The standards that are almost completed will provide guidelines for county superintendents concerned about the survey results from their schools. And the fervent hope is that the State Department staff will include a specialist in health services in the very near future who can spearhead implementation of state standards. Note that the time frame from adoption of school

health law to the present represents almost eight years. But most of the progress occurred in the space of one and one-half years. The strongest identifiable factor for change would have to be the state legislature, for they

passed the resolution. It must be noted, however, that state legislators don’t move unless there is a demand for change. In this case, the demand came from educators and health professionals. Together they formed a team and together they are closing the gaps in school health services in the state of Maryland.

Louise Blauvelt, RN, BS, MA, i s Supervisor of Health Services, Prince George’s County Public Schools, Upper Marlboro, MD 20870.

School Health - 1977

Georgia P. Macdonougb, RN, MA It has been a very long journey for school health from

the early 1900s when Miss Lina Rogers of the Henry Street Nursing Association engaged in a one month’s demonstration project to prove the worth of a nurse in the school.

In those days, pupils were excluded from school because of communicable and “nuisance” diseases. Rogers was able to show, through nursing follow-up, that children could return to school instead of wandering around the streets of New York. Today, school health, although still concerned with

communicable disease control, has encompassed many additional services, which are constantly changing to meet society’s needs. I have been asked to prepare this paper, discussing

school health on the national, state, and local levels, as I see the picture. I will give an overview of priorities, discuss some gaps, and suggest one or more approaches to some challenging situations. On the national level, the goals and priorities for

school health, for the most part, emanate from the Bureau of Community Health Services Regional Workplan Guidance. The Department of Health, Education, and Welfare designates the regional offices to carry out work activities to ensure the meeting of program objectives. Since Arizona is served by Region IX headquarters in San Francisco, much of my information comes from communication with the Maternal and Child Health staff there. One of the national program objectives is to increase

the number of children receiving appropriate preventive

health care services (including health education), particularly junior and senior high school students. One activity supporting this objective is the stimulation and funding of research projects to obtain cost effectiveness data regarding preventative child health services. Another national priority is to implement a strategy to identify more children, prior to their entering school, who have a vision or hearing loss. Still another objective is to develop and disseminate guidance materials on nutritional disorders of children (screening, diagnosis, and follow-up). On the national level, a great deal of emphasis has been

given to increasing the levels of immunization for both preschool and school-age children. For a few years, October has been designated “Immunization Action Month.” In June 1976, a national conference was held in St. Louis to mobilize voluntary and official agencies in a concerted effort to immunize “every child by 76/77.” Unfortunately, the impetus was interrupted by the Swine Flu program. Most of the costs of these immunization programs, in terms of provision of low-cost vaccine, is defrayed by the Center for Disease Control in Atlanta. A new major program has been recently proposed

called Comprehensive Health Assessments and Primary Care for Children (CHAP). This program would constitute an expansion of Early Periodic Screening, Detection, and Treatment (EPSDT). President Carter has recommended amendments to Medicaid that would increase EPSDT funding from $137 million in 1977 to $345 million in 1978.

SEPTEMBER 1977 THE JOURNAL OF SCHOOL HEALTH 425

Several national organizations are continuing efforts to upgrade the school health scene in a variety of ways. The American Nurses Association, American School Health Association, Department of School Nurses of the National Education Association, and American Academy of Pediatrics have brm cooperating to publish a joint statement on standards for education programs for the preparation of school nursc practitioners. The ANA, DSN of NEA, and ASHA have begun planning for a national educational conference for school nursds. This cooperation between national organizations will promote coordination of programs and wil l certainly limit the duplication of individual efforts. The ASHA has, for many years, had a variety of study

committees to address all components of school health. Multidisciplined in composition, these committees give professions such as medicine, nursing, dentistry, podiatry, education, nutrition, optometry, and others an opportunity to work together, consider each other’s needs, hear each one’s opinions, and then problem-solve for the ultimate good of the ochool-age child. Tlrc Journal of School Health continues to be the outstanding national publication solely dedicated to issues in school health. Although a young organization, the National Associa-

tion of State School Nurse Consultants is planning and working toward the goal of ensuring equalization of school health services for all children in the United States. There still exists, in this country, many areas where little or no school health services are available. Through periodic exchange of “how we did it” success stories, perhaps the members of this organization will be able, in some small way, to influence the quality of school health within their states. Some of the gaps on the national level are:

1. There is no Vision Consultant position in HEW, although there has been a Spcech and Hearing Consultant for over 20 years. If the objectivc of early identification of children with both vision and haring loss is to be accomplished, some guidance from national and regional offices is extremely important. Results of a 1975 survey sent out by the Arizona State DCpartment of Health Services Vision Consultant showed that only 13 states have some specifically designed vision comer- vation program, while 15 states have little or nothing in the way of a coordinated or directed program of vision conservation. There was no response from 24 staten. It could be presumed that in those 24 states, then was no person directly concerned with vision who could respond to the survey.

2. Research about school health is small compared to that in other areas. Perhaps it is because school health personnel are not prepared in the art of “grantsman- ship.’, Perhaps we do not see the need to extend the scientific base on which the principles of professional

school nursing, health education, and provision of a healthful school environment are founded. Grant money is available. School health personnel should investigate how they can obtain it for the advancement of their programs. Members of the National Association of State School

Nurse Consultants report a very high priority given to school health in their states. In Arizona, in addition to supporting the position of School Health Consultant, the Bureau of Maternal and Child Health also supports a Vision Consultant, a Hearing Consultant, three Audiomctricians, A Sickle Cell Program Manager, and an Associate Chief of MCH who, as part of his duties, is responsible for coordination of the School Health Program. The other bureaus and divisions of the State Pepartment of Health Services give invaluable assist- ance. The laboratory, communicable disease control and epidemiology scction, nutrition health education, film library, environmental health, dental health, and many others are most cooperative in assisting with problems in the area of school health. There seems to be less priority given to school health

within the State Department of Education in Arizona. At present, although a liaison person has been named to work with the Department of Health Services, no p i t i o n exists that encompasses total school health responsibility. Such a position was discontinued several years ago and has never been reactivated. Although several divisions of the Department of Education, such as substance abuse, school safety, career education, and special education, are operating, requests for consulta- tion and assistance in the areas of health services, health education, and healthful and safe school environment arc most frequently sent to the Department of Health services. There is no requirement for specific health education

to be taught in Arizona Common Schools nor is there any requirement for a health class for high school students. The guidelines for health education in elementary schools are stated in terms of a percentage of the school day for health or physical education.

In terms of mandated school health services, there is no state law that requires either a physical examination for school entrance or the hiring of a school nurse to oversee the school health program. A hearing screening program is mandated, but no such rule applies to vision screening. A compulsory immunization law was passed in 1976 for school entry, but it requires that parents give a history of immunizations and sign a statement of compliance, with no provision in the rules and regulations for exclusion if immunization is not accomplished. Specific requirements for school sanita- tion are in effect, and periodic visits are made by county sanitarians. It is common practice, however, that the sanitarians check over only the food service areas of the

426 THE JOURNAL OF SCHOOL HEALTH SEPTEMBER 1977

schools unless specifically given a complaint to investigate.

In spite of these restrictions, the State of Arizona has high quality health services available to the majority of school-age children. At present, there are about 560 school nurses who are hired by local school boards. In addition to this, nurses from each of the 14 county health departments provide some services to schools that do not have their own school nurse.

In order to ensure some standardization in school health, a workshop is offered annually for nurses who are new to school health practice and any others who care to attend for review purposes. This is free of charge, since it is wholly supported by the State Department of Health Services, and continuing education credits are offered. Since there are no certifi- cation requirements for school nurses in Arizona, school nurses come with a variety of preparation, including A. D. programs, hospital-based programs, and university programs. Although this workshop provides orientation to school health and preparation for “job readiness“ through how-to-do-it sessions in record keeping, screening techniques, communicable disease control methods, and others, the follow-up visit by the consultant seems to provide security to the new nurse in terms of having someone available to listen to her problems, to give advice, and to act as a sounding board. Cumulative health records, School Health Guidelines,

flip charts on first aid and communicable disease control are among the items provided to every school in Arizona - public, private, or parochial, as one method of stressing the importance of school health practices.

One of the major gaps that exists in the school health services of Arizona is the lack of resources for follow-up after defects have been uncovered. There are large rural areas, some of which are understaffed with physicians. In addition, it is the only state in which Medicaid has not yet been implemented. To prepare for this program, particularly the Early Periodic Screening, Diagnosis, and Treatment portion (EPSDT), which makes medical services available before health problems become chronic and expensive to treat, the State Department of Health Services received funding from Region IX, Department of Health, Education, and Welfare, to run a pilot project in a local school district. It was our belief that because the school is the center of activity in many towns and also because the majority of children are readily available in the school setting, this might prove a beneficial location for providing the outreach, screen- ings, and follow-up necessary to ensure the early diagnosis and treatment to those needing it. An additional goal of this project was to train health assistants, people indigenous to the community, who

SEPTEMBER 1977

would provide some of the services not needinp professional nursing competency.

A nurse practitioner was responsible for seven health assistants in this project. I t was assumed by the Committee on Services for Children of The Arizona Medical Association, which initially developed this model screening unit, that one pediatrician or family physician could be responsible for approximately four nurse practitioners. The active caseload for these seven health assistants was 750 children, 0 - 21 years of age. The methods of outreach, which proved most beneficial, were direct contact and telephone contact, not mail contact.

Each phase of this project gave major emphasis to health education. Both children and parents were given health information during outreach, screening, and follow-up activities. The staff was convinced that at the conclusion of the project the families involved were not only health conscious but were prevention oriented. Since one of the barrriers to providing health services

to school-age children (and others) is frequently a lack of money, perhaps this pilot project can be a prototype of alternative methods of providing such care. Perhaps we, as school health people, need to evaluate our systems and methods. Can we provide quality service to more students by using trained, nonprofessional personnel? Can we join with official health and social agencies to coordinate outreach activities, screening programs, health education, and follow-through, so that we are not duplicating efforts and thereby raising the cost of service?

This is a challenge to every state. The needs for school health services are apparent. Communicable disease remains. You need only study the reports of cases of chicken-pox, measles, mumps, hepatitis, gonorrhea, and syphilis prevalent in the under 21-year categories to prove this to the doubting Thomases. Absence rates remain high. Childhood mental health problems continue to increase, and physical health needs become more apparent, particularly with the emphasis on getting handicapped children into the mainstream of school life. Dr. Henry K. Silver in 1976 stated in an article in

Pediatrics, “of the fifty million school children in the United States, an appreciable number never see a physician or nurse except for extreme illness or in an emergency.” He advocates the use of school nurse practitioners to expand and improve health care for school-age children. There are less than 500 full-time school-health physicians in the United States; however, there are approximately 29,000 school nurses who could be prepared as school nurse practitioners. Then, such things as emotional disturbances, perceptual handicaps, and physical problems could be uncovered early by

THE JOURNAL OF SCHOOL HEALTH 427

them, so the student’s ability to learn would be less hampered. The priority demonstrated on the local level empha-

sizes personal responsibility for maintaining health, preventing disease, and decreasing injury. In small towns and communities, at least in Arizona, there is a willingness for people to care for and be concerned about one another. The gap on the local level is the lack of emphasis

placed on the school nurse’s expertise as a nurse. Her combination of intellectual skills, interpersonal skills, and the technical skills of nursing make her a unique individual in the school setting.

In summary, consider the three “Cs” -communication, cooperation, and coordination. Consider - Sequential health education grades K through 12 with concurrent adult health education for parents. The schools and

voluntary or official agencies must join forces to accomplish this common goal.

Consider - Standardized inspection of all school facilities by public health sanitarians, and formation of sanitation and safety committees in each school to work together to upgrade the environment.

Consider - Health services that coordinate with Medicaid and other primary health-care providers to decrease duplication of efforts. Use trained, nonprofes- sional personnel and community volunteers to stretch the available dollars. First and foremost-Consider the ChUd.

Georgia P. Macdonough, RN, MA, is School Health Consultant, Arizona Department of Health Services, Bureau of Maternal and Child Health, 200 North Curry Road, Tempe, AZ 8.5281.

New Policies in School Health

Vince L. Hutchins, MD “Instruct a child in the way he should go, and when he

grows old, he will not leave it.” ’ More than 30 years ago, in 1945, representatives of

federal health and education and other professional associations met to consider the health needs of school children and ways of meeting those needs. The resultant report * noted that in the preceding 20 years there had been a wave of legislation designed to prevent the conditions that had been revealed by the health assessments of the military inductees in World War I. The conferees expressed concern that the results of the health assessments for World War I1 continued to reveal physical and mental health conditions that could have been prevented in early childhood. The recommenda- tions made by that group are of interest because they are basic and acceptable objectives for present programs. There isn’t time, nor is there a need, to review each of the recommendations in detail, but recounting a few of them allows comparisons to be made to present-day objectives . The fact that these statements are so similar to present-

day statements is a reminder, not of the tendency of professionals to repeat basic principles, but rather a reminder of the inability of the health service system to achieve and maintain success in health education, health services, and environmental control.

428 THE JOURNAL OF SCHOOL HEALTH

These are some edited statements of needs from the report:

An environment in which boys and girls are freed as far as possible from conditions that produce unnecessary fear, anxieties, conflicts, and emotional stresses.

An opportunity to receive necessary immunization and testing procedures.

Adequate medical and dental care . . . adequate nutrition. . . .

Participation in a program of physical activity. Participation in a recreational program . . . making

for wholesome living. . . . An opportunity to . . . form health habits and

attitudes based on scientific knowledge. . . . to . . , assume increasing responsibility for one’s

own personal health. Teachers . . . who are , . . emotionally stable and

adjusted because the development of healthful person- alities is dependent upon the relationships and attitudes which are built up between teacher and children.

One of the outcomes of the 1945 conference was the establishment of a Committee on the School-Age Child that included representatives of the Office of Education, the Public Hcalth Service, and the Children’s Bureau, which at that time administered the Federal Program

SEPTEMBER 1977