Enabling the Nation's Schools to Help Prevent Heart Disease ... - NCBI

Practice Articles

Enabling the Nation’s Schools to Help Prevent Heart Disease, Stroke, Cancer, COPD, Diabetes, and Other Serious Health Problems

Lloyd Kolbe, PhDa Laura Kann, PhDb Beth Patterson, MEdc Howell Wechsler, EdDd Jenny Osorio, MPAe Janet Collins, PhDa

SYNOPSIS In the United States, more than 53 million young people attend nearly 120,000 schools, usually for 13 of their most formative years. Modern school health programs—if appropriately designed and implemented—could become one of the most efficient means the nation might employ to reduce the establishment of four main chronic disease risks: tobacco use, unhealthy eating patterns, inadequate physical activity, and obesity. The U.S. Centers for Disease Control and Prevention and its partners have developed four integrated strategies to help the nation’s schools reduce these risks. Participating national, state, and local agencies (1) monitor critical health risks among students, and monitor school policies and programs to reduce those risks; (2) synthesize and apply research to identify, and to provide information about, effective school policies and programs; (3) enable state, large city, and national education and health agencies to jointly help local schools implement effective policies and programs; and (4) evaluate implemented policies and programs to iteratively assess and improve their effectiveness.

a

Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA (currently at Department of Applied Health Science, Indiana University, Bloomington, IN)

b Surveillance and Evaluation Research Branch, Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA c

Program Development and Services Branch, Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA

d

Research Application Branch, Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA e

Planning, Evaluation, and Legislation, Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA Address correspondence to: Janet Collins, PhD, Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy. NE, MS K-29, Atlanta, GA 30341-3717; tel. 770-488-6100; fax 770-488-6191; e-mail .

286 䉫

Public Health Reports / May–June 2004 / Volume 119

Enabling Schools to Help Prevent Chronic Disease

Nearly three-quarters of all deaths among adults aged 25 years and older in the United States are caused by five chronic diseases: heart disease and stroke (41%), cancer (24%), chronic obstructive pulmonary disease (COPD)—e.g., asthma, bronchitis, and emphysema— (4%), and diabetes (3%).1 In every state, these diseases are also the source of widespread illness, unnecessary disability, extensive human suffering, and enormous health care costs. Today, nearly 100 million Americans are already living with one or more of these diseases, and the treatment of these diseases generates 60% of the $1 trillion the nation spends on health care each year.2 In any population, these diseases are more likely to occur with increasing age. Consequently, as the average age of the U.S. population increases (from 17% of the population older than 60 years in 2000 to 25% in 2020), each American will need to pay for increasingly higher health care costs, and these chronic diseases may burden the nation’s medical, insurance, business, and economic systems to the breaking point. Much of the morbidity and mortality from these chronic diseases could be prevented because it derives from only four risk factors: tobacco use, unhealthy diets, inadequate physical activity, and obesity.3,4 These risks usually are established during childhood and adolescence; they frequently are interrelated; and they are difficult to change once they have become established. By the time young people in this country graduate from high school, 35% smoke cigarettes, 80% do not eat enough fruits and vegetables, 39% do not participate in enough physical activity, and 21% are already either overweight or at risk of becoming overweight.5 Our nation likely will not be able to control chronic diseases unless it can prevent the establishment of relevant risks among young people; and the nation likely will not be able to prevent these risks among young people unless it systematically enables its schools to help. Indeed, modern, coordinated school health programs could become one of the most efficient means the nation might employ to reduce these four risks and the serious diseases they cause.6,7 More than 53 million students attend nearly 120,000 schools every school day, usually for 13 of the most formative years of their lives.8 In addition, nearly five million faculty and staff are employed by schools, and these employees constitute a vital and influential workforce. Thus, when students and employees are combined, nearly one-quarter of the U.S. population spends about six hours each school day in a school facility. Modern, coordinated school health programs often comprise eight interactive components: health

䉫

287

education; physical education and other physical activities; food services; health services; counseling, psychological, and social services; a healthy biophysical and psychosocial environment; health programs for faculty and staff; and integrated efforts of schools, parents, and communities to improve the health of students.9–11 School health programs can be designed specifically to achieve four distinct, but interrelated, goals, to improve: (1) health literacy, (2) health behaviors and health outcomes, (3) educational outcomes, and/or (4) social outcomes.12 Surveys show that school administrators, parents, students, and the public at large want school health programs;13,14 and businesses15 and state legislatures16 increasingly appreciate the benefits of these programs. Further, national plans to prevent obesity,17 heart disease and stroke,18 and cancer 19 articulate the need to help schools reduce risks as part of these plans. The Institute of Medicine has called for the U.S. to improve its school health programs,20 as have the Surgeon General,21 the Secretary of Education and the Secretary of Health and Human Services,22,23 and Congress.24,25 The World Health Organization has called on all nations to improve school health programs,26 including school health programs to prevent heart disease, stroke, and diabetes.27 ENABLING SCHOOLS TO PREVENT CHRONIC DISEASES: FOUR STRATEGIES In 1988, the U.S. Centers for Disease Control and Prevention (CDC) established a Division of Adolescent and School Health, in part to develop means to help the nation’s schools prevent a wide range of health risk behaviors and health problems, many of which are interrelated. In the late 1980s, the CDC developed four national strategies and began to work with national, state, and large city health and education partner organizations specifically to help the nation’s schools prevent risks for HIV infection. In the late 1990s, the CDC and partner organizations began to focus these same public health strategies specifically on helping the nation’s schools prevent risks for chronic diseases. This article describes each of the four interrelated national strategies—including materials, resources, and partner activities that comprise the strategies—specifically designed to prevent chronic disease risks. The purpose of this article is to help interested national, state, and local health and education organizations effectively participate in implementing relevant strategies to prevent chronic disease risks; and to provide a source document that might facilitate analyses, cri-


288 䉫

Practice Articles

tiques, revisions, and refinements of these strategies and their components over time. The four strategies, implemented by CDC and its partner agencies collaboratively, include: (1) monitoring critical chronic disease risks among students, and monitoring school policies and programs to reduce those risks; (2) synthesizing and applying research to identify, and provide information about, effective school policies and programs to prevent chronic disease risks; (3) enabling state, large city, and national education and health agencies to jointly help local schools implement effective policies and programs to prevent these risks; and (4) evaluating implemented chronic disease risk reduction policies and programs to assess and consequently improve their effectiveness. (As described in other publications and on the CDC’s adolescent and school health program website [http:// www.cdc.gov/hccdphp/dash/],12 these same strategies are also employed—but with different foci, materials, resources, and partner activities—to reduce other health risks and health problems, and to attain other important goals of modern school health programs.) 1. Monitoring the prevalence of critical health risks among students, and monitoring school policies and programs to reduce those risks The CDC has developed several means of monitoring the prevalence of critical health risks among students and school policies and programs to reduce those risks. To focus the nation, states, and relevant agencies on reducing critical risks, and to assess the extent to which these risks consequently change over time, the CDC established the Youth Risk Behavior Surveillance System.28 This system biennially employs the Youth Risk Behavior Survey to monitor the prevalence of six types of risk behaviors among our nation’s 9th- to 12th-grade students: tobacco use, unhealthy eating patterns, inadequate physical activity, behaviors that result in unintentional injuries and violence, alcohol and drug use, and sexual risk behaviors. In addition to providing data about the national prevalence of these risks, this system more importantly provides comparable data about the prevalence of these risks among students in participating states and large cities. In 2001, 38 states and 18 large cities implemented the Youth Risk Behavior Survey.5,29 Among them, 22 states and 14 large cities obtained samples that could be generalized to all 9th- to 12th-grade students in respective jurisdictions. The Youth Risk Behavior Survey also provides data to assess the extent to which the nation as a whole, as well as each participating state and large city, is achieving relevant Healthy People 2010 National Health Ob-

jectives,30 including the following objectives relevant to chronic diseases: • Objective 27-2b, which is also number three among the nation’s 10 Leading Health Indicators,31 is to reduce the proportion of adolescents who smoke cigarettes or use other tobacco products; • Objectives 19-5 and 19-6 (combined) are to increase the proportion of adolescents who consume at least five daily servings of fruits and vegetables; • Objective 22-7 (which is also Leading Health Indicator number one) is to increase the proportion of adolescents who engage in vigorous physical activity that promotes cardiorespiratory fitness three or more days a week for 20 or more minutes per occasion; • Objective 19-3c (which is Leading Health Indicator number two) is to reduce the proportion of children and adolescents who are overweight or obese. To help develop standards for various programs and school subjects (e.g., science, social studies), and to help develop instruments that can measure achievement of these standards, the Council of Chief State School Officers, which represents the nation’s state school superintendents, established a State Collaborative on Assessment and Student Standards. To assess health literacy, the Collaborative created a threedimensional (9⫻6⫻3) Health Literacy Assessment Framework Matrix32 that provides a framework for developing test items within nine content areas (alcohol and other drugs, injury prevention, nutrition, physical activity, sexual health, tobacco, mental health, personal and consumer health, and community and environmental health) for six core concepts and skills that reflect the National Health Education Standards33 (accessing information, self-management, internal and external influences, interpersonal communication, decision making/goal setting, advocacy) across three grade levels (elementary, middle, and high school). These items can be used by schools, districts, and states to assess critical student health knowledge, attitudes, and skills. Specific health knowledge, attitudes, and skills may influence whether students engage in a given health risk behavior (e.g., tobacco use), but they are not the only important determinants. To focus the nation, states, and relevant agencies on helping schools implement the kinds of policies and programs that can effectively reduce critical risks, and to assess the extent to which school policies and programs consequently change over time, the CDC established a second surveillance system called the



School Health Policies and Programs Study. This surveillance system was initiated in 1994, was repeated in 2000, and is slated to be conducted periodically. It provides national data about school health policies and programs from a probability sample of the nation’s 14,000 school districts and 120,000 schools;34–36 and also provides data about state-level school health policies and programs.37,38 It monitors seven Healthy People 2010 objectives, including Objective 7-2, which is to increase the proportion of the nation’s schools that provide health education to reduce each of the six types of critical risk behaviors monitored by the Youth Risk Behavior Survey. Data from this system illustrate, for example, that only 25% of states, 46% of districts, and 45% of schools have policies to assure tobaccofree school environments;39 20% of schools offer brandname fast foods to students;40 and 92% of elementary schools, 94% of middle/junior high schools, and 94% of senior high schools do not provide daily physical education or its equivalent for students.41 In addition to conducting the School Health Policies and Program Study, the CDC helps interested state education agencies (SEAs), state health departments (SHDs), large city local education agencies (large city LEAs), and large city local health departments (large city LHDs) implement School Health Profiles as a means to monitor and improve school health education policies and programs within their respective jurisdictions.42,43 To develop these profiles, each participating state or large city uses probability samples of middle and senior high school principals and lead health education teachers to assess the following areas among schools within the state: required health education courses, as well as curricula, guidelines, frameworks, and content for these required courses; coordination of health education; professional preparation of lead health education teachers; in-service training for various health education topics; and parental and community involvement in school health education. Data from these profiles provide information about policies to prevent tobacco use, information about healthy foods, and information about physical activity and physical education among schools in the state. School Health Profile data across participating states and large cities illustrate, for example, that only 6% of the nation’s lead health education teachers had professional preparation in health education; and that the median percentage of the nation’s lead health education teachers who wanted in-service training in preventing tobacco use, unhealthy eating patterns, and inadequate physical activity was 42%, 43%, and 33%, respectively. The CDC includes “State-by-State Information”44 on its Adolescent and School Health website

䉫

289

(http://www.cdc.gov/nccdphp/dash/) that contains state Youth Risk Behavior Survey, School Health Policies and Programs Study, and School Health Profile data. In addition to the surveillance mechanisms developed by the CDC, the Council of Chief State School Officers, under contract with the Healthy Schools Summit and the National Dairy Council, has developed State Profiles on Nutrition and Fitness.45 Each State Profile provides information about school demographics; student nutrition and physical activity behaviors and risks; oral health data; school food programs and hunger; national income demographics; state legislation pertaining to nutrition and fitness; policies on food, physical education, and physical activity in schools; standards and assessment; state priorities for school nutrition and physical activity; and resources. In 1984, the U.S. implemented the first National Children and Youth Fitness Study to assess the physical fitness of the nation’s students aged 10 years and older.46 In 1986, the second of these studies was conducted to assess the physical fitness of 6- to 9-year-old students.47 Since that time, the U.S. has not had the means to assess the extent to which the strength, endurance, flexibility, cardiorespiratory fitness, athletic abilities, and other important indicators of well-being among the young people of our nation have improved or deteriorated. An additional surveillance mechanism in this area is critically needed. Finally, the CDC initiated Healthy Passages: A Community-Based Longitudinal Study of Adolescent Health.48 Healthy Passages is designed to monitor the development of critical health, education, and social outcomes among cohorts of young people in three different communities as they progress from 10 to 20 years of age. The functions of this study will be to illuminate the evolution of these multiple outcomes. An especially important function will be to provide information about how the nation might consequently shape school policies and programs to reduce adverse outcomes and disparities, and policies and programs to help families, health care providers, media, community organizations that serve youth, faith-based organizations, and government agencies reduce adverse outcomes and disparities.49 By providing the means to monitor the prevalence of critical health risks, and to monitor the implementation of school policies and programs, the CDC and its partners can help the nation, states, and relevant agencies focus on reducing those risks by implementing the most effective policies and programs—and they can assess comparative progress among jurisdictions over time.50,51


290 䉫

Practice Articles

2. Synthesizing and applying research to identify, and provide information about, effective policies and programs The CDC has developed several means to synthesize and apply research to identify effective policies and programs and to provide information about them. To help interested agencies identify effective types of interventions, the CDC helped develop an independent Task Force on, and Guide to, Community Preventive Services.52 The Task Force and Guide provide systematic reviews of research evidence about specific types of population-based interventions, and they translate that evidence either into a recommendation to implement a certain intervention, or into a finding that insufficient research evidence exists to warrant such a recommendation.53 In 2002, the Task Force and Guide issued a recommendation to implement programs that increase the length of, or activity levels in, schoolbased physical education classes based on strong evidence of effectiveness.54,55 A recommendation about school-based tobacco education is pending,56 and evidence about school-based nutrition programs is being reviewed.57 Recommendations about other schoolbased programs, such as oral health and vaccinations, have also been made.58,59 To help SEAs, school districts, and schools plan and implement effective policies and programs to reduce various risks, the CDC has published several sets of school health guidelines, including Guidelines for School Health Programs to Prevent Tobacco Use and Addiction,60 Guidelines for School Health Programs to Promote Lifelong Healthy Eating,61 and Guidelines for School and Community Programs to Promote Lifelong Physical Activity among Young People,62 among others.63,64 Each set of guidelines is based on, and includes, a synthesis of theory, research, and best practices; and each has been developed jointly by scientific experts, school practitioners, and national organizations most involved in reducing the risk. The guidelines feature recommended actions that schools can take in developing policies, training staff, involving families and communities, and evaluating program efforts. Several tools have been developed to help schools implement the CDC school health guideline recommendations. These include the School Health Index: A Self-Assessment and Planning Guide, published by CDC;65 Fit, Healthy, and Ready to Learn: A School Health Policy Guide, published by the National Association of State Boards of Education;66 and three tools currently being developed by CDC to help schools and communitybased organizations select curricula that are likely to be effective in promoting healthy behaviors.

The School Health Index is designed to help schools involve teachers, parents, students, and the community in identifying the strengths and weaknesses of their school’s health policies and programs, and then in developing an action plan to improve policies and programs. The index comprises eight self-assessment modules, corresponding to the eight coordinated school health program component areas, and is packaged in two versions: one for elementary schools, and one for middle schools or high schools. The current version of the index helps schools address issues related to physical activity, nutrition, and tobacco-use prevention; future versions will allow schools to address other content areas as well. Fit, Healthy, and Ready to Learn provides sample policies to help states, districts, and local schools establish an overall policy framework for coordinated school health programs; it also provides sample policies to reduce specific health risks and health problems. The sample policies are written as statements of best practice that agencies should endeavor to adopt, and the policies can be adapted to fit the needs of individual states, districts, and schools. Part One of this document provides sample policies to encourage physical activity, to encourage healthy eating, and to discourage tobacco use. Other parts of the document provide model policies for schools to reduce other health risks and health problems. Finally, the CDC is developing three means to help agencies and schools identify and select effective curricula. First, the Health Education Curriculum Analysis Tool is a self-assessment tool, similar in format to the School Health Index, that can help users select, develop, or assess health education curricula to be delivered either in school or in community settings.67 Criteria for the Health Education Curriculum Analysis Tool are based on the National Health Education Standards and on curriculum recommendations in relevant CDC school health guidelines. Second, a companion Physical Education Curriculum Analysis Tool is being developed to help schools and agencies develop or assess physical education curricula.68 Criteria for this Curriculum Analysis Tool are based on the National Standards for Physical Education.69 Third, the Guide to Health Education Curricula 70 is a resource document that provides useful information about the characteristics of curricula, based largely on the Health Education Curriculum Analysis Tool criteria. For those curricula that have been rigorously evaluated, the guide also provides information about the quality and findings of the evaluation.



3. Enabling state, large city, and national education and health agencies to jointly help local schools implement effective policies and programs The CDC and its partners have developed several means to enable education and health agencies to jointly help local schools implement effective policies and programs. The CDC provides fiscal and technical support for interested and eligible SEAs, territorial education agencies, and large city LEAs to help schools in their respective jurisdictions reduce specific health risks and health problems. In 2002, the CDC published a Notice of Availability of Funds to assist these agencies in improving the health, education, and wellbeing of young people through coordinated school health programs.71 This consolidated program announcement enabled eligible state, territorial, and large city education agencies to apply simultaneously for funding to implement any one, or any combination, of six elements for which funding was available: (1) implement the Youth Risk Behavior Survey; (2) build coordinated school health programs and prevent chronic disease risks; (3) prevent asthma episodes; (4) prevent food borne illnesses; (5) prevent HIV infection; and (6) help provide national professional development. More states, territories, and large cities applied for funding than the resources could support. By March 1, 2003, the CDC had awarded cooperative agreements for 89 states, territories, and large cities to implement 176 separate elements during the five-year funding cycle from Fiscal Year 2003 to 2007. A national directory of school health program staff in each SEA and SHD has been published.72 As shown in Table 1 (column 1), between 1996 and 2002, the CDC was able to provide support for 20 states to build coordinated school health programs and prevent chronic disease risks. As depicted in the second column, for 2003–2007, the CDC is able to provide support for 18 of the 39 states that applied for such funding. To help the states build coordinated school health programs and prevent chronic disease risks, funds are provided to establish and maintain a full-time senior staff position in the SEA who can provide leadership and coordination for all SEA school health program efforts (e.g., across the eight components of a modern school health program), and a fulltime senior staff position in the SHD who can provide leadership and coordination for all SHD efforts to help schools improve health (e.g., immunizations, Medicaid, environmental hazards, chronic disease prevention). These leaders work together and with the state school superintendent, health commissioner, legislature, governor’s office, and other state, local, and

䉫

291

federal agencies to protect and improve the health of all K-12 students in the state. The coordinated school health programs they jointly build can be used to help implement and integrate other efforts to improve the health of students, including any of the other five elements for which the state may have received funds as part of the CDC-consolidated cooperative agreement. As an integral part of the element to build coordinated school health programs and prevent chronic disease risks, the CDC provides support for funded SEAs and SHDs to jointly help schools in the state specifically prevent chronic disease risks by measurably reducing tobacco use, unhealthy diets, inadequate physical activity, and obesity among school students and employees. Funded SEAs and SHDs are enabled to (1) dedicate necessary staff; (2) develop intra- and interagency plans; (3) develop and implement a broader state plan that engages other public- and private-sector organizations; (4) provide support for school districts in the state to help local schools implement the plan; (5) include strategies specifically to reduce disparities among populations that may be disproportionately affected by heath risks and health problems, especially among communities of color; (6) inform stakeholders and the public about efforts; (7) evaluate to assess and improve efforts; and (8) collaborate with other states and large cities, participating national nongovernmental organizations, the CDC, and other federal agencies to collectively improve efforts over time. Cooperative Agreement Performance Measures71 have been written to help the state education and health agencies assess the extent to which they are enabling schools to (1) implement effective policies, environmental changes, and education strategies to reduce tobacco use, unhealthy eating patterns, inadequate physical activity, and obesity among students; (2) implement strategies to reduce disparities among sub-populations that may be disproportionately affected by chronic disease health risk and outcomes; and (3) integrate effective school-based policies, programs, and strategies to reduce these health risks with community-based strategies to reduce the same risks, while building a sustainable local resource and funding base. To enable SEAs, SHDs, and others to jointly help schools implement effective health policies and programs, the CDC published Promising Practices: Building a Healthier Future through School Health Programs.73 The publication describes five promising practices and eight priority actions that SEAs and SHDs can take jointly to improve the health of young people, and gives an estimated annual cost of each action. One of the five


292 䉫

Practice Articles

Table 1. CDC cooperative agreements for SEAs/SHDs to help build coordinated school programs and prevent chronic disease risks

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, DC West Virginia Wisconsin Wyoming Total

1996–02 DASH CSHP SEAs/SHDs

2003–07 DASH CSHP SEAs/SHDs

X X X

X

X X

X

X

X X

X

X

X X X

X X

X

X X X

X X X X X

X

X X X

X X X X

X

2002 DCPC SHDs X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

2002 DCPC SEAs

X

2002 DNPA SHDs

X X X X

X X X X

X X

X

X

X X X X X X X X X X X

X

X X

X

X X X

X

20

18

X X X X 49

X

7

12

2002 OSH SHDs

2002 DACH CVD SHDs

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 51

2002 DACH PRC

2002 DDT SHDs

X

X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X

X X

X X X X X X X

X X

X

X

X X X

X X X

X X X X X X

X X X X X

X X

X X X

X X

X X X X X X X X 31

SEA = state education agencies

OSH = Office on Smoking and Health

SHD = state health departments

DACH = Division of Adult and Community Health

DASH = Division of Adolescent and School Health

CVD = Cardiovascular disease

CSHP = Coordinated School Health Program

PRC = Prevention Research Centers

DCPC = Division of Cancer Prevention and Control

DDT = Division of Diabetes Translation

DNPA = Division of Nutrition and Physical Activity

DOH = Division of Oral Health

X

51

2002 DOH SHDs X X X

X

X

X

X

X X X X

X

12



promising practices is to “. . . coordinate the activities of health and education agencies and other organizations working to improve the health of young people. . . .” Indeed, SEA efforts to help schools reduce specific health problems are likely to be most effective when school efforts are designed and implemented with support and involvement of the SHD agency responsible for that health risk or health problem. For example, SEA efforts to prevent tobacco use are likely to be most effective when they are planned and implemented in close collaboration with the SHD agency responsible for preventing tobacco use, and when, as suggested by the Surgeon General’s report on preventing tobacco use among youth,74 school efforts are specifically designed to complement other state efforts to reduce tobacco use among youth such as increasing price, engaging media, or implementing communitybased efforts that address young people. Thus, as depicted in Table 1, many states currently funded by CDC’s Division of Adolescent and School Health (DASH) to build coordinated school health programs and prevent chronic disease risks (listed in column 2), also are funded by other CDC divisions to prevent similar risks. For example, the CDC’s Division of Cancer Prevention and Control provides funds for many SHDs (column 3) and some SEAs (column 4) to prevent cancer risks.75 The CDC’s Division of Nutrition and Physical Activity provides funds for some SHDs (column 5) to prevent dietary risks and inadequate physical activity.76 The CDC’s Office on Smoking and Health and Division of Adult and Community Health (DACH) respectively provide funds for SHDs to prevent tobacco use77 (column 6), and risks for heart disease and stroke78 (column 7). The CDC’s DACH also provides funds for universities and medical care organizations in many states (Column 8) to help prevent a wide range of health problems, including chronic diseases. Finally, the CDC’s Division of Diabetes Translation and Division of Oral Health also provide funds for many states to help reduce chronic disease risks (columns 9 and 10, respectively). These CDC divisions and DASH work closely together,79 and they encourage and support the SHD agencies they fund to work closely with their respective SEAs and each other to reduce relevant risks and health problems. Descriptions of successful local school efforts to improve the health of young people have been published in the CDC’s Stories from the Field.80 Other examples include West Virginia, which has adopted some of the strongest standards in the nation to assure that foods and beverages served in schools are nutritious and healthy. The state implements a week-long nutrition symposium for school food service and other

䉫

293

school staff to help them implement the standard. California has added health to its new statewide standards for teacher training, and has added physical fitness test results to report cards that measure school district performance. The North Carolina State Board of Education passed a Healthy Active Children Policy. This policy enabled and encouraged each local school to establish and maintain a local School Health Advisory Council, which provided training for each school district to help schools implement the eight components of a coordinated school health program. The CDC also provides fiscal and technical support for national nongovernmental education and health organizations that can efficiently and collaboratively help the nation’s 50 SEAs and SHDs, large city LEAs and LHDs, 15,000 districts, and 120,000 schools implement effective school health policies and programs. During Fiscal Years 1998 to 2003, the CDC provided support for 52 national nongovernmental organizations (Table 2),81 largely to help schools implement HIV prevention efforts as an integral part of coordinated school health programs. Each organization has published a brief description of its efforts.82 For example, the National Association of State Boards of Education has established a Safe and Healthy Schools Project83 that (1) publishes policy guides on important school health issues; (2) maintains a database of state policies related to school health; (3) provides training and technical assistance to help policymakers develop new, or revise existing, school health policies and programs; (4) works with the National School Boards Association to implement the Healthy Schools Network, which facilitates discussions among interested state board members, state education and health agency staff, and other committed individuals to improve schools health programs within and across their states; (5) maintains collaborative partnerships with other national nongovernmental organizations to improve school health programs; and (6) convenes study groups and task forces which bring together policymakers, administrators, and practitioners from different disciplines to address pressing school health issues. The National Association of State Boards of Education recently published How Schools Work & How to Work with Schools: A Primer for Professionals Who Serve Children and Youth.84 Organizations that have worked together specifically to prevent chronic disease risks include, among others, the Society of State Directors of Health, Physical Education, and Recreation (which includes the nation’s SEA school health directors and physical education directors);85 the Chronic Disease Directors;86,87 and the Association of State and Territorial Directors


294 䉫

Practice Articles

Table 2. Nongovernmental education and health organizations that received CDC support to help the nation’s schools implement effective school health policies and programs, Fiscal years 1998–2002 Advocates for Youth American Academy of Pediatrics American Association of School Administrators American Cancer Society American Lung Association American Nurses Foundation American Psychological Association American School Health Association Association of Maternal and Child Health Programs Association of State and Territorial Chronic Disease Program Directors Association of State and Territorial Directors of Health Promotion and Public Health Education Association of State and Territorial Health Officials Asthma and Allergy Foundation of America Comprehensive Health Education Foundation Congress of National Black Churches Council of Chief State School Officers Education Development Center ETR Associates GIRLS, Incorporated Harvard School of Public Health Indian Health Services Institute for Youth Development National 4-H Council National 4-H Council; University of Arizona National Alliance for Hispanic Health National Alliance of State and Territorial AIDS Directors

National Assembly on School-Based Health Care National Association of Community Health Centers, Inc. National Association of County and City Health Officials National Association of People With AIDS National Association of School Nurses National Association of State Boards of Education National Center for Health Education National Coalition of Advocates for Students National Coalition of STD Directors National Coalition of STD Directors/ASHA National Commission of Correctional Health Care National Conference of State Legislatures National Council of LaRaza National Education Association: Health Information Network National Environmental Health Association National Governor’s Association National Latina Health Network National Middle School Association National Network for Youth National School Boards Association National Youth Advocacy Coalition Public Education Network School Food Service Foundation Sexuality Information and Education Council of the U.S. Society of State Directors of Health, Physical Education and Recreation STARBRIGHT

of Health Promotion and Public Health Education (which includes the nation’s SHD directors of health promotion and health education).88,89 The CDC also provides technical and fiscal support for nongovernmental organizations that can efficiently help the nation’s two- and four-year colleges and universities, and the nation’s organizations that serve youth in high-risk situations (e.g., homeless and runaway youth, adjudicated youth), to implement policies and programs that can improve the health of the nation’s college students and youth in high-risk situations, respectively. In 2003, the CDC published a Notice of Availability of Funds to implement National Programs to Improve the Health, Education, and Well-Being of Young People.90 This consolidated announcement provides support during Fiscal Year 2004–2009 for six separate elements: (1) helping the nation’s schools build coordinated school health programs and reduce chronic disease risks; (2) helping the nation’s schools

implement effective HIV, STD, and pregnancy prevention programs; (3) building partnerships to support sexual abstinence among young people; (4) helping the nation’s school’s prevent asthma episodes; (5) helping the nation’s schools prevent food borne illnesses; (6) helping the nation’s two- and four-year colleges and universities prevent HIV infection; and (7) helping the nation’s organizations that serve youth in highrisk situations prevent HIV infection. These and other national nongovernmental organizations and their local affiliates, such as the American Cancer Society,91 the American Heart Association,92 and the American Lung Association,93 have long been active in helping schools reduce chronic disease risks and are beginning to work together more closely. A National Coordinating Committee on School Health,94 and an organization called Friends of School Health,95 have been established to help integrate and advance the efforts of about 50 national nongovernmental



organizations that are working to improve school health programs nationwide. To help integrate federal efforts, the CDC has delegated one of its staff 96 to work within and for the U.S. Department of Education’s Office of Safe and Drug Free Schools, which implements, for example, the Carol M. White Physical Education Program Grants.97 In addition, a Federal Interagency Committee on School Health98 has been established to help integrate relevant efforts among a wide range of federal agencies. The committee is cochaired by the Department of Health and Human Services’ Assistant Secretary for Health, the Department of Education’s Deputy Undersecretary for Safe and Drug Free Schools, and the Department of Agriculture’s Undersecretary for Food and Nutrition Services. To further enable the nation’s schools to implement effective policies and programs, the CDC maintains its Adolescent and School Health website99 that provides a wide range of resources, including, for example, the Healthy Youth Funding Database (www2 .cdc.gov/nccdphp/shpfp/index.asp), which enables users to search online for federal, state, and private sector funding available to help implement various types of school health programs.100 In addition, the CDC provides fiscal and technical support for relevant local, state, national, and federal agencies to work together as part of a National Professional Development Consortium to provide skills needed by those implementing programs.101 Finally, the CDC convenes Annual National School Health Meetings102 to involve local, state, national, and federal agencies in collectively using, assessing, and improving the strategies described in this report. 4. Evaluating to assess and improve the effectiveness of implemented policies and programs Recent evaluation research studies provide increasing evidence that carefully designed school health policies and programs can be effective in reducing health risks and health problems, including risks for chronic diseases. As two of many examples, one school intervention was able to modify the fat content of school lunches, increase moderate-to-vigorous physical activity in physical education classes, and improve eating and physical activity behaviors among elementary school children,103 while another was able to reduce the prevalence of obesity among girls.104 The CDC conducts only a small number of such studies; during the next five years, the CDC will conduct two studies of promising school programs to reduce chronic disease risk behaviors. Instead, CDC devotes most of its evaluation resources to helping individual SEAs and large city LEAs

䉫

295

purposefully plan, evaluate, and consequently improve their respective efforts. The Logic Model for Planning and Evaluating SEA & Large City LEA Efforts to Help Schools Improve Health (Figure) provides a common evaluation framework. The columns in the model read progressively from left to right. As listed in the first column, inputs to improve health are usually provided to address a specific health problem, such as to prevent chronic diseases, HIV infection, asthma episodes, or food borne illnesses. These inputs can include funds, assigned staff, legislation and administrative policies, technical assistance, collaboration, and professional development. As indicated at the bottom of column 1, various documents can be used to describe the attainment of these inputs. With such inputs to prevent a specific disease, agencies are enabled to implement the SEA/SHD activities listed in the second column to prevent that disease. These eight priority activities are defined in more detail by Promising Practices.73 As described at the bottom of column 2, various documents can be used to describe the implementation of these activities. The SEA/SHD activities should produce the outputs listed in the next column. These outputs are defined in more detail by Indicators for School Health Programs.105 As indicated at the bottom of column 3, the attainment of these outputs can be assessed by data from Indicators for School Health Programs,105 the School Health Policies and Programs Study,34–38 and evaluations of SEA/SHD efforts. The outputs should produce the short-term effects/ outcomes listed in the next column. These short-term effects/outcomes are defined in more detail by Cooperative Agreement Performance Measures.71As indicated at the bottom of the column, the attainment of these short-term effects/outcomes can be assessed by data from the Health Literacy Assessment Framework,32 the School Health Policies and Programs Study,34–38 School Health Profiles,42–43 and evaluations of SEA/SHD efforts. The short-term effects/outcomes should produce the intermediate effects/outcomes listed in the next column. These intermediate effects/outcomes are defined in more detail by Cooperative Agreement Outcome Objectives,71 relevant Healthy People 2010 Objectives,30–31 relevant CDC Government Performance & Results Act (GPRA) Goals,106 and relevant objectives from CDC’s HIV Prevention Strategic Plan.107 As indicated at the bottom of the column, the attainment of these intermediate effects/outcomes can be assessed by data from the Youth Risk Behavior Survey,28,29 health outcome data, and evaluations of SEA/SHD efforts. Finally, the intermediate effects/outcomes should produce the long-term effects/outcomes listed in the right-


296 䉫

Practice Articles

Figure. Logic model for planning and evaluating SEA/LEA efforts to help schools improve health INPUTS TO IMPROVE HEALTH

Funds — CDC/DASH A. Prevent chronic diseases B. Prevent HIV infection C. Prevent asthma episodes D. Prevent food borne illnesses — Other federal sources — State sources — Private sources Assigned staff — SEA/LEA & SHD/LHD — District- and school-level — Advisory groups State, local, and federal legislation and administrative policy Technical assistance and collaboration — Federal agencies — State agencies — Local agencies — NGOs & affiliates

➡

SEA/SHD ACTIVITIES (For funded inputs A-D)

OUTPUTS (For funded inputs A-D)

As defined by the Eight Priority Activities in Promising Practices

As defined by Indicators for School Health Programs

— Monitor health behaviors and school policies and programs

— Number and quality of surveys conducted

— Establish and maintain program management and administrative support systems

— Existence of program management and administrative support systems

— Build effective partnerships

— Number and nature of partnerships

— Establish policies — Establish a technical assistance and resource plan for school districts — Implement health communications strategies — Develop a professional development plan for school officials and teachers — Establish a system for evaluating and improving policies and programs

➡

— Number and nature of policies — Number of technical assistance contacts and amount of materials disseminated

➡

— Number and nature of communication campaigns — Number of school officials and teachers provided with professional development — Amount of resources acquired to support coordinated school health program — Number of program activities evaluated

Professional development

Evaluation

Evaluation

Evaluation

— Documents to describe attainment of inputs

— Documents to describe activities

— Indicators for School Health Programs — School Health Policies and Programs Study — Program evaluation data

SEA = state education agencies

LEA = large city local education agencies

SHD = state health departments



SHORT-TERM EFFECTS/ OUTCOMES ⬇1 to 3 years (For funded inputs A-D)

INTERMEDIATE EFFECTS/ OUTCOMES ⬇3 to 5 years (For funded inputs A-D)

As defined by Cooperative Agreement Performance Measures

As defined by the Cooperative Agreement Outcome Objectives, Healthy People 2010, GPRA, CDC’s HIV Prevention Strategic Plan

— Effective policies, environmental changes, and educational strategies

A. Prevent chronic disease — Increased consumption of at least five daily servings of fruits and vegetables

— Improved health outcomes

— Increased reports of vigorous physical activity at recommended levels

— Improved social outcomes

— Strategies to reduce health disparities among subpopulations disproportionately affected

➡

䉫

— Integrated school-based policies, programs, and strategies with communitybased strategies — Changes in knowledge, attitudes, and skills

➡

— Reduced proportion overweight or at risk for being overweight — Reduced current use of cigarettes or other tobacco products

LONG-TERM EFFECTS/ OUTCOMES ⬇5 or more years (For funded inputs A-D)

— Improved educational outcomes

➡

B. Prevent HIV infection — Increased abstinence from sexual intercourse or condom use if currently sexually active — Reduced reports of multiple sex partners — Reduced use of alcohol or drugs before last sexual intercourse C. Prevent asthma episodes — Reduced number of school days missed because of persistent asthma — Increased proportion with persistent asthma who have asthma care plans on file at school D. Prevent food borne illnesses — Decreased incidence of food borne illnesses Evaluation

Evaluation

Evaluation

— Health Literacy Assessment Framework — School Health Policies and Programs Study — School Health Profiles — Program evaluation data

— Youth Risk Behavior Survey — Health outcome data — Program evaluation data

— Health outcome data — Education outcome data — Social outcome data

LHD = local health departments

NGOs = national nongovernmental organizations


297

298 䉫

Practice Articles

most column. As indicated at the bottom of the column, the attainment of these long-term effects/outcomes can be assessed by state health, education, and social outcome data. The CDC helps each funded state and large city to adapt the Logic Model to meet their own unique needs and to purposefully plan inputs and activities to prevent chronic diseases; evaluate consequent outputs and effects/outcomes; and subsequently modify inputs and activities to improve outputs and effects/outcomes over time. The CDC also helps funded states and large cities share findings from these evaluations with national, state, and local partners to identify more and less successful approaches.

3. 4.

5.

6. 7.

CONCLUSION As recounted by Rash and Pigg,108 during the 1940s, Willard W. Patty repeatedly told his students that, “. . . School health is public health in a special place.” Modern, coordinated school health programs could provide one of the most efficient means our nation could employ to prevent some of its most serious health problems—especially chronic diseases. During the 1990s, national, state, and local health and education organizations collaboratively developed four public health strategies that could be used to prevent such health problems. By 2003, 48 states, seven territories, and 18 large cities were receiving support to use these strategies to prevent HIV infection; and 18 states were receiving support to use them to prevent chronic diseases. Our nation’s schools are very special places. By working closely with them, public health agencies could efficiently prevent chronic diseases and other serious health problems among successive generations of Americans.

8.

9.

10.

11.

12.

13.

14.

Michael Schmoyer compiled the references and websites for this article. Katherine Vasso developed the graphics. In addition, two anonymous reviewers and an editor for Public Health Reports offered helpful suggestions. The authors gratefully acknowledge their assistance.

REFERENCES 1. Centers for Disease Control and Prevention (US). Chronic diseases and their risk factors: the nation’s leading causes of death, 1999. Atlanta: Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion; 1999. Also available from: URL: http://www.cdc.gov/nccdphp/ statbook/pdf/cdrf1999.pdf 2. Centers for Disease Control and Prevention (US). Unrealized prevention opportunities: reducing the health and economic burden of chronic diseases. Atlanta:

15.

16.

17.

Centers for Disease Control and Prevention, National Center and Chronic Disease Prevention and Health Promotion; 2000. Also available from: URL: http:// www.cdc.gov/nccdphp/upo/pdf/upo.pdf McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-12. McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff 2002;21:78-93. Grunbaum JA, Kann L, Kinchen SA, Williams B, Ross JG, Lowry R, et al. Youth risk behavior surveillance— United States, 2001. MMWR Morb Mortal Wkly Rep 2002;51(SS-4):1-62 [cited 2004 Jan 20]. Available from: URL: http://www.cdc.gov/mmwr/PDF/SS/SS5104.pdf Kolbe LJ. An essential strategy to improve the health and education of Americans. Prev Med 1993;22:544-60. Kolbe LJ, Collins J, Cortese P. Building the capacity of schools to improve the health of the nation. A call for assistance from psychologists. Am Psychol 1997;52:25665. Department of Education (US), National Center for Education Statistics. The condition of education 2001. NCES Publication 2001072. Washington: U.S. Government Printing Office; 2001. Kolbe LJ. Increasing the impact of school health promotion programs: emerging research perspectives. Health Educ 1986;17:47-52. Allensworth DD, Kolbe LJ. The comprehensive school health program: exploring an expanded concept. J Sch Health 1987;57:409-12. Marx E, Wooley SF, Northrup D. Health is academic: a guide to coordinated school health programs. New York: Teachers College Press; 1998. Kolbe LJ. Education reform and the goals of modern school health programs. The State Education Standard 2002;3:4-11. The Gallup Organization. Values and opinions of comprehensive school health education in U.S. public schools: adolescents, parents, and school district administrators. Atlanta: American Cancer Society; 1994. Marzano R, Kendall J, Cicchinelli L. Survey by the Mid-Continent Regional Educational Laboratory. What Americans believe students should know: a survey of U.S. adults. Executive summary. Washington: Office of Educational Research and Improvement, Department of Education; 1998 [cited 2003 Jan 17]. Available from: URL: http://www.mcrel.org/pdfconversion /standards/whatamericansbelieve%5Fexecsumm.html Vega-Matos C, Fraser K, editors. Building business support for school health programs: an action guide. Alexandria (VA): National Association of State Boards of Education; 1999. Guiden M. From the dinner table to the state house. State Legislatures Magazine 2001;27:28-9. Also available from: URL: http://www.ncsl.org/programs /health/1101sclhl.htm Jackson Y, Dietz WH, Sanders C, Kolbe LJ, Whyte JJ, Wechsler H, et al. Summary of the 2000 Surgeon



18.

19.

20.

21.

22.

23.

24. 25. 26.

27.

28.

General’s listening session: toward a national action plan on overweight and obesity. Obes Res 2002;10:12991305. Department of Health and Human Services (US). The national action plan to prevent heart disease and stroke: a comprehensive public health strategy. Atlanta: Department of Health and Human Services, Centers for Disease Control and Prevention; 2003. American Cancer Society. American Cancer Society nationwide goals and objectives cancer prevention and early detection facts and figures 2003. Atlanta: American Cancer Society; 2003. Available from: URL: http:// www.cancer.org/downloads/STT/CPED2003PWSe cured.pdf Allensworth D, Lawson E, Nicholson L, Wyche J, editors. Schools and health: our nation’s investment. Washington: National Academy Press; 1997. Department of Health and Human Services (US). The Surgeon General’s call to action to prevent and decrease overweight and obesity. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General: U.S. Government Printing Office; 2001 [cited 2003 Jan 17]. Available from: URL: http://www.surgeongeneral.gov /topics/obesity/calltoaction/CalltoAction.pdf National Center for Chronic Disease Prevention and Health Promotion. Promoting better health for young people through physical activity and sports: a report to the President from the Secretary of Health and Human Services and the Secretary of Education. Atlanta: Centers for Disease Control and Prevention; Dec 2000 [cited 2003 Jan 17]. Available from: URL: http://www.cdc.gov/nccdphp/dash/physicalactivity /promoting_health/index.htm Department of Health and Human Services (US). HHS budget proposal to include $100 million increase to prevent diabetes, obesity, and asthma across the country: new initiative would support community efforts to combat growing epidemics. Press release, 2003 Jan 22. Healthy Students-Healthy Schools Act of 1992, S. 2191, 102nd Cong., 2nd Sess. (1992). Improved Nutrition and Physical Activity Act of 2002, S. 2821, 107th Cong., 2nd Sess. (2002). World Health Organization. Promoting health through schools. Report of a WHO expert committee on comprehensive school health education and promotion. Geneva: WHO; 1997 [cited 2003 Jan 17]. Available from: URL: http://www.who.int/wormcontrol /documents/en/trs_870.pdf Aboderin I, Kalache A, Ben-Shlomo Y, Lynch JW, Yajnik CS, Kuh D, et al. Life course perspectives on coronary heart disease, stroke, and diabetes: key issues and implications for policy and research. Geneva: World Health Organization; 2001. p. 49 [cited 2003 Jan 17]. Available from: URL: http://www.who.int/hpr/ageing /life%20 course%20short%20report.PDF Kolbe LJ, Kann L, Collins JL. Overview of the Youth


29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

䉫

299

Risk Behavior Surveillance System. Public Health Rep 1993;108(Suppl 1):2-10. Centers for Disease Control and Prevention (US). Leading causes of morbidity and mortality: summary results: YRBSS United States and by state [cited 2003 Jan 17]. Available from: URL: http://www.cdc.gov /nccdphp/dash/yrbs/2001/summary_results/ Department of Health and Human Services (US). Healthy people 2010. Volumes I and II, 2nd ed. Washington: U.S. Government Printing Office; 2000. Also available from: URL: http://www.healthypeople.gov /Publications/ Department of Health and Human Services (US). Leading Health Indicators. In: Healthy people 2010 Volume I, 2nd ed. Washington: U.S. Government Printing Office; 2000. p. 24-46. Also available from: URL: http://www.healthypeople.gov/LHI/ Council of Chief State School Officers and State Collaborative on Assessment and Student Standards. Assessing health literacy: assessment framework. Santa Cruz (CA): Toucan Education; 1998. Joint Committee on National Health Education Standards. National health standards: achieving health literacy. Reston (VA): American Alliance for Health, Physical Education, Recreation and Dance (AAHPERD); 1995. Centers for Disease Control and Prevention (US). School Health Policies and Programs Study (SHPPS): a summary report. J Sch Health 1995;65:281-353. Centers for Disease Control and Prevention (US). School Health Policies and Programs Study (SHPPS): in depth analyses. J Health Educ 1999;30:558-64. Centers for Disease Control and Prevention (US). School Health Policies and Programs Study (SHPPS) 2000: a summary report. J Sch Health 2001;71:251350. Centers for Disease Control and Prevention (US). Statelevel school health policies and practices: a state-bystate summary from the School Health Policies and Programs Study 2000. Atlanta: Centers for Disease Control and Prevention; 2001. Centers for Disease Control and Prevention (US). School Health Policies and Programs Study 2000, state report cards. Atlanta: Centers for Disease Control and Prevention; 2000 [cited 2003 Jan 17]. Available from: URL: http://www.cdc.gov/nccdphp/dash/shpps /report_cards/index.htm Centers for Disease Control and Prevention (US). Fact sheet: tobacco use prevention. From CDC’s School Health Policies and Programs Study (SHPPS) 2000 [cited 2003 Jan 17]. Available from: URL: http:// www.cdc.gov/nccdphp/dash/shpps/factsheets /pdf00/tobacco.pdf Centers for Disease Control and Prevention (US). Fact sheet: nutrition services. From CDC’s School Health Policies and Programs Study (SHPPS) 2000 [cited 2003 Jan 17]. Available from: URL: http://www.cdc.gov /nccdphp/dash/shpps/factsheets/fs00_ns.htm

300 䉫

Practice Articles

41. Centers for Disease Control and Prevention (US). Physical education and activity fact sheet. From CDC’s School Health Policies and Programs Study (SHPPS) 2000 [cited 2003 Jan 17]. Available from: URL: http:// www.cdc.gov/nccdphp/dash/shpps/factsheets /fs00_pe.htm 42. Grunbaum JA, Kann L, Williams B, Kinchen SA, Collins J, Kolbe LJ. Characteristics of health education among secondary schools—School Health Education Profiles, 1996. MMWR Morb Mortal Wkly Rep 1998;47(SS04):163. Also available from: URL: http://www.cdc.gov /mmwr/PDF/SS/SS4704.pdf 43. Grunbaum JA, Kann L, Williams B, Kinchen SA, Collins J, Baumler E, et al. Surveillance for characteristics of health education among secondary schools—School Health Education Profiles, 1998. MMWR Morb Mortal Wkly Rep 2000;49(SS-8):1-41 [cited 2003 Jan 17]. Available from: URL: http://www.cdc.gov/mmwr/preview /mmwrhtml/ss4908a1.htm 44. Centers for Disease Control and Prevention (US). Adolescent and school health state-by-state information. Dec 2002 [cited 2003 Jan 17]. Available from: URL: http://www.cdc.gov/nccdphp/dash/state_info/ 45. Council of Chief State School Officers. Action for healthy kids: national and state profiles [cited 2003 Jan 17]. Available from: URL: http://www.actionfor healthykids.org/tools/profiles.htm 46. Department of Health and Human Services (US). Summary of findings from National Children and Youth Fitness Study. J Phys Educ Recreat Dance 1985;56 (1):44–90. 47. Department of Health and Human Services (US). Summary of findings from National Children and Youth Fitness Study II. J Phys Educ Recreat Dance 1987;58(9): 50–96. 48. Centers for Disease Control and Prevention (US). Healthy Passages: a multilevel, multimethod longitudinal study of adolescent health (Fact Sheet); 2003. 49. Windle M, Berry S, Collins J, Elliott M, Gilliland J, Grunbaum JA, et al. Healthy Passages: a multilevel, multimethod longitudinal study of adolescent health. In press 2004. 50. Council of Chief State School Officers. Incorporating health-related indicators in education accountability systems. Washington: Council of Chief State School Officers; 1998. 51. Kolbe L. Indicators for planning and monitoring school health programs. In S Kar, D Churgin, E Berkanovic, editors. Health promoting indicators and actions. New York: Springer; 1988. p. 221-48. 52. Centers for Disease Control and Prevention (US). The Guide to Community Preventive Services [cited 2003 Jan 17]. Available from: URL: http://www.cdc.gov /epo/communityguide.htm 53. Truman BI, Smith-Akin CK, Hinman AR, Gebbie KM, Brownson R, Novick LF, et al. Developing the Guide to Community Preventive Services—overview and rationale. Am J Prev Med 2000;18(1 Suppl):18-26.

54. Centers for Disease Control and Prevention (US). Increasing physical activity: a report on recommendations of the Task Force on Community Preventive Services. MMWR Morb Mortal Wkly Rep 2001:50 (RR18):1-16. Also available from: URL: http://www.cdc .gov/mmwr/PDF/RR/RR5018.pdf 55. Kahn EB, Ramsey LT, Brownson RC, Heath GW, Howze EH, Powell KE, et al. The effectiveness of interventions to increase physical activity. A systematic review. Am J Prev Med 2002;22(4 Suppl):73-107. 56. Centers for Disease Control and Prevention (US). Strategies for reducing exposure to environmental tobacco smoke, increasing tobacco-use cessation, and reducing initiation in communities and health-care systems: a report on recommendations of the Task Force on Community Preventive Services. MMWR Morb Mortal Wkly Rep 2000;49(RR12):1-11. Also available from: URL: http://www.cdc.gov/mmwr/PDF/RR/RR4912 .pdf 57. Taskforce on Community Preventive Services. The Guide to Community Preventive Services: nutrition [cited 2003 Jan 17]. Available from: URL: http:// www.thecommunity guide.org/nutrition/ 58. Taskforce on Community Preventive Services. The Guide to Community Preventive Services: school-based or school-linked pit and fissure sealant delivery programs are effective in reducing tooth decay in children and adolescents [cited 2003 Jan 17]. Available from: URL: http://www.thecommunityguide.org/oral /oral-int-seal.pdf 59. Taskforce on Community Preventive Services. The Guide to Community Preventive Services: effectiveness of requiring vaccinations for child care, school, and college attendance to increase vaccination coverage [cited 2003 Jan 17]. Available from: URL: http:// www.thecommunity guide.org/vaccine/vpd-intdemand-require.pdf 60. Centers for Disease Control and Prevention (US). Guidelines for school health programs to prevent tobacco use and addiction. MMWR Morb Mortal Wkly Rep 1994;43(RR02):1-20. Also available from: URL: http://www.cdc.gov/mmwr/PDF/RR/RR4302 61. Centers for Disease Control and Prevention (US). Guidelines for school health programs to promote lifelong healthy eating. MMWR Morb Mortal Wkly Rep 1996;45(RR09):1-42. Also available from: URL: http://www.cdc.gov/mmwr/PDF/RR/RR4509.pdf 62. Centers for Disease Control and Prevention (US). Guidelines for school and community programs to promote lifelong physical activity among young people. MMWR Morb Mortal Wkly Rep 1997;46(RR06):1-37. Also available from: URL: http://www.cdc.gov/mmwr /RR/RR4606.pdf 63. Centers for Disease Control and Prevention (US). School health guidelines to prevent unintentional injuries and violence. MMWR Morb Mortal Wkly Rep 2001;50 (RR22):1-76. Also available from: URL: http:// www.cdc.gov/mmwr/PDF/RR/RR5022.pdf



64. Centers for Disease Control and Prevention (US). Guidelines for school programs to prevent skin cancer. MMWR Morb Mortal Wkly Rep 2002;51(RR04):116. Also available from: URL: http://www.cdc.gov /mmwr/PDF/RR/RR5104.pdf 65. Centers for Disease Control and Prevention (US). The School Health Index website [cited 2003 Jan 17]. Available from: URL: http://www.cdc.gov/nccdphp/dash /SHI/ 66. National Association of State Boards of Education. Fit, Healthy, and Ready to Learn: a school health policy guide. Part 1: Physical activity, healthy eating, and tobacco-use prevention. Alexandria (VA): NASBE; 2002. 67. Centers for Disease Control and Prevention (US). Health Education Curriculum Analysis Tool (HE-CAT) [DRAFT]. Atlanta: Centers for Disease Control and Prevention. Forthcoming 2004. 68. Centers for Disease Control and Prevention (US). Physical Education Curriculum Analysis Tool (PE-CAT) [DRAFT]. Atlanta: Centers for Disease Control and Prevention. Forthcoming 2004. 69. Joint Committee on Health Education Standards. National Health Education Standards: achieving health literacy. Reston (VA): American Alliance for Health, Physical Education, Recreation & Dance (AAHPERD); 1995. 70. Centers for Disease Control and Prevention (US). Guide to health education curricula [DRAFT]. Atlanta: Centers for Disease Control and Prevention. Forthcoming 2004. 71. Department of Health and Human Services (US). Improving the health, education, and well-being of young people through coordinated school health programs. Notice of availability of funds [program announcement 03004]. Fed Regist 2002;67(180):58610-24. 72. Council of Chief State School Officers, Society of State Directors of Health, Physical Education, and Recreation, and Association of State and Territorial Health Officials. Directory of coordinated school health program staff 2002–2003. Washington: CCSO; 2002 [cited 2003 Jan 17]. Available from: URL: http://www.ccsso .org/Projects/school_health_project/directory_of_ coordinated_school_health_program_staff/ 73. Fisher C, Hunt P, Kann L, Kolbe LJ, Patterson B, Wechsler H. Building a healthier future through school health programs. In: Promising practices for chronic disease prevention and control. Atlanta: Department of Health and Human Services; 2003. 74. Department of Health and Human Services (US). Preventing tobacco use among young people: a report of the Surgeon General. Washington: U.S. Government Printing Office; 1994: p. 225-6. 75. Department of Health and Human Services (US). National Cancer Prevention and Control Program. Open season; notice of availability of funds [program announcement 02060-FY03]. Fed Regist 2003;68(13): 2780-3. 76. Department of Health and Human Services (US). Public Health Reports / May–June 2004 / Volume 119

77.

78.

79.

80.

81.

82.

83.

84.

85.

86.

87.

䉫

301

Chronic Disease Prevention and Health Promotion Programs; component 2: State Nutrition and Physical Activity Programs to Prevent Obesity and Other Chronic Diseases [program announcement 03022]. Fed Regist 2003;68(15):3333-8. Department of Health and Human Services (US). Chronic Disease Prevention and Health Promotion Programs; component 1: Comprehensive State-Based Tobacco Prevention and Control Programs [program announcement 03022]. Fed Regist 2003;68(15):332833. Department of Health and Human Services (US). Cardiovascular health programs. Notice of availability of funds [program announcement 02045-FY03]. Fed Regist 2002;67(40):9281-9. Centers for Disease Control and Prevention (US). Cardiovascular Disease Prevention – National Center for Chronic Disease Prevention and Health Promotion Coordination Plan [DRAFT]. Atlanta: Centers for Disease Control and Prevention; 2004. Centers for Disease Control and Prevention (US). Stories from the field: lessons learned about building coordinated school health programs. Atlanta: Centers for Disease Control and Prevention; 2003. Department of Health and Human Services (US). Cooperative agreement for national programs to prevent HIV infection and other important health problems among youth strengthen coordinated school heath programs; notice of availability of funds [program announcement 99023]. Fed Regist 1998;63 (218):6331924. Also available from: URL: http://frwebgate6 .access.gpo.gov/cgi-bin/waisgate.cgi?WAISdocID =09503457828+0+0+0&WAISaction=retrieve Centers for Disease Control and Prevention (US). National organizations working for healthy youth: 2001 project summaries. Atlanta: National Center for Chronic Disease Prevention and Health Promotion; 2001. National Association of State Boards of Education. Safe and healthy schools [cited 2004 Jan 17]. Available from: URL: http://www.nasbe.org HealthySchools /index .html Bogden J. How schools work & how to work with schools: a primer for professionals who serve children and youth. Alexandria (VA): National Association of State Boards of Education; 2003. Society of State Directors of Health, Physical Education and Recreation (SSDHPER). SSDHPER home page [cited 2004 Feb 5]. Available from: URL: http:// www.thesociety.org/ Chronic Disease Directors. Chronic disease directors home page [cited 2003 January 17]. Available from: URL: http://www.chronicdisease.org/ Coordinated School Health Program Collaborative. School business: building effective strategies for chronic disease prevention and health promotion in schools. McLean (VA): Chronic Disease Directors; 2002.

302 䉫

Practice Articles

88. Directors of Health Promotion and Education (DHPE). DHPE home page [cited 2004 Feb 5]. Available from: URL: http://www.astdhpphe.org/ 89. Directors of Health Promotion and Education (DHPE) and Chronic Disease Directors (CDD). 2001 needs assessment overview: state health agency involvement in coordinated school health programs. McLean (VA): Chronic Disease Directors; 2003. 90. Department of Health and Human Services (US). National Programs to Improve the Health, Education, and Well-Being of Young People. Notice of availability of funds. [program announcement 04010]. Fed Regist 2003;68(195):58103-10. Also available from: URL: http:// frwebgate4.access.gpo.gov/cgi-bin/waisgate.cgi? WAISdocID=09688119322+2+0+0&WAISaction= retrieve 91. American Cancer Society. School health program elements of excellence: helping children to grow up healthy and able to learn. Atlanta: American Cancer Society; 2000 92. American Heart Association. Comprehensive school health programs website [cited 2003 Jan 17]. Available from: URL: http://www.americanheart.org/presenter .jhtml? identifier=3003754 93. American Lung Association. School programs index site [cited 2003 Jan 17]. Available from: URL: http:// www.lungusa.org/school/index.html 94. National Coordinating Committee on School Health. Vision and mission statement [cited 2003 Jan 17]. Available from: URL: http://www.healthy students.org /mission.cfm 95. Friends of School Health. Informal membership list. Unpublished; 2003. 96. Department of Education (US) and Centers for Disease Control and Prevention (US). Letter of agreement concerning the coordination of school health activities between the Office of Safe and Drug-Free Schools and the Division of Adolescent and School Health at CDC. Unpublished 2003. 97. Department of Education (US). Office of Elementary and Secondary Education. Carol M. White Physical Education Program. Notice inviting applications for new awards for FY 2002 [CFDA No. 84.215]. Fed Regist 2002;67 (78):19737-40 [cited 2003 Jan 17]. Available from: URL: http://www.ed.gov/legislation/Fed Register/announcements/2002-2/042302a.html 98. Payzant TW, Lee PR, Haas EW. Federal Interagency Committee on School Health Charter. Atlanta: Centers for Disease Control and Prevention; 1994.

99. Centers for Disease Control and Prevention (US). CDC’s adolescent and school health program website [cited 2003 Jan 17]. Available from: URL: http:// www.cdc.gov/nccdphp/dash/ 100. Centers for Disease Control and Prevention (US). Healthy youth funding database [cited 2003 Jan 17]. Available from: URL: http://apps.nccd.cdc.gov/shpfp/ 101. Department of Health and Human Services (US). National Programs to Improve the Health, Education, and Well-Being of Young People: notice of availability of funds; training consortium section (program announcement 04010). Atlanta: Centers for Disease Control and Prevention; 2003. Also available from: URL: http://frwebgate4.access.gpo.gov/cgi-bin/waisgate .cgi?WAISdocID=09688119322+2+0+0&WAISaction =retrieve 102. Centers for Disease Control and Prevention (US). DASH conference website [cited 2003 Jan 17]. Available from: URL: http://www.cdc.gov/nccdphp/dash /conference/index.htm 103. Luepker RV, Perry CL, McKinlay SM, Nader PR, Parcel GS, Stone EJ, et al. Outcomes of a field trial to improve children’s dietary patterns and physical activity. CATCH collaborative group. JAMA 1996;275:76876. 104. Gortmaker SL, Peterson K, Wiecha J, Sobol AM, Dixit S, Fox MK, Laird N. Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Arch Pediatr Adolesc Med 1999;153:409-18. 105. Centers for Disease Control and Prevention (US). Indicators for School Health Programs (ISHP). Atlanta: Centers for Disease Control and Prevention [DRAFT]; forthcoming 2004. 106. Centers for Disease Control and Prevention (US). Final FY2004 GPRA Annual Performance Plans; Revised FY2003 GPRA Annual Performance Plans; FY2002 GPRA Annual Performance Report. Atlanta: CDC [cited 2004 Jan 7]. Available from: URL: http:// www.cdc.gov/od/perfplan/2003pt1.pdf 107. Centers for Disease Control and Prevention (US). HIV Prevention Strategic Plan through 2005. Atlanta: CDC. Available from: URL: http://www.cdc.gov/nchstp/od /hiv_plan/default.htm 108. Rash JK, Pigg RM. The health education curriculum: a guide for curriculum development in health education. New York: John Wiley & Sons; 1979. p. 39.
