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Applying the School Health Index to a Nationally Representative Sample of Schools

Posted on: Friday, 3 March 2006, 06:00 CST

By Brener, Nancy D; Pejavara, Anu; Barrios, Lisa C; Crossett, Linda; Et al

ABSTRACT:

The School Health Index (SHI) is a self-assessment and planning tool that helps individual schools identify the strengths and weaknesses of their health policies and programs. To determine the percentage of US schools meeting the recommendations in the SHI, the present study analyzed data from the School Health Policies and Programs Study (SHPPS) 2000. The SHPPS 2000 data were collected through computer-assisted personal interviews with faculty and staff in a nationally representative sample of schools. The SHPPS 2000 questions were then matched to SHI items to calculate the percentage of schools meeting the recommendations in 4 areas: school health and safety policies and environment, health education, physical education and other physical activity programs, and nutrition services. Although schools nationwide are meeting a few SHI items in each of these areas, few schools are addressing the entire breadth of items. A more coordinated approach to school health would help schools reinforce health messages. (J Sch Health. 2006;76(2):57-66)

The School Health Index: A Self-Assessment and Planning Guide (SHI) was developed in 2000 by the Centers for Disease Control and Prevention (CDC) in partnership with school administrators and staff, school health experts, parents, and national nongovernmental organizations.1 The third edition of the SHI was released in 2004 and includes content related to physical activity and physical education, healthy eating, tobacco-use prevention, and unintentional injury and violence prevention. Two versions are available: 1 for elementary schools and 1 for middle and high schools.

The SHI enables schools to (1) identify the strengths and weaknesses of their health-promotion policies and programs, (2) develop an action plan for improving student health, and (3) involve teachers, parents, students, and the community in improving school policies, programs, and services. Because the health and safety of students is influenced by multiple factors, the SHI has 8 different modules, each of which corresponds with a component of a coordinated school health program.

Module 1: School health and safety policies and environment

Module 2: Health education

Module 3: Physical education and other physical activity programs

Module 4: Nutrition services

Module 5: Health services

Module 6: School counseling, psychological, and social services

Module 7: Health promotion for staff

Module 8: Family and community involvement

Each item in the SHI represents a research-based recommendation for a school health policy or program that is based on CDC's guidelines for school health programs.2-5 A sample SHI item from Module 1 is shown in Figure 1.

To measure school health policies and programs nationwide, CDC established the School Health Policies and Programs Study (SHPPS).6 The SHPPS was conducted for the first time in 1994 and again in 2000. It provides data from a nationally representative sample of schools and covers the same 8 school health program components that make up the SHI.

The analysis presented here uses data from SHPPS 2000 to achieve 3 objectives: (1) to establish a baseline estimate of the percentage of schools in the United States that meet the recommendations in the SHI, (2) to provide schools completing the SHI with information they can use as a benchmark of how they relate to schools nationally, and (3) to help identify the strengths and weaknesses of health and safety policies and programs in schools nationwide. This information can then be used to help target national efforts to address weaker areas.

Although SHPPS data corresponding to all 8 SHI modules are available, because of space limitations, this article focuses on the first 4 SHI modules: health and safety policies and environment, health education, physical education and other physical activity programs, and nutrition services. This study provides data on the percentage of elementary schools and middle and high schools meeting SHI items and also assesses whether the percentages vary by school level (elementary vs middle and high school).

METHODS

The present analysis used data from 6 of the 8 school health program components assessed in SHPPS 2000. Four of the SHPPS components-school policy and environment, health education, physical education and activity, and food service-correspond directly with the first 4 SHI modules. Measurement of some SHI items within these modules also used data from the health services and mental health and social services components of SHPPS.

Figure 1

Sample item, School Health Index, third edition

SHPPS 2000 Methods

In SHPPS 2000, data were collected at the state, district, school, and classroom levels, but because the SHI is designed for self-assessment at the school level, the current analysis used the school- and classroom-level data only. The SHPPS school-level data were collected from a nationally representative sample of public and private elementary, middle/junior high, and senior high schools. The data were collected through computer-assisted personal interviews completed between January and June 2000. During recruitment, the principal or another school-level contact designated a faculty or staff respondent for each school health program component questionnaire. This respondent either had primary responsibility for or was the most knowledgeable about the particular component. For example, the most common respondents for the health services interview were school nurses, whereas the most common respondents for the food service interview were school food service managers.

In elementary schools, classroom-level data were collected through computer-assisted personal interviews with teachers of randomly selected classes. In middle/junior and senior high schools, interviews were conducted with teachers of randomly selected required health education and physical education courses.

Interviews were conducted by 115 field interviewers employed by a professional survey research firm. Most of the interviewers had previous interviewing experience. Before data collection began, the interviewers completed an 11-day training session that included demonstrations and practice interviews.

Response rates for the interviews and the number of schools completing interviews varied depending on the school health program component. The response rate for health education was 70% (n = 920 schools); physical education, 69% (n = 921); health services, 71% (n = 938); mental health and social services, 67% (n = 876); food service, 70%, (n = 841); and school policy and environment, 70% (n = 927). At the classroom level, 1706 courses or classes were eligible for the health education interview; a teacher completed the interview for 1534 (90%) of these. Similarly, 1729 courses or classes were eligible for the physical education interview; a teacher completed the interview for 1564 (90%) of these. The CDCs Institutional Review Board determined that SHPPS 2000 was exempt from review. A more detailed description of SHPPS 2000 methodology can be found elsewhere,7 as can information about the reliability of the school- and classroom-level questionnaires.8

Matching SHPPS Data to the SHI

Each SHI item represents a research-based recommendation for a school health policy or program. To determine which SHPPS questions would be used to measure each SHI item, the authors first considered all SHPPS questions relevant to the SHI item. Several SHI items could not be measured by any SHPPS questions; these items were excluded from analyses. For some SHI items, only 1 SHPPS question was relevant, so the match was evident. For example, 1 SHI item in Module 1 asks whether the school has a representative school health committee that oversees school health and safety policies and programs. The relevant SHPPS question asks, "Is there one or more groups at (school name) that develops policies or coordinates activities that address health topics like tobacco-use prevention, injury prevention, physical activity, and nutrition? These groups are sometimes called school health councils." In other cases, only 1 SHPPS question was relevant yet measured only 1 aspect of the SHI item. For example, another SHI item in Module 1 asks whether the school provides a safe physical environment, inside and outside school buildings. Among elementary schools, this item was measured by a single SHPPS question: "Does your school use the safety checklist and equipment guidelines published in the Handbook for Public Playground Safety by the US Consumer Product Safety Commission?"

For most SHI items, several SHPPS questions were relevant. In those cases, the authors decided as a group which combination of SHPPS questions would provide data to assess whether schools were meeting the SHI item. For example, for a school to meet the SHI item in Module 4 that addresses whether school meals include a variety of foods, a school had to answer "yes" to each of 4 SHPPS questions: "Each week, are students at [school name] offered 5 or more foods containing whole grain?"; "Each day for lunch, are students at [school name] offered a choice between 2 or more different entrees or main courses?"; "Two or more different \vegetables?"; "Two or more different fruits or types of 100% fruit juice?" Complete tables showing which SHPPS questions were used to define each SHI item are available from the first author.

An additional challenge in matching the SHI items to the SHPPS questions was that the SHI uses a 4-point scale to assess the extent to which a school has a particular policy or program in place. For the present analysis, this scale was converted to a simple yes or no. Measurement of whether a school was meeting the SHI item, therefore, was restricted to whether the school was achieving the highest standard and not whether the school might be meeting the recommendation to a lesser degree. For example, for a school to meet the SHI item in Figure 1, that school had to score "3," meaning that the school has all elements of a tobacco policy in place. Schools scoring 0, 1, or 2 were considered not to have met the item.

Data Analysis

All the analyses used SUDAAN statistical analysis software9 to account for the complex sampling design used in SHPPS 2000; results are based on weighted data. Classroomlevel data were aggregated to the school level, and appropriate weights were applied so that all analyses could be stated in terms of percentage of US schools. For example, 1 SHI item in Module 2 asks, "Do all who teach health education participate at least once a year in professional development/continuing education in health education?" To assess this, the analysis used SHPPS data to calculate the percentage of US schools in which all sampled health education teachers said they had received any staff development on at least 2 health education topics during the 2 years preceding the study.

The percentage of schools meeting each SHI item was calculated along with a 95% confidence interval. T tests were used to determine whether, after applying a Bonferroni correction to account for multiple comparisons, elementary schools differed significantly from middle and high schools. In addition, the number of items in each module that each school met was calculated. Some items did not apply to all schools, such as those pertaining to special needs students. When that occurred, a separate analysis was performed for these schools in which this item was omitted from the total possible number of items.

RESULTS

The percentage of elementary schools and middle and high schools meeting each item in SHI Modules 1 through 4 are shown in Tables 1 through 4, respectively. The SHI items that could not be matched to SHPPS questions for either school level are not included in the tables. The percentages in each table are derived from SHPPS 2000 data combined as described above to match the SHI items. These combinations represent a secondary analysis of SHPPS 2000 data, and the results, therefore, differ from descriptive SHPPS 2000 data reported elsewhere.10

Module 1: School Health and Safety Policies and Environment

For Module 1, SHPPS questions were matched to 21 of a possible 25 elementary school SHI items and 20 of a possible 24 middle and high school SHI items. Although 79.6% of elementary schools have a written crisis response plan, other SHI items pertaining to school health and safety policies and environment were met by less than 50% of elementary schools (Table 1). More than 75% of middle and high schools have a written crisis response plan, prohibit tobacco advertising, and provide tobaccouse cessation services, but other items were met by less than 50% of middle and high schools. At all school levels, fund-raising efforts were rarely supportive of healthy eating; during the 12 months preceding the survey, all but 9.6% of elementary schools and 4.5% of middle and high schools sold chocolate candy, other candy, soft drinks, or cookies as part of fund-raising for a school organization.

Elementary schools were significantly more likely than middle and high schools to provide services designed to overcome barriers to learning. Specifically, 69.6% of elementary schools and 40.8% of middle and high schools provide case management for students with chronic health conditions, crisis intervention for personal problems, identification of or counseling for mental or emotional disorders, and assistance with enrolling in Medicaid or Children's Health Insurance Programs. Elementary schools also were significantly more likely than middle and high schools to restrict access to foods of minimal nutritional value. That is, 69.6% of elementary schools and 24.4% of middle and high schools either do not have any vending machines, school stores, canteens, or snack bars where students can purchase foods or beverages or, if they do have these venues, do not have nonchocolate candy, soft drinks, sports drinks, or fruit drinks that are not 100% juice available for purchase. Similarly, elementary schools were significantly more likely than middle and high schools to restrict access to other foods of low nutritive value: 73.6% of elementary schools and 36.9% of middle and high schools either do not have any vending machines, school stores, canteens, or snack bars where students can purchase foods or beverages or, if they do have these venues, do not have chocolate candy, baked goods not low in fat, or salty snacks not low in fat available for purchase.

Module 2: Health Education

For Module 2, SHPPS questions were matched to 10 of a possible 13 elementary school SHI items and 12 of a possible 15 middle and high school SHI items. No SHI item pertaining to health education was met by more than 73.1% of elementary schools, but 81.0% of middle and high schools reported that students receive grades for health education and that grades from required health education are used the same as grades from other subject areas when determining grade point averages, honor roll status, and other indicators of academic standing (Table 2). Few schools at any level have at least 1 teacher who taught all essential health topics in a particular area. For example, 7.6% of elementary schools and 13.4% of middle and high schools have at least 1 teacher who taught all essential topics pertaining to physical activity, and 1.0% of elementary schools and 3.8% of middle and high schools had at least 1 teacher who taught all essential topics pertaining to unintentional injuries, violence, and suicide. Middle and high schools were significantly more likely than elementary schools to have teachers who cover essential topics related to tobacco use.

Table 1

Percentage of Elementary and Middle and High Schools Meeting Module 1 (School Health and Safety Policies and Environment) School Health Index (SHI) Items, School Health Policies and Programs Study (SHPPS)-United States, 2000

Elementary schools were significantly more likely than middle and high schools to have teachers who use active learning strategies. Specifically, in 72.5% of elementary schools and 49.4% of middle and high schools, all sampled teachers reported using at least 3 of a list of 6 active learning strategies, including cooperative group activities; role play, simulations, or practice; visual, performing, or language arts; pledges or contracts for behavior change; peer teaching; and computer-assisted instruction. Elementary schools also were more likely than middle and high schools to have teachers who use culturally appropriate examples and activities. That is, in 73.1% of elementary schools and 60.9% of middle and high schools, all sampled teachers reported at least 2 of the following 5 practices: using textbooks or curricular materials reflective of various cultures, using textbooks or curricular materials designed for students with limited English proficiency, asking students to share their own cultural experiences related to health topics, teaching about cultural differences and similarities, and modifying teaching methods to match students' learning styles, health beliefs, or cultural values.

Module 3: Physical Education and Other Physical Activity Programs

For Module 3, SHPPS questions were matched to 9 of a possible 13 elementary school SHI items and 13 of a possible 19 middle and high school SHI items. In 79.8% of elementary schools and 77.0% of middle and high schools, all sampled teachers reported teaching about health-related fitness; these schools met the SHI item pertaining to health-related physical fitness (Table 3). Many schools also met the SHI item related to professional development for teachers: in 78.7% of elementary schools and 75.1% of middle and high schools, all sampled teachers reported receiving staff development on at least 1 physical education topic during the 2 years preceding the study. In contrast, few schools require minimum recommended amounts of physical education: 8.0% of elementary schools require 150 minutes and 6.2% of middle and high schools require 225 minutes of physical education per week for students in all grades in the school for the entire school year, defined as 36 weeks.

Table 2

Percentage of Elementary and Middle and High Schools Meeting Module 2 (Health Education) School Health Index (SHI) Items, School Health Policies and Programs Study (SHPPS)-United States, 2000

Elementary schools were significantly more likely than middle and high schools to promote community physical activities. In 46.8% of elementary schools and 29.6% of middle and high schools, all sampled teachers reported asking students in their class to perform volunteer work with a physical activity program or event, participate in or attend a community health fair, or gather information about physical activity programs available in the community. Middle and high schools were more likely than elementary schools to have credentialed physical education teachers. In 38.2% of elementary schools, all sampled teachers were certified, licensed, or endorsed by the state to teach physical education at the elementary school level, whereas in 72.2% of middle and high schools, all sampled teachers werecertified, licensed, or endorsed by the state to teach physical education at the middle/junior or senior high school level.

Table 3

Percentage of Elementary and Middle and High Schools Meeting Module 3 (Physical Education and Other Physical Activity Programs) School Health Index (SHI) Items, School Health Policies and Programs Study (SHPPS)-United States, 2000

Table 4

Percentage of Elementary and Middle and High Schools Meeting Module 4 (Nutrition Services) School Health Index (SHI) Items, School Health Policies and Programs Study (SHPPS)-United States, 2000

Module 4: Nutrition Services

For Module 4, SHPPS questions were matched to 12 of a possible 14 elementary school SHI items and 12 of a possible 14 middle and high school SHI items (Table 4). Although more than 90% of food service managers received staff development on at least 2 food service topics during the 2 years preceding the study, far fewer had an undergraduate degree plus certification from a food service association, professional group, or state agency. Both elementary and middle and high schools were unlikely to have low-fat and skim milk available for students. In addition, few schools reported multiple types of collaboration between teachers and food service staff. Specifically, 8.4% of elementary schools and 3.7% of middle and high schools reported all of the following during the 12 months preceding the study: (1) students visited the cafeteria to learn about food safety, food preparation, or other nutrition-related topics; (2) school food service staff talked about good nutrition or healthy eating habits to a class; and (3) school food service staff worked on school food service or nutrition activities with health education staff.

Middle and high schools were significantly more likely than elementary schools to have a la carte offerings that include appealing low-fat items. Specifically, 31.8% of elementary schools and 47.3% of middle and high schools offered students at least 1 item in each of the following groups during a typical week: (1) 100% fruit juice, 100% vegetable juice, or fruit; (2) lettuce, vegetable, or bean salads or other vegetables; and (3) low-fat or nonfat yogurt or low-fat or fat-free ice cream, frozen yogurt, or sherbet.

Summary Analysis

For each module, the number of SHI items each school met was calculated and then averaged across all sampled schools. These averages, the total possible number of items, and the maximum number of items met are shown in TableS. The average number of items any school met in the school health and safety policies and environment module represented 12% of the total possible elementary school items and 18% of the total possible middle and high school items, making that module the one with the smallest percentage of items met, on average. On average, 33% of items in the health education module were met among elementary schools and 34% among middle and high schools; that module was the only 1 for which any school met all possible items. On average, 25% of items in the physical education module were met among elementary schools and 28% among middle and high schools; no school met more than 50% of the items. The nutrition services module had the highest average percentage of items met: 42% among elementary schools and 44% among middle and high schools.

Table 5

Average and Maximum Number of School Health Index (SHI) Items Met, By Module-School Health Policies and Programs Study (SHPPS), 2000

DISCUSSION

Although on average, schools nationwide are meeting relatively few of the research-based recommendations set forth in the SHI, an examination of the frequency distributions used to create the averages (data not shown) shows that the policies and programs addressed in the SHI are distributed across schools. It is not the case that one half of schools are meeting all SHI items and the other half are meeting none or that all schools are addressing the same few SHI items. Rather, it seems that each school is meeting a few of the recommendations in each module. Essentially, schools are focusing their efforts on a few policies and programs rather than addressing the entire set of recommendations in the SHI.

When each SHI item was examined separately, however, a large percentage of schools had particular policies or programs in place. For example, most schools reported having school health councils, many food service and physical education staff had received professional development in their respective areas, and tobacco-use prevention and cessation activities are prevalent in schools nationwide.

School Health and Safety Policies and Environment

Although school health recommendations sometimes vary by school level, in most cases, all schools should be implementing the recommendations. This study, however, showed some differences between elementary schools and secondary schools. For example, more elementary schools provide services designed to overcome barriers to learning. Barriers to learning continue to exist, however, as children grow and progress through school. Secondary schools should address barriers to the same degree as do elementary schools.

In addition to creating key policies to enforce school health, it is critical that schools provide a supportive environment in which to reinforce these directives. For example, although many elementary schools restrict access to foods of minimal nutritional value and promote healthy food and beverage choices, less than 10% ensure that fund-raising efforts in the school are supportive of healthy eating. Fund-raising programs should complement other healthy eating messages students are receiving in school,11 either by selling nonfood items or by selling healthy foods.

Another example of a lack of consistent messages relates to the use of physical activity as a punishment or food as a reward. Although many schools prohibit using physical activity as a punishment, far fewer prohibit using food as a reward, a practice that can have negative consequences when attempting to encourage healthy eating.12 These differences were found at all school levels. In light of the recent obesity epidemic, both physical activity and nutrition need to be addressed in the school environment. Encouraging healthy eating and physical activity through policies, health education, and health promotion will help create a supportive environment for instilling these behaviors in students.2,3

Although tobacco-use prevention and cessation activities are prevalent overall, they also provide another example of inconsistent messages. Although nearly three fourths of schools prohibit tobacco use among students, only about one half prohibit tobacco use by staff and visitors. Schools have the opportunity to create a tobacco- free environment by prohibiting tobacco use not only among students but also among school staff and visitors.

To develop school policies, schools can use Fit, Healthy, and Ready to Learn: A School Policy Guide" from the National Association of State Boards of Education, which provides sample school policies for implementing the CDC guidelines on physical activity, healthy eating, and tobacco-use prevention and offers direction on developing a school health policy framework. It also supplies background information on how to influence the educational policy- making process and data to help make the case for these policies.

Health Education

The SHI health education module provides guidance on essential health education topics to be taught in schools. Overall, few schools provide instruction to students in all critical areas. Almost twice as many secondary schools as elementary schools address all essential topics on preventing tobacco use, but the overall percentage of schools addressing all tobacco-use prevention topics was low as were the percentages of schools addressing all essential topics related to injury, physical activity, and nutrition.

In more than three fourths of schools, physical education teachers reported teaching about health-related fitness (ie, cardiovascular endurance, muscular endurance, muscular strength, flexibility, and body composition). Few schools, however, address essential physical activity topics in the context of health education, such as social influences on physical activity, benefits and barriers to physical activity, and safety during physical activity. Although physical education teachers may be covering some of these topics in physical education class, health education programs should not neglect these essential topics. As part of a coordinated school health program, health education related to physical activity can be addressed and integrated in multiple areas and not just in physical education class.2

Although few schools address all essential health topics on the prevention of injuries, violence, and suicide, the percentages were somewhat higher when the topics were examined separately (data not shown). For example, whereas 7.1% of elementary schools teach about unintentional injuries and 3.4% teach about violence and suicide, only 1.0% address all topics combined.

These data reinforce the importance of initiatives to incorporate the entire breadth of health education topics into school health curricula. Unintentional injuries and violence are the leading causes of death and disability among children, adolescents, and young adults.14 Physical inactivity, poor eating habits, and tobacco use are the primary causes of chronic diseases (such as heart disease, cancer, stroke, and diabetes) that are the leading causes of death and disability among adults in our nation.15 These risk behaviors that lead to chronic diseases are typically established in childhood and adolescence and thus should be addressed in schools.

To help schools ensure that they are using quality curricula that address the most essential topics, CDC and its key partners are developing the Health Education Curriculum Analysis Tool (HECAT). Th\e HECAT is an assessment tool that assists educators in selecting high-quality health education curricula and highlights the critical areas of health education to be addressed in schools. Schools also can use the federally developed lists of rigorously evaluated school and community programs likely to be most effective for reducing youth risk behaviors.16

Physical Education

Several differences between elementary and secondary school physical education emerged in this study. Elementary school physical education teachers were considerably more likely than secondary school physical education teachers to encourage students to participate in community physical activity opportunities, such as community health fairs or fun runs. Although many physical education staff at all school levels had received professional development, almost twice as many secondary schools as elementary schools have credentialed physical education teachers. It is important to have credentialed physical education teachers or specialists in both secondary schools and in elementary schools so that instruction can be focused on those skills most critical at a young age, such as motor learning skills.2,17 Teachers with specialized training or credentials in physical education are better equipped to teach and promote health-related and age-appropriate physical activities and skills that encourage adherence to a physically active lifestyle.18,19

Few elementary and secondary schools require daily physical education, or its equivalent, in each grade for the entire school year. For many students, the time spent being physically active in school might be the only time in the day they are active. Guidelines recommending 150 minutes per week for elementary school students and 225 minutes per week for secondary school students are set to incorporate regular physical activity in school and to encourage students to make physical activity a part of their daily lives.2,17 When schools do not meet this recommendation, students are unlikely to have sufficient physical activity, placing them at higher risk for poor health.20 Schools can use the Physical Education Curriculum Analysis Tool, which CDC is developing, to help assess the extent to which written physical education curricula reflect the national physical education standards of the National Association for Sport and Physical Education and characteristics of effective physical education programs.2,21

Nutrition Services

According to the present study, most schools provide professional development to food service managers, but few food service managers have nutrition-related degrees or certifications. Because managing a food service program requires a diverse set of skills, it is important that food service personnel are trained appropriately and receive ongoing professional development. In addition, few schools at all levels offer low-fat and skim milk, and few schools report collaboration between teachers and food service staff.

Two tools may be especially useful in strengthening school nutrition policies and practices. The US Department of Agriculture's Team Nutrition, an initiative designed to help schools successfully and easily implement dietary guidelines policies, has developed a kit entitled Changing the Scene: Improving the School Nutrition Environment22 that helps key stakeholders work together to support changes in the school nutrition environment. In addition, Making It Happen! School Nutrition Success Stories11 provides examples and success stories from 32 schools and school districts that have implemented innovative approaches to improve the school nutrition environment. One of the key lessons learned from these stories is that students will buy healthful foods and beverages if they are available, and schools can make money from selling healthier options.

Limitations

A few limitations to this study exist. The SHPPS and SHI were originally designed with different purposes: the former as a surveillance system and the latter as a schoollevel self-assessment and planning tool. This difference increased the difficulty of matching items between the 2 instruments. Furthermore, in some cases, only 1 SHPPS item was used to measure a given SHI item, whereas in other cases multiple SHPPS questions were used but still might not have covered the full scope of the SHI item. Thus, the data presented here are not exact measures of the percentages of schools meeting school health standards as defined by the SHI but instead can be viewed as approximate markers. In addition, although the SHI items were designed to be answered on a 4-point scale, this study measured only whether schools achieved the highest standards. Although these standards were high, the finding that every recommendation was met by at least some schools indicates that the standards are not impossible to meet. Last, not all SHI items could be measured with SHPPS 2000 data because SHPPS questions were finalized before the SHI was completed. Future versions of SHPPS, to be conducted next in 2006, will more thoroughly address all SHI items.

CONCLUSIONS

This study has demonstrated that, although many schools in the United States have several important school health policies and programs in place, more work needs to be done to assist schools in implementing a comprehensive set of policies and a coordinated school health program. The CDC will continue assisting states and other partners with the adoption of comprehensive policies, the provision of training for key personnel, and ultimately, the implementation of coordinated programs. For example, CDC recently released Make a Difference at Your School!,23 a document to guide schools in implementing a comprehensive approach to prevent obesity. This document outlines 10 key strategies to promote physical activity and healthy eating and provides resources to help schools implement each one.

Progress in the implementation of school health policies and programs can be measured at the national, state, and local levels. At the national level, school health policies and programs can be measured every 6 years through SHPPS. At the state level, School Health Profiles24 allows states to assess and monitor school-level health policies and programs biennially. Profiles questions are better suited for research or evaluation than is the SHI. At the local level, schools can use the SHI to identify their strengths and weaknesses within the context of a coordinated school health program and use the tools mentioned above as resources for developing and improving their school health and safety policies and programs. These systems will help drive continual improvements in school health at all levels.

References

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2. Centers for Disease Control and Prevention. Guidelines for school and community programs to promote lifelong physical activity among young people. MMWR Morb Mortal WkIy Rep. 1997;46(RR-6): 1-36.

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4. Centers for Disease Control and Prevention. Guidelines for school health programs to prevent tobacco use and addiction. MMWR Morb Mortal Wkly Rep. 1994;43(RR-2):1-18.

5. Centers for Disease Control and Prevention. School health guidelines to prevent unintentional injuries and violence. MMWR Morb Mortal Wkly Rep. 2001;50(RR-22):1-73.

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11. Food and Nutrition Service, US Department of Agriculture; Centers for Disease Control and Prevention, US Department of Health and Human Services; US Department of Education. Making it Happen! School Nutrition Success Stories. Alexandria, Va: Government Printing Office; January 2005. FNS-374.

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17. National Association for Sport and Physical Education. Opportunity to Learn Standards for Elementary School Physical Education. Reston, Va: National Association for Sport and Physical Education; 2004.

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19. McKenzie TL, Sallis JF, Faucette N, Roby JJ, Kolody B. Effects of \a curriculum and inservice program on the quantity and quality of elementary physical education classes. Res Q Exerc Sport. 1993;64:178-187.

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21. National Association for Sport and Physical Education. Moving Into the Future: National Standards for Physical Education. Reston, Va: National Association for Sport and Physical Education; 2004.

22. US Department of Agriculture. Changing the scene-improving the school nutrition environment, 2000. Available at: www.fns.usda.gov/ tn/Resources/changing.html. Accessed May 10, 2005.

23. Centers for Disease Control and Prevention. Make a difference at your school!, 2005. Available at: http://www.cdc.gov/ healthyyouth/keystrategies/obesity_catalog.pdf. Accessed November 2, 2005.

24. Centers for Disease Control and Prevention. School health profiles. Available at: http://www.cdc.gov/healthyyouth/profiles/ index.htm. Accessed November 2, 2005.

Nancy D. Brener, PhD, Acting Team Leader, Surveillance Research Team, (nad1@cdc.gov), Maitstop K-33; Anu Pejavara, MPH, CHES, School Health Resource Coordinator, (bkz5@cdc.gov), Mailstop K-12; Lisa C. Barrios, DrPH, Chief, Research Application Branch, (lic8@cdc.gov), Mailstop K-12; Linda Crossett, RDH, Health Scientist, (lsc4@cdc.gov), Mailstop K-12; Sarah M. Lee, PhD, Health Scientist, (skeuplee@ cdc.gov), Mailstop K-12; Mary McKenna, PhD, Health Scientist, (zyc3@ cdc.gov), Mailstop K-12; Shannon Michael, MPH, Public Health Analyst, (sot2@cdc.gov), Mailstop K-12; and Howell Wechsler, EdD, MPH, Director, (haw7@cdc.gov), Mailstop K-29, Division of Adolescent and School Health, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Atlanta, GA 30341.

Copyright American School Health Association Feb 2006

Source: Journal of School Health, The

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