Transcript Title

The Case for School
Health
Washington State Public Health Association
Annual Conference, October 14, 2003,
Yakima, WA
Julia Graham Lear, PhD, Director, Center for Health &
Health Care in Schools, The George Washington
University School of Public Health and Health Services
The Center for
Health and Health Care in Schools
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The Case for School Health:
The Elevator Speech
• 53 million school-age children in the U.S.
attend school 7 hrs a day, 9 mos a year.
• Many of them have unmet needs for acute
care, chronic care, and help with emotional
problems.
• All children need health education and other
related supports to help them become healthy
adults.
• Many, perhaps most, schools do not have
effective school health programs in place.
• For children’s sake, we need to turn school
health into the powerful force for children’s
good health that it can be.
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The Case for School Health:
An Overview
• Children’s health, children’s schools, and the
history of school health
• Current organization and funding; Schoolbased interventions to improve children’s
health
• Political support for school health: building
demand for school health programs
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Children’s Health, Children’s Schools
and the History of School Health
“What we have before us are some
breathtaking opportunities disguised
as insoluble problems.”
John Gardner, 1965
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Children’s Health:
Acute and Chronic Health Issues
• Asthma
– 14% (7.4 m) ever told he/she had asthma
– 6% (3.1 m) have had an asthma attack in past 12
months
• Common mental health disorders
– Anxiety ( 8 - 10 out of 100)
– Depression (7 and 100)
– Conduct (6 out of 100)
• ADHD - ever told he/she had ADHD- 7.5% (3.9m)
• Children on meds for at least 3 months during
calendar year - 13.3% (7.0m)
Source: Mental Health data -- CDC,NHIS 1997. Other data -5
CDC, NHIS 2000, October 2003.
Children’s Health:
Teen Risky Behaviors
Risk Behaviors
1997
1999
2001
16.8%
13.8%
31.5%
29.9%
4.0%
4.2%
4.0%
5.2%
8.9%
7.5%
7.7%
6.6%
Frequent cigarette 16.7%
use
Episodic heavy
34.4%
drinking
Current cocaine use 3.3%
Threatened or
injured on school
property
Felt too unsafe to go
to school
Source: CDC Youth Risk Behavior Survey, 1997, 1999,
2001
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Children’s Health:
Access to Care
• Insurance status in 2001 (CPS):
– Private employer insured: 65.3%
– Medicaid/SCHIP insured: 22.8%
– Full-year uninsured: 11.9%
• Access to care or medical home barriers:
– Insurance status
– Geography/transportation
– Family factors
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Children’s Health:
Health Promotion and Protection
• Health education: Learning basic information to
make a healthy transition to adulthood
• Health practice: Learning by doing -- physical
exercise at recess, physical education, sound
nutrition programs
• Safe physical environments: For example, Clean
air, fire safety, protection from exposure to toxins
• Safe emotional environments: A healthy social
environment in which violence and bullying are
not acceptable
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Where We’ve Come From:
School Health - Early Years
1890s: Boston & NYC: Physicians and nurses hired to
examine children in school & exclude the potentially
contagious.
Focus: Protect students & staff from infectious disease
Early 1900s: School health services spread. Educators
launch first full-service schools. Early opposition from
immigrant parents and institutions affiliated with them.
Focus: Infection control, uplift the poor
Post 1910: AMA opposition to all publicly-funded
treatment services in schools.
Focus: Keep a low profile; School health defined by
debates external to school health
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Where We’ve Come From:
School Health - 1920s through 1970s
• 1920s to1950s: School health = health education,
immunization documentation, screenings, treatment for
minor injuries, referrals for diagnosis & treatment. Focus:
Containing scope of school health.
• 1960s & 1970s: New provider types: nurse practitioners,
school-based health centers. New emphasis on getting
care to poor children. Federal law mandates healthrelated services for students with disabilities.
Focus: New attention to individual student health,
provision of mandated services for children with
disabilities.
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Where We’ve Come From:
School Health - 1980s &1990s
1980s and 1990s:
- school-based health centers expand;
- school-based mental health care increases;
- coordinated school health programs
(emphasis on universal approaches to
healthy school environment
- changes in education (accountability,
testing, success for all)
- new forces in health care (accountability,
managed care, outcomes focus)
Focus: Individual health services; CDC emphasis on
multi-faceted school health programs; importance
of HIV-AIDS to health education focus
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School Health Today:
Services Uneven and Under-Funded
• Facilities & equipment less than optimum
–
–
–
–
81% of buildings have nurse’s office
65.4% have separate medicine cabinet with lock
57% have refrigerator reserved for health
17.8% have glucose meter, 13% have nebulizer not just
for specific individuals
• Staffing
–
–
–
–
–
School nurse estimates 25,000 - 40,000.
School-based health centers - 1500.
School psychologists -- 20,000 - 22,000
School social workers -- 12,000
School counselors - 81,000
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School Health Today:
Health Education: A Mixed Picture
• Curriculum
– National Education Goals: “all students will have
access to physical education and health education
to ensure they are healthy and fit”. Followed by
CDC-sponsored National Health Education Stds
– SHPPS study concluded that limited instruction hours,
poorly trained teachers, and inadequate curricular
material limit health ed effectiveness
• Staffing
– 62.7% of schools have a health education coordinator
or manager
– Health is taught by many school staff; with health ed.
specialists used in a minority of health classes
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School Health Today:
The School Building
Good News for Many, Not All
• 93,273 school buildings in nearly 15,000
school districts
• Majority of buildings are in adequate or
better condition; a sizable minority are not
• 10% of schools have enrollments that are
25% or more above capacity
• Schools with highest concentration of poor
children were more likely to be in less than
adequate condition
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School Health and Schools
• School priorities
– Academic performance
– Facilities
– Building safety (School staff & students)
• School health priorities
– IDEA related services (federal mandate)
– Services that support effective classrooms
• School health program staff
– Dedicated staff primarily school nurses, not in every
school
– Few, if any, specialty back-ups, and managerial staff.
Sometimes hard to find the person in charge of various
aspects of school health program
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Organizing & Funding
School Health
“It must be remembered that there is nothing
more doubtful of success, nor more dangerous
to manage than the creation of a new system.
For the initiator has the opposition of all who
would profit by the preservation of the old
institutions and merely lukewarm defenders in
those who would gain by the new ones.”
Machiavelli, The Prince
1513
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Organizing and Funding School
Health: Some Background
• Except for health services, schools have
responsibility for most aspects of school
health
• Health services may be organized by school
systems, public health, or community-based
organizations
• Funding for school health programs come
from local tax dollars or local allocations of
state general fund dollars
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Organizing and Funding School
Health: Background Continued
• Some states, eg. PA, MA, provide general fund
support for school nurses
• Medicaid payments may cover health-related
services of special education , Medicaid
administration activities, covered services to
Medicaid beneficiaries
• Federal government provides limited support to
schools & school health
• Private foundations support some school health
efforts
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Traditional School Health Services
Funding & Management
-School system funding/management, eg. Boston,
MA, Seattle, WA
Strengths: Institutional understanding of characteristics
of health programs in schools; community good will;
support for individual school nurses
Weaknesses: Schools are led by educators; health
competes with education for education dollars, Ltd
commitment to management/training
-School system funding/health department
management of services, eg. Detroit, MI, NYC
Strengths: SNs connected to community/public health,
Weaknesses: Services for dollars still compete for education
dollars; SN disconnected from other school health
components
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Newer School Health Services
Funding/Management Arrangements
• School system funding/private system
management eg. DCPS/Children’s Medical Ctr,
Washington, DC
• School system funding/federal partici-pation
via Medicaid/various management
arrangements eg. Baltimore County PS, Baltimore
City
• School system funding plus local-state
dollars for underserved, Medicaid,
philanthropy/various management
arrangements eg. Palm Beach County, Fl;
Denver, CO
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Strengths and Weaknesses of
Newer Approaches
Strengths
• Establishes broader funding base and political
support
• Changes in program management, accountability
structure will strengthen content and outcomes of
program
Weaknesses
• Requires on-going collaboration, partnerships
• Requires major changes in management,
accountability measures
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Challenges to Developing Effective
School Health Programs
• Money: School health programs locally funded,
primarily with education dollars
• Leadership: Few advocates on behalf of school
health within school boards, school administration
and state legislatures
• Politics: Public dollars (to support school health)
require public support. Where are the strategies
to build public support?
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Meeting the Challenges:
It’s Been Done
• Money: Seton Health System (Austin, TX)
documented school health services programs,
demonstrated their effectiveness & got
additional dollar support.
• Leadership: CDC DASH, other public health
offices, nutritionists & health educators have
moved childhood obesity to center stage.
• Politics: The Detroit MI & Oregon SBHCs
organized parent lobbying & got SBHCs dollars
that had been struck from funding put back in
local & state budgets.
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School Health Programs
Currently Attracting Support
• Programs that increase access to care
– School-based health or wellness centers
– Mental health services in school
– Dental health programs in school
• Programs that promote healthy
behaviors
– Physical exercise
– Nutrition programs
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Towards the Future: Building a
Political Base for School Health
“The problem with children is that they
cannot lend you a truly interesting sum of
money.”
Fran Leibowitz
Metropolitan Life. 1988
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The Greatest Challenge
Facing School Health
The greatest challenge is not developing
excellent services, identifying most effective
health promotion programs, nor finding the
best model for delivering care, the greatest
challenge is developing effective strategies to
build political support for any model of health
programming in the schools.
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Parent Attitudes Towards
Health & Health Care in Schools
Poll Methodology
• Nationwide telephone poll of 1,101
parents of school-aged children.
• Conducted February 25 through
March 10, 2003.
• Margin of Error = plus or minus 3
percentage points.
• Includes oversample of parents in
household earning less than $37,000*
annually.
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Parent Attitudes towards
Health Education
How important is it for these services to be
provided in school?
83%
Prevention and education
about drug and alcohol abuse
Educating students about
health issues like eating right
and exercising
13%
77%
Providing age-appropriate
sex education
56%
Very Important
96%
19%
28%
96%
84%
Somewhat Important
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Parent Attitudes Towards
Health Care in Schools
• 83% of parents
say they support
health care in
schools; over
half (56%) are
strong
supporters.
• Only one in ten
(11%) oppose
health care in
schools.
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Support Across Political and
Demographic Groups
– Democrats are the most enthusiastic (90% support/
71% strongly). Independents (83% / 58%) and
Republicans (72% / 41%) are also supporters
– Parents in households with incomes under $37K a
year are particularly enthusiastic (91% / 66%). There
is also support among those with incomes over $37K
(79% / 52%).
– African-Americans (91% / 78%); Hispanics (88% /
66%); Whites (81% / 52%).
– Mothers (84% / 58%), fathers (81% / 54%).
– Northeasterners (83% / 61%), Southerners (83% /
60%), West (83% / 52%) , Midwest (82% / 53%)
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Elementary School Health Care
Is the First Priority
• If forced to choose,
parents across the
board feel it is most
important to offer
health care at the
elementary school
level.
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Contact Information:
The Center for
Health and Health Care in Schools
1350 Connecticut Avenue, NW, Suite 505
Washington, DC 20036
202-466-3396
202-466-3467 fax
www.healthinschools.org
The Center for
Health and Health Care in Schools
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