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Promoting School Health-An Expanded Paradigm

Posted on: Wednesday, 4 May 2005, 03:00 CDT

It is an honor and privilege to be the recipient of the prestigious Howe Award-the highest award of the American School Health Association (ASHA). I would like to thank all those who encouraged me to be a nominee, especially my longtime friend and colleague, ASHA Past President and Howe Award recipient Dr Larry Olsen, who took the time and effort to forward my name for nomination.

Several weeks ago, I received a call from the Awards Committee Chair informing me of the Award. What a way to make one's day. Having been a member of ASHA for many decades, it was especially welcomed knowing the many excellent contributions of those who had received this award before me. I was asked and would like to take this opportunity to share a few thoughts with you on how I believe we can better promote school health.

SCHOOL HEALTH IS A PARADOX

School health is a paradox. The challenges are significant. You know them better than I: an epidemic of obesity; poor nutritional choices; ongoing problems with tobacco, alcohol and other drugs, and sexual activity; increasing violence; and inadequate health insurance and health services for millions of children. The list goes on and on. At a time when the need is obvious, and the effectiveness of coordinated school health programs has been demonstrated, many school health programs are at risk of downsizing or elimination. At the same time, professional preparation programs at colleges and universities have experienced similar problems. I suggest that we need a more functional paradigm so that others better understand the ultimate value of school health programs. Let me explain.

LESSONS FROM HEALTH POLICY AND POLITICS

From my involvement in health policy issues and also in politics, both as a past candidate and as a volunteer working for other candidates, as well as a current member of the County Board of Health, I know it is extremely important how issues or objectives are framed. In her article "Access to What? Health Care for Whom?" Nancy Oswald mentions: "how problems are defined determines how solutions are crafted. Those who name the issues in a policy debate set the parameters-the bottom lines, the outcomes, even which facts and figures have relevance."1

There is a counterpart in politics. It's called "political spin." I would like to suggest that one might learn from both framing and defining health policy and political spin. Both can be useful for expanding the school health paradigm.

EXPANDING THE SCHOOL HEALTH PARADIGM

As you know, paradigms are models that often produce a useful way of viewing a situation, issue, or problem. They guide contemporary thinking in many areas. Paradigms evolve as the world around us evolves. At any time there may be multiple and/or competing paradigms guiding our policies. For example, the past decade has seen many advances in tobacco policy ranging from increased taxes and restricting access by youth to promoting clean air, smoke-free environments. Initially, it was anticipated by health advocates that much of the state tobacco settlement funds would be used primarily to enhance antismoking efforts. In many states including mine, Illinois, in the midst of budget crises, there has been a significant decline in that paradigm as evidenced by the drastic reduction in the amount of resources devoted to these efforts. Last year, as in the past several years, Illinois received some $30 million annually in state tobacco settlement funds. This year only $11 million, or 3.7%, is now devoted to tobacco prevention and cessation efforts. In North Carolina, some of those funds have actually been directed to support tobacco growers.

Similarly, paradigms of school health have changed over the years. Previously, many school health efforts focused on hygiene and disease, especially communicable diseases. Later, through the efforts and writings of McGinnis and Foege2 and others,3 emphasis shifted from leading causes of death such as heart disease and cancer to real causes such as tobacco, diet, activity patterns, alcohol, other drug use, unintentional injuries, violence firearms, etc. Coupled with this approach was the increased focus on risk reduction behaviors. While meritorious in many respects, I think a broader perspective is needed. The purpose of a broader perspective is not to disparage, discredit, or even change what we are doing in school health now, whether in the classroom, cafeteria, or as part of health services delivery in our community. However, it may be helpful to put a slightly different spin on how we package our school health programs. We have done it with some success in my local community but, admittedly, have a way to go.

INTERVENTIONS AND THE FUNCTIONAL PERSPECTIVE

Let me suggest an expanded paradigm-a utilitarian, or more easily understandable, functional perspective approach. In any basic college course in political science, one encounters various reasons for public intervention. One often cited is paternalism, that is, restriction of the liberty of a class of individuals to confer a benefit on that same class. Examples would be mandatory seat belt use, mandatory safety helmet use by motorcycle drivers, or mandatory school attendance.

We can also intervene for reasons of equality, such as public education through high school, or for reasons of equity, which aim to distribute the benefits of a society in proportion to need, as in Medicaid, state children's health insurance programs (known as SHIP), or special education programs.

However, the perspective I propose here is called the utilitarian or functional approach. By classic definition, a utilitarian or functional approach justifies intervention on the grounds that it "serves a more productive work force or a more fit army."4 Let me translate that. It allows society to function better for the general welfare. Note that this is not a beneficent approach, which is intervention on the grounds of humanitarianism or charity in that it is good to benefit another. Rather, it is done to help an individual in order to promote the common or collective good. That is, our society will be better off by this intervention. This was, in part, the rationale for Germany establishing a universal health care program since about the late 186Os-people will be healthier and thus able to work better to contribute to the welfare and protection of the country as a whole.

For decades I have heard, and continue to hear, that the emphasis of our schools needs to be on the 3 R's, since those skills are necessary for our youth to function in society. For the most part that is understandable to me, but not sufficient. I would suggest that we need to increase our effort to promote the idea of healthy school-aged children not for the sake of having healthy school-aged children, but rather because healthy school-aged children can be functional and contributing citizens in our society.

The functional perspective goes beyond the risk factor emphasis to one that promotes coordinated school health as a contributor to improved functional capacity and participation of school-aged youth in an increasingly technologically oriented world economy. Coordinated school health needs to be viewed as a contributor to broader societal goals such as an improved work force and more functional citizenry, and as an investment in human capital, not expenditure. An expanded coordinated school health paradigm needs to focus on the broader outputs of an effective school heath program, not its costs.

What does all this have to do with school health? We need to tie up coordinated school health as an indispensable contributor to utilitarian outputs rather than simply a contributor to individual risk reduction or improved health alone. New concepts are needed; new approaches suggested; new and larger communities engaged.

I suggest a functional approach where the emphasis is not on disease or risk factors that influence health. We need to tie coordinated school health to enhancing the opportunity to learn. Coordinated school health is an essential contributor to the three R's. Coordinated school health is an important element in promoting critical thinking, analysis, decision making, and problem solving. Coordinated school health is an important element for our youth of today securing employment for tomorrow.

Coordinated school health is an indispensable element in helping our youth function effectively in what is known today as a "knowledge economy." As Reutter5 has clearly indicated in the The Earning Curve, the comparative advantage of a country and its citizens no longer lies in geography or natural resources. He maintains that "The heyday of industrial mass production has passed. We're now in a knowledge economy. Those who thrive today need a daunting array of skills and must make themselves more mentally nimble than those who came of age in earlier decades." To this end, I believe that it would be productive to advance or "spin" coordinated school health as an indispensable element necessary to function in a global economy. We should promote coordinated school health as an effective strategy to strengthening a healthy future work force. Coordinated school health is an indispensable element in being a productive citizen. We should view coordinated sc\hool health in a similar fashion as the herd immunity concept. The more people exposed, the better for the general population. We should promote the notion that coordinated school health is not an expenditure but rather an investment-an investment that can pay off many times over.

We also should promote coordinated school health in terms of having an enormous opportunity cost. This is not the cost of having a school health program. It is the cost of not doing it all or not doing it well that is significant and will carry through for generations.

TYING THE FUNCTIONAL PERSPECTIVE TO IMMEDIATE OUTCOMES

In addition, I do not think we need to tie coordinated school health only with longer-term outcomes. Rather, those outcomes will never eventuate without current recognition of the immediate and practical benefits of a coordinated school health program. Let me share a current personal experience. Initiated by our local public health department, and with the full support and involvement of the local school district, community support was generated from a vast array of health and mental health providers, both organizationally and individually, to open a school health center providing health services from a multidisciplinary team of professionals along with risk reduction educational efforts and other components of the coordinated school health program. We didn't achieve this by focusing primarily on having healthy children. Rather, we focused on the immediate benefits of having healthier children, such as reduced absenteeism, reduced discipline problems, enhanced ability to learn, higher test scores, fewer students left behind, higher graduation rates, and so forth.

CONCLUSION

School administrators who may believe that they can't afford a school health program for its educational value may amazingly find money if they believe that that program will lead to lower absenteeism (read more state funding) or higher test scores (read more prestige and less hassle from parents and the Board of Education). We know that coordinated school health programs can lead to a broad range of positive outcomes for years to come. Maybe we just need to do a better job of packaging those benefits so that those in positions of fiscal decision making finally figure that out. Let's help them "see the light."

References

1. Oswald N. Access to what? Health care for whom? Health Pac Bull. 1992;(spring):28-31.

2. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270:2207-2212.

3. Mokdad AH, Marks JM, Stroup DF, et al. Actual causes of death in the United States, 2000. JAMA. 2004;291:1238-1245.

4. Pickett GP, Hanlon JJ. Public Health-Administration and Practice. St Louis, Mo: Times Mirror/Mosby College Publishing; 1990:93.

5. Reutter M. The Earning Curve. Champaign: University of Illinois; 1997:3.

Thomas O'Rourke, PhD, MPH, FASHA, CHES, Professor, (torourke@uiuc.edu), Department of Community Health, University of Illinois, 1206 S Fourth St, Room 120, Champaign, IL 61820. Dr O'Rourke received the 2004 William A. Howe Award, which recognizes individuals for outstanding contributions and distinguished service in school health. Presented in memory of William A. Howe, MD (1862- 1940), a founder and first president of the American School Health Association (ASHA), the award acknowledges the recipient's outstanding professional contributions paralleling the aims and objectives of the Association. Remarks presented at the 2004 ASHA Awards Presentation, 78th Annual ASHA School Health Conference, October 13, 2004, Pittsburgh, Pa.

Copyright American School Health Association Mar 2005

Source: Journal of School Health, The

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