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December 1, 2009
Vol. 67
No. 4

Coordinated School Health: Getting It All Together

Tennessee is implementing coordinated school health statewide—and here's what it looks like.

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In 1918, the National Education Association included health as one of seven cardinal principles of education. The authors noted that "'book larnin' may be inhibited by an overworked thyroid or an undernourished body" and "temper tantrums or daydreaming may be induced by hunger" (Oberteuffer, 1918, p. 8). More recently, David Satcher, former U.S. Surgeon General, stated, "Ignoring student health is shortsighted . . . because an investment in health is an investment in better academic performance" (Satcher & Bradford, 2003).
Research confirms a strong relationship between student health and school performance (Association of State and Territorial Health Officials & Society of State Directors of Health, Physical Education, and Recreation, 2002; Ehrlich, 2005; Symons, Cinelli, James, & Groff, 1997). So why have U.S. schools and districts minimized or eliminated health and physical education programs; reduced the number of school nurses, counselors, and other health professionals; and focused only on "the basics"? In large part, because of No Child Left Behind (NCLB).
But in these difficult times, one approach can help—coordinated school health. In the short term, this program can provide a safe haven for teaching and learning by addressing the immediate needs of the whole child. In the long term, it can have a significant effect on youth development and academic achievement (Fetro, 2005; Murray, Low, Hollis, Cross, & Davis, 2007).

What Is Coordinated School Health?

Coordinated school health is not another new program to add to schools' already overflowing plates; it's a framework for managing new and existing health-related programs and services in schools and the surrounding community. Such an approach incorporates eight interrelated components that historically have functioned independently: health education; physical education; school health services; counseling, psychological, and social services; nutrition services; staff wellness; a healthy school environment; and family and community involvement. These eight components can help improve students' knowledge, behaviors, attitudes, and skills in health; they can also improve academic and social outcomes (Kolbe, 2002, 2005).
Coordinated school health is an ongoing process. People committed to the health of young people communicate; they share what they believe and what they are doing to promote student health. They cooperate, functioning independently while supporting one another's programs and services. Theycoordinate by reviewing related program goals and action plans for compatibility and by identifying gaps and duplication. They collaborate by working together to develop a common vision and to establish priorities and shared goals. Finally, they integrate, developing seamless, blended programs and services with shared responsibility and accountability (Fetro, 2005).
Because every school and district has different programs and services to support students' health-related needs, coordinated school health looks different in every school. Schools need to begin by looking at what they already have in place. Most likely, every school has programs and services that are related, to some degree, to each of the eight components. The ultimate goal, however, is for the eight components to be coordinated.

The Essential Eight

In 2000, recognizing the connection between adolescent health and academic achievement, Tennessee's state legislature funded a five-year pilot program to implement coordinated school health in 10 counties. On the basis of this successful pilot, school health advocates convinced state legislators to expand and fund coordinated school health statewide. Tennessee is now focusing on integrating and coordinating the eight components of the framework.

Health Education

Every day, students are bombarded with new information about health. How can they know what is accurate, what is relevant, and how to use that new health information? The goal of health education is to develop health-literate youth who understand basic health concepts and use personal and social skills—for example, skills related to advocacy, decision making, goal setting, and stress management—to promote and enhance their health (Joint Committee on National Health Education Standards, 2007). Although it rarely occurs, students should receive health education in every grade.

Physical Education

Lack of physical activity among youth is a major concern today. Research has documented the link between physical education and school performance. High-quality physical education programs increase physical competence, fitness, and responsibility, encouraging students to value lifelong physical activity (National Association for Sport and Physical Education, 2005).
In each of its six elementary schools, Tennessee's Loudon County installed a new Beanstalk Fitness Adventure Playground, complete with ropes courses and a tree house. Students scrambled to use the new structures. At one school, an autistic boy came out of his protective shell momentarily and smiled for the first time that year at the sight of the playground.

School Health Services

Despite efforts of parents and guardians, many students arrive at school with health issues that could affect their academic performance. Health services can include first aid, emergency, and diagnostic health care; health assessments and screenings; assistance with medication; and management of acute and chronic health conditions. School health services can work with community health agencies and professionals to provide more comprehensive services.
Students in Tennessee have benefited from routine health screenings. An 8-year-old who didn't pass her school's vision screening was referred to an optometrist who was able to treat the girl for a condition that, if left untreated, might have blinded her. A well-child exam revealed that a kindergartner who was having trouble learning his colors was, in fact, colorblind. A Project Diabetes grant enabled two schools to work closely with 27 students who were at risk for developing type 1 or type 2 diabetes.

Counseling, Psychological, and Social Services

Schools need to provide additional support to students at risk of academic failure as a result of emotional challenges brought about by situations in or out of school. Services in school can include career counseling, peer mentoring and counseling, mental health counseling, peer support groups, and positive alternative programs. In collaboration with community-based programs and services, the school or district can establish a system for early identification, assessment, and referral of students needing assistance.


Many students take advantage of meals offered at school. Food service programs should provide breakfasts and lunches that are not only nutritionally balanced, but also appealing. In addition, the school cafeteria can be a learning laboratory that reinforces what students learn in health classes, encouraging students to make healthier food choices when they are out of school.
With community support, one school in rural Tennessee created an on-site supermarket. The school is developing lesson plans that teach students how to read food labels, what foods are necessary for a healthy diet, and how to prepare food; in addition, students learn about food preservatives, processed foods, hand washing, and food safety. Lessons incorporate math (for example, figuring out percentages of the daily recommended amount of fiber in certain products); language arts (signs in the store are written in both English and Spanish); and social studies.

Staff Wellness

Teachers and other school staff are important role models for students. The more teachers value health, the more their classroom practices support student health. Staff health promotion programs usually are an afterthought, when in reality they are crucial. Programs for teachers and staff include workshops related to healthy dietary patterns; stress management; weight management; cardiovascular fitness; first aid and cardiopulmonary resuscitation (CPR); safety issues; and tobacco, alcohol, and other drug use.
Partnering with the Putnam County Health Department, a Tennessee school system created a weight-loss program for its teachers and administrators, which involved the use of treadmills that the county had purchased. One teacher who lost a substantial amount of weight served as a role model for her students, one of whom asked whether he could come in early and use the treadmill before school started.

A Healthy School Environment

To learn effectively, students and teachers need a healthy school environment, one that is clean, well lit, comfortable, physically safe, and graffiti-free, with minimal noise and other distractions. Equally important, the psychosocial environment should support diversity and promote personal growth, wellness, and healthy relationships. The school should communicate and consistently enforce formal and informal policies and procedures related to student health, safety, and conduct. These policies typically address such issues as the use of tobacco, alcohol, and other drugs; name calling; sexual harassment; violent behaviors; and emergency preparedness.

Family and Community Involvement

Increasing schools' capacity to address students' diverse needs requires family and community involvement. Every school community, no matter how large or small, has untapped resources. Schools should coordinate and integrate activities and initiatives both inside and outside the school. This partnership should be two-way and should include advisory groups and coalitions, advocacy campaigns, family and community outreach programs, and adult mentor programs.
For example, many schools invite in community speakers when discussing health issues in class. As human resources dwindle in schools, parent and community volunteers can assist with coordinated school health activities. Schools can also provide outreach to parents and community members, beginning with awareness sessions and broadening to parenting skills.

Tennessee Takes Action

Tennessee is moving steadily toward full implementation of coordinated school health by the 2012–13 school year. All school districts are striving for compliance with Tennessee school health laws and coordinated school health standards and guidelines. They are hiring full-time coordinators for the program; sending educators to mandatory professional development institutes; and establishing community school health advisory committees, district-level staff coordinating councils, and healthy school teams. Districts are also completing the School Health Index and Youth Risk Behavior Survey—both of which are available from the Centers for Disease Control and Prevention (CDC)—and using the results to develop annual action plans with measurable objectives.
The School Health Index has eight modules, each of which addresses one of the eight components of coordinated school health. The index asks schools such questions as, Do you have 225 minutes of physical education per week? Do you have breakfast and lunch programs? and Do you offer health screening for all staff?
The CDC's Youth Risk Behavior Survey that the schools administered in 2007 had some eye-opening results. Among other findings, it showed that approximately 11 percent of students rarely or never wore a seat belt when riding in a car driven by someone else; that 29 percent of students had recently ridden in a car driven by someone who had been drinking; that 35 percent had been in a physical fight during the 12 months before the survey; that in the previous 30 days, 14.5 percent had seriously considered suicide; and that before the age of 13, 14 percent of students had smoked their first cigarette, 24 percent had tried alcohol, 8 percent had used marijuana, and 7 percent had had sexual intercourse.

A District Success Story

The CDC's Division of Adolescent and School Health selected Gibson County Special School District in western Tennessee as one of six districts across the United States that has an outstanding coordinated school health program. One of the 10 original pilot districts in Tennessee, the school district includes nine schools, with a total enrollment of 3,425 students in grades preK–12.
All Gibson County students explore health concepts and develop health-promoting skills as their schools follow the Michigan Model, a comprehensive school health education program that is currently being implemented in 30 U.S. states as well as in several foreign countries.
Many other programs in Gibson County enhance the health education curriculum. For example, school nurses teach 5th and 6th graders about changes occurring during puberty. Tennessee's National Guard Counterdrug Task Force facilitates a 14-week life skills program to reduce drug use in middle schools. A community partner, Right Choices of West Tennessee, provides a youth development program to help middle school students refrain from engaging in risky behaviors. In collaboration with numerous community partners, each school hosts a health fair.
In addition to providing physical education to all county students, elementary schools participate in the Blue Cross Walking Works for Schools program, which requires students to walk at least 5 minutes every school day for 12 weeks each semester. Five schools incorporate Wii Fit, Wii Yoga, and Wii Sports into their after-school programs. Other elementary schools use PlayStation 2 and Dance Dance Revolution to increase physical activity. Middle school and high school students as well as adults can use the ACES challenge ropes course.
Several activities reinforce positive dietary choices in the cafeteria—for example, Nutri Notes newsletters for students and parents, nutrition bulletin boards, and My Pyramid posters, which remind students ages 6–11 to be physically active and make healthy food choices. A registered dietitian works with healthy school teams to develop individualized nutrition plans for students or staff members needing assistance in this area.
School nurses organize student health screenings for vision, hearing, scoliosis, and body mass index. School staff members receive free health screenings, which address weight, hearing, vision, body mass index, blood pressure, cholesterol levels, blood glucose levels, blood iron levels, and bone density. They also receive professional development about first aid/CPR and blood-borne pathogens, such as hepatitis B and HIV/AIDS. The county is moving toward establishing a school-based health clinic for students, staff, and families.
In addition to day-to-day responsibilities, school counselors provide suicide prevention and intervention training to staff; facilitate a teen parenting program; assist parents and guardians with CoverKids (comprehensive health coverage for uninsured children); and run an anticyberbullying program.
With community partners, Gibson County's Office of Community School Health developed a dramatization of a car crash and presented it to county high schools. Students saw police, medical, and rescue personnel arrive on the scene. They witnessed the police handcuffing the driver and taking him away in a police car, a seriously injured passenger being treated and then airlifted to a hospital, and the reactions of the distraught parents of the injured students.
Outside speakers present at Parent Teacher Organization meetings as requested. A teen action group participates in creating public service announcements to help students make responsible decisions concerning alcohol, tobacco, and other substances. Parent volunteers assist nurses in completing required health screenings. All schools implement a local wellness policy consistent with that of their district.
Gibson County's Office of Coordinated School Health maintains a Web site with helpful links for staff members (see www.gcssd.org/csh/index.htm). All faculty and staff members receive Walk Smart tips, nutrition fact sheets, obesity education information, and a quarterly newsletter on health. Two district schools have staff wellness rooms with fitness equipment and resources. All district employees also receive flu and Hepatitis B shots.

Making It Happen

Currently, the Centers for Disease Control and Prevention provides funding for 22 states to assist schools and school districts in effectively implementing coordinated school health (seewww.cdc.gov/healthyyouth). The Massachusetts Department of Education and San Francisco Unified School District also provide professional development and technical support to state and local education agencies in their efforts to effectively implement the program.
But the bottom line is about people. When everyone—from state legislators to county coordinators, to healthy school teams, to community partners, to teachers, to parents—is committed to young people's well-being, coordinated school health can become a reality. It takes time, often years, to put it together. But the Tennessee story is one example of people making it happen.

Association of State and Territorial Health Officials & Society of State Directors of Health, Physical Education, and Recreation. (2002). Making the connection: Health and student achievement. Available:www.thesociety.org/info.html

Ehrlich, G. (2005). Healthy kids learn better. . .and perform better. The RMC Health Educator, 6, 1–4.

Fetro, J. V. (2005). Step by step to health-promoting schools: Program planning guide. Santa Cruz, CA: ETR Associates.

Joint Committee on National Health Education Standards. (2007). National health education standards: Achieving excellence(2nd ed.). Atlanta: Author.

Kolbe, L. J. (2002, Autumn). Education reform and the goals of modern school health programs. The State Education Standard, 4–10.

Kolbe, L. J. (2005). A framework for school health programs in the 21st century.Journal of School Health, 75, 226–228.

Murray, N. G., Low, B. J., Hollis, C., Cross, A. W., & Davis, S. M. (2007). Coordinated school health programs and academic achievement: A systematic review of the literature. Journal of School Health, 77, 589–600.

National Association for Sport and Physical Education. (2005). Moving into the future: National standards for physical education(2nd ed.). Alexandria, VA: Author.

Oberteuffer, D. (1918). Health. In National Education Association, Committee on Reorganization of Secondary Education (Ed.), Cardinal principles of secondary Education (pp. 7–13). Washington, DC: Author.

Satcher, D., & Bradford, M. T. (2003, March). Healthy schools, healthy kids.American School Board Journal, 190(3). Available:www.nsba.org/MainMenu/SchoolHealth/SelectedNSBAPublications/ComprehensiveCoordinatedSchoolHealth/HealthySchoolsHealthyKids.aspx

Symons, C. W., Cinelli, B., James, T. C., & Groff, P. (1997). Bridging student health risks and academic achievement through comprehensive school health programs.Journal of School Health, 67, 220–227.

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