1 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 The Case for School Health

2 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.

3 The Case for School Health: An Overview Children’s health, children’s schools, and the history of school health Current organization and funding; School- based interventions to improve children’s health Political support for school health: building demand for school health programs

4 “ What we have before us are some breathtaking opportunities disguised as insoluble problems.” John Gardner, 1965 Children’s Health, Children’s Schools and the History of School Health

5 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 ( 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 % (7.0m) Source: Mental Health data -- CDC,NHIS Other data -- CDC, NHIS 2000, October 2003.

6 Children’s Health: Teen Risky Behaviors

7 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

8 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

9 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

10 Where We’ve Come From: School Health s 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 health- related services for students with disabilities. Focus: New attention to individual student health, provision of mandated services for children with disabilities.

11 Where We’ve Come From: School Health s &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

12 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. –School-based health centers –School psychologists -- 20, ,000 –School social workers -- 12,000 –School counselors - 81,000

13 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

14 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

15 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

16 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

17 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

18 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

19 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

20 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

21 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

22 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?

23 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.

24 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

25 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

26 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. The Greatest Challenge Facing School Health

27 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, Margin of Error = plus or minus 3 percentage points. Includes oversample of parents in household earning less than $37,000* annually.

28 Parent Attitudes towards Health Education

29 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. Parent Attitudes Towards Health Care in Schools

30 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%)

31 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.

32 The Center for Health and Health Care in Schools Contact Information: The Center for Health and Health Care in Schools 1350 Connecticut Avenue, NW, Suite 505 Washington, DC fax