approach is a coordinated set of programs, policies, benefits, and environmental supports designed to address multiple risk
factors (lack of physical activity and tobacco use) and health conditions (diabetes and depression) to meet the health and
safety needs of all employees. Partnerships between school districts and their health insurance providers can help offer
resources, including personalized health assessments and flu vaccinations. Employee wellness programs and healthy work
environments can improve a district’s bottom line by decreasing employee health insurance premiums, reducing employee
turnover, and cutting costs of substitutes.
Social and emotional school climate refers to the psychosocial aspects of students’ educational experience that influence their
social and emotional development. The social and emotional climate of a school can impact student engagement in school
activities; relationships with other students, staff, family, and community; and academic performance. A positive social and
emotional school climate is conducive to effective teaching and learning. Such climates promote health, growth, and
development by providing a safe and supportive learning environment.
A healthy and safe physical school environment promotes learning by ensuring the health and safety of students and staff. The
physical school environment encompasses the school building and its contents, the land on which the school is located, and
the area surrounding it. A healthy school environment will address a school’s physical condition during normal operation as
well as during renovation (ventilation, moisture, temperature, noise, and natural and artificial lighting), and protect occupants
fromphysical threats (crime, violence, traffic, and injuries) and biological and chemical agents in the air, water, or soil as well as
those purposefully brought into the school (pollution, mold, hazardous materials, pesticides, and cleaning agents).
School health services intervene with actual and potential health problems, including providing first aid, emergency care and
assessment and planning for the management of chronic conditions (such as asthma or diabetes). In addition, wellness
promotion, preventive services and staff, student and parent education complement the provision of care coordination
services. These services are also designed to ensure access and/or referrals to the medical home or private healthcare
provider. Health services connect school staff, students, families, community, and healthcare providers to promote the health
care of students and a healthy and safe school environment. School health services actively collaborate with school and
community support services to increase the ability of students and families to adapt to health and social stressors, such as
chronic health conditions or social and economic barriers to health, and to be able to manage these stressors and advocate
for their own health and learning needs. Qualified professionals such as school nurses, nurse practitioners, dentists, health
educators, physicians, physician assistants and allied health personnel provide these services.
Nutrition Environment
and Services
Employee Wellness
Social and Emotional
School Climate
Physical Environment
Health Services
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Table 1. Continued
WSCC component
Description
Counseling,
Psychological, and
Social Services
These prevention and intervention services support the mental, behavioral, and social-emotional health of students and
promote success in the learning process. Services include psychological, psychoeducational, and psychosocial assessments;
direct and indirect interventions to address psychological, academic, and social barriers to learning, such as individual or
group counseling and consultation; and referrals to school and community support services as needed. In addition,
systems-level assessment, prevention, intervention, and program design by school-employed mental health professionals
contribute to the mental and behavioral health of students as well as to the health of the school environment. These can be
done through resource identification and needs assessments, school-community-family collaboration, and ongoing
participation in school safety and crisis response efforts. In sddtion, school-employed professionals can provide skilled
consultation with other school staff and community resources and community providers. School-employed mental health
professionals ensure that services provided in school reinforce learning and help to align interventions provided by
community providers with the school environment. Professionals such as certified school counselors, school psychologists,
and school social workers provide these services.
Community groups, organizations, and local businesses create partnerships with schools, share resources, and volunteer to
support student learning, development, and health-related activities. The school, its students, and their families benefit when
leaders and staff at the district or school solicits and coordinates information, resources, and services available from
community-based organizations, businesses, cultural and civic organizations, social service agencies, faith-based
organizations, health clinics, colleges and universities, and other community groups. Schools, students, and their families can
contribute to the community through service-learning opportunities and by sharing school facilities with community
members (school-based community health centers and fitness facilities)
Families and school staff work together to support and improve the learning, development, and health of students. Family
engagement with schools is a shared responsibility of both school staff and families. School staffs are committed to making
families feel welcomed, engaging families in a variety of meaningful ways, and sustaining family engagement. Families are
committed to actively supporting their child’s learning and development. This relationship between school staff and families
cuts across and reinforces student health and learning in multiple settings—at home, in school, in out-of-school programs,
and in the community. Family engagement should be continuous across a child’s life and requires an ongoing commitment
as children mature into young adulthood.
Schools can create an environment that offers many opportunities for students to be physically active throughout the school
day. A comprehensive school physical activity program (CSPAP) is the national framework for physical education and youth
physical activity. A CSPAP reflects strong coordination across five components: physical education, physical activity during
school, physical activity before and after school, staff involvement, and family and community engagement. Physical
education serves as the foundation of a CSPAP and is an academic subject characterized by a planned, sequential K-12
curriculum (course of study) that is based on the national standards for physical education. Physical education provides
cognitive content and instruction designed to develop motor skills, knowledge, and behaviors for healthy active living,
physical fitness, sportsmanship, self-efficacy, and emotional intelligence. A well-designed physical education program
provides the opportunity for students to learn key concepts and practice critical skills needed to establish and maintain
physically active lifestyles throughout childhood, adolescence and into adulthood. Teachers should be certified or licensed,
and endorsed by the state to teach physical education.
Community
Involvement
Family Engagement
Physical Education and
Physical Activity
∗ Adapted from Ref. 14
meals that meet the health and nutrition needs of
students. School nutrition services and the nutrition environment provide a learning laboratory for
classroom health education. The intended outcome
of physical education is to help improve the physical activity levels of students and help them improve
their knowledge, skills, and confidence to enjoy a lifetime of healthy physical activity. School counselors,
psychologists, and social workers attend to students’
mental, emotional, and social health, either as individuals or in groups, or by addressing the whole school
environment. Employee wellness programs improve
productivity, decrease absenteeism, and reduce health
insurance costs by addressing the health needs of
school staff. In addition, these programs might help
school staff better serve as models of healthy living to
both students and parents. Each of these components
also tends to have devoted staff, at least parttime.
Some components might not be as readily identified
as contributing to school health. Community involvement benefits school health by sharing resources that
support student learning, development, and health
and creating opportunities for students to contribute to
their community. Family engagement happens when
families and schools work together to support the
health and academic achievement of students. Schools
or districts might have staff members who focus on
improving community involvement or family engagement (for example, parent engagement centers), but
they might not yet see the importance of working
with these groups to improve health beyond involvement in homework or classroom assignments. Facility
managers, site designers, and custodial staff might
not immediately recognize their work as contributing to a healthy and safe physical school environment.
Many others (other school staff, parents, students,
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and visitors) can play important roles in creating a
healthy and safe physical environment. The social and
emotional climate of a school is even more strongly
determined by the actions of the whole school community. In turn, how students experience the school
climate impacts their heath and academic success.
IMPLICATIONS FOR SCHOOL HEALTH
A Collaborative Approach to Learning and Health
Bringing together multiple components of the
whole school has the potential to create synergy
and lead to health and academic results that could
not be achieved otherwise. The WSCC model calls
for greater collaboration, alignment, and integration
to improve each child’s cognitive, physical, social,
and emotional development. Collaboration means
to work together or cooperate. Alignment takes
working together a step further, implying agreement
among people on a common cause, ensuring that
all components are working together toward the
same purpose. Integration is the highest level of
coordination—combining multiple components so
that they function as a single whole. It is the rare
school intervention or program that does not require
at least some degree of collaboration, but not all
need an integrated approach to be effective. Similarly,
although it is unlikely that all 10 WSCC components
will be engaged in every action, it is rare that an
intervention would not be improved by integrating
multiple components.
An integrated approach to learning and health
goes beyond the coordination of specific interventions
to the implementation of regular, ongoing, and
systematic processes. In a complex environment such
as a school, with 10 possible components to coordinate,
systematizing such a process might help maximize use
of component assets, facilitate a natural interaction
among components, and engage school, public health,
and community partners in achieving priority health
and academic outcomes. A systematic process might
also help overcome some of the common challenges
that arise in addressing the health needs of students as
part of a whole child approach to education.
A Systematic Process for Putting the Model
Into Action
This article adds to the WSCC model by describing
a systematic process districts and schools can use to
implement the WSCC model and improve health and
academic outcomes. The following 10-step process
is designed to help schools or districts implement
a systematic approach to integrating health and
education and minimize or overcome the challenges,
such as lack of readiness, personnel shortages,
insufficient resources, and competing priorities that
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often delay or halt plans for school health and
education improvement.
1. Form a committee of individuals who are interested
and passionate in improving health and academic
outcomes of students. Many districts and schools
have already established committees (such as a
school health advisory or action committee or a
school improvement committee) that could adopt
this process. Establishment of a committee should
include a clear statement about the authority
given to the committee and which decisions
will require approval from an administrator
or school board. When determining committee
membership, keep all 10 WSCC components in
mind. Some staff members are clearly associated
with specific WSCC components. Creativity may
be needed to identify individuals who can
represent the needs and interests of other
components that might not have assigned staff.
It is more important to identify dedicated,
passionate, and knowledgeable individuals who
can represent the interest of components as
related to the whole child, instead of focusing
only on officially appointed individuals. The
committee should also include other school staff,
especially a school administrator, and individuals
representing the interest of students, families,
and the community. These individuals should be
interested in and knowledgeable about improving
health and academic outcomes. The committee’s
voice can help advance the importance of
addressing health needs over other competing
priorities. Support from administrators is critical
to ensure the committee has the power to develop
and implement any action plan.
2. Conduct a needs assessment to determine the healthrisk and health-promoting behaviors that are prevalent
among students and how these behaviors are related
to academic achievement. A variety of sources and
tools can be used to identify the priority health
problems and health risk behaviors of students
in a district or school. The Youth Risk Behavior
Surveillance System (YRBSS) monitors 6 types
of health-risk behaviors that contribute to the
leading causes of death and disability among
youth and adults.15 Existing YRBSS data can be
used to highlight priority health risk behaviors
among middle and high school students. For
example, local data might show that students are
not meeting physical activity recommendations.
Students who are physically active tend to have
better grades and classroom behaviors.16 Many
county health departments have other data about
health problems and health risks experienced by
young people in their community or even in
neighborhoods that make up a school cluster. Staff
© 2015 The Authors. Journal of School Health published by Wiley Periodicals, Inc. on behalf of American School Health Association.
within the school or district might have access to
additional useful data. For example, the nutrition
services director has data on breakfast and
lunch meal counts, and might have information
concerning the specific foods students eat from
school meals. The school counselor and school
psychologist might have data from school climate
surveys.17
3. Identify the specific outcomes of greatest priority.
Ensuring that all committee members are focusing
on the same outcomes is critical for alignment and
a successfully coordinated approach. Committee
members should review the results of the needs
assessment, and identify priority health-related
areas that need improvement. It is desirable to
narrow the list of priorities to a manageable
number of health problems or risk behaviors. In
addition, it is important to set specific and realistic
outcome expectations with clear indicators that
will demonstrate what success will look like when
the outcomes are achieved.
4. Determine the relationship between the selected health
outcome and academic achievement. Given all the possible priorities that could be identified in Step 3,
it is practical for the committee to choose priorities that have both clear health and academic
outcomes. Significant research has been conducted showing the relationship between many
health behaviors and academic achievement.5,12,16
Selecting outcomes that address both interests will
increase participation and engagement by many
stakeholders across health, education, and community settings.
5. Identify promising or effective interventions that have
the greatest potential for impacting the chosen health
outcomes. Instead of reinventing the wheel, review
the existing literature to determine interventions
and programs that have been evaluated and have
demonstrated success at significantly impacting
target health problems or risk behaviors. For
example, the US Community Preventive Services Task Force (www.thecommunityguide.org)
conducts systematic reviews to determine which
program and policy interventions have been
proven effective while the Substance Abuse and
Mental Health Services Administration’s National
Registry of Evidence-based Programs and Practices is a searchable online database of mental health and substance abuse interventions
(nrepp.samhsa.gov/Index.aspx). Candidate interventions also should be reviewed in relation to
the capacity of the staff working in each relevant WSCC component. In addition to these
types of interventions, policies, processes, and
practices should be reviewed and modified to
help improve the chosen health and academic
outcomes.
6. Determine how staff and other committee members
will collaborate and align to maximize success in
achieving priority health and academic outcomes. After
identifying the specific outcome expectations,
and selecting interventions to be administered,
engage the key individuals representing or
working within the WSCC components who
will be involved in implementing interventions.
Keep in mind that not every intervention or
action will require the involvement of all 10
components. In addition, just because someone
sits on the committee does not mean that
they are necessarily the best representative of a
component to implement a plan. Others might
need to be involved depending on their abilities
and resources. Determining how interventions
or actions will be coordinated requires concrete
steps including establishing schedules, timelines,
milestones, and deliverables; establishing effective
communications; holding periodic meetings to
identify problems and effective solutions to those
problems; and reporting progress as a form of
accountability.
7. Invite community agencies and organizations that have
a mission or similar interest in addressing the identified
priority health and academic outcomes. Expand the
committee’s membership beyond school or district
staff to include neighborhood and community
members who can focus school and community
resources on achieving the identified priority
health and education outcomes. Volunteers or
public health agencies frequently have health
expertise and resources that can help districts or
schools successfully reach their goal. This step
also challenges community members to identify
strategies they can implement outside of the school
setting, thus reinforcing, or even improving, the
impact of school programs.
8. Create an action plan to impact the chosen health
outcome. Make plans concrete, with timelines and
all actions assigned to specific people such as
those responsible for implementing interventions,
completing committee tasks, and monitoring
progress in meeting expected outcomes.
9. Develop a plan to monitor the implementation and
outcomes of interventions. An action plan is only good
if people act on it, if it is implemented as intended,
and if there is a way to tell if it made a difference.
Districts and schools rarely have the resources
to conduct full-scale outcome evaluation, but
using interventions with evidence of effectiveness
minimizes the need for this type of evaluation.
Instead, districts and schools can determine how
they will use their evaluation findings and shape
their monitoring and evaluation plan around
these goals. The committee can collect and
analyze simple monitoring data to determine how,
Journal of School Health • November 2015, Vol. 85, No. 11 •
807
© 2015 The Authors. Journal of School Health published by Wiley Periodicals, Inc. on behalf of American School Health Association.
when, and where activities are conducted and
who participates in each activity.18 In terms of
outcomes, the committee can determine the level
of changes they wish to explore. Some might
decide to document changes observed in the
classroom, school environment, or provision of
services. Others might want to identify strengths
and weaknesses of their policies or practices and
make a plan for improvement.
10. Implement and monitor the implementation of the
action plan. During implementation, the committee should meet regularly to ensure that all tasks
are being completed on time and to troubleshoot
any problems that arise. Plans are not static and
might need to be changed during the implementation process. Evaluation should be a regular
part of committee meetings to monitor implementation and look for barriers and unexpected
difficulties. Collection of information throughout
the implementation process will help ensure that
the committee is able to understand the implementation of new interventions or practices.
Addressing Common Barriers
There are some common challenges in implementing any planning and implementation process in a
district or school.
•
Lack of clear leadership. It is essential to identify a
school health lead, coordinator, or champion who
is assigned to attend only to school health priorities
and is not distracted by competing priorities. For
example, a school could assign an existing school
health position (such as a school nurse or health
education teacher) to lead the steps for assessing
school health priorities, coordinate relevant school
health staff ideas, and convene a community/school
council. These responsibilities might be assigned
in place of athletic coaching or other school
improvement or instructional responsibilities.
• Lack of administrative support. In addition to identifying a school health lead, it is critical to secure administrative support for school health. For example,
work with the assistant superintendent or principal
to be an advocate for student health by publicly identifying student health outcomes as district or school
priorities.
• Lack of clear messages and communication channels
to increase understanding and buy-in from school staff
and the community. It is necessary to develop communication messages and identify communication
networks, such as staff meetings, bulletin boards,
and parent newsletters, to increase understanding
and build school staff and community support for
school health programs. Consistent and sustained
messages can influence support for and adoption of
808
•
Journal of School Health • November 2015, Vol. 85, No. 11
school health programs by the school staff and larger
community.
• Lack of funding resources. Districts and schools should
seek federal, state, and local funding sources for
school health as a natural part of school fund-raising
efforts. Educational funding is a constant challenge.
Districts and schools seek grant funding, community
support, and foundational funding to support the
costs of education. Districts and schools should
investigate and apply for health-related funding as
a routine part of their annual educational funding
process.
• Lack of engagement by community health partners.
It is important to build partnerships with the
local community health providers proactively and
continuously. It is easier to build support, seek
funding, and focus school plans on improving health
and education outcomes when there are community
health advocates. Local health providers (such as
physicians, health department staff, and mental and
social health clinicians) can advocate for improving
health outcomes for students and persuade others to
support school health efforts. Their investment and
interest in the health of their community makes
them likely to participate in the 10-step action
planning process.
The WSCC model presents a logical approach to
improving health and academic outcomes. The 10
action planning steps demonstrate a systematic and
achievable process to help a district or school focus
on priority health and academic outcomes. Attending
to some critical actions, such as identifying a leader,
garnering support, and securing funding can help
overcome many of the barriers that might arise in the
priority planning and implementation process. Schools
must attend to improving the whole child, including
addressing health needs, if they expect to have a
lasting impact on student learning. But, any model
and proposed processes and actions require testing and
evidence to confirm their value. District and schools
will need to test this model and put plans into action
to show that significant, substantial, and sustainable
health and academic outcomes can be achieved.
Human Subjects Approval Statement
The preparation of this paper required no original
research involving human subjects.
REFERENCES
1. ASCD, Centers for Disease Control and Prevention. Whole School,
Whole Community, Whole Child: A Collaborative Approach to Learning
and Health. Alexandria, VA: ASCD; 2014.
2. Allensworth DD, Kolbe LJ. The comprehensive school health
program: exploring an expanded concept. J Sch Health.
1987;57(19):409-412.
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3. Marx E, Wooley SF, Northrop D, eds. Health is Academic: A Guide
to Coordinated School Health Programs. New York, NY: Teachers
College Press; 1998.
4. Institute of Medicine. Schools and Health: Our Nation’s Investment.
Washington, DC: National Academy of Press; 1997:247-252.
5. Basch CE. Healthier students are better learners: a missing link
in school reforms to close the achievement gap. J Sch Health.
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6. Freudenberg N, Ruglis J. Reframing school dropout as a
public health issue. Prev Chronic Dis. 2007;4(4):1-11. Available at: http://www.cdc.gov/pcd/isues/2007/oct/07_0063.htm.
Accessed July 6, 2015.
7. Community Preventive Services Task Force. High school
completion programs recommended to improve health equity.
Am J Prev Med. 2015;48(5):609-612.
8. Carlson SA, Fulton JE, Lee SM, et al. Physical education
and academic achievement in elementary school: data from
the Early Childhood Longitudinal Study. Am J Public Health.
2008;98(4):721-727.
9. MacLellan D, Taylor J, Wood K. Food intake and academic performance among adolescents. Can J Diet Pract Res.
2008;69(3):141-144.
10. Spriggs AL, Halpern CT. Timing of sexual debut and initiation of
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associated with bullying behaviors in American adolescents. Int
J Adolesc Med Health. 2008;20(2):223-233.
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and Human Services; 2010.
Muenning P, Woolf SH. Health and economic benefits of
reducing the number of students per classroom in US primary
schools. Am J Public Health. 2007;97:2020-2027.
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Coordinated School Health. Available at: http://www.cdc.gov/
healthyyouth/cshp/components.htm. Accessed May 5, 2015.
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gov/healthyyouth/yrbs/index.htm. Accessed May 5, 2015.
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Academic Achievement. Atlanta, GA: US Department of Health
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healthyyouth/health_and_academics/pdf/health-academicachievement.pdf. Accessed July 6, 2015.
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Health Outcomes Associated with HIV, Other STD, and
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http://www.cdc.gov/healthyyouth/publications/pdf Published in 2014. Accessed in January 2016.
9
BUILDING A HEALTHIER FUTURE
THROUGH SCHOOL HEALTH PROGRAMS
Carolyn Fisher, EdD, Pete Hunt, MPH, Laura Kann, PhD,
Lloyd Kolbe, PhD, Beth Patterson, MEd, and Howell Wechsler, EdD
The Critical Need for Effective School
Health Programs
• Engaging
in behaviors that can result in violence
or unintentional injuries.
In the United States, 53 million young people attend
nearly 129,000 schools for about 6 hours of class­
room time each day for up to 13 of the most
formative years of their lives.1 More than 95% of
young people aged 5–17 years are enrolled in school.
Because schools are the only institutions that can
reach nearly all youth, they are in a unique position
to improve both the education and health status of
young people throughout the nation.
Three of these behaviors—tobacco use, unhealthy
eating, and inadequate physical activity—contribute
to chronic diseases such as cardiovascular disease,
cancer, and type 2 diabetes. These behaviors are
typically established during childhood and adoles­
cence, and recent trends have been alarming. Young
people are clearly at risk, as the following data show:
• Every
day, nearly 5,000 young people try their
first cigarette.2
• In 2001, only 32% of high school students
participated in daily physical education classes,
compared with 42% of students in 1991.3
• Seventy-nine percent of young people do not eat
the recommended five servings of fruits and
vegetables each day.4
• Each year, more than 900,000 adolescents become
pregnant,5,6 and about 3 million become infected
with a sexually transmitted disease.7
Supporting school health programs to improve the
health status of our nation's young people has never
been more important. Many of the health challenges
facing young people today are different from those of
past decades. Advances in medications and vaccines
have largely reduced the illness, disability, and death
that common infectious diseases once caused among
children. Today, the health of young people, and the
adults they will become, is critically linked to the
health-related behaviors they choose to adopt.
Certain behaviors that are often established during
youth contribute markedly to today's major causes
of death, such as heart disease, cancer, and injuries.
These behaviors include
•
•
•
•
•
Rigorous studies in the 1990s showed that health
education in schools can reduce the prevalence of
health-risk behaviors among young people.
• Studies
using a multiple-session school curriculum
based on the social influences model and delivered
to sixth and seventh grade students achieved
significant reductions in smoking among these
students through the ninth grade.8
• The prevalence of obesity decreased among girls
in grades 6–8 who participated in a school-based
intervention program.9
Using
tobacco.
Eating unhealthy foods.
Not being physically active.
Using alcohol and other drugs.
Engaging in sexual behaviors that can cause HIV
infection, other sexually transmitted diseases, and
unintended pregnancies.
9–2
BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS
• Middle/junior
high school students enrolled in the
school-based Life Skills Training Program were less
likely than other students to use tobacco, alcohol,
or marijuana, and these effects lasted through the
12th grade (www.lifeskillstraining.com).10
Healthy People 2010 Objectives Related to
Schools and Chronic Disease Prevention
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.
School health programs can play a critical role in
promoting healthy behaviors while enhancing
academic performance. In 1998, Congress noted the
opportunity our nation's schools offer when it urged
CDC to "expand its support of coordinated health
education programs in schools."
• Objective 07-02: Increase the proportion of
middle, junior high, and senior high schools that
provide school health education to prevent health
problems in the following areas: unintentional
injury; violence; suicide; tobacco use and
addiction; alcohol or other drug use; unintended
pregnancy, HIV/AIDS, and STD infection;
unhealthy dietary patterns; inadequate physical
activity; and environmental health.
• Objective 07-04: Increase the proportion of
elementary, middle, junior high, and senior high
schools that have a nurse-to-student ratio of at
least 1:750.
• Objective 15-31: Increase the proportion of
public and private schools that require use of
appropriate head, face, eye, and mouth protection
for students participating in school-sponsored
physical activities.
• Objective 19-15: Increase the proportion of
children and adolescents aged 6 to 19 years whose
intake of meals and snacks at schools contributes
proportionally to good overall dietary quality.
• Objective 21-13: Increase the proportion of
school-based health centers with an oral health
component.
• Objective 22-08: Increase the proportion of public
and private schools that require daily physical
education for all students.
• Objective 22-09: Increase the proportion of
adolescents who participate in daily school
physical education.
• Objective 22-10: Increase the proportion of
adolescents who spend at least 50% of school
physical education class time being physically active.
• Objective 22-12. Increase the proportion of public
and private schools that provide access to their
physical activity spaces and facilities for all persons
outside of normal school hours (that is, before and
Healthy People 2010
Healthy People 2010 outlines 467 national health
objectives, of which 107 are directed specifically
toward adolescents and young adults (i.e., 10- to
24-year-olds). Among these 107 objectives, 21 are
identified as "critical" on the basis of two criteria:
1) they involve critical health outcomes or behaviors
that contribute to them, and 2) state-level data
necessary to measure progress in meeting the
objective are available or soon will be.4
Healthy People 2010 Critical Objectives Related
to Chronic Disease Prevention Among
Adolescents and Young Adults
Among the 21 critical objectives for adolescents and
young adults, four relate directly to chronic disease
prevention.
• Objective 27-02: Reduce tobacco use by
adolescents.
• Objective 27-03: Reduce initiation of tobacco use
among children and adolescents.
• Objective 19-03: Reduce the proportion of children
and adolescents who are overweight or obese.
• Objective 22-07: Increase the proportion of
adolescents who engage in vigorous physical
activity that promotes cardiorespiratory fitness
3 or more days per week for 20 minutes
per occasion.
9–3
CHRONIC DISEASE PREVENTION AND CONTROL
after the school day, on weekends, and during
summer and other vacations).
• Objective 27-11: Increase smoke-free and
tobacco-free environments in schools, including
all school facilities, property, and vehicles, and at
all school events.
A coordinated school health program provides a
framework for school districts and schools to use in
organizing and managing school health initiatives. It
also provides an organizational framework for state
agencies to use in planning and coordinating 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.
Promising Practices for School Health Programs
This document describes promising practices that
states should consider when planning school-based
policies and programs to help young people avoid
behaviors that increase their risk for obesity and
chronic disease, especially tobacco use, unhealthy
eating, and inadequate physical activity. These
promising practices incorporate four key concepts.
1. Coordinate Multiple Components and Use
Multiple Strategies.
Modern school health programs integrate the
efforts and resources of education, health, and
social service agencies to provide a comprehen­
sive set of programs and services to promote
health and prevent chronic diseases and their
risk factors among young people. Such school
health programs systematically coordinate
the following eight components: 1) health
services; 2) health education; 3) efforts to
ensure healthy physical and social environ­
ments; 4) nutrition services; 5) physical
education and other physical activities;
6) counseling, psychological, and
social services; 7) health programs for
faculty and staff; and 8) collaborative
efforts of schools, families, and
communities to improve the health of
students, faculty, and staff (Figure 1).
Resources
• Building Business Support for
School Health Programs. 1999.
National Association of State
Boards of Education. Available
from www.nasbe.org/
HealthySchools.
2. Coordinate the Activities of Health and Education
Agencies and Other Organizations Working to Improve
the Health of Young People.
Health and education agencies share the common
goal of improving and protecting the health and
well-being of young people, so collaboration should
be encouraged at all levels. It is important to build a
Figure 1. A Coordinated School Health
Program (CSHP)
T
8
he
m
Co
en
pon
ts o f
a Coordinated Scho
ol H
eal
th
Pr
og
ra
m
Health
Services
Counseling,
Psychological
& Social
Services
Family/
Community
Involvement
Physical
Education
Health
Education
Health
Promotion
for Staff
Nutrition
Services
Healthy School
Environment
9–4
BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS
state-level structure that supports the implemen­
tation of a coordinated approach to school health.
Bringing together key resources, programs, and
decision makers within a supportive structure
demonstrates that school health programs are a
priority and models a collaborative structure for
those involved in implementing school health
programs at the local level. State health and edu­
cation agencies that do not have a school health
coordinator position should be encouraged to
establish one to facilitate communication and
coordination of programs among key players.
Resources
• Guidelines for School Health Programs to
Prevent Tobacco Use and Addiction. MMWR
1994;43(RR-2). Available at www.cdc.gov/
nccdphp/dash/guidelines.
• Guidelines for School and Community
Programs to Promote Lifelong Physical Activity
Among Young People. MMWR 1997;46
(RR-6). Available at www.cdc.gov/nccdphp/
dash/guidelines.
• Guidelines for School Health Programs to
Promote Lifelong Healthy Eating. CDC.
MMWR 1996;45(RR-9). Available at
www.cdc.gov/nccdphp/dash/guidelines.
3. Implement CDC's School Health Guidelines.
Developed after an exhaustive review of published
research and with input from academic experts and
national, federal, and voluntary organizations
interested in child and adolescent health, CDC's
school health guidelines offer specific recomenda­
tions to help states, districts, and schools implement
school health programs and policies that have been
found to be most effective in promoting healthy
behaviors among young people.
A number of tools have been developed that can
help schools implement the CDC school health
guidelines. These include the following:
programs; develop an action plan for improving
student health; and involve teachers, students,
parents and the community in promoting healthenhancing behaviors and better health.
• Fit, Healthy, and Ready to Learn: A School Health
Policy Guide. This policy guide from the National
Association of State Boards of Education provides
direction on establishing an overall policy frame­
work for school health programs and specific
school policies to promote physical activity and
healthy eating and discourage the use of tobacco.
The guide is designed for use by states, school
districts, and individual schools, both public
and private.
• Changing the Scene: A Guide to Local Action. This
kit from the U.S. Department of Agriculture
promotes discussion of healthy school nutrition
environments at the local, state, and national
levels. Tools within the kit will help school
administrators, teachers, parents, school foodservice professionals, and community and business
leaders to work together to support changes in the
school nutrition environment.
• CDC's School Health Index for Physical Activity,
Healthy Eating, and a Tobacco-Free Lifestyle: A
Self-Assessment and Planning Guide. This tool
enables schools to identify strengths and
weaknesses of health promotion policies and
4. Use a Program Planning Process to Achieve Health
Promotion Goals.
The exact nature of coordinated school health
programs depends on the unique needs of the school
CDC's school health guidelines emphasize multiple
strategies to prevent tobacco use, promote physical
activity and healthy eating, and reduce rates of
obesity among young people. The guidelines also
identify priorities for state decision makers to
consider. Recommendations address policy devel­
opment, curriculum development and selection,
instructional strategies, environmental changes,
direct interventions, professional development,
family and community involvement, program
evaluation, and linkages among components of a
coordinated school health program.
9–5
CHRONIC DISEASE PREVENTION AND CONTROL
population and on the resources available to the
school and community. Having a program planning
process in place is critical for program improvement
and long-range planning. This process, which should
involve all stakeholders, includes defining priorities
on the basis of a population's unique needs, deter­
mining what resources are available, developing a
strategic plan based on realistic goals and measurable
objectives, and establishing processes for determining
whether these goals and objectives are met and for
continuously improving the program.11
6. Implement health communications strategies to
inform decision makers and the public about the
role of school health programs in promoting
health and academic success among young people.
7. Develop a professional-development plan for school
officials and others responsible for establishing
coordinated school health programs and imple­
menting CDC's school health guidelines.
8. Establish a system for evaluating and continuously
improving state and local school health policies
and programs.
Resources
• Step by Step to Comprehensive School Health:
The Program Planning Guide. ETR Associates.
Available at www.etr.org/pub.
• Step by Step to Health-Promoting Schools. ETR
Associates. Available at www.etr.org/pub.
Priority 1. Monitor Critical Health-Related Behaviors
Among Young People and the Effectiveness of School
Policies and Programs in Promoting Health-Enhancing
Behaviors and Better Health.
Conduct a statewide assessment of critical health-risk behaviors
and the policies and programs designed to discourage them.
School health programs should be based on highquality data describing the health-risk behaviors of
young people and the characteristics of the policies
and programs already in place to address those
behaviors. The Council of State and Territorial
Epidemiologists has approved the following set of
adolescent health-risk indicators for inclusion in the
National Public Health Surveillance System:12
Eight Priority Actions for Improving the Health of
Young People
In the remainder of this chapter, we discuss the
following eight priority actions that states can take to
improve the health and academic outcomes of their
young people.
• Cigarette smoking.
• Smokeless tobacco use.
• Consumption of fewer than five servings of fruits
or vegetables daily.
• Lack of vigorous and moderate physical activity.
• At risk for being overweight.
• Overweight.
• Alcohol use.
• Binge drinking.
1. Monitor critical health-related behaviors among
young people and the effectiveness of school
policies and programs in promoting healthenhancing behaviors and better health.
2. Establish and maintain dedicated programmanagement and administrative-support systems
at the state level.
3. Build effective partnerships among state-level
governmental and nongovernmental agencies
and organizations.
4. Establish policies to help local schools effectively
implement coordinated school health programs
and CDC's school health guidelines.
5. Establish a technical-assistance and resource plan
that will provide local school districts with the
help they need to effectively implement CDC’s
school health guidelines.
To obtain continuous, high-quality, comparable data
for each indicator and other measures of chronic
disease risk factors, states can conduct a Youth Risk
Behavior Survey (YRBS) every
2 years among
th
th
representative samples of 9 through 12 grade
students. States can supplement the YRBS data with
data from the Youth Tobacco Survey (YTS) or other
9–6
BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS
surveys assessing relevant health-related behaviors
and their determinants among young people. States
conducting the YRBS, YTS, or other school-based
surveys can receive technical assistance from CDC in
selecting the sample and implementing the survey,
thus reducing the burden that multiple school-based
surveys can place on schools.
developed tools to help states plan and conduct these
important surveillance activities.
YRBS and School Health Education Profiles data can
be used to describe the extent and type of health-risk
behaviors among students, raise public awareness of
these behaviors, set program goals, develop health
education programs, monitor health education
policies and programs, support professional
development, and support health-related legislation.
To evaluate the effectiveness of school health policies
and programs, states can develop School Health
Education Profiles every 2 years by surveying
representative samples of middle/junior high and
senior high schools. These surveys provide
information on local education and health policies,
including tobacco-use-prevention policies, nutritionrelated policies, violence-prevention policies, health
education, and physical education and physical
activity programs.
States can also participate in national surveys that
measure health-risk behaviors among young people,
such as the National Youth Risk Behavior Survey, or
that measure school health policies and programs,
such as the School Health Policies and Programs
Study (SHPPS). These surveys provide national data
that can be compared with state-level data.
States should create a framework for coordinating
state-level data-gathering and data-analysis activities
and establish ongoing processes for selecting samples,
collecting data, interpreting results, writing reports
for state and local decision makers, and sharing data
with agencies and organizations interested in
improving the health of young people. Results from
the YRBS and the profiles can be disseminated to
key decision makers in both the public health and
education sectors, such as state and local health
officers, education administrators, school board
members, legislators, and parents. CDC, in
collaboration with state and local agencies, has
As an example of how state survey data can be used,
every 2 years the Montana Office of Public Instruc­
tion distributes the Montana School Health Education
Profile: The Status of Health Education in Montana
Schools to state leaders, parents, and others interested
in school health education. This document is used to
set policy and establish priorities for improving
health education programs. For more information,
contact the Montana Department of Education at
406-444-1963.
Funding Estimate: CDC provides technical assistance and support
to help states conduct the YRBS. CDC recommends that states
appropriate about $50,000 every 2 years to complete a state-level
YRBS.
Resources
• Youth Risk Behavior Surveillance System (YRBSS): Information about the YRBSS is available at
www.cdc.gov/yrbs.
• School Health Policies and Programs Study (SHPPS): Information about SHPPS and sample questionnaires
are available at www.cdc.gov/shpps.
• Handbook for Conducting Youth Risk Behavior Surveys (YRBS). Centers for Disease Control and
Prevention, 2000. Contact CDC at 770-488-6170.
• PC Sample/PC School: Survey TA Sampling Software. Centers for Disease Control and Prevention, 2000.
Contact CDC at 770-488-6170.
• Handbook for Developing School Health Education Profiles (SHEP). Centers for Disease Control and
Prevention, 2000. Contact CDC at 770-488-6170.
9–7
CHRONIC DISEASE PREVENTION AND CONTROL
Support local-level assessments of school health policies
and programs.
States can support local assessments of school health
policies and programs to determine their strengths
and weaknesses and to identify the resources needed
to successfully implement priority school health
guidelines. The information can be useful to local
school and community leaders in developing a stra­
tegic plan for improving the health and education
of youth.
Priority 2. Establish and Maintain Dedicated ProgramManagement and Administrative-Support Systems at the
State Level.
State agencies collectively build the support systems
to plan, implement, and evaluate fully functioning
coordinated school health programs. By coordinating
the allocation of new resources and using existing
resources more efficiently, state agencies can help
schools to meet the health needs of students and
their families. To build a state-level infrastructure
that supports coordinated school health programs,
health and education agencies must work with other
relevant state agencies such as social services, mental
health, and environmental health as well as with
nongovernmental organizations in the state. The
heads of state government agencies must commit
to supporting the process of infrastructure
development. These leaders should focus on the
following when developing infrastructure.
CDC's School Health Index for Physical Activity,
Healthy Eating, and a Tobacco-Free Lifestyle: A SelfAssessment and Planning Guide can help school
officials assess the strengths and weaknesses of the
eight components of their school health program
and of other policies and programs related to
chronic disease prevention, establish priorities for
improving programs, and monitor changes in
processes and outcomes.
• Personnel and Organizational Involvement:
State leaders of school health programs should
identify the relevant state agencies and the
personnel responsible for implementing school
health-related policies and programs and should
help to coordinate the delivery and use of
resources for multi-agency programs related to
school health.
• Authorization and Funding: State leaders should
also 1) identify laws, directives, policies, and
mandates that authorize school health programs
and promote the implementation of school health
guidelines at the local level and suggest new ones
that may be needed; 2) obtain the funding needed
to support school health programs and ensure
that the funding can be used in flexible ways; and
3) establish interagency agreements to facilitate
collaborative program planning and to provide
resources for local school health programs.
The search for funding sources can be compli­
cated because coordinated school health programs
cover many content areas and health problems.
In addition, funding sources and application
protocols change substantially from year to year.
Resources
• School Health Index for Physical Activity,
Healthy Eating, and a Tobacco-Free Lifestyle: A
Self-Assessment and Planning Guide. Atlanta:
U.S. Department of Health and Human
Services, Centers for Disease Control and
Prevention, 2000. Available at www.cdc.gov/
nccdphp/dash/SHI/index.htm.
State health and education agencies should also
provide technical assistance and resources to support
local-level assessment and assist schools in analyzing
and using assessment results gathered through the
School Health Index or other instruments.
Funding Estimate: While there are no state estimates for statewide
use of the School Health Index, CDC estimates that the per-school
cost of administering the Index should be minimal. The personnel
costs for collecting and analyzing data and developing assessment
reports could be borne by the school or school district.
9–8
BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS
CDC's Healthy Youth Funding Database provides
access to an array of current information on
federal, state, and private-sector funding. The
easy-to-use database offers examples of how states
use federal funds to support adolescent and school
health programs.
the skills they need to effectively organize and
manage school health programs. CDC, in collab­
oration with state agency staff in states funded for
coordinated school health programs, has developed
the Coordinated School Health Program Infrastructure
Development: Process Evaluation Manual as a tool to
help states build the necessary support for coordi­
nated school health programs and institutionalize
this support at the state and local levels.
Resources
• Healthy Youth Funding Database. CDC.
Available at www.cdc.gov/nccdphp/shpfp/
index.asp.
Resources
• Coordinated School Health Program
Infrastructure Development: Process Evaluation
Manual. Atlanta: U.S. Department of Health
and Human Services, Centers for Disease
Control and Prevention, 1997. Available at
www.cdc.gov/nccdphp/dash/publications/
index.htm.
• Technical Assistance and Resources: State
agency leaders should develop processes for
identifying, developing, and disseminating
resources for supporting coordinated school health
programs and implementing CDC's school health
guidelines at the school and district levels. They
should identify existing human, data, techno­
logical, and material resources that could be used
to enhance school health programs; obtain
additional resources if they are needed; coordinate
the use of professional development resources to
improve statewide training networks; and
coordinate the support provided by external
partners, including institutions of higher
education and philanthropic agencies.
• Communications and Linkages: State leaders
must establish and strengthen linkages that will
1) build the state's capacity to assist in the local
implementation of school health guidelines and
coordinated school health programs, 2) strengthen
collaborations among relevant partners, and
3) facilitate advocacy for school health programs.
They should also establish communications net­
works to promote broad-based decision-making,
to ensure that state-level policies and programs are
adopted at the local level, and to promote the
effective use of local school and district resources
to enhance school health programs.
State agencies in Wisconsin and Rhode Island have
completed assessments of their organizational
capacity and leadership for school health and are
using the results to strengthen their infrastructure
for school health. California created a consensus
document, Blueprint for Action, to set directions for
state school health programs.
In collaboration with CDC and the National
Professional Development Consortium for School
Health, eight school health managers from state
health and education agencies drafted Responsibilities
and Competencies for Managers of School Health
Programs. The draft document identifies five key
areas of responsibility for such managers (manage­
ment; policy; curriculum, instruction, and student
assessment; professional development and technical
assistance; and surveillance) and four types of com­
petencies that these managers need to be successful
(competency in needs assessment, planning, and
collaboration; in marketing, information dis­
semination, and communications; in program
implementation; and in monitoring and evaluation).
Reducing health-risk behaviors among young people
is a complex effort that requires cooperation and
collaboration among many partners at the state,
In addition to focusing on these important
organizational supports, health and education leaders
must help state school health-related staff develop
9–9
CHRONIC DISEASE PREVENTION AND CONTROL
Similarly, state departments of education can foster
the intra-agency coordination of programs such as
Safe and Drug-Free Schools, health education,
physical education, food services, health services, and
counseling and psychological services. In short, state
departments of both health and education should
strive to build structures that foster intra-agency
collaboration and planning. Such internal partner­
ships allow agencies to use resources more efficiently,
improve communication among staff involved with
complimentary programs, and, as a result, strengthen
the programs themselves.
Resources
• Final Report: Comprehensive School Health
Program Infrastructure Needs Assessment.
Providence: Rhode Island Department of
Education and Department of Health, 1996.
Available at www.health.state.ri.us/disprev/
hshk/home.htm.
• Supporting School Health: An Initial Assessment
of Infrastructure for Comprehensive School
Health, Student Services, Prevention and
Wellness Programs. Phase One, DPI Status and
Dynamics. Madison, WI: Wisconsin
Department of Public Instruction, 1995.
• Building Infrastructure for Coordinated School
Health: California’s Blueprint. Sacramento:
California Department of Education, 2000.
Available at www.cde.ca.gov.
Resources
• Schools and Health: Our Nation’s Investment.
Institute of Medicine. Washington, DC:
National Academy of Science Press, 1997;
247-52.
• Coordinated School Health Program
Infrastructure: Process Evaluation Manual.
Atlanta: U.S. Department of Health and
Human Services, Centers for Disease Control
and Prevention, 1997. Available at
www.cdc.gov/nccdphp/dash/publications/
index.htm.
regional, and local levels. At the state level, structures
for intra-agency, interagency, and community
partnerships must be developed.
Funding Estimate: CDC recommends that states allocate an average
of $200,000 per year to support key positions in the health and
education agencies.
Priority 3. Build Effective Partnerships Among StateLevel Governmental and Nongovernmental Agencies
and Organizations.
Reducing health-risk behaviors among young people
is a complex effort that requires cooperation and
collaboration among many partners at the state,
regional, and local levels. At the state level, structures
for intra-agency, interagency, and community
partnerships must be developed.
Funding Estimate: Intra-agency coordinated planning does not
necessitate a separate allocation; it should naturally occur as a part
of effective program planning and implementation.
Promote collaboration among state agencies.
To reduce duplication of effort and maximize the use
of limited state resources, leaders of state agencies
should establish a school health interagency program
committee. This committee's primary role would be
to coordinate the management and implementation
of multiple school health-related programs across
agencies. State agencies can develop agreements
(e.g., memoranda of understanding) that include
jointly prepared plans for coordinating administra­
tive responsibilities and activities among agencies.13
The interagency collaboration can be coordinated
and jointly led by school health leaders from the
state education and health agencies. Other members
Build coordination and planning within state agencies.
State departments of health can foster the intra­
agency coordination of programs that address the
needs of young people (e.g., maternal and child
health, chronic disease, cardiovascular health, physi­
cal activity, nutrition, tobacco control) to ensure
that these programs, which are often delivered in
both community and school settings, are connected
and efficient.
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BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS
of this committee might include representatives from
state agencies that address social services, justice,
mental health, agriculture, substance abuse, parks
and recreation, labor, economic development, and
transportation, as well as representatives from the
governor's office.
The Oregon Coordinated School Health Initiative is
steered by the Blueprint Working Group, which is
responsible for guiding the development of the
Coordinated School Health Blueprint for Action.
This 5-year strategic plan will outline the priority
state and local actions to
• Build
infrastructure for coordinated school
health programs.
• Strengthen the components of coordinated
school health programs.
• Address key health-risk behaviors among
children and adolescents.
Such an interagency committee should not be
limited to agency leaders. It should include the
program staff who are responsible for promoting
the implementation of school health guidelines and
strengthening the delivery of services through local
school health programs. The committee may take
on a variety of roles and responsibilities, including
the following:14
The Blueprint Working Group is made up of state
agency program coordinators responsible for the
various components of a coordinated school health
program and health-related risk factors among
children and adolescents. Members of the working
group from the Oregon Department of Education
include the coordinated school health program
director, an HIV prevention specialist, the director of
federal programs, a physical education specialist, a
child nutrition programs specialist, the juvenile
corrections director, a school counseling specialist,
and a safe and drug-free schools specialist. Members
from the the Oregon Department of Health include
the coordinated school health program director, the
adolescent health manager, Tobacco Program staff,
Cardiovascular Health staff, School-Based Health
Program staff, Immunization Program staff, the
YRBS coordinator, Environmental Health staff,
Family Planning/Teen Pregnancy Prevention staff,
and Asthma Program staff. The working group also
includes representatives from the Oregon Office of
Alcohol and Drug Abuse Program, including staff
from the Governor's Council on Alcohol Tobacco
and Other Drugs, and the Youth Development
Director from the Oregon Commission on Children
and Families.
• Improve
communication, planning, coordination,
and collaboration among state agencies engaged
in ongoing activities relevant to the health and
academic achievement of young people.
• Identify needs and strategies for improving state
leadership of school health programs.
• Identify and implement state policies and pro­
grams to facilitate quality school health programs.
• Coordinate federal, state, and philanthropic
funding for school health programs awarded to
state agencies.
• Help identify successful school health programs
and disseminate information about them to school
health officials throughout the state.
• Help coordinate health programs in private,
voluntary, and post-secondary institutions.
• Prepare reports and make policy recommendations
to relevant state officials.
Strong working relationships between state agencies
are evident in Tennessee and Oregon. In Tennessee,
for example, the state commissioners of education
and health issued a joint statement on school health
that resulted in the formation of a working group
with members from each agency. As a result of this
group's efforts, the agencies executed a memorandum
of agreement that established a permanent working
relationship between the two agencies and addressed
all components of the Tennessee Coordinated School
Health Program.
Funding Estimate: CDC recommends that states allocate
approximately $5,000 per year to support state interagency program
committee activities, including monthly meetings and the production
and dissemination of materials and documents to the legislature,
government agencies, schools, and others.
9–11
CHRONIC DISEASE PREVENTION AND CONTROL
Establish a state school health coordinating council.
To expand access to school health resources and
coordinate efforts of the larger community interested
in improving the health of students, states can
establish a school health coordinating council.10
This council can include representatives from the
interagency program committee; health and
education leadership organizations such as the state
school boards association; nongovernmental
organizations such as the American Cancer Society;
and associations representing health education,
physical education, health care providers, post­
secondary institutions, businesses, and community
health coalitions, as well as parents and students.
comprehensive school health initiative, Healthy
Schools! Healthy Kids! The council comprises
approximately 150 members representing various
constituency groups concerned with changing health
priorities, including representatives from state
government, the state chapter of the American
Academy of Pediatrics, hospitals, schools, com­
munity groups, colleges and universities, and various
heart, lung, and cancer associations. The council
developed Rhode Island's Healthy Schools! Healthy
Kids! Plan for Comprehensive School Health and
continues to implement the recommendations in the
plan and to help identify new and emerging health
priorities in school health.
Funding Estimate: CDC recommends that states allocate
approximately $10,000–$25,000 per year to support a state school
health coordinating council. These funds can support travel of nonstate agency members, meeting facilities for four meetings per year,
and the production of materials and documents for dissemination to
the legislature, government agencies, schools, and others. Funds for
the council could be allocated separately or could be included as a
line item in a program budget to specifically address chronic disease
risk reduction.
States should establish policies and guidelines that
will clearly define the roles and responsibilities of the
school health coordinating council in establishing
priorities for state school health programs. These
roles and responsibilities could include the following:
• Developing statewide consensus on key issues
related to school health programs and policies and
communicating these issues to the interagency
program committee.
• Showcasing effective and innovative coordinated
school health programs for multiple audiences,
including the state legislature.
• Conveying a clear vision of the role of school
health programs in improving the health and
academic achievement of students. Councils
might convey this vision by developing consensus
statements about the correlations between
participation in such programs and academic
success, by identifying and reducing the barriers
to collaboration among state organizations
concerned with the health and well-being of
children and adolescents, or by integrating
programs across agencies and organizations.
• Proposing appropriate state policies and legislation
and helping school districts and schools implement
the school health guidelines by disseminating
resources such as the School Health Index.
Priority 4. Establish Policies to Help Local Schools
Effectively Implement Coordinated School Health
Programs and CDC's School Health Guidelines.
States use laws, policy statements, and administrative
regulations to articulate their expectations and
recommendations for school health programs and
the important role that schools have in improving
the health of young people.14 State agency leaders can
establish policies to support local implementation of
the school health guidelines and programs. In
addition, state education and health agencies can
provide model implementation policies to local
school districts. This option is especially important
in states that have minimal legislative mandates for
school health. Model policies should be developed in
cooperation with the state's board of education and
association of school boards.
The National Association of State Boards of
Education (NASBE), in cooperation with the
National School Boards Association (NSBA), has
developed Fit, Healthy, and Ready to Learn, a school
health policy guide that translates CDC's school
The Rhode Island School Health Advisory Council
was formed as a primary partner in the state's
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BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS
law enforcement officers, media representatives, and
university faculty members—with the school district.
Virginia and Texas require districts to have school
health councils.
Resources
• Fit, Healthy, and Ready to Learn: A School
Health Policy Guide. National Association of
State Boards of Education. Washington, DC:
NASBE, 1999. Available at www.nasbe.org/
HealthySchools/nasbepubs.mgi.
• Changing the Scene, Improving the School
Nutrition Environment: A Guide to Local
Action. U.S. Department of Agriculture, Food
and Nutrition Service, 2000. Available at
www.fns.usda.gov/tn/Healthy/changing.html.
The size of a superintendent's staff depends on the
size and the resources of the district. A district may
or may not have school health program coordinators
who provide guidance and technical assistance to
school personnel. If they are present, such staff
members are natural points of contact for outside
professionals who want to work with schools.
health guidelines into model policy language.15
This document can help guide policy development
at the state, district, and school levels. It also con­
tains a wealth of information that can guide state
health leaders through the process of creating
educational policy.
Resources
• Improving School Health: A Guide to the Role of
the School Health Coordinator. Atlanta:
American Cancer Society, 1999. Available at
www.schoolhealth/info.
• Improving School Health: A Guide to School
Health Councils. Atlanta: American Cancer
Society, 1998. Available at www.schoolhealth/
info.
• Promoting Healthy Youth, Schools, and
Communities: A Guide to Community-School
Health Advisory Councils. Des Moines: Iowa
Department of Public Health, 1999. Available
at www.idph.state.ia.us/fch/fam_serv/
advisory.htm.
State school health policies typically are enacted or
adopted by either the state legislature, the state board
of education, or state commissions. Some regulations
that have the force of policy can be adopted by the
state education agency, which typically is also
responsible for implementing state school health
policies. The state health department can provide
data and testimony to help guide the development of
state school health policies. Following are some of
the issues that these state-level policies can address.
Instructional delivery and curricula content.
State education agencies and local school districts
may use the National Health Education Standards,
which are based on health education theory and
practice, to establish curriculum frameworks and
standards. These standards provide a framework for
decisions about which lessons, strategies, activities,
and types of assessment to include in a health
education curriculum. Health education curricula
based on the national standards can foster universal
health literacy, which the Joint Committee on
National Health Education Standards defines as the
ability to obtain, interpret, and understand basic
health information and services and to use such
information and services to improve one's health.
The formation of school health councils and placement of school
health coordinators at the district level.
Some school boards delegate oversight authority on
specified health-related issues to a school health
coordinating council that includes parents and
community representatives. This council might
operate as a standing committee of the board or as a
distinct body. It might simply be an advisory body or
might have authority to enhance program coordi­
nation among staff members working in the various
school health components. When such a council is
active and has real influence, it is a natural forum for
involving outside professionals—such as physicians,
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CHRONIC DISEASE PREVENTION AND CONTROL
education. These standards can serve as the basis for
local school health education and physical education
programs and the development of performance
standards for teachers. Many states have developed
student performance standards that are either based
on or aligned with national health- and physicaleducation standards.
Resources
• National Health Education Standards:
Achieving Health Literacy. Joint Committee on
National Health Education Standards.
Atlanta: American Cancer Society, 1995.
Available at www.aahperd.org/aahe/
natl_health_education_standards.html.
• Moving into the Future: National Standards for
Physical Education. National Association for
Sports and Physical Education. Washington,
DC : NASPE, 1995. Available at
www.aahperd.org/naspe/publications­
nationalstandards.html.
Specifications for a healthy school nutrition environment.
State boards of education can adopt policies that
limit the number of times that students have access
to food and beverages in vending machines at school
or that set specific nutritional quality standards for
the types of food and beverages available on campus,
including those in vending machines. In West
Virginia, the state board of education adopted a
nutrition policy for the types of foods available in
school vending machines that is one of the strongest
in the nation.
Resources
• School Health: Findings from Evaluated
Programs. 2nd ed. U.S. Department of
Health and Human Services, Office of
Disease Prevention and Health Promotion.
Washington, DC: DHHS, 1998.
• Safe and Drug-Free Schools Program. Principles
of Effectiveness. U.S. Department of
Education. Federal Register. Vol. 63, No.
104, 1998:29902–6. June 1, 1998. Available
at www.ed.gov/legislation/FedRegister/
announcements/1998-2.
• Exemplary and Promising Safe, Disciplined
and Drug-Free Schools Programs. U.S.
Department of Education, Office of Special
Educational Research and Improvement and
Office of Reform Assistance and Dissemi­
nation. Washington, DC: DoE, 2001.
• Health Framework for California Public
Schools Kindergarten Through Grade Twelve.
California Department of Education.
Sacramento: Calif. DoE, 1994.
Tobacco-free schools.
A tobacco-free environment, as defined by CDC,
means tobacco use is prohibited on school property,
including buildings, grounds, and vehicles, and at
school-sponsored events on and off school property.
This rule applies to students, staff members, and
visitors. Policies that ensure a tobacco-free environ­
ment can be adopted at the school, district, or state
level. At the state level, these policies are generally
enacted as law by the state legislature, but some
states have empowered their state boards of educa­
tion with the authority to mandate policies that
affect districts and schools. States with tobacco-free
school policies include Alabama, Arizona, Arkansas,
California, Colorado, Hawaii, Mississippi, New
Mexico, New York, Ohio, Texas, Utah, Washington,
and West Virginia.
Procedures for monitoring and enforcing tobaccofree schools policy can also be established at the
local or state level. For example, a state department
of education may require districts to report tobaccouse violations; a local school board might require a
progressive discipline plan for student policy
violations that begins with an educational
Student and staff performance standards.
State boards of education, state school boards
associations, and public health boards can set
learning standards for health education and physical
9–14
BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS
Appropriations to fund school health programs.
States can enact legislation that establishes
appropriations to support
Resources
• Fit, Healthy, and Ready to Learn: A School
Health Policy Guide. National Association of
State Boards of Education. Washington, DC:
NASBE, 1999. Available at www.nasbe.org/
HealthySchools/fithealthy.mgi.
• Creating and Maintaining a Tobacco-Free School
Policy. Partnership for a Tobacco-Free Maine,
Department of Human Services. Augusta, ME:
2000. Available at www.tobaccofreemaine.org.
• Tobacco-Free School Policy Guide. Available from
the Office of Public Instruction, P.O. Box
202501, Helena, MT 59620-2501.
• Guidelines for Implementation of West Virginia
Board of Education Policy 2422.5A: Tobacco
Control. Available from the West Virginia
Department of Education, 1900 Kanawaha
Blvd. East, Charleston, WV 25305-0330.
• Hiring
school health coordinators, physical educa­
tion teachers, health education teachers, school
counselors, or school nurses in all school districts.
• Assessing local school health standards, policies,
and programs.
• Providing professional development for school
staff responsible for delivering school health pro­
grams and implementing school health guidelines.
• Ensuring that young people have access to
facilities that promote physical activity.
Funding Estimate: Although the cost of developing and enacting
state-level policies will be minimal, the implementation of these
policies may require additional appropriations for materials and
resource development or professional development specific to a new
program priority. In these cases, funds can be included in program
costs. Some policies might require additional funding to ensure locallevel implementation. For example, state appropriations are necessary
to support school health programs at the local level. State agencies
need to consider these costs in addition to specific state program
costs. CDC recommends that states allocate sufficient funds to
support a school health council and school health coordinator and
to implement a school health program in all school districts.
intervention. The National Association of State
Boards of Education and a number of state and
local education and health agencies have produced
guidelines for implementing tobacco-free school
policies.
Priority 5. Establish a Technical-Assistance and Resource
Plan that Will Provide Local School Districts with the
Help They Need to Effectively Implement School Health
Guidelines.
To advance state policies and support the local
implementation of priority school health policies
and programs that are consistent with the school
health guidelines, state agencies can develop and
implement a plan for providing technical assistance
and resources to school districts and schools. State
education and health agencies must develop the
capacity to help schools improve their school health
programs and provide school personnel with the
tools they need to help reduce tobacco use, increase
physical activity, and support healthy eating patterns
among students. State health and education agency
leaders can
Quality professional development of school health staff.
State boards of education can set professional devel­
opment requirements for school health program staff
and other personnel who implement health programs
in schools. For example, Maine decided to focus on
middle school students as part of its efforts to reduce
tobacco addiction rates among teens and young
adults. All of the state's middle school teachers were
offered professional development in Life Skills
Training, a program to help teens develop healthy
personal and social skills. Since the program began in
1997, smoking among Maine high school students
has dropped more than 20%. Increases in the state
excise tax and new community-based programs also
contributed to this decrease. (For more information
about the importance of professional development,
see Priority 7.)
• Establish criteria to help local schools develop,
assess, and select effective curricula; institute
9–15
CHRONIC DISEASE PREVENTION AND CONTROL
processes for identifying and reviewing potential
programs based on these established criteria; and
develop strategies for disseminating information
about selected programs to teachers and
community members.
• Develop and disseminate guidelines and resources
to assist school districts in establishing school
health councils.
• Identify and promote the use of resources for
developing school health policy and for planning
and assessing school health programs (e.g., CDC's
School Health Index; NASBE's Fit, Healthy, and
Ready to Learn; and USDA's Changing the Scene)
and make these resources available to local school
districts. For example, in Georgia, the DeKalb
County Board of Education and Board of Health
have collaborated to promote the use of the School
Health Index in DeKalb's elementary schools. In
the 2001-2002 school year, 17 schools completed
the index, including the action plans, and
8 schools received funding from a variety of
Board of Health programs. Funded activities
include the following:
• Hiring certified physical education teachers
for the first time.
• Developing walking clubs.
• Establishing wellness programs for school
staff members.
• Purchasing exercise equipment for students
to use.
• Developing fitness stations on the school
campus for use by students, staff members,
and the community.
• Providing professional development for
teachers.
• Offering healthier choices in the school
vending machines.
• Identify community-resource personnel and
programs that complement school health policies
and make these available to local school districts
to foster community-school partnerships.
Resources
• Moving into the Future: National Standards
for Physical Education. National Association
for Sports and Physical Education.
Washington, DC: NASPE, 1995. Available
at www.aahperd.org/naspe/publications­
nationalstandards.html.
• National Health Education Standards:
Achieving Health Literacy. Joint Committee
on National Health Education Standards.
Atlanta: American Cancer Society, 1995.
Available at www.aahperlth_education_
standards.htm.
• Keys to Excellence: Standards of Practice for
Nutrition Integrity. American School Food
Service Association. Alexandria, VA:
ASFSA, 1995. Available at www.asfsa.org.
(Search “Keys to Excellence.”)
• Scope and Standards for Professional School
Nursing Practice. National Association of
School Nurses, Inc. and American Nurses
Association. American Nurses Publishing.
Washington, DC, 2001. Available at
www.nasn.org and at www/ana.org.
Resources
• State of Maine Guidelines for Coordinating
School Health Programs. Maine Department of
Education. Available at www.mainecshp.com.
• Identify
national standards and guidelines for
health education, physical education, school
nutrition programs, and school health services
and convey this information to local school
districts to facilitate effective policy and pro­
gram implementation.
• Establish technical-assistance communication
networks (e.g., e-mail networks) or refer school
health staff to existing national technicalassistance communication networks. For example,
the Maine Department of Education, through its
9–16
BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS
Maine's Learning Results, has developed a
technical-assistance plan to strengthen state and
local efforts to improve student learning, define
professional development needs, update local
curricula and instructional practices, and assess
student achievement. It also provided additional
resources to improve school health programs
through its publications, communications
networks, and technical assistance.
• Identify a contact or lead person in every school
to receive regular school health communications
and resources.
• Identify appropriate media campaign materials
and resources that can help local health agencies
and school districts promote positive health
messages and programs for youth.
State health and education agencies can establish
frameworks for allocating funds to support local
school health policies and programs that are
consistent with the intent of state policies and
appropriations. For example, in response to legis­
lation that appropriated health protection funds to
the Massachusetts Department of Education, the
agency developed specific assurance documents that
established school health councils and coordinators
in the districts that received these funds. The edu­
cation agency also provided technical assistance to
help local coordinators implement a comprehensive,
interdisciplinary Pre-K–12 health education and
human services program.
Resources
• Health Protection Fund. Massachusetts
Department of Education. Available at
www.doe.mass.edu. (Search “Health
Protection Fund.”)
Resources
• CDC’s Youth Media Campaign. Available at
www.verbnow.com.
• Respond
to requests for technical assistance and
information from local school health staff or
strengthen regional technical-assistance systems to
support local needs.
• Communicate school health-related findings from
the Community Guide to Preventive Services, which
features systematic reviews of published studies
conducted by the Task Force on Community
Preventive Services in coordination with a broad
team of experts, including those from CDC. In
one such review, the Task Force found that physi­
cal education classes are effective in improving
both physical activity levels and physical fitness
among school-age children. On the basis of these
findings, the Task Force issued a strong recom­
mendation to implement programs that increase
the amount of time that students spend in schoolbased physical education classes.
Funding Estimate: Funding for this priority provides materials and
tools necessary to accomplish program priorities. Depending on the
program, costs can vary. CDC recommends that approximately
$120,000 per year be allocated to support personnel, technicalassistance delivery, and resource development to implement school
health guidelines.
Priority 6. Implement Health Communications Strategies
to Inform Decision Makers and the Public About the Role
of School Health Programs in Promoting Health and
Academic Success Among Young People.
State agencies need to build support at both the state
and local levels for school-based programs to reduce
tobacco use, increase physical activity, and improve
eating behaviors among students. As an important
part of this effort, state health and education agen­
cies can develop and implement a school health
communications plan to promote the value of school
health programs among legislative leaders, state
government policy makers (including health and
education leaders), local school leaders, business
leaders, parents, students, and other community
members. Such a plan should foster communication
among state-level partners working to improve
Resources
• Community Guide to Preventive Services.
Available at www.thecommunityguide.org.
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CHRONIC DISEASE PREVENTION AND CONTROL
Priority 7. Develop a Professional Development Plan for
School Officials and Others Responsible for Establishing
Coordinated School Health Programs and Implementing
CDC's School Health Guidelines.
Professional development is critical to the effective
implementation of the school health guidelines and
coordinated school health programs.13 Any state plan
for reducing the risk for chronic disease among
young people should include a comprehensive plan
for teaching the skills that state and local decision
makers, school staff, parents, and community mem­
bers will need to support and implement a coordi­
nated school health program. This development plan
should address the specific training needs of the
various target groups and should be informed by
literature from the field of professional development
and training. States can provide or support profes­
sional development training in a variety of ways:
school health programs and increase the flow of
information and resources between the state and
local levels.
Resources
• Building Business Support for School Health
Programs. National Association of State
Boards of Education, 1999. Available at
www.nasbe.org/Educational_Issues/
Safe_Healthy.html.
• School Health Starter Kit: For Motivated
People Who Want to Get Others Involved.
Washington, DC: Council of Chief State
School Officers, 1999. Available at
www.publications.ccsso.org.
For example, the Oregon Department of Education
formed an external communications work group to
develop and implement an awareness campaign to
promote coordinated school health programs among
local decision makers and gatekeepers (e.g., school
board members, school administrators, county
commissioners). The campaign has stressed the links
between students' educational outcomes and their
physical, social, and emotional health and the critical
role that school health programs can play in
improving these outcomes. This work group includes
representatives from a wide variety of state partners
interested in school health, including the Oregon
Association for Health, Physical Education,
Recreation and Dance; the Oregon School Health
Education Coalition; the Oregon Dairy Council; the
Oregon Partnership (alcohol-use prevention); the
Northwest affiliate of the American Cancer Society;
the Oregon School Nurses Association; and Children
First for Oregon (a Kids Count affiliate). As a result
of the work group's efforts, in many districts, school
health councils have been formed to plan the
implementation of school health programs.
• Through a cadre of trainers who can provide and
model interactive professional development and
who are themselves provided with ongoing
support, training, and feedback.
• Through multiple delivery systems, such as
scheduled workshops, materials centers, inter­
active Web sites, and district mentoring programs.
• By providing funds for professional-development
events and materials.
• By providing support staff to manage the logistics
of training.
• Through marketing strategies to create awareness
of and encourage participation in professional
development and training.
Resources
• Strategies for Professional Development in
Cooperative Agreements with State Education
Agencies, Local Education Agencies, and
National Non-Governmental Organizations.
Available at www.cdc.gov/nccdphp/dash.
• Assumptions about staff development based
on research and best practice. Wood FH,
Thompson SR. Journal of Staff Development
1993;14(4):52-57.
Funding Estimate: State communications planning and
implementation costs vary greatly, depending on personnel costs and
the communications activities planned each year. CDC recommends
that approximately $25,000 per year be allocated to support
communications personnel and the implementation of a school
health communications plan.
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BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS
Plans should specify the target audience for each
professional-development event and should include
learning and performance objectives. Insofar as
possible, participants in these events should develop
action plans that describe how they will incorporate
their newly acquired knowledge and skills into
their professional responsibilities. Professionaldevelopment events should be evaluated by the
quality of those plans and how well they are
implemented.
Education Resources
• American School Food Service Association
(ASFSA): www.asfsa.org
• Association for Supervision and Curriculum
Development (ASCD): www.ascd.org
• American Association for Health Education
(AAHE): www.aahperd.org/aahe
• National Association for Sport and Physical
Education (NASPE): www.aahperd.org/naspe
• American School Counselor Association
(ASCA): www.schoolcounselor.org
• National Association of School Nurses
(NASN): www.nasn.org
• National Association of School Psychologists
(NASP): www.nasponline.org
• Society of State Directors of Health, Physical
Education and Recreation (SSDHPER):
www.thesociety.org
Professional-development events may be needed for
school personnel, such as health and physical
education teachers, nurses, school counselors, food
service directors, and administrators. Others who
require professional development may include school
board members; parents; health educators in state
health departments; health department staff who
work with youth-focused, community-based
organizations; parks and recreation staff; business
leaders; clergy; and social services and juvenile justice
staff. Depending upon the work plan and desired
outcomes, professional development could include
awareness sessions, skill-building training, topical
events, or customized offerings for teachers and
school health coordinators.
Public Health Resources
• American Public Health Association
(APHA): www.apha.org
• Association of State and Territorial Chronic
Disease Program Directors (ASTCDPD):
www.chronicdisease.org
• Association of State and Territorial Directors
of Health Promotion and Public Health
Education (ASTDHPPHE):
www.astdhpphe.org
• Society of Public Health Educators
(SOPHE): www.sophe.org
Opportunities for professional development to
support school health programs are available through
a variety of venues, including national and state-level
conferences and other continuing education oppor­
tunities offered by professional organizations.
National health organizations also offer specialized
opportunities for professional development, such as
those offered at the American Cancer Society's
School Health Coordinator Leadership Institute.
Several states have replicated the institute or are
planning to do so. For more information, contact
Federal Resources
• U.S. Department of Agriculture (USDA):
www.usda.gov
• U.S. Department of Health and Human
Services, Centers for Disease Control and
Prevention (CDC): www.cdc.gov/tobacco
• The President’s Council on Physical Fitness
and Sports:: www.fitness.gov
Resources
• Training Tracker: A Computer-Based Training
Tool. (E-mail request for information to
[email protected].)
9–19
CHRONIC DISEASE PREVENTION AND CONTROL
foster learning and ongoing improvement. Routine,
practical evaluations that provide information for
management and improve program effectiveness
should be a part of education and public health
programs at both the state and local levels.
the American Cancer Society, Children and Youth
Initiatives, at 404-982-3672.
Other venues for professional development include
professional-preparation programs offered by
institutions of higher education, professional
journals, online courses, and listservs. States should
develop systems to provide follow-up support to
participants after the professional-development
events have concluded. Such support could be
provided through booster sessions, peer counseling,
networking groups, or ongoing sequential training.
CDC has developed Training Tracker, a database
program that enables agencies and organizations to
track their various training and professionaldevelopment activities over time. Training Tracker
will store data useful for planning and evaluating
professional development events.
Program evaluation helps program officials to
better understand their programs' needs and assets,
to establish priorities, and to use their resources
more effectively.
As an agency develops its program goals, objectives,
and implementation plans, it should also develop
procedures for measuring its success in meeting these
goals and objectives. Evaluations can be used to assess
the following four aspects of program activities:
1. The development and implementation of healthrelated education policies.
2. The provision of professional development
activities for decision makers and education and
public health agency staff.
3. The development and implementation of effective
curricula and programs for students.
4. The establishment of sufficient capacity to develop
and implement program activities and collaborate
with other organizations.
State health and education agencies should support
policies and identify funding that will advance the
development of a statewide, comprehensive
professional-development plan. In general, state
agencies should designate staff to both develop this
plan and ensure its implementation at the state and
school-district level. However, if professionaldevelopment events are typically delivered at the
regional level, it might be more appropriate for
regional, county, or local education agency staff to
develop their own plans.
Agencies can perform two kinds of evaluations:
process evaluations and outcome evaluations. Process
evaluations require accurate and organized records of
program activities and are central to the ability of
program staff to effectively monitor and report on
their activities. By delineating the who, what, when,
and where of program activities, process evaluations
allow agency staff to assess whether these activities
met their goals and objectives. Agency staff can also
use process evaluations to chart and report on activi­
ties across time in a very systematic and cost-effective
manner. Because a basic understanding of the process
of program activities is critical to evaluating their
outcomes, education and public health agencies
should conduct process evaluations annually.
Outcome evaluations are used to assess the impact of
program activities on their participants, including
Funding Estimate: Professional development costs can vary greatly
depending on length of events, content, and participant costs. CDC
recommends that states allocate approximately $120,000 of their
annual budget for professional development.
Priority 8. Establish a System for Evaluating and
Continuously Improving State and Local School Health
Programs.
Program evaluation is an essential ongoing organiza­
tional practice in public health and education. The
results of such evaluations not only measure a
program's success in meeting its goals but also
provide information for planning future program
activities. Agencies need to develop clear plans,
inclusive partnerships, and feedback systems that
9–20
BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS
development activities, and curricula implementation.
Similarly, national Youth Risk Behavior Survey
(YRBS) data may help education and public health
agencies understand long-term trends in student
health-risk behaviors. Although process evaluations
are generally easier to conduct, agencies should
conduct outcome evaluations for at least one major
program activity annually. They should also conduct
an overall program outcome evaluation at the end of
a program's 5-year funding cycle.
Resources
• Framework for program evaluation in public
health. MMWR 1999;48(RR-11). Available at
www.cdc.gov/eval/framework.htm.
• Evaluating a national program of school-based
HIV prevention. Collins J, Rugg D, Kann L,
Pateman B, Banspach S, Kolbe L. Evaluation
and Program Planning 1996;19(3): 209–18.
• Introduction to Program Evaluation for
Comprehensive Tobacco Control Programs.
MacDonald G, Starr G, Schooley M, Yee SL,
Klimowski K, Turner K. Atlanta: CDC, 2001.
• Handbook for Evaluating HIV Education.
Atlanta: CDC, 1992. Available at
www.cdc.gov/nccdphp/dash/publications/
index.htm.
• Coordinated School Health Program
Infrastructure Development Process Evaluation
Manual. Atlanta: CDC, 1997. Available at
www.cdc.gov/nccdphp/dash/publications/
index.htm.
• Physical Activity Evaluation Handbook.
Atlanta: CDC, 2002. Available at
www.cdc.gov/nccdphp/dnpa/physical/
handbook/index.htm.
Evaluation results are only valuable when they are
used to develop and improve program activities.
Evaluation results may be communicated to national,
state, and local education and public health agen­
cies; to school districts and individual schools;
to community-based organizations; and to
community members.
State agencies should develop evaluation resources,
tools, and a technical assistance process to help local
agencies evaluate their program activities. Agencies
may want to consider enlisting the help of post­
secondary institutions or of independent evaluators
or evaluation firms. However, the respective roles
and duties of agency staff and hired evaluators must
be clearly outlined, and evaluators and agency staff
must agree on the purpose, methods, and procedures
of evaluations.
changes in their knowledge, attitudes, skills, and
behaviors both immediately following program
activities and over the long term.
There are four commonly accepted standards for
evaluation: utility, feasibility, propriety, and accuracy.
Utility refers to the usefulness of evaluation results.
Evaluations with good utility specify the amount and
type of information collected, make clear the values
used in interpreting collected data, and present
findings in a clear and timely way. Feasibility refers to
the extent that evaluations employ practical, nondisruptive procedures, take into account the differing
political interests of those involved, and use resources
prudently. Propriety is a measure of how well the
rights of those affected by the evaluation are
respected. Evaluations with good propriety have
protocols and other agreements to ensure that the
welfare of human subjects is protected, that the
findings are disclosed in a complete and balanced
Objectives measured by process evaluations may be
defined by the four key concepts and eight priority
actions described in this chapter and by performance
measures identified by CDC program announcements.
Objectives measured by outcome evaluations also
may be defined by performance measures identified
in CDC program announcements as well as by
Healthy People 2010 objectives.
National data can help place program data in a more
useful context for understanding program outcomes.
For example, the School Health Policies and
Programs Study (SHPPS)16 may help administrators
understand the outcomes of policies, professional-
9–21
CHRONIC DISEASE PREVENTION AND CONTROL
support to state education agencies, large urban
school districts, and national nongovernmental
organizations to improve school health programs
and the health of young people. DASH has also
developed numerous tools and resources to assist
organizations, agencies, and schools in achieving
many of the priorities identified in this chapter.
(These tools and resources are available at www.cdc.gov/
nccdphp/dash/publications/index.html.) In addition,
DASH sponsors the National School Health
Leadership Conference every 2 years to promote
promising practices in school health and to build
national and state partnerships to improve school
health policies and programs.
fashion that reflects multiple perspectives, and that
conflicts of interest are addressed in an open and fair
manner. Accuracy is a measure of how well evaluation
results reflect reality. Accurate evaluations describe
the program activities and their contexts, articulate
the purpose and methods of the evaluation, employ
systematic procedures to gather valid and reliable
information, apply appropriate methods of analysis
and synthesis, and produce impartial reports
containing justified conclusions.
One example of an evaluation performed by a state
education agency is the Kentucky Department of
Education's assessment of training on an HIV pre­
vention curriculum that was provided to 113 school
teachers. For this evaluation, the teachers answered
questions immediately before, immediately after, and
6 months after their training about their comfort in
discussing or teaching topics related to HIV and
pregnancy prevention, their comfort with various
instructional methods, and their attitudes toward
people with HIV. Evaluation results indicated that
teachers' comfort with teaching HIV and pregnancy
prevention topics, their comfort with instructional
methods, and their attitudes about people with HIV
significantly improved immediately after their
training. The evaluators recommended that current
training practices should be continued but that
additional evaluation should be performed to
determine the fidelity with which teachers
implemented programs in the classroom.
DASH continues to work closely with NCCDPHP's
Office on Smoking and Health and its divisions of
Adult and Community Health, Cancer Prevention
and Control, Diabetes Translation, Nutrition and
Physical Activity, Oral Health, and Reproductive
Health to achieve national health objectives for
preventing risks that contribute to chronic disease.
Collaborative strategies are necessary to promote
healthy communities, healthy schools, and healthy
children within our nation. In recognition of the
need for sustained and coordinated federal efforts to
strengthen and improve the education and health of
school-age children and youth, the U.S. Depart­
ments of Education, Health and Human Services,
and Agriculture established the Interagency Com­
mittee on School Health in 1994. The committee,
which meets twice each year, is co-chaired by the
Assistant Secretary for Health in the Department of
Health and Human Services, the Assistant Secretary
for Elementary and Secondary Education in the
Department of Education, and the Under Secretary
of Food, Nutrition and Consumer Affairs in the
Department of Agriculture. Committee members
represent the Department of Defense, the Depart­
ment of Justice, the Environmental Protection
Agency, the Indian Health Service, the Bureau of
Indian Affairs, and the Consumer Product Safety
Commission, as well as the Departments of Educa­
tion, Agriculture, and Health and Human Services.
Funding Estimate: States need to build their capacity to evaluate
school health policies and programs and provide technical assistance
in evaluation to local school districts. CDC recommends that states
allocate approximately $24,000 to support evaluation efforts.
National Leadership
Leadership in these efforts can come from various
sources, including federal agencies and partnerships
among governmental and nongovernmental
organizations at both the national and state levels.
Since 1987, the Division of Adolescent and School
Health (DASH) within CDC's National Center for
Chronic Disease Prevention and Health Promotion
(NCCDPHP) has provided fiscal and technical
9–22
BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS
National Partnerships
The National Coordinating Committee on School
Health (NCCSH) was established in 1994 by the
Secretaries of the Departments of Education and
Health and Human Services. Shortly after NCCSH
was created, the Department of Agriculture added its
support. The NCCSH was formed to link federal
departments with national nongovernmental organi­
zations to support quality, coordinated school health
programs in our nation's schools. Its responsibilities
include providing national leadership for the promo­
tion of quality school health programs; improving
communications, collaboration, and information
sharing among national organizations; identifying
local, state, and federal barriers to the development
and implementation of effective school health pro­
grams; and collecting and disseminating information
that can help to improve the effectiveness of these
programs. Membership has grown to approximately
75 national organizations.
Many national education groups have worked
together to gain and sustain support for imple­
menting school health programs. These groups have
developed several tools to help build support for a
coordinated approach to school health. One such
tool, the School Health Starter Kit, developed by the
Association of State and Territorial Health Officials
and the Council of Chief State School Officers, is a
powerful package of research-based materials
specifically designed to help communities build
support for school health programs.
State Partnerships
Funding for Coordinated School Health Programs
DASH supports coordinated school health programs
to discourage unhealthy behaviors such as poor
eating habits, physical inactivity, and tobacco use
and to promote healthy behaviors. These programs
aim to reduce young people's risk for chronic disease
later in life. The eight components of a school health
program systematically address these risk behaviors.
DASH's funding and support enable state depart­
ments of education and health to work together
efficiently, respond to changing health priorities,
and effectively use limited resources to meet a wide
range of health needs among the state's school-age
population. With this support, state and local
departments of education and health are able to
1) provide high-level staff members to coordinate,
support, and evaluate local school health programs;
2) build a training and development system for
health and education professionals at the state and
local levels; and 3) bring together various organi­
zations to develop and coordinate strategies for
reducing risk behaviors among young people.
DASH has established formal partnerships with
more than 40 national nongovernmental health and
education organizations, which work with DASH to
develop model policies, guidelines, and professional
development opportunities to help states establish
high-quality school health programs. In addition, the
Association of State and Territorial Chronic Disease
Program Directors (ASTCDPD), the Association of
State and Territorial Directors of Health Promotion
and Public Health Education (ASTDHPPHE), and
the Society of State Directors of Health, Physical
Education, and Recreation (SSDHPER) have estab­
lished the Coordinated School Health Program
Collaborative to help reduce chronic disease risks
and promote healthy behaviors among students.
ASTCDPD and ASTDHPPHE also collaborated on
the development of the School Business Resource
Kit, which provides convenient access to valuable
resources for learning more about coordinated school
health programs, effective strategies for implement­
ing them at the state and local levels, and ways to
strengthen partnerships between health and
education agencies.
Professional Development Consortium
DASH also supports the national Professional
Development Consortium, which helps DASHfunded state and local education agencies and
national nongovernmental organizations strengthen
their ability to implement professional-development
activities that will improve the quality of compre­
hensive school health education and coordinated
school health programs, including HIV prevention
9–23
CHRONIC DISEASE PREVENTION AND CONTROL
education. One example of such a professionaldevelopment opportunity is the National Profes­
sional Development Workshop on School-Based
Tobacco Prevention and Control, sponsored by
DASH, CDC's Office on Smoking and Health,
and the Professional Development Consortium.
Three of these national workshops, attended by
teams of representatives from the education and
health agencies in 32 states, have been held to
improve the capacity of states to implement effective
school-based tobacco-use prevention and control
programs and to develop strategies for ensuring and
reporting progress.
and responsibility to effectively implement and
improve school health programs. CDC maintains its
commitment to work with these state leaders and
with national organizations to make coordinated
school health programs available in every state.
References
1. Snyder T, Hoffman C, editors. Digest of
Education Statistics 2001. Jessup, MD: National
Center for Education Statistics, 2002: Table 2
(Pub. #2002130).
2. Centers for Disease Control and Prevention,
Office on Smoking and Health. Unpublished
data. Calculated from: Substance Abuse and
Mental Health Services Administration. National
Household Survey on Drug Abuse, 1999 and 2000.
Table F64.
3. Centers for Disease Control and Prevention.
Youth Risk Behavior Surveillance—United
States, 2001. MMWR Surveill Summ 2002;
51(SS-04):1–64. Available at www.cdc.gov/yrbs.
4. U.S. Department of Health and Human
Services. Healthy People 2010. 2nd ed. 2 vols.
Washington, DC: U.S. Government Printing
Office, 2000. Available at www.health.gov/
healthypeople.
5. National Campaign to Prevent Teen Pregnancy.
Special Report: U.S. Teenage Pregnancy Statistics
with Comparative Statistics for Women Aged 20–
24. Available at www.agi-usa.org/pubs/
teen_preg_sr_0699.html.
6. Ventura SJ, Martin JA, Curtin SC, Mathews TJ.
Report on final natality statistics, 1996. Monthly
Vital Statistics Report 1998;46(11s).
7. Eng TR, Butler WT, editors. The Hidden
Epidemic. Washington, DC: National Academy
Press, 1997.
8. Centers for Disease Control and Prevention.
Reducing Tobacco Use: A Report of the Surgeon
General. Washington, DC: Department of
Health and Human Services, 2000. DHHS Pub.
No. S/N 017-001-00544-4.
Progress to Date and Challenges Ahead
In 1987, CDC established the Division of
Adolescent and School Health to help the nation's
schools implement coordinated school health
programs. Through this division, CDC
• Monitors
the prevalence of health risks among
students and the prevalence of school policies
and programs to reduce those risks.
• Applies research to identify effective policies
and programs.
• Evaluates the effectiveness of implemented
policies and programs.
• Provides funds for state and large city depart­
ments of education and health to help schools
in their jurisdictions implement coordinated
school health programs.
• Provides funds for national education and health
and national nongovernmental organizations,
including the National Association of State
Boards of Education and the National School
Boards Association, to help the nation's schools
implement such programs.
Because every child needs sound preparation for a
healthy future, school health programs should be
established in all U.S. schools. Convincing children
and adolescents to adopt behaviors that reduce their
risk for chronic diseases is a continual challenge and
should be a goal of all public health programs.
Achieving this goal requires that state leaders in
public health and education accept the opportunity
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BUILDING A HEALTHIER FUTURE THROUGH SCHOOL HEALTH PROGRAMS
9. Gortmaker SL, Wiecha J, Sobol AM, Dixit S,
Fox MK, Laird N. Reducing obesity via a schoolbased inter-disciplinary intervention among
youth: Planet Health. Arch Pediatr Adolesc Med
1999;153(4):409–18.
10. Botvin GJ, Baker E, Dusenbury L, Botvin EM,
Diaz T. Long-term follow-up results of a ran­
domized drug abuse prevention trial in a white
middle-class population. JAMA 1995;273(14):
1106–12.
11. Allensworth DD. Improving the health of youth
through coordinated school health programmes.
Promot Educ 1997;1(4):42–7.
12. Indicators for chronic disease surveillance.
Available at http://cdi.hmc.psu.edu. Accessed
August 18, 2002.
13. Sweeney DB, Nichols P. The state role in
coordinated school health programs. In: Marx E,
Wooley S, editors. Health is Academic: A Guide to
Coordinated School Health Programs. New York:
Teachers College Press, 1998:244–68.
14. Institute of Medicine. Schools and Health: Our
Nation's Investment. Washington, DC: National
Academy Press, 1997.
15. National Association of State Boards of
Education (NASBE). Fit, Healthy, and Ready to
Learn: A School Health Policy Guide. Washington,
DC: NASBE, 1999.
16. Centers for Disease Control and Prevention.
School Health Policy and Programs Study 2000.
J Sch Health 2001;71(7).
9–25