Building a Healthier Future Through School Health Programs

Eight Priority Actions for Improving the Health of Young People — Part 1

• 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.
  
  
• Priority 2. Establish and Maintain Dedicated Program-Management and Administrative-Support Systems.
  
  
• Priority 3. Build Effective Partnerships Among State-Level Governmental and Nongovernmental Agencies and Organizations.
  
  
• Priority 4. Establish Policies to Help Local Schools Effectively Implement Coordinated School Health Programs and the School Health Guidelines.
  
  

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.

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.

2. Establish and maintain dedicated program-management 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 the 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 the school health guidelines.

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 implementing the school health guidelines.

8. Establish a system for evaluating and continuously improving state and local school health policies and programs.

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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 high-quality 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

• 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.

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 representative samples of 9th- through 12th-grade students. States can supplement the YRBS data with data from the Youth Tobacco Survey (YTS) or other 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.

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, nutrition-related policies, violence-prevention policies, health education, and physical education and physical activity programs.

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.

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.

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.

As an example of how state survey data can be used, every 2 years the Montana Office of Public Instruction 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.

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 strategic plan for improving the health and education of youth.

The School Health Index for Physical Activity, Healthy Eating, and a Tobacco-Free Lifestyle: A Self-Assessment 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.

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.

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Priority 2. Establish and Maintain Dedicated Program-Management and Administrative-Support Systems.
State and local 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.

• Personnel and Organizational Involvement: State and local leaders of school health programs should identify the relevant 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 multiagency programs related to school health.

• Authorization and Funding: State and local 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 complicated 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. The Healthy Youth Funding Database from CDC 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.

• Technical Assistance and Resources: State and local agency leaders should develop processes for identifying, developing, and disseminating resources for supporting coordinated school health programs and implementing the school health guidelines at the school and district levels. They should identify existing human, data, technological, 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 and local 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 networks 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.

In addition to focusing on these important organizational supports, health and education leaders must help state and local school health-related staff develop the skills they need to effectively organize and manage school health programs. The Coordinated School Health Program Infrastructure Development: Process Evaluation Manual can help build the necessary support for coordinated school health programs and institutionalize this support at the state and local levels.

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.

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Priority 3. Build Effective Partnerships Among State-Level 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.

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, physical activity, nutrition, tobacco control) to ensure that these programs, which are often delivered in both community and school settings, are connected and efficient.

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 partnerships allow agencies to use resources more efficiently, improve communication among staff involved with complementary programs, and, as a result, strengthen the programs themselves.

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 administrative 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 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.

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

• 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 programs 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 postsecondary 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.

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.

The Blueprint Working Group is made up of state agency program coordinators responsible for the various components of a coordinated school health program and for reducing 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, the YRBS coordinator, and staff from the following programs: tobacco, cardiovascular health, school-based health, immunization, environmental health, family planning/teen pregnancy prevention, and asthma. 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.

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.

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.

The Rhode Island School Health Advisory Council was formed as a primary partner in the state's 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, community 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.

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Priority 4. Establish Policies to Help Local Schools Effectively Implement Coordinated School Health Programs and the 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 and local 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 the school health guidelines into model policy language.¹⁵ This document can help guide policy development at the state, district, and school levels. It also contains a wealth of information that can guide state health leaders through the process of creating educational policy.

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.

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 coordination 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, law enforcement officers, media representatives, and university faculty members—with the school district. Virginia and Texas require districts to have school health councils.

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.

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.

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 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 physical-education standards.

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.

Tobacco-free schools.
A tobacco-free environment is one in which 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 environment 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 education 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 tobacco-free schools policy can also be established at the local or state level. For example, a state department of education may require districts to report tobacco-use violations; a local school board might require a progressive discipline plan for student policy violations that begins with an educational 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.

Quality professional development of school health staff.
State boards of education can set professional development 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.)

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