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Using the Whole School, Whole Community, Whole Child Model: Implications for Practice

Authors

Laura E. Rooney MP

Donna M. Videto PhD, MCHES,

David A. Birch PhD, MCHES

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Using the Whole School, Whole Community, Whole Child Model: Implications for Practice

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Schools, school districts, and communities seeking to implement the Whole School, Whole Community, Whole Child (WSCC) model should carefully and deliberately select planning, implementation, and evaluation...

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Placing Students at the Center: The Whole School, Whole Community, Whole Child Model

Authors

Linda L. Morse RN, MA, FASHA,

Diane D. Allensworth PhD

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GENERAL ARTICLE

Authors

Linda L. Morse RN, MA, FASHA,

President, Corresponding author

American School Health Association

Address correspondence to: Linda L. Morse, President, ( info@ashaweb.org), American School Health Association.

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Diane D. Allensworth PhD

Emeritus Professor of School of Health Sciences

Kent State University-Kent, OH, Snellville, GA 30039
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Most education reform efforts focus on curriculum, instruction, and assessment. This emphasis places responsibility for student success on school administrators and teachers. Little attention has been paid to the student-the consumer most impacted by educational policy and practice. The dissemination of the Whole School, Whole Community, Whole Child (WSCC) model,[ 1] which combines and builds on elements of the traditional coordinated school health approach[ 2] and the Whole Child Framework,[ 3] provides the opportunity for emphasizing and promoting a student-centered approach in schools. The WSCC model places the 10 components of the coordinated school health model around the 5 Whole Child Tenets. The Whole Child Tenets are the intermediary, desired outcomes for every K-12 student. They contribute to academic achievement and ultimately a high-quality, healthy, productive life. The community envelopes the entire WSCC model, indicating that schools cannot accomplish these goals without community support. Peeling back these layers, students are at the very core of the model. The purpose of this article is to underscore that a student-centered model implies that students should be both recipients of services to ensure that they become healthy, safe, engaged, supported, and challenged and empowered as full partners in the implementation of the WSCC model.

Launched in 2007, the ASCD (formerly known as the Association for Supervision and Curriculum Development) Whole Child Initiative helped move the educational conversation from a singular focus on academic achievement to one that promotes the long-term development and success of children by ensuring that all students have the fundamental resources they need to succeed. The updated WSCC approach combines a 10-component coordinated school health model with the original Whole Child Tenets, embedded in the WSCC model:

Each student enters school healthy and learns about and practices a healthy lifestyle.

Each student learns in an environment that is physically and emotionally safe for students and adults.

Each student is actively engaged in learning and is connected to the school and broader community.

Each student has access to personalized learning and is supported by qualified, caring adults.

Each student is challenged academically and prepared for success in college or further study and for employment and participation in a global environment.[1]

The WSCC model aims to change the way health and education intersect and support student health and achievement. By its very design, the model places the student at the core of this change. Rogers'[ 4] research identified the variables needed for change to occur. This includes having individuals with authority and respect who articulate the needed changes (heterophily) as well as individuals that are similar (peers) voicing the need for a particular change (homophily). We believe that students can do so much more than just voice adult recommendations for change. Student-centered schools acknowledge the critical contributions students can and should make to their own learning and well-being. Students can become agents for change and allies for school improvement if schools create and nurture authentic relationships where students are perceived as essential, legitimate contributors to achieving their own health and academic success. Students can be the catalyst for change.

DISCUSSION

Educational reform leader Michael Fullan[ 5]( p170) observed that: "When adults do think of students, they think of them as the potential beneficiaries of change...they rarely think of students as participants in a process of school change and organizational life." Fullan[ 5] says that engaging the hearts and minds of students is the key to success in school but many schools see students only as sources of interesting and usable data. Students soon tire of invitations that address matters they do not think are important, use language they find restrictive, alienating, or patronizing and that rarely result in action or dialog that affects their lives. Despite demonstrated valuable and realistic ideas, student voice is not widespread and students are vastly underutilized resources. "Student engagement strategies must reach all students, those doing okay but bored by the irrelevance of school, and those who are disadvantaged and find schools increasingly alienating as they move through the grades."[ 5](p187)

The research on empowering students validates the wisdom of engaging youth in education, health, and social issues. Efficacy studies on youth peer mediation programs in which students are empowered to share responsibility for creating a safe and secure school environment demonstrated the value of turning to students as partners[ 6, 7] Students learned peer mediation skills, reduced suspensions and discipline referrals in schools, and improved the school climate.[ 7] Research has also demonstrated that student peer educators achieve similar or better results than adult educators.[ 8] A review article on the effects of giving students voice in the school decision-making process found evidence of moderate positive effects of student participation on life skills, democratic skills and citizenship, student-adult relationships, and school ethos while finding low evidence of negative effects.[ 9] Wallerstein,[ 10] who has supported the use of youth empowerment strategies in all aspects of health promotion, noted that student participation enhances self-awareness and social achievement, improves mental health and academic performance, and reduces rates of dropping out of school, delinquency, and substance abuse. A 2014 review of 26 articles[ 11] to identify the effects of student participation in designing, planning, implementing, and/or evaluating school health promotion measures found conclusive evidence showing (1) enhanced personal effects on students (enhanced motivation, improved attitudes, skills, competencies, and knowledge); (2) improved school climate; and (3) improved interactions and social relationships in schools both among peers and between students and adults.

Both educational[ 12, 13] and health experts,[ 10] as well as youth development experts,[ 14] have advocated engaging students as partners to improve the health of peers, family, and community as well as improve the very process of school reform.[ 5, 12, 13] Pittman et al noted that

Change happens fastest when youth and community development are seen as two sides of the same coin and young people are afforded the tools, training and trust to apply their creativity and energy to affect meaningful change in their own lives and in the future of their neighborhoods and communities.

Toshalis and Nakkula[ 13] support the effectiveness of students as partners in promoting change within the school. They noted that student voice most often is only at the far left of the spectrum, using students as data sources (Figure 1). However, in those schools that have tried involving students as leaders of change, remarkable success has occurred. Various forms of youth engagement such as peer education, peer mentoring, youth action, student voice, community service, service-learning, youth organizing, civic engagement, and youth-adult partnerships provide students with a sense of safety, belonging, and efficacy; gains in their sociopolitical awareness and civic competence; strengthened community connections;[ 16] and improved achievement.[ 14]

Given the opportunity to discover their true passion, students will accept the challenge and deliver. High school student Zak Malamed[ 17] and a few friends decided it was time for students to speak up. They held their first Twitter chat for students who were feeling frustrated about how little say they had in the school reform discussions going on around them. The question to students became "What can we do to improve this school?" from the impetus of several frustrated students to the organization known as Student Voice ( http://www.studentvoice.org), the conversation has grown to a movement dedicated to revolutionizing education through the voices and actions of students. Supporters promise to advocate for students to be authentic partners in education and ensure that they have a genuine influence on decisions that affect their lives.

The Student Voice Collaboration[ 18] was started by the New York City Department of Education to help students improve themselves and their schools. Participating students learned how the educational system works, interviewed school leaders about decision-making, and created a 1-page map showing how decisions were made in their school. Students conducted research on a challenge in their schools and then developed a student-led campaign to address the challenge. Finally, they set a city-wide agenda-identifying something that would benefit all New York City students. As a result of this work, one student group developed 6 recommendations that were shared with the New York City Chancellor of Education. The program's goal was to show students that they can bring about change by working within the system.

The Student-Centered Schools: Closing the Opportunity Gap evaluation study, conducted by the Stanford Center for Opportunity Policy in Education,[ 19] described how 4 student-centered high schools in California supported student success. Student-centered practices focused on the needs of students through a rigorous, rich, and relevant curriculum that connected to the world beyond school. Students engaged in activities that deepened learning and addressed their needs. Personalization was critical and students were provided with instructional supports that enabled success. Each of the 4 schools supported students' leadership capacities and autonomy through inquiry-based, student-directed, and collaborative learning within the classroom and in the community. Advisory programs, a culture of celebration, student voice, leadership opportunities, and connections to parents and community were embedded in each school. The study revealed that creating high schools designed around student rather than adult needs requires a shift in beliefs that must be translated into action.

The Stanford study[ 19] also showed that teachers and administrators need to be prepared to address students' academic, social, and emotional needs in ways that empower students to take control of their own learning. This has significant implications for teacher and administrator preparation programs, teacher induction, and professional development. A culture of collaboration and partnership must go beyond traditional educator networks to include students as partners and consumers of educational programs and services. Meaningful student involvement requires educators to provide learning experiences that enhance students' skill development. Effective teachers guide students to discovery, help students make meaning of what they learn, and include students as essential and legitimate contributors to achieving their own health and success. Schools must continuously acknowledge the diversity of students by validating and authorizing them to represent their own ideas, opinions, knowledge, and experiences and truly become partners in every facet of school change but certainly in those programs and services that directly impact their health and well-being.

Student empowerment can and should begin in the elementary grades. Serriere et al[ 20] described a youth-adult partnership in one elementary school in which mixed grade level K-5 students participated in Small School Gatherings described as social, civic, and academic networks designed to create a sense of community and encourage student voice. Group projects focused on "making a difference," defined by the students as helping the poor, writing letters to military personnel, or aiding a local animal shelter. These authentic activities incorporated critical thinking, decision-making, collaboration, and planning skills and demonstrated that given the right circumstances, even the youngest students can have a voice in their work.

Similarly, the National Health Education Standards[ 21] emphasize effective communication, goal setting, decision-making, and advocacy-all skills that enable students to take a more active role in their school and community. Ultimately, the goal is to prepare all students for college, career, and life, educating and empowering them to become informed, responsible, and active citizens.

The WSCC model provides a vehicle for students to create meaningful learning experiences in education and health that help create a safe and supportive school. Students can best articulate their own needs, thus maximizing the provision of health and counseling services. However, schools cannot simply ask a select few for their opinions or blessings; rather, schools must make concerted and genuine efforts to move from the contrived student voice of a few students to the meaningful student involvement of all students. "At the heart of meaningful student involvement are students whose voices have long been silenced."[ 12](p4)

Students' Perceptions of Achieving the 5 Whole Child Tenets

Every student deserves to be healthy, safe, engaged, supported, and challenged but evidence suggests that most students do not receive the supports they need to achieve these outcomes. While the Five Promises articulated by the America's Promise Alliance[ 22] do not use the same terms as the WSCC model, they are quite similar in describing the fundamental needs of students: Healthy Start, Safe Places, Caring Adults (Supported), Opportunities to Help Others (Engaged), and, Effective Education (Challenged). A survey completed in 2006 by America's Promise revealed that 7 in 10 young people ages 12 to 17 (69%) received only 3 or less of the 5 fundamental resources needed to flourish. Only 31% (or 15·3 million students out of 49·4 million students) in grades 6-12 received 4 to 5 of these fundamental resources.

The 2014 Quaglia Institute for Student Aspirations' My Voice survey[ 23] also confirmed the need for more resources. The survey, completed by a racially and socioeconomically diverse sample of 66,314 students in grades 6-12 representing 234 schools across the nation, was designed to measure variables affecting student academic motivation and concentrated on the following student constructs: self-worth, engagement, purpose/motivation along with peer support, and teacher support. The authors of the survey noted that the results of the 2014 survey demonstrated little change with the annual results since 2009. Students with a sense of self-worth were 5 times more likely to be academically motivated, yet 45% of students did not have a sense of self-worth. Those who described themselves as engaged were 16 times more likely to be academically motivated but 40% reported that they were not engaged. Students with a sense of purpose were 18 times more likely to be academically motivated but 15% reported no purpose. Teacher support increased academic motivation 8 times over while peer support increased academic motivation 4 times over. However, 39% of the students reported no teacher support and 56% reported no peer support.[ 23]

Clearly, there is a need for a more coordinated and collaborative approach to meeting students' basic needs-one involving families, schools, communities, and peers. The WSCC model could be one mechanism schools and communities use to improve students' feelings and experiences of self-worth, engagement, purpose, peer support, and teacher support as students become partners in the dissemination of the model.

How Schools Can Empower and Engage Students

Meaningful youth involvement in promoting the WSCC model needs to be promoted. Learning opportunities to empower youth can be divided into individual empowerment, organizational empowerment, and community empowerment.[ 24] Individual empowerment occurs when youth develop the self-management skills, improve competence and exert control over their life, while organizational empowerment refers to schools and community organizations that provide opportunities for engaging in student empowerment as well as benefit from student empowerment. Community empowerment refers to the provision of opportunities for citizen participation at the local, state, and national level and the ensuing efforts to improve lives, organizations, and the community.[ 25] Successful youth-adult partnerships happen when the relationships between youth and adults are characterized by mutuality in teaching, learning, and action. While these relationships usually occur within youth organizations or in democratic schools, they could become one mechanism for disseminating the WSCC model.

Fletcher asks adults to:

Imagine a school where democracy is more than a buzzword, and involvement is more than attendance. It is a place where all adults and students interact as co-learners and leaders, and where students are encouraged to speak out about their schools. Picture all adults actively valuing student engagement and empowerment, and all students actively striving to become more engaged and empowered. Envision school classrooms where teachers place the experiences of students at the center of learning, and education boardrooms where everyone can learn from students as partners in school change... [to improve not only education outcomes but also health outcomes]. 12(p4)

What can schools do to empower students and support student voice? The authors suggest adapting 4 goals identified by Fletcher,[ 25] to include a health focus as well as a school improvement focus:

Engage all students at all grade levels and in all subjects as contributing stakeholders in teaching, learning, and leading in school [to ensure that student needs are being met].

Expand the common expectation of every student to become an active and equal partner in school change [that includes health-promoting student support programs and services as cornerstones of school improvement].

Provide students and educators with sustainable, responsive, and systemic approaches to engaging all students [in school improvement and health promotion] and

Validate the experience, perspectives, and knowledge of all students through sustainable, powerful, and purposeful school-oriented and school-community roles.[25](pp7-8)

Table 1, an adaptation of a chart by Fletcher,[ 12] provides examples of empowerment roles students can assume as partners in promoting achievement and health through the implementation of the WSCC model. While the table identifies opportunities at 3 grade clusters (E = elementary/K-5, M = middle grades/6-8, HS = high school/9-12), these suggestions can be easily adapted for any grade level.

Planners/Consultants

* Planning the school day calendar (E, M, HS)

* Designing classroom seating and work areas (E, M, HS)

* Co-designing lessons and/or curriculum (E, M, HS)

* Membership on school health team (E, M, HS)

* Membership on school improvement team (E, M, HS)

* Student-created district budget (HS)

* Serving on community boards (M, HS)

* Serving on planning team for a student health center (M, HS)

* Advising the local Board of Education on health-related policies (M, HS)

* Planning school-wide health activities such as a health fair, fun run, or activity night (E, M, HS)

Educators

* Learning styles

* Teaching skills

* Evaluation methods

* Classroom planning

* Topic understanding

* Facilitation and presentation skills

* Evaluation skills

* Content expertise

* Adapting for differences

* Using background knowledge

* Assessing skills and knowledge

* Co-designing, delivering, and evaluating lesson plans (E, M)

* Providing peer education on 6 health risk behaviors related to premature death and disease (E, M, HS)

* Participating in student/adult co-teaching (M, HS)

* Teaching lessons on local health and education issues (HS)

* Presenting health-related issues to community leaders (E, M, HS)

* Conducting workshops for parents on health and education issues (E, M, HS)

* Creating and sharing online lessons for students in another school or country (E, M, HS)

* Providing instructional information over social media and other school and community media opportunities such as black boards, white boards, bulletin boards, table tents, public address system, school and community newspapers (E, M, HS)

Researchers

* Research methods

* Identifying issues in health and education

* Assessing research results

* Designing action projects

* Communicating findings in various formats

* Applications to real world

* Cause and effect

* Cost-benefit analysis

* Representing data in meaningful ways for various audiences

* Conducting school psychological climate evaluations (E, M, HS)

* Conducting classroom and school physical environment assessments (M, HS)

* Conducting surveys of student health and safety behaviors (E, M, HS)

* Conducting student-designed action research (M, HS)

* Identifying local issues (eg, disparities, diversity, youth issues, and community needs) (HS)

* Studying access to health care issues for adolescents and making recommendations to school and public health officials (M, HS)

* Analyzing the student/adult relationships within the school (E, M, HS)

* Analyzing data about new programs (eg, new health education program, school-based clinic services, absentee reduction programs, and new student orientation programs) (E, M, HS)

* Identifying access to community services for various age groups and make recommendations (E, M, HS)

Organizers

* Creating petitions

* Understanding school governance

* Understanding democratic process

* Group process skills

* Collaboration skills

* Relationship skills

* Issues in governance

* Public speaking

* Using social media in positive ways to reach various audiences

* Conducting needs assessments

Evaluators

Decision Makers/Leaders

* Creating consensus

* Teambuilding

* Conflict resolution

* Community building

* Issues in education and health

* Triage and prioritizing

* Cause and effect

* Adapting for differences

* Establishing student-led classroom governance (E, M, HS)

* Implementing school wide promotion of health behavior issues (E, M, HS)

* Promoting school wide student initiatives to improve school climate (E, M, HS)

* Serving on teacher and principal hiring committees (HS)

* Developing and participating in a student-teacher team leadership training (M, HS)

* Developing and participating in student advisory, peer mediation, service learning, or community service (M, HS)

Advocates/Activists

* Active listening

* Problem solving

* Communication skills

* Issues in education and health

* Group decision-making

* Diversity awareness

* Facilitation skills

* Event planning

* Public speaking

* Writing for different audiences

A number of researchers[ 14-16] have provided guidelines and recommendations for schools and communities on how to begin this process by:

assessing the needs of youth on a regular basis;[14, 15]

developing a local database of resources for youth development;[14]

asking community-based organizations (CBOs) to document and share with schools what they specifically accomplish related to learning outcomes[14] to coordinate a scope and sequence of learning;[14]

developing curricula that integrates community resources for learning and teaching;[14]

providing youth with a supportive "home base" in which youth can work with dedicated and nurturing adults;[15]

creating youth-adult teams that are intentional about the long-term social changes to be achieved;[15]

balancing the need for short-term individual supports for youth with long-term goal of community change;[15]

recognizing and rewarding youth for their participation in youth organizations;[14]

providing professional development for educators to learn about the power of youth organizations to assist in providing youth with skills;[14]

advocating for a line item in the community budget to support youth as partners in improving the community and schools;[14]

providing multiple options for youth participation ensuring that youth receive the support to progressively take on more responsibility as they gain experience and skills;[16]

providing coaching and ongoing feedback to both youth and adults;[14, 15]

establishing strategies to recruit and retain a diverse core of youth;[15, 16]

providing organizational resources such as budget, staff training, and physical space aligned to support quality youth-adult partnership;[16] and

providing adults and youth with opportunities to reflect and learn with same-age peers.[16]

In addition, Kania and Kramer[ 26] identified 5 conditions needed for achieving collective impact on any issue (but particularly educational reform) that could be instructive for school-community partnerships that support youth engagement and empowerment. These include a common agenda, shared measurement systems, mutually reinforcing activities, continuous communication, and backbone support functions (such as convening partners, conducting needs assessments, developing a shared strategic plan for aligning efforts, selecting success metrics, and designing an evaluation). Hung et al[ 27] in a review of the factors that facilitated the implementation of health-promoting schools which also engaged community agencies as partners in the process, identified the following effective and somewhat similar strategies: following a framework/guideline; obtaining committed support from the school staff, school board, management, health agencies, and other stakeholders; adopting a multidisciplinary, collaborative approach; establishing professional networks and relationships; and continuing training and education. Hung et al also noted that coordination was the key to promoting school-community partnerships and encouraged a 2-pronged approach: a top-down approach, a more effective initiating force to introduce and support the coordination role; and a bottom-up commitment, including the participation of parents and students, critical for sustaining an initiative.

Ten years of research,[ 14] assessing the contributions of 120 community youth-based organizations in 34 cities across the nation, revealed that students working with CBOs, when compared to youth in general, were 26% more likely to report having received recognition for good grades. Almost 20% were more likely to rate their chances of graduating from high school as "very high," 20% were more likely to rate the prospect of their going to college as "very high," and more than 2-1/2 times were more likely to think it is "very important" to do community service or to volunteer and give back to their community.[ 14]

Students can also play an important role within their own school or district. The Centers for Disease Control and Prevention[ 28] recommends that schools and communities establish school health coordinating councils at the community level to facilitate the communication and common goals recommended by Kania and Kramer as well as the professional networks and relationships identified by Hung et al as drivers of quality school health programs. District school health councils collaborate and coordinate with school-level teams. Members of both the district level and school councils/teams include representatives from education, public health, health and social service agencies, community leadership, and families. Some schools and districts have found that including students as critical contributors to the work of the councils/teams is vital.

The Center Consolidated School District (Colorado),[ 29] recognizing the importance of a collaborative approach to student health and learning, has a Health Advisory Committee that represents the WSCC components and includes community professionals, school staff, parents, and students. The district believes that, with support, students can achieve academically and be successful in life. Health and wellness efforts are integrated into the work of the Center School District as reflected by a health and wellness goal for the district's Unified Improvement Plan. "The district sees wellness as the foundation for learning... sustained by creating and maintaining environments, comprehensive health, policies, practices, access to services and resources, and attitudes that develop and support the inter-related dimensions of physical, mental, emotional, and social health."[ 29] Persons at the district's Skoglund Middle School believe that "Educating students about leading a healthy lifestyle is important-and because students educate others about a healthy lifestyle and its impact, sustainability is enhanced. As administrators, staff, parents and students understand the importance of coordinated school health efforts, they become the school's strongest advocates."[ 30](p2) Skoglund has discovered that when parents and students demand something, it continues.[ 30](p2) Clearly, student voice and involvement is valued in the district which uses the WSCC model to guide its work. Table 2 provides examples of resources to assist school and community agency staff members to empower students as partners, enable student voice, and develop students as partners for change.

Act for Youth Center of Excellence

Publications, e-news, and presentations on youth-adult partnerships and youth development
http://www.actforyouth.net/youth_development/engagement/partnerships.cfm

Education Commission of the States

Articles and materials for student voice in service learning
http://www.ecs.org/html/projectspartners/nclc/SOS/nclc_SOSresources-studentvoice.htm

The Freechild Project

The Freechild Project, an international effort to foster social change led by and with young people connects young people and adults to the tools, training, and technical assistance they need to create new roles for youth
http://freechild.org/

4-H Clubs

* Youth-Adult Partnerships in Community Decision-Making publication, http://4h.ucanr.edu/files/2427.pdf

* Youth development programs focused on leadership development and community action

* Health and safety initiatives
http://www.4-h.org/

The Forum for Youth Investment

* Workshops and trainings

* Publications and guides

* Focused on whole child, whole community approach to collective impact and continuous improvement

* Research on youth services, youth development and community change
http://forumfyi.org

Student Voice

* Student Voice in a Box toolkit

* Podcasts, videos, blogs, and classroom demonstrations
www.stuvoice.org

Soundout: Promoting Student Voice

SoundOut works with K-12 schools, districts, state and provincial education agencies, and non-profit education to promote Student Voice and student involvement in education. Provides research, resource, and leadership guides for youth alliances, service learning and student voice projects
http://www.soundout.org/

Southern Poverty Law Center

* Provides an inventory to help teachers reflect on how student voice and input are integrated into schools and classrooms

* Blog posts on student voice

* Lesson plans on social justice, activism, and respect

* Students as teachers
http://www.tolerance.org/magazine/number-46-spring-2014/feature/i-start-year-nothing

Youth Empowered Solutions

* Provides customized training and consulting to help adults, youth and organizations further their mission of engaging youth

* Using a 3-pronged approach, their model engages youth in work that challenges them to develop skills, gain critical awareness, and participate in opportunities necessary for creating community change
http://www.youthempoweredsolutions.org/

IMPLICATIONS FOR SCHOOL HEALTH

The WSCC model places students in the center for a reason: students are the consumers of the programs and services we, the adults, provide. A student-centered school considers the thoughts and opinions of the students it serves. That means schools must seek out the opinions and ideas of every student, not just those elected to student government or acknowledged as school leaders. This dialogue must begin in elementary grades as students learn how to develop and present a convincing argument and advocate for their own health, safety, engagement, support for learning and academic challenges as well as these supports for their peers. These skills can be developed, refined, and supported by the implementation of a comprehensive, sequential PreK-12 health education program aligned with the National Health Education Standards.

School administrators must regularly engage all students through social media, surveys, town hall meetings, and focus groups. Creating a continuous feedback loop, where comments are welcomed and expected, is critical to supporting student voice. Whereas having student representatives on the school health committee/team is important, asking all students to participate in developing and implementing school health policies is necessary in order to create a safe environment for discussion. It is critical that students become involved in the conversation at the outset and not after decisions have already been made. Building trust in the "system" is crucial to the success of the WSCC model. As schools implement the WSCC approach, they must create an ongoing dialog about school health policies, programs and services and ensure that the student body is well-represented in those conversations. Three simple questions are critical to that process: What do students think about the planned policy, program or service? How will the policies, programs, and services impact all students in the school? What would the students do differently if given the opportunity to do so?

Ensuring that all students have the skills needed to become effective communicators is but a first step toward creating an environment where students feel safe and supported. Empowering students as partners in the dissemination of the WSCC model will help generate trust and acceptance and ensure that students' needs are being met. ASCD's The Learning Compact Redefined: A Call to Action set the stage for the development of the WSCC model with this statement: "We are calling for a simple change that will have radical implications: put the child at the center of decision-making and allocate resources-time, space, and human-to ensure each child's success."[ 3](p19) Creating meaningful roles for students as allies, decision makers, planners, and foremost, as consumers, ensures that our focus is truly student-centered. Placing students in the center of the WSCC model makes visible the commitment of education and health to collaboratively prepare today's students for the challenges of today and the possibilities of tomorrow. We can accomplish this by engaging and empowering students and acknowledging them as capable and valuable partners in the process (Figure 2).

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27 Hung TTM, Chiang VCL, Dawson A, Lee RLT. Understanding of factors that enable health promoters in implementing health-promoting schools: a systematic review and narrative synthesis of qualitative evidence. PLoS One. 2014;9(9):e108284. DOI: 10.1371/journal.pone.0108284. Available at: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0108284#pone.0108284-Kolbe1. Accessed January 21, 2015.

28 Centers for Disease Control and Prevention (CDC). How schools can implement coordinated school health. 2013. Available at: http://www.cdc.gov/healthyyouth/cshp/schools.htm. Accessed January 25, 2015.

29 Center Consolidated School District 26JT. Why school health? Available at: http://centerschoolshealthandwellness.weebly.com/why-school-health.html. Accessed January 25, 2015.

30 Healthy Schools Champions Magazine. 2014. Available at: http://www.coloradoedinitiative.org/resources/2014-healthy-school-champions/. Accessed January 25, 2015.

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Citing Literature

GENERAL ARTICLE

Authors

Linda L. Morse RN, MA, FASHA,

President, Corresponding author

American School Health Association

Address correspondence to: Linda L. Morse, President, ( info@ashaweb.org), American School Health Association.

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Diane D. Allensworth PhD

Emeritus Professor of School of Health Sciences

Kent State University-Kent, OH, Snellville, GA 30039
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ABSTRACT

BACKGROUND

Students are the heart of the Whole School, Whole Community, Whole Child (WSCC) model. Students are the recipients of programs and services to ensure that they are healthy, safe, engaged, supported, and challenged and also serve as partners in the implementation and dissemination of the WSCC model.

METHODS

A review of the number of students nationwide enjoying the 5 Whole Child tenets reveals severe deficiencies while a review of student-centered approaches, including student engagement and student voice, appears to be one way to remedy these deficiencies.

RESULTS

Research in both education and health reveals that giving students a voice and engaging students as partners benefits them by fostering development of skills, improvement in competence, and exertion of control over their lives while simultaneously improving outcomes for their peers and the entire school/organization.

CONCLUSIONS

Creating meaningful roles for students as allies, decision makers, planners, and consumers shows a commitment to prepare them for the challenges of today and the possibilities of tomorrow.

Most education reform efforts focus on curriculum, instruction, and assessment. This emphasis places responsibility for student success on school administrators and teachers. Little attention has been paid to the student-the consumer most impacted by educational policy and practice. The dissemination of the Whole School, Whole Community, Whole Child (WSCC) model,[ 1] which combines and builds on elements of the traditional coordinated school health approach[ 2] and the Whole Child Framework,[ 3] provides the opportunity for emphasizing and promoting a student-centered approach in schools. The WSCC model places the 10 components of the coordinated school health model around the 5 Whole Child Tenets. The Whole Child Tenets are the intermediary, desired outcomes for every K-12 student. They contribute to academic achievement and ultimately a high-quality, healthy, productive life. The community envelopes the entire WSCC model, indicating that schools cannot accomplish these goals without community support. Peeling back these layers, students are at the very core of the model. The purpose of this article is to underscore that a student-centered model implies that students should be both recipients of services to ensure that they become healthy, safe, engaged, supported, and challenged and empowered as full partners in the implementation of the WSCC model.

Launched in 2007, the ASCD (formerly known as the Association for Supervision and Curriculum Development) Whole Child Initiative helped move the educational conversation from a singular focus on academic achievement to one that promotes the long-term development and success of children by ensuring that all students have the fundamental resources they need to succeed. The updated WSCC approach combines a 10-component coordinated school health model with the original Whole Child Tenets, embedded in the WSCC model:

Each student enters school healthy and learns about and practices a healthy lifestyle.

Each student learns in an environment that is physically and emotionally safe for students and adults.

Each student is actively engaged in learning and is connected to the school and broader community.

Each student has access to personalized learning and is supported by qualified, caring adults.

Each student is challenged academically and prepared for success in college or further study and for employment and participation in a global environment.[1]

The WSCC model aims to change the way health and education intersect and support student health and achievement. By its very design, the model places the student at the core of this change. Rogers'[ 4] research identified the variables needed for change to occur. This includes having individuals with authority and respect who articulate the needed changes (heterophily) as well as individuals that are similar (peers) voicing the need for a particular change (homophily). We believe that students can do so much more than just voice adult recommendations for change. Student-centered schools acknowledge the critical contributions students can and should make to their own learning and well-being. Students can become agents for change and allies for school improvement if schools create and nurture authentic relationships where students are perceived as essential, legitimate contributors to achieving their own health and academic success. Students can be the catalyst for change.

DISCUSSION

Educational reform leader Michael Fullan[ 5]( p170) observed that: "When adults do think of students, they think of them as the potential beneficiaries of change...they rarely think of students as participants in a process of school change and organizational life." Fullan[ 5] says that engaging the hearts and minds of students is the key to success in school but many schools see students only as sources of interesting and usable data. Students soon tire of invitations that address matters they do not think are important, use language they find restrictive, alienating, or patronizing and that rarely result in action or dialog that affects their lives. Despite demonstrated valuable and realistic ideas, student voice is not widespread and students are vastly underutilized resources. "Student engagement strategies must reach all students, those doing okay but bored by the irrelevance of school, and those who are disadvantaged and find schools increasingly alienating as they move through the grades."[ 5](p187)

The research on empowering students validates the wisdom of engaging youth in education, health, and social issues. Efficacy studies on youth peer mediation programs in which students are empowered to share responsibility for creating a safe and secure school environment demonstrated the value of turning to students as partners[ 6, 7] Students learned peer mediation skills, reduced suspensions and discipline referrals in schools, and improved the school climate.[ 7] Research has also demonstrated that student peer educators achieve similar or better results than adult educators.[ 8] A review article on the effects of giving students voice in the school decision-making process found evidence of moderate positive effects of student participation on life skills, democratic skills and citizenship, student-adult relationships, and school ethos while finding low evidence of negative effects.[ 9] Wallerstein,[ 10] who has supported the use of youth empowerment strategies in all aspects of health promotion, noted that student participation enhances self-awareness and social achievement, improves mental health and academic performance, and reduces rates of dropping out of school, delinquency, and substance abuse. A 2014 review of 26 articles[ 11] to identify the effects of student participation in designing, planning, implementing, and/or evaluating school health promotion measures found conclusive evidence showing (1) enhanced personal effects on students (enhanced motivation, improved attitudes, skills, competencies, and knowledge); (2) improved school climate; and (3) improved interactions and social relationships in schools both among peers and between students and adults.

Both educational[ 12, 13] and health experts,[ 10] as well as youth development experts,[ 14] have advocated engaging students as partners to improve the health of peers, family, and community as well as improve the very process of school reform.[ 5, 12, 13] Pittman et al noted that

Change happens fastest when youth and community development are seen as two sides of the same coin and young people are afforded the tools, training and trust to apply their creativity and energy to affect meaningful change in their own lives and in the future of their neighborhoods and communities.

Toshalis and Nakkula[ 13] support the effectiveness of students as partners in promoting change within the school. They noted that student voice most often is only at the far left of the spectrum, using students as data sources (Figure 1). However, in those schools that have tried involving students as leaders of change, remarkable success has occurred. Various forms of youth engagement such as peer education, peer mentoring, youth action, student voice, community service, service-learning, youth organizing, civic engagement, and youth-adult partnerships provide students with a sense of safety, belonging, and efficacy; gains in their sociopolitical awareness and civic competence; strengthened community connections;[ 16] and improved achievement.[ 14]

Given the opportunity to discover their true passion, students will accept the challenge and deliver. High school student Zak Malamed[ 17] and a few friends decided it was time for students to speak up. They held their first Twitter chat for students who were feeling frustrated about how little say they had in the school reform discussions going on around them. The question to students became "What can we do to improve this school?" from the impetus of several frustrated students to the organization known as Student Voice ( http://www.studentvoice.org), the conversation has grown to a movement dedicated to revolutionizing education through the voices and actions of students. Supporters promise to advocate for students to be authentic partners in education and ensure that they have a genuine influence on decisions that affect their lives.

The Student Voice Collaboration[ 18] was started by the New York City Department of Education to help students improve themselves and their schools. Participating students learned how the educational system works, interviewed school leaders about decision-making, and created a 1-page map showing how decisions were made in their school. Students conducted research on a challenge in their schools and then developed a student-led campaign to address the challenge. Finally, they set a city-wide agenda-identifying something that would benefit all New York City students. As a result of this work, one student group developed 6 recommendations that were shared with the New York City Chancellor of Education. The program's goal was to show students that they can bring about change by working within the system.

The Student-Centered Schools: Closing the Opportunity Gap evaluation study, conducted by the Stanford Center for Opportunity Policy in Education,[ 19] described how 4 student-centered high schools in California supported student success. Student-centered practices focused on the needs of students through a rigorous, rich, and relevant curriculum that connected to the world beyond school. Students engaged in activities that deepened learning and addressed their needs. Personalization was critical and students were provided with instructional supports that enabled success. Each of the 4 schools supported students' leadership capacities and autonomy through inquiry-based, student-directed, and collaborative learning within the classroom and in the community. Advisory programs, a culture of celebration, student voice, leadership opportunities, and connections to parents and community were embedded in each school. The study revealed that creating high schools designed around student rather than adult needs requires a shift in beliefs that must be translated into action.

The Stanford study[ 19] also showed that teachers and administrators need to be prepared to address students' academic, social, and emotional needs in ways that empower students to take control of their own learning. This has significant implications for teacher and administrator preparation programs, teacher induction, and professional development. A culture of collaboration and partnership must go beyond traditional educator networks to include students as partners and consumers of educational programs and services. Meaningful student involvement requires educators to provide learning experiences that enhance students' skill development. Effective teachers guide students to discovery, help students make meaning of what they learn, and include students as essential and legitimate contributors to achieving their own health and success. Schools must continuously acknowledge the diversity of students by validating and authorizing them to represent their own ideas, opinions, knowledge, and experiences and truly become partners in every facet of school change but certainly in those programs and services that directly impact their health and well-being.

Student empowerment can and should begin in the elementary grades. Serriere et al[ 20] described a youth-adult partnership in one elementary school in which mixed grade level K-5 students participated in Small School Gatherings described as social, civic, and academic networks designed to create a sense of community and encourage student voice. Group projects focused on "making a difference," defined by the students as helping the poor, writing letters to military personnel, or aiding a local animal shelter. These authentic activities incorporated critical thinking, decision-making, collaboration, and planning skills and demonstrated that given the right circumstances, even the youngest students can have a voice in their work.

Similarly, the National Health Education Standards[ 21] emphasize effective communication, goal setting, decision-making, and advocacy-all skills that enable students to take a more active role in their school and community. Ultimately, the goal is to prepare all students for college, career, and life, educating and empowering them to become informed, responsible, and active citizens.

The WSCC model provides a vehicle for students to create meaningful learning experiences in education and health that help create a safe and supportive school. Students can best articulate their own needs, thus maximizing the provision of health and counseling services. However, schools cannot simply ask a select few for their opinions or blessings; rather, schools must make concerted and genuine efforts to move from the contrived student voice of a few students to the meaningful student involvement of all students. "At the heart of meaningful student involvement are students whose voices have long been silenced."[ 12](p4)

Students' Perceptions of Achieving the 5 Whole Child Tenets

Every student deserves to be healthy, safe, engaged, supported, and challenged but evidence suggests that most students do not receive the supports they need to achieve these outcomes. While the Five Promises articulated by the America's Promise Alliance[ 22] do not use the same terms as the WSCC model, they are quite similar in describing the fundamental needs of students: Healthy Start, Safe Places, Caring Adults (Supported), Opportunities to Help Others (Engaged), and, Effective Education (Challenged). A survey completed in 2006 by America's Promise revealed that 7 in 10 young people ages 12 to 17 (69%) received only 3 or less of the 5 fundamental resources needed to flourish. Only 31% (or 15·3 million students out of 49·4 million students) in grades 6-12 received 4 to 5 of these fundamental resources.

The 2014 Quaglia Institute for Student Aspirations' My Voice survey[ 23] also confirmed the need for more resources. The survey, completed by a racially and socioeconomically diverse sample of 66,314 students in grades 6-12 representing 234 schools across the nation, was designed to measure variables affecting student academic motivation and concentrated on the following student constructs: self-worth, engagement, purpose/motivation along with peer support, and teacher support. The authors of the survey noted that the results of the 2014 survey demonstrated little change with the annual results since 2009. Students with a sense of self-worth were 5 times more likely to be academically motivated, yet 45% of students did not have a sense of self-worth. Those who described themselves as engaged were 16 times more likely to be academically motivated but 40% reported that they were not engaged. Students with a sense of purpose were 18 times more likely to be academically motivated but 15% reported no purpose. Teacher support increased academic motivation 8 times over while peer support increased academic motivation 4 times over. However, 39% of the students reported no teacher support and 56% reported no peer support.[ 23]

Clearly, there is a need for a more coordinated and collaborative approach to meeting students' basic needs-one involving families, schools, communities, and peers. The WSCC model could be one mechanism schools and communities use to improve students' feelings and experiences of self-worth, engagement, purpose, peer support, and teacher support as students become partners in the dissemination of the model.

How Schools Can Empower and Engage Students

Meaningful youth involvement in promoting the WSCC model needs to be promoted. Learning opportunities to empower youth can be divided into individual empowerment, organizational empowerment, and community empowerment.[ 24] Individual empowerment occurs when youth develop the self-management skills, improve competence and exert control over their life, while organizational empowerment refers to schools and community organizations that provide opportunities for engaging in student empowerment as well as benefit from student empowerment. Community empowerment refers to the provision of opportunities for citizen participation at the local, state, and national level and the ensuing efforts to improve lives, organizations, and the community.[ 25] Successful youth-adult partnerships happen when the relationships between youth and adults are characterized by mutuality in teaching, learning, and action. While these relationships usually occur within youth organizations or in democratic schools, they could become one mechanism for disseminating the WSCC model.

Fletcher asks adults to:

Imagine a school where democracy is more than a buzzword, and involvement is more than attendance. It is a place where all adults and students interact as co-learners and leaders, and where students are encouraged to speak out about their schools. Picture all adults actively valuing student engagement and empowerment, and all students actively striving to become more engaged and empowered. Envision school classrooms where teachers place the experiences of students at the center of learning, and education boardrooms where everyone can learn from students as partners in school change... [to improve not only education outcomes but also health outcomes]. 12(p4)

What can schools do to empower students and support student voice? The authors suggest adapting 4 goals identified by Fletcher,[ 25] to include a health focus as well as a school improvement focus:

Engage all students at all grade levels and in all subjects as contributing stakeholders in teaching, learning, and leading in school [to ensure that student needs are being met].

Expand the common expectation of every student to become an active and equal partner in school change [that includes health-promoting student support programs and services as cornerstones of school improvement].

Provide students and educators with sustainable, responsive, and systemic approaches to engaging all students [in school improvement and health promotion] and

Validate the experience, perspectives, and knowledge of all students through sustainable, powerful, and purposeful school-oriented and school-community roles.[25](pp7-8)

Table 1, an adaptation of a chart by Fletcher,[ 12] provides examples of empowerment roles students can assume as partners in promoting achievement and health through the implementation of the WSCC model. While the table identifies opportunities at 3 grade clusters (E = elementary/K-5, M = middle grades/6-8, HS = high school/9-12), these suggestions can be easily adapted for any grade level.

Planners/Consultants

* Planning the school day calendar (E, M, HS)

* Designing classroom seating and work areas (E, M, HS)

* Co-designing lessons and/or curriculum (E, M, HS)

* Membership on school health team (E, M, HS)

* Membership on school improvement team (E, M, HS)

* Student-created district budget (HS)

* Serving on community boards (M, HS)

* Serving on planning team for a student health center (M, HS)

* Advising the local Board of Education on health-related policies (M, HS)

* Planning school-wide health activities such as a health fair, fun run, or activity night (E, M, HS)

Educators

* Learning styles

* Teaching skills

* Evaluation methods

* Classroom planning

* Topic understanding

* Facilitation and presentation skills

* Evaluation skills

* Content expertise

* Adapting for differences

* Using background knowledge

* Assessing skills and knowledge

* Co-designing, delivering, and evaluating lesson plans (E, M)

* Providing peer education on 6 health risk behaviors related to premature death and disease (E, M, HS)

* Participating in student/adult co-teaching (M, HS)

* Teaching lessons on local health and education issues (HS)

* Presenting health-related issues to community leaders (E, M, HS)

* Conducting workshops for parents on health and education issues (E, M, HS)

* Creating and sharing online lessons for students in another school or country (E, M, HS)

* Providing instructional information over social media and other school and community media opportunities such as black boards, white boards, bulletin boards, table tents, public address system, school and community newspapers (E, M, HS)

Researchers

* Research methods

* Identifying issues in health and education

* Assessing research results

* Designing action projects

* Communicating findings in various formats

* Applications to real world

* Cause and effect

* Cost-benefit analysis

* Representing data in meaningful ways for various audiences

* Conducting school psychological climate evaluations (E, M, HS)

* Conducting classroom and school physical environment assessments (M, HS)

* Conducting surveys of student health and safety behaviors (E, M, HS)

* Conducting student-designed action research (M, HS)

* Identifying local issues (eg, disparities, diversity, youth issues, and community needs) (HS)

* Studying access to health care issues for adolescents and making recommendations to school and public health officials (M, HS)

* Analyzing the student/adult relationships within the school (E, M, HS)

* Analyzing data about new programs (eg, new health education program, school-based clinic services, absentee reduction programs, and new student orientation programs) (E, M, HS)

* Identifying access to community services for various age groups and make recommendations (E, M, HS)

Organizers

* Creating petitions

* Understanding school governance

* Understanding democratic process

* Group process skills

* Collaboration skills

* Relationship skills

* Issues in governance

* Public speaking

* Using social media in positive ways to reach various audiences

* Conducting needs assessments

Evaluators

Decision Makers/Leaders

* Creating consensus

* Teambuilding

* Conflict resolution

* Community building

* Issues in education and health

* Triage and prioritizing

* Cause and effect

* Adapting for differences

* Establishing student-led classroom governance (E, M, HS)

* Implementing school wide promotion of health behavior issues (E, M, HS)

* Promoting school wide student initiatives to improve school climate (E, M, HS)

* Serving on teacher and principal hiring committees (HS)

* Developing and participating in a student-teacher team leadership training (M, HS)

* Developing and participating in student advisory, peer mediation, service learning, or community service (M, HS)

Advocates/Activists

* Active listening

* Problem solving

* Communication skills

* Issues in education and health

* Group decision-making

* Diversity awareness

* Facilitation skills

* Event planning

* Public speaking

* Writing for different audiences

A number of researchers[ 14-16] have provided guidelines and recommendations for schools and communities on how to begin this process by:

assessing the needs of youth on a regular basis;[14, 15]

developing a local database of resources for youth development;[14]

asking community-based organizations (CBOs) to document and share with schools what they specifically accomplish related to learning outcomes[14] to coordinate a scope and sequence of learning;[14]

developing curricula that integrates community resources for learning and teaching;[14]

providing youth with a supportive "home base" in which youth can work with dedicated and nurturing adults;[15]

creating youth-adult teams that are intentional about the long-term social changes to be achieved;[15]

balancing the need for short-term individual supports for youth with long-term goal of community change;[15]

recognizing and rewarding youth for their participation in youth organizations;[14]

providing professional development for educators to learn about the power of youth organizations to assist in providing youth with skills;[14]

advocating for a line item in the community budget to support youth as partners in improving the community and schools;[14]

providing multiple options for youth participation ensuring that youth receive the support to progressively take on more responsibility as they gain experience and skills;[16]

providing coaching and ongoing feedback to both youth and adults;[14, 15]

establishing strategies to recruit and retain a diverse core of youth;[15, 16]

providing organizational resources such as budget, staff training, and physical space aligned to support quality youth-adult partnership;[16] and

providing adults and youth with opportunities to reflect and learn with same-age peers.[16]

In addition, Kania and Kramer[ 26] identified 5 conditions needed for achieving collective impact on any issue (but particularly educational reform) that could be instructive for school-community partnerships that support youth engagement and empowerment. These include a common agenda, shared measurement systems, mutually reinforcing activities, continuous communication, and backbone support functions (such as convening partners, conducting needs assessments, developing a shared strategic plan for aligning efforts, selecting success metrics, and designing an evaluation). Hung et al[ 27] in a review of the factors that facilitated the implementation of health-promoting schools which also engaged community agencies as partners in the process, identified the following effective and somewhat similar strategies: following a framework/guideline; obtaining committed support from the school staff, school board, management, health agencies, and other stakeholders; adopting a multidisciplinary, collaborative approach; establishing professional networks and relationships; and continuing training and education. Hung et al also noted that coordination was the key to promoting school-community partnerships and encouraged a 2-pronged approach: a top-down approach, a more effective initiating force to introduce and support the coordination role; and a bottom-up commitment, including the participation of parents and students, critical for sustaining an initiative.

Ten years of research,[ 14] assessing the contributions of 120 community youth-based organizations in 34 cities across the nation, revealed that students working with CBOs, when compared to youth in general, were 26% more likely to report having received recognition for good grades. Almost 20% were more likely to rate their chances of graduating from high school as "very high," 20% were more likely to rate the prospect of their going to college as "very high," and more than 2-1/2 times were more likely to think it is "very important" to do community service or to volunteer and give back to their community.[ 14]

Students can also play an important role within their own school or district. The Centers for Disease Control and Prevention[ 28] recommends that schools and communities establish school health coordinating councils at the community level to facilitate the communication and common goals recommended by Kania and Kramer as well as the professional networks and relationships identified by Hung et al as drivers of quality school health programs. District school health councils collaborate and coordinate with school-level teams. Members of both the district level and school councils/teams include representatives from education, public health, health and social service agencies, community leadership, and families. Some schools and districts have found that including students as critical contributors to the work of the councils/teams is vital.

The Center Consolidated School District (Colorado),[ 29] recognizing the importance of a collaborative approach to student health and learning, has a Health Advisory Committee that represents the WSCC components and includes community professionals, school staff, parents, and students. The district believes that, with support, students can achieve academically and be successful in life. Health and wellness efforts are integrated into the work of the Center School District as reflected by a health and wellness goal for the district's Unified Improvement Plan. "The district sees wellness as the foundation for learning... sustained by creating and maintaining environments, comprehensive health, policies, practices, access to services and resources, and attitudes that develop and support the inter-related dimensions of physical, mental, emotional, and social health."[ 29] Persons at the district's Skoglund Middle School believe that "Educating students about leading a healthy lifestyle is important-and because students educate others about a healthy lifestyle and its impact, sustainability is enhanced. As administrators, staff, parents and students understand the importance of coordinated school health efforts, they become the school's strongest advocates."[ 30](p2) Skoglund has discovered that when parents and students demand something, it continues.[ 30](p2) Clearly, student voice and involvement is valued in the district which uses the WSCC model to guide its work. Table 2 provides examples of resources to assist school and community agency staff members to empower students as partners, enable student voice, and develop students as partners for change.

Act for Youth Center of Excellence

Publications, e-news, and presentations on youth-adult partnerships and youth development
http://www.actforyouth.net/youth_development/engagement/partnerships.cfm

Education Commission of the States

Articles and materials for student voice in service learning
http://www.ecs.org/html/projectspartners/nclc/SOS/nclc_SOSresources-studentvoice.htm

The Freechild Project

The Freechild Project, an international effort to foster social change led by and with young people connects young people and adults to the tools, training, and technical assistance they need to create new roles for youth
http://freechild.org/

4-H Clubs

* Youth-Adult Partnerships in Community Decision-Making publication, http://4h.ucanr.edu/files/2427.pdf

* Youth development programs focused on leadership development and community action

* Health and safety initiatives
http://www.4-h.org/

The Forum for Youth Investment

* Workshops and trainings

* Publications and guides

* Focused on whole child, whole community approach to collective impact and continuous improvement

* Research on youth services, youth development and community change
http://forumfyi.org

Student Voice

* Student Voice in a Box toolkit

* Podcasts, videos, blogs, and classroom demonstrations
www.stuvoice.org

Soundout: Promoting Student Voice

SoundOut works with K-12 schools, districts, state and provincial education agencies, and non-profit education to promote Student Voice and student involvement in education. Provides research, resource, and leadership guides for youth alliances, service learning and student voice projects
http://www.soundout.org/

Southern Poverty Law Center

* Provides an inventory to help teachers reflect on how student voice and input are integrated into schools and classrooms

* Blog posts on student voice

* Lesson plans on social justice, activism, and respect

* Students as teachers
http://www.tolerance.org/magazine/number-46-spring-2014/feature/i-start-year-nothing

Youth Empowered Solutions

* Provides customized training and consulting to help adults, youth and organizations further their mission of engaging youth

* Using a 3-pronged approach, their model engages youth in work that challenges them to develop skills, gain critical awareness, and participate in opportunities necessary for creating community change
http://www.youthempoweredsolutions.org/

IMPLICATIONS FOR SCHOOL HEALTH

The WSCC model places students in the center for a reason: students are the consumers of the programs and services we, the adults, provide. A student-centered school considers the thoughts and opinions of the students it serves. That means schools must seek out the opinions and ideas of every student, not just those elected to student government or acknowledged as school leaders. This dialogue must begin in elementary grades as students learn how to develop and present a convincing argument and advocate for their own health, safety, engagement, support for learning and academic challenges as well as these supports for their peers. These skills can be developed, refined, and supported by the implementation of a comprehensive, sequential PreK-12 health education program aligned with the National Health Education Standards.

School administrators must regularly engage all students through social media, surveys, town hall meetings, and focus groups. Creating a continuous feedback loop, where comments are welcomed and expected, is critical to supporting student voice. Whereas having student representatives on the school health committee/team is important, asking all students to participate in developing and implementing school health policies is necessary in order to create a safe environment for discussion. It is critical that students become involved in the conversation at the outset and not after decisions have already been made. Building trust in the "system" is crucial to the success of the WSCC model. As schools implement the WSCC approach, they must create an ongoing dialog about school health policies, programs and services and ensure that the student body is well-represented in those conversations. Three simple questions are critical to that process: What do students think about the planned policy, program or service? How will the policies, programs, and services impact all students in the school? What would the students do differently if given the opportunity to do so?

Ensuring that all students have the skills needed to become effective communicators is but a first step toward creating an environment where students feel safe and supported. Empowering students as partners in the dissemination of the WSCC model will help generate trust and acceptance and ensure that students' needs are being met. ASCD's The Learning Compact Redefined: A Call to Action set the stage for the development of the WSCC model with this statement: "We are calling for a simple change that will have radical implications: put the child at the center of decision-making and allocate resources-time, space, and human-to ensure each child's success."[ 3](p19) Creating meaningful roles for students as allies, decision makers, planners, and foremost, as consumers, ensures that our focus is truly student-centered. Placing students in the center of the WSCC model makes visible the commitment of education and health to collaboratively prepare today's students for the challenges of today and the possibilities of tomorrow. We can accomplish this by engaging and empowering students and acknowledging them as capable and valuable partners in the process (Figure 2).

Human Subjects Approval Statement

The preparation of this paper involved no original research with human subjects.

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REFERENCES

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9 Mager U, Nowak P. Effects of student participation in decision making at school. A systematic review and synthesis of empirical research. Educ Res Rev. 2012;7(1):38-61.

11 Griebler U, Rojatz D, Simovska V, Forster R. Effects of student participation in school health promotion: a systematic review. Health Promotion Int. 2014; [E-pub ahead of print]. Available at: http://heapro.oxfordjournals.org/content/early/2014/01/05/heapro.dat090.full.pdf. Accessed January 6, 2015.

15 Pittman K, Martin S, Williams A. Core Principles for Engaging Young People in Community Change. Washington, DC: The Forum for Youth Investment, Impact Strategies, Inc; 2007:15. Available at: http://forumfyi.org/files/FINALYouth_Engagment_8.15pdf.pdf. Accessed January 25, 2015.

17 Korbey H. How can students have more say in school decisions. Available at: http://blogs.kqed.org/mindshift/2014/10/how-can-students-have-more-say-in-school-decisions/. Accessed December 15, 2014.

18 Student Voice Collaborative (SVC). About us. 2013. Available at: http://www.studentvoicecollaborative.com/about-us.html. Accessed January 20, 2015.

20 Serriere SC, Mitra D, Reed K. Student voice in the elementary years: fostering youth-adult partnerships in elementary service-learning. Theor Res Soc Educ. 2011;39(4):541-575.

24 Ledford MK, Lucas B, Dairaghi J, Ravelli P. Youth Empowerment: The Theory and Its Implementation. Youth Empowered Solutions: Raleigh, NC; 2013. Available at: http://www.youthempoweredsolutions.org/wp-content/uploads/2013/11/Youth_Empowerment_The_Theory_and_Its_Implementation_YES-11-13-13.pdf. Accessed January 20, 2015.

26 Kania J, Kramer M. Collective impact. Stanford Social Innov Rev. 2011;97:36-41. Available at http://www.ssireview.org/articles/entry/collective_impact. Accessed January 15, 2015.

27 Hung TTM, Chiang VCL, Dawson A, Lee RLT. Understanding of factors that enable health promoters in implementing health-promoting schools: a systematic review and narrative synthesis of qualitative evidence. PLoS One. 2014;9(9):e108284. DOI: 10.1371/journal.pone.0108284. Available at: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0108284#pone.0108284-Kolbe1. Accessed January 21, 2015.

28 Centers for Disease Control and Prevention (CDC). How schools can implement coordinated school health. 2013. Available at: http://www.cdc.gov/healthyyouth/cshp/schools.htm. Accessed January 25, 2015.

29 Center Consolidated School District 26JT. Why school health? Available at: http://centerschoolshealthandwellness.weebly.com/why-school-health.html. Accessed January 25, 2015.

30 Healthy Schools Champions Magazine. 2014. Available at: http://www.coloradoedinitiative.org/resources/2014-healthy-school-champions/. Accessed January 25, 2015.

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Citing Literature

GENERAL ARTICLE

Authors

Linda L. Morse RN, MA, FASHA,

President, Corresponding author

American School Health Association

Address correspondence to: Linda L. Morse, President, ( info@ashaweb.org), American School Health Association.

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Diane D. Allensworth PhD

Emeritus Professor of School of Health Sciences

Kent State University-Kent, OH, Snellville, GA 30039
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ABSTRACT

BACKGROUND

Students are the heart of the Whole School, Whole Community, Whole Child (WSCC) model. Students are the recipients of programs and services to ensure that they are healthy, safe, engaged, supported, and challenged and also serve as partners in the implementation and dissemination of the WSCC model.

METHODS

A review of the number of students nationwide enjoying the 5 Whole Child tenets reveals severe deficiencies while a review of student-centered approaches, including student engagement and student voice, appears to be one way to remedy these deficiencies.

RESULTS

Research in both education and health reveals that giving students a voice and engaging students as partners benefits them by fostering development of skills, improvement in competence, and exertion of control over their lives while simultaneously improving outcomes for their peers and the entire school/organization.

CONCLUSIONS

Creating meaningful roles for students as allies, decision makers, planners, and consumers shows a commitment to prepare them for the challenges of today and the possibilities of tomorrow.

Most education reform efforts focus on curriculum, instruction, and assessment. This emphasis places responsibility for student success on school administrators and teachers. Little attention has been paid to the student-the consumer most impacted by educational policy and practice. The dissemination of the Whole School, Whole Community, Whole Child (WSCC) model,[ 1] which combines and builds on elements of the traditional coordinated school health approach[ 2] and the Whole Child Framework,[ 3] provides the opportunity for emphasizing and promoting a student-centered approach in schools. The WSCC model places the 10 components of the coordinated school health model around the 5 Whole Child Tenets. The Whole Child Tenets are the intermediary, desired outcomes for every K-12 student. They contribute to academic achievement and ultimately a high-quality, healthy, productive life. The community envelopes the entire WSCC model, indicating that schools cannot accomplish these goals without community support. Peeling back these layers, students are at the very core of the model. The purpose of this article is to underscore that a student-centered model implies that students should be both recipients of services to ensure that they become healthy, safe, engaged, supported, and challenged and empowered as full partners in the implementation of the WSCC model.

Launched in 2007, the ASCD (formerly known as the Association for Supervision and Curriculum Development) Whole Child Initiative helped move the educational conversation from a singular focus on academic achievement to one that promotes the long-term development and success of children by ensuring that all students have the fundamental resources they need to succeed. The updated WSCC approach combines a 10-component coordinated school health model with the original Whole Child Tenets, embedded in the WSCC model:

Each student enters school healthy and learns about and practices a healthy lifestyle.

Each student learns in an environment that is physically and emotionally safe for students and adults.

Each student is actively engaged in learning and is connected to the school and broader community.

Each student has access to personalized learning and is supported by qualified, caring adults.

Each student is challenged academically and prepared for success in college or further study and for employment and participation in a global environment.[1]

The WSCC model aims to change the way health and education intersect and support student health and achievement. By its very design, the model places the student at the core of this change. Rogers'[ 4] research identified the variables needed for change to occur. This includes having individuals with authority and respect who articulate the needed changes (heterophily) as well as individuals that are similar (peers) voicing the need for a particular change (homophily). We believe that students can do so much more than just voice adult recommendations for change. Student-centered schools acknowledge the critical contributions students can and should make to their own learning and well-being. Students can become agents for change and allies for school improvement if schools create and nurture authentic relationships where students are perceived as essential, legitimate contributors to achieving their own health and academic success. Students can be the catalyst for change.

DISCUSSION

Educational reform leader Michael Fullan[ 5]( p170) observed that: "When adults do think of students, they think of them as the potential beneficiaries of change...they rarely think of students as participants in a process of school change and organizational life." Fullan[ 5] says that engaging the hearts and minds of students is the key to success in school but many schools see students only as sources of interesting and usable data. Students soon tire of invitations that address matters they do not think are important, use language they find restrictive, alienating, or patronizing and that rarely result in action or dialog that affects their lives. Despite demonstrated valuable and realistic ideas, student voice is not widespread and students are vastly underutilized resources. "Student engagement strategies must reach all students, those doing okay but bored by the irrelevance of school, and those who are disadvantaged and find schools increasingly alienating as they move through the grades."[ 5](p187)

The research on empowering students validates the wisdom of engaging youth in education, health, and social issues. Efficacy studies on youth peer mediation programs in which students are empowered to share responsibility for creating a safe and secure school environment demonstrated the value of turning to students as partners[ 6, 7] Students learned peer mediation skills, reduced suspensions and discipline referrals in schools, and improved the school climate.[ 7] Research has also demonstrated that student peer educators achieve similar or better results than adult educators.[ 8] A review article on the effects of giving students voice in the school decision-making process found evidence of moderate positive effects of student participation on life skills, democratic skills and citizenship, student-adult relationships, and school ethos while finding low evidence of negative effects.[ 9] Wallerstein,[ 10] who has supported the use of youth empowerment strategies in all aspects of health promotion, noted that student participation enhances self-awareness and social achievement, improves mental health and academic performance, and reduces rates of dropping out of school, delinquency, and substance abuse. A 2014 review of 26 articles[ 11] to identify the effects of student participation in designing, planning, implementing, and/or evaluating school health promotion measures found conclusive evidence showing (1) enhanced personal effects on students (enhanced motivation, improved attitudes, skills, competencies, and knowledge); (2) improved school climate; and (3) improved interactions and social relationships in schools both among peers and between students and adults.

Both educational[ 12, 13] and health experts,[ 10] as well as youth development experts,[ 14] have advocated engaging students as partners to improve the health of peers, family, and community as well as improve the very process of school reform.[ 5, 12, 13] Pittman et al noted that

Change happens fastest when youth and community development are seen as two sides of the same coin and young people are afforded the tools, training and trust to apply their creativity and energy to affect meaningful change in their own lives and in the future of their neighborhoods and communities.

Toshalis and Nakkula[ 13] support the effectiveness of students as partners in promoting change within the school. They noted that student voice most often is only at the far left of the spectrum, using students as data sources (Figure 1). However, in those schools that have tried involving students as leaders of change, remarkable success has occurred. Various forms of youth engagement such as peer education, peer mentoring, youth action, student voice, community service, service-learning, youth organizing, civic engagement, and youth-adult partnerships provide students with a sense of safety, belonging, and efficacy; gains in their sociopolitical awareness and civic competence; strengthened community connections;[ 16] and improved achievement.[ 14]

Given the opportunity to discover their true passion, students will accept the challenge and deliver. High school student Zak Malamed[ 17] and a few friends decided it was time for students to speak up. They held their first Twitter chat for students who were feeling frustrated about how little say they had in the school reform discussions going on around them. The question to students became "What can we do to improve this school?" from the impetus of several frustrated students to the organization known as Student Voice ( http://www.studentvoice.org), the conversation has grown to a movement dedicated to revolutionizing education through the voices and actions of students. Supporters promise to advocate for students to be authentic partners in education and ensure that they have a genuine influence on decisions that affect their lives.

The Student Voice Collaboration[ 18] was started by the New York City Department of Education to help students improve themselves and their schools. Participating students learned how the educational system works, interviewed school leaders about decision-making, and created a 1-page map showing how decisions were made in their school. Students conducted research on a challenge in their schools and then developed a student-led campaign to address the challenge. Finally, they set a city-wide agenda-identifying something that would benefit all New York City students. As a result of this work, one student group developed 6 recommendations that were shared with the New York City Chancellor of Education. The program's goal was to show students that they can bring about change by working within the system.

The Student-Centered Schools: Closing the Opportunity Gap evaluation study, conducted by the Stanford Center for Opportunity Policy in Education,[ 19] described how 4 student-centered high schools in California supported student success. Student-centered practices focused on the needs of students through a rigorous, rich, and relevant curriculum that connected to the world beyond school. Students engaged in activities that deepened learning and addressed their needs. Personalization was critical and students were provided with instructional supports that enabled success. Each of the 4 schools supported students' leadership capacities and autonomy through inquiry-based, student-directed, and collaborative learning within the classroom and in the community. Advisory programs, a culture of celebration, student voice, leadership opportunities, and connections to parents and community were embedded in each school. The study revealed that creating high schools designed around student rather than adult needs requires a shift in beliefs that must be translated into action.

The Stanford study[ 19] also showed that teachers and administrators need to be prepared to address students' academic, social, and emotional needs in ways that empower students to take control of their own learning. This has significant implications for teacher and administrator preparation programs, teacher induction, and professional development. A culture of collaboration and partnership must go beyond traditional educator networks to include students as partners and consumers of educational programs and services. Meaningful student involvement requires educators to provide learning experiences that enhance students' skill development. Effective teachers guide students to discovery, help students make meaning of what they learn, and include students as essential and legitimate contributors to achieving their own health and success. Schools must continuously acknowledge the diversity of students by validating and authorizing them to represent their own ideas, opinions, knowledge, and experiences and truly become partners in every facet of school change but certainly in those programs and services that directly impact their health and well-being.

Student empowerment can and should begin in the elementary grades. Serriere et al[ 20] described a youth-adult partnership in one elementary school in which mixed grade level K-5 students participated in Small School Gatherings described as social, civic, and academic networks designed to create a sense of community and encourage student voice. Group projects focused on "making a difference," defined by the students as helping the poor, writing letters to military personnel, or aiding a local animal shelter. These authentic activities incorporated critical thinking, decision-making, collaboration, and planning skills and demonstrated that given the right circumstances, even the youngest students can have a voice in their work.

Similarly, the National Health Education Standards[ 21] emphasize effective communication, goal setting, decision-making, and advocacy-all skills that enable students to take a more active role in their school and community. Ultimately, the goal is to prepare all students for college, career, and life, educating and empowering them to become informed, responsible, and active citizens.

The WSCC model provides a vehicle for students to create meaningful learning experiences in education and health that help create a safe and supportive school. Students can best articulate their own needs, thus maximizing the provision of health and counseling services. However, schools cannot simply ask a select few for their opinions or blessings; rather, schools must make concerted and genuine efforts to move from the contrived student voice of a few students to the meaningful student involvement of all students. "At the heart of meaningful student involvement are students whose voices have long been silenced."[ 12](p4)

Students' Perceptions of Achieving the 5 Whole Child Tenets

Every student deserves to be healthy, safe, engaged, supported, and challenged but evidence suggests that most students do not receive the supports they need to achieve these outcomes. While the Five Promises articulated by the America's Promise Alliance[ 22] do not use the same terms as the WSCC model, they are quite similar in describing the fundamental needs of students: Healthy Start, Safe Places, Caring Adults (Supported), Opportunities to Help Others (Engaged), and, Effective Education (Challenged). A survey completed in 2006 by America's Promise revealed that 7 in 10 young people ages 12 to 17 (69%) received only 3 or less of the 5 fundamental resources needed to flourish. Only 31% (or 15·3 million students out of 49·4 million students) in grades 6-12 received 4 to 5 of these fundamental resources.

The 2014 Quaglia Institute for Student Aspirations' My Voice survey[ 23] also confirmed the need for more resources. The survey, completed by a racially and socioeconomically diverse sample of 66,314 students in grades 6-12 representing 234 schools across the nation, was designed to measure variables affecting student academic motivation and concentrated on the following student constructs: self-worth, engagement, purpose/motivation along with peer support, and teacher support. The authors of the survey noted that the results of the 2014 survey demonstrated little change with the annual results since 2009. Students with a sense of self-worth were 5 times more likely to be academically motivated, yet 45% of students did not have a sense of self-worth. Those who described themselves as engaged were 16 times more likely to be academically motivated but 40% reported that they were not engaged. Students with a sense of purpose were 18 times more likely to be academically motivated but 15% reported no purpose. Teacher support increased academic motivation 8 times over while peer support increased academic motivation 4 times over. However, 39% of the students reported no teacher support and 56% reported no peer support.[ 23]

Clearly, there is a need for a more coordinated and collaborative approach to meeting students' basic needs-one involving families, schools, communities, and peers. The WSCC model could be one mechanism schools and communities use to improve students' feelings and experiences of self-worth, engagement, purpose, peer support, and teacher support as students become partners in the dissemination of the model.

How Schools Can Empower and Engage Students

Meaningful youth involvement in promoting the WSCC model needs to be promoted. Learning opportunities to empower youth can be divided into individual empowerment, organizational empowerment, and community empowerment.[ 24] Individual empowerment occurs when youth develop the self-management skills, improve competence and exert control over their life, while organizational empowerment refers to schools and community organizations that provide opportunities for engaging in student empowerment as well as benefit from student empowerment. Community empowerment refers to the provision of opportunities for citizen participation at the local, state, and national level and the ensuing efforts to improve lives, organizations, and the community.[ 25] Successful youth-adult partnerships happen when the relationships between youth and adults are characterized by mutuality in teaching, learning, and action. While these relationships usually occur within youth organizations or in democratic schools, they could become one mechanism for disseminating the WSCC model.

Fletcher asks adults to:

Imagine a school where democracy is more than a buzzword, and involvement is more than attendance. It is a place where all adults and students interact as co-learners and leaders, and where students are encouraged to speak out about their schools. Picture all adults actively valuing student engagement and empowerment, and all students actively striving to become more engaged and empowered. Envision school classrooms where teachers place the experiences of students at the center of learning, and education boardrooms where everyone can learn from students as partners in school change... [to improve not only education outcomes but also health outcomes]. 12(p4)

What can schools do to empower students and support student voice? The authors suggest adapting 4 goals identified by Fletcher,[ 25] to include a health focus as well as a school improvement focus:

Engage all students at all grade levels and in all subjects as contributing stakeholders in teaching, learning, and leading in school [to ensure that student needs are being met].

Expand the common expectation of every student to become an active and equal partner in school change [that includes health-promoting student support programs and services as cornerstones of school improvement].

Provide students and educators with sustainable, responsive, and systemic approaches to engaging all students [in school improvement and health promotion] and

Validate the experience, perspectives, and knowledge of all students through sustainable, powerful, and purposeful school-oriented and school-community roles.[25](pp7-8)

Table 1, an adaptation of a chart by Fletcher,[ 12] provides examples of empowerment roles students can assume as partners in promoting achievement and health through the implementation of the WSCC model. While the table identifies opportunities at 3 grade clusters (E = elementary/K-5, M = middle grades/6-8, HS = high school/9-12), these suggestions can be easily adapted for any grade level.

Planners/Consultants

* Planning the school day calendar (E, M, HS)

* Designing classroom seating and work areas (E, M, HS)

* Co-designing lessons and/or curriculum (E, M, HS)

* Membership on school health team (E, M, HS)

* Membership on school improvement team (E, M, HS)

* Student-created district budget (HS)

* Serving on community boards (M, HS)

* Serving on planning team for a student health center (M, HS)

* Advising the local Board of Education on health-related policies (M, HS)

* Planning school-wide health activities such as a health fair, fun run, or activity night (E, M, HS)

Educators

* Learning styles

* Teaching skills

* Evaluation methods

* Classroom planning

* Topic understanding

* Facilitation and presentation skills

* Evaluation skills

* Content expertise

* Adapting for differences

* Using background knowledge

* Assessing skills and knowledge

* Co-designing, delivering, and evaluating lesson plans (E, M)

* Providing peer education on 6 health risk behaviors related to premature death and disease (E, M, HS)

* Participating in student/adult co-teaching (M, HS)

* Teaching lessons on local health and education issues (HS)

* Presenting health-related issues to community leaders (E, M, HS)

* Conducting workshops for parents on health and education issues (E, M, HS)

* Creating and sharing online lessons for students in another school or country (E, M, HS)

* Providing instructional information over social media and other school and community media opportunities such as black boards, white boards, bulletin boards, table tents, public address system, school and community newspapers (E, M, HS)

Researchers

* Research methods

* Identifying issues in health and education

* Assessing research results

* Designing action projects

* Communicating findings in various formats

* Applications to real world

* Cause and effect

* Cost-benefit analysis

* Representing data in meaningful ways for various audiences

* Conducting school psychological climate evaluations (E, M, HS)

* Conducting classroom and school physical environment assessments (M, HS)

* Conducting surveys of student health and safety behaviors (E, M, HS)

* Conducting student-designed action research (M, HS)

* Identifying local issues (eg, disparities, diversity, youth issues, and community needs) (HS)

* Studying access to health care issues for adolescents and making recommendations to school and public health officials (M, HS)

* Analyzing the student/adult relationships within the school (E, M, HS)

* Analyzing data about new programs (eg, new health education program, school-based clinic services, absentee reduction programs, and new student orientation programs) (E, M, HS)

* Identifying access to community services for various age groups and make recommendations (E, M, HS)

Organizers

* Creating petitions

* Understanding school governance

* Understanding democratic process

* Group process skills

* Collaboration skills

* Relationship skills

* Issues in governance

* Public speaking

* Using social media in positive ways to reach various audiences

* Conducting needs assessments

Evaluators

Decision Makers/Leaders

* Creating consensus

* Teambuilding

* Conflict resolution

* Community building

* Issues in education and health

* Triage and prioritizing

* Cause and effect

* Adapting for differences

* Establishing student-led classroom governance (E, M, HS)

* Implementing school wide promotion of health behavior issues (E, M, HS)

* Promoting school wide student initiatives to improve school climate (E, M, HS)

* Serving on teacher and principal hiring committees (HS)

* Developing and participating in a student-teacher team leadership training (M, HS)

* Developing and participating in student advisory, peer mediation, service learning, or community service (M, HS)

Advocates/Activists

* Active listening

* Problem solving

* Communication skills

* Issues in education and health

* Group decision-making

* Diversity awareness

* Facilitation skills

* Event planning

* Public speaking

* Writing for different audiences

A number of researchers[ 14-16] have provided guidelines and recommendations for schools and communities on how to begin this process by:

assessing the needs of youth on a regular basis;[14, 15]

developing a local database of resources for youth development;[14]

asking community-based organizations (CBOs) to document and share with schools what they specifically accomplish related to learning outcomes[14] to coordinate a scope and sequence of learning;[14]

developing curricula that integrates community resources for learning and teaching;[14]

providing youth with a supportive "home base" in which youth can work with dedicated and nurturing adults;[15]

creating youth-adult teams that are intentional about the long-term social changes to be achieved;[15]

balancing the need for short-term individual supports for youth with long-term goal of community change;[15]

recognizing and rewarding youth for their participation in youth organizations;[14]

providing professional development for educators to learn about the power of youth organizations to assist in providing youth with skills;[14]

advocating for a line item in the community budget to support youth as partners in improving the community and schools;[14]

providing multiple options for youth participation ensuring that youth receive the support to progressively take on more responsibility as they gain experience and skills;[16]

providing coaching and ongoing feedback to both youth and adults;[14, 15]

establishing strategies to recruit and retain a diverse core of youth;[15, 16]

providing organizational resources such as budget, staff training, and physical space aligned to support quality youth-adult partnership;[16] and

providing adults and youth with opportunities to reflect and learn with same-age peers.[16]

In addition, Kania and Kramer[ 26] identified 5 conditions needed for achieving collective impact on any issue (but particularly educational reform) that could be instructive for school-community partnerships that support youth engagement and empowerment. These include a common agenda, shared measurement systems, mutually reinforcing activities, continuous communication, and backbone support functions (such as convening partners, conducting needs assessments, developing a shared strategic plan for aligning efforts, selecting success metrics, and designing an evaluation). Hung et al[ 27] in a review of the factors that facilitated the implementation of health-promoting schools which also engaged community agencies as partners in the process, identified the following effective and somewhat similar strategies: following a framework/guideline; obtaining committed support from the school staff, school board, management, health agencies, and other stakeholders; adopting a multidisciplinary, collaborative approach; establishing professional networks and relationships; and continuing training and education. Hung et al also noted that coordination was the key to promoting school-community partnerships and encouraged a 2-pronged approach: a top-down approach, a more effective initiating force to introduce and support the coordination role; and a bottom-up commitment, including the participation of parents and students, critical for sustaining an initiative.

Ten years of research,[ 14] assessing the contributions of 120 community youth-based organizations in 34 cities across the nation, revealed that students working with CBOs, when compared to youth in general, were 26% more likely to report having received recognition for good grades. Almost 20% were more likely to rate their chances of graduating from high school as "very high," 20% were more likely to rate the prospect of their going to college as "very high," and more than 2-1/2 times were more likely to think it is "very important" to do community service or to volunteer and give back to their community.[ 14]

Students can also play an important role within their own school or district. The Centers for Disease Control and Prevention[ 28] recommends that schools and communities establish school health coordinating councils at the community level to facilitate the communication and common goals recommended by Kania and Kramer as well as the professional networks and relationships identified by Hung et al as drivers of quality school health programs. District school health councils collaborate and coordinate with school-level teams. Members of both the district level and school councils/teams include representatives from education, public health, health and social service agencies, community leadership, and families. Some schools and districts have found that including students as critical contributors to the work of the councils/teams is vital.

The Center Consolidated School District (Colorado),[ 29] recognizing the importance of a collaborative approach to student health and learning, has a Health Advisory Committee that represents the WSCC components and includes community professionals, school staff, parents, and students. The district believes that, with support, students can achieve academically and be successful in life. Health and wellness efforts are integrated into the work of the Center School District as reflected by a health and wellness goal for the district's Unified Improvement Plan. "The district sees wellness as the foundation for learning... sustained by creating and maintaining environments, comprehensive health, policies, practices, access to services and resources, and attitudes that develop and support the inter-related dimensions of physical, mental, emotional, and social health."[ 29] Persons at the district's Skoglund Middle School believe that "Educating students about leading a healthy lifestyle is important-and because students educate others about a healthy lifestyle and its impact, sustainability is enhanced. As administrators, staff, parents and students understand the importance of coordinated school health efforts, they become the school's strongest advocates."[ 30](p2) Skoglund has discovered that when parents and students demand something, it continues.[ 30](p2) Clearly, student voice and involvement is valued in the district which uses the WSCC model to guide its work. Table 2 provides examples of resources to assist school and community agency staff members to empower students as partners, enable student voice, and develop students as partners for change.

Act for Youth Center of Excellence

Publications, e-news, and presentations on youth-adult partnerships and youth development
http://www.actforyouth.net/youth_development/engagement/partnerships.cfm

Education Commission of the States

Articles and materials for student voice in service learning
http://www.ecs.org/html/projectspartners/nclc/SOS/nclc_SOSresources-studentvoice.htm

The Freechild Project

The Freechild Project, an international effort to foster social change led by and with young people connects young people and adults to the tools, training, and technical assistance they need to create new roles for youth
http://freechild.org/

4-H Clubs

* Youth-Adult Partnerships in Community Decision-Making publication, http://4h.ucanr.edu/files/2427.pdf

* Youth development programs focused on leadership development and community action

* Health and safety initiatives
http://www.4-h.org/

The Forum for Youth Investment

* Workshops and trainings

* Publications and guides

* Focused on whole child, whole community approach to collective impact and continuous improvement

* Research on youth services, youth development and community change
http://forumfyi.org

Student Voice

* Student Voice in a Box toolkit

* Podcasts, videos, blogs, and classroom demonstrations
www.stuvoice.org

Soundout: Promoting Student Voice

SoundOut works with K-12 schools, districts, state and provincial education agencies, and non-profit education to promote Student Voice and student involvement in education. Provides research, resource, and leadership guides for youth alliances, service learning and student voice projects
http://www.soundout.org/

Southern Poverty Law Center

* Provides an inventory to help teachers reflect on how student voice and input are integrated into schools and classrooms

* Blog posts on student voice

* Lesson plans on social justice, activism, and respect

* Students as teachers
http://www.tolerance.org/magazine/number-46-spring-2014/feature/i-start-year-nothing

Youth Empowered Solutions

* Provides customized training and consulting to help adults, youth and organizations further their mission of engaging youth

* Using a 3-pronged approach, their model engages youth in work that challenges them to develop skills, gain critical awareness, and participate in opportunities necessary for creating community change
http://www.youthempoweredsolutions.org/

IMPLICATIONS FOR SCHOOL HEALTH

The WSCC model places students in the center for a reason: students are the consumers of the programs and services we, the adults, provide. A student-centered school considers the thoughts and opinions of the students it serves. That means schools must seek out the opinions and ideas of every student, not just those elected to student government or acknowledged as school leaders. This dialogue must begin in elementary grades as students learn how to develop and present a convincing argument and advocate for their own health, safety, engagement, support for learning and academic challenges as well as these supports for their peers. These skills can be developed, refined, and supported by the implementation of a comprehensive, sequential PreK-12 health education program aligned with the National Health Education Standards.

School administrators must regularly engage all students through social media, surveys, town hall meetings, and focus groups. Creating a continuous feedback loop, where comments are welcomed and expected, is critical to supporting student voice. Whereas having student representatives on the school health committee/team is important, asking all students to participate in developing and implementing school health policies is necessary in order to create a safe environment for discussion. It is critical that students become involved in the conversation at the outset and not after decisions have already been made. Building trust in the "system" is crucial to the success of the WSCC model. As schools implement the WSCC approach, they must create an ongoing dialog about school health policies, programs and services and ensure that the student body is well-represented in those conversations. Three simple questions are critical to that process: What do students think about the planned policy, program or service? How will the policies, programs, and services impact all students in the school? What would the students do differently if given the opportunity to do so?

Ensuring that all students have the skills needed to become effective communicators is but a first step toward creating an environment where students feel safe and supported. Empowering students as partners in the dissemination of the WSCC model will help generate trust and acceptance and ensure that students' needs are being met. ASCD's The Learning Compact Redefined: A Call to Action set the stage for the development of the WSCC model with this statement: "We are calling for a simple change that will have radical implications: put the child at the center of decision-making and allocate resources-time, space, and human-to ensure each child's success."[ 3](p19) Creating meaningful roles for students as allies, decision makers, planners, and foremost, as consumers, ensures that our focus is truly student-centered. Placing students in the center of the WSCC model makes visible the commitment of education and health to collaboratively prepare today's students for the challenges of today and the possibilities of tomorrow. We can accomplish this by engaging and empowering students and acknowledging them as capable and valuable partners in the process (Figure 2).

Human Subjects Approval Statement

The preparation of this paper involved no original research with human subjects.

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REFERENCES

2 Centers for Disease Control and Prevention (CDC). Components of coordinated school health. 2013. Available at: http://www.cdc.gov/healthyyouth/cshp/components.htm. Accessed January 25, 2015.

7 Harris RD. Unlocking the learning potential in peer mediation: an evaluation of peer mediator modeling and disputant learning. Conflict Resol Q. 2005;23(2):141-146.

8 Mellanby AR, Rees JB, Tripp JH. Peer-led and adult-led school health education: a critical review of available comparative research. Health Educ Res. 2000;15(5):533-545.

9 Mager U, Nowak P. Effects of student participation in decision making at school. A systematic review and synthesis of empirical research. Educ Res Rev. 2012;7(1):38-61.

11 Griebler U, Rojatz D, Simovska V, Forster R. Effects of student participation in school health promotion: a systematic review. Health Promotion Int. 2014; [E-pub ahead of print]. Available at: http://heapro.oxfordjournals.org/content/early/2014/01/05/heapro.dat090.full.pdf. Accessed January 6, 2015.

15 Pittman K, Martin S, Williams A. Core Principles for Engaging Young People in Community Change. Washington, DC: The Forum for Youth Investment, Impact Strategies, Inc; 2007:15. Available at: http://forumfyi.org/files/FINALYouth_Engagment_8.15pdf.pdf. Accessed January 25, 2015.

17 Korbey H. How can students have more say in school decisions. Available at: http://blogs.kqed.org/mindshift/2014/10/how-can-students-have-more-say-in-school-decisions/. Accessed December 15, 2014.

18 Student Voice Collaborative (SVC). About us. 2013. Available at: http://www.studentvoicecollaborative.com/about-us.html. Accessed January 20, 2015.

20 Serriere SC, Mitra D, Reed K. Student voice in the elementary years: fostering youth-adult partnerships in elementary service-learning. Theor Res Soc Educ. 2011;39(4):541-575.

24 Ledford MK, Lucas B, Dairaghi J, Ravelli P. Youth Empowerment: The Theory and Its Implementation. Youth Empowered Solutions: Raleigh, NC; 2013. Available at: http://www.youthempoweredsolutions.org/wp-content/uploads/2013/11/Youth_Empowerment_The_Theory_and_Its_Implementation_YES-11-13-13.pdf. Accessed January 20, 2015.

26 Kania J, Kramer M. Collective impact. Stanford Social Innov Rev. 2011;97:36-41. Available at http://www.ssireview.org/articles/entry/collective_impact. Accessed January 15, 2015.

27 Hung TTM, Chiang VCL, Dawson A, Lee RLT. Understanding of factors that enable health promoters in implementing health-promoting schools: a systematic review and narrative synthesis of qualitative evidence. PLoS One. 2014;9(9):e108284. DOI: 10.1371/journal.pone.0108284. Available at: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0108284#pone.0108284-Kolbe1. Accessed January 21, 2015.

28 Centers for Disease Control and Prevention (CDC). How schools can implement coordinated school health. 2013. Available at: http://www.cdc.gov/healthyyouth/cshp/schools.htm. Accessed January 25, 2015.

29 Center Consolidated School District 26JT. Why school health? Available at: http://centerschoolshealthandwellness.weebly.com/why-school-health.html. Accessed January 25, 2015.

30 Healthy Schools Champions Magazine. 2014. Available at: http://www.coloradoedinitiative.org/resources/2014-healthy-school-champions/. Accessed January 25, 2015.

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# data[].attributes.attachment_link.title
Placing Students at the Center: The Whole School, Whole Community, Whole Child Model

# data[].attributes.attachment_link.description
GENERAL ARTICLE President, Corresponding author American School Health Association Address correspondence to: Linda L. Morse, President, ( info@ashaweb.org), American School Health Association. Search for more papers by this author Emeritus Professor of School of Health Sciences Kent State University-Kent, OH, Snellville, GA 30039 Search for more papers by this author Most education reform efforts focus on curriculum, instruction, and assessment.

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How the Whole School, Whole Community, Whole Child Model Works: Creating Greater Alignment, Integration, and Collaboration Between Health and Education

Authors

Rachelle Johnsson Chiang MPH

Whitney Meagher MSW

Sean Slade MEd

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GENERAL ARTICLE

Authors

Rachelle Johnsson Chiang MPH,

Senior Consultant, Corresponding author

School Health, National Association of Chronic Disease Directors, Atlanta, GA 30345

Address correspondence to: Rachelle Johnsson Chiang, Senior Consultant, ( rchiang@chronicdisease.org), School Health, National Association of Chronic Disease Directors, 2200 Century Parkway, Suite 250, Atlanta, GA 30345.

Search for more papers by this author

Whitney Meagher MSW,

Senior Associate

The Pew Charitable Trusts, Washington, DC 20004
Search for more papers by this author

Sean Slade MEd

Director

Whole Child Programs, ASCD, Alexandria, VA 22311-1714
Search for more papers by this author

ABSTRACT

BACKGROUND

The Whole School, Whole Community, Whole Child (WSCC) model calls for greater collaboration across the community, school, and health sectors to meet the needs and support the full potential of each child. This article reports on how 3 states and 2 local school districts have implemented aspects of the WSCC model through collaboration, leadership and policy creation, alignment, and implementation.

METHODS

We searched state health and education department websites, local school district websites, state legislative databases, and sources of peer-reviewed and gray literature to identify materials demonstrating adoption and implementation of coordinated school health, the WSCC model, and associated policies and practices in identified states and districts. We conducted informal interviews in each state and district to reinforce the document review.

RESULTS

States and local school districts have been able to strategically increase collaboration, integration, and alignment of health and education through the adoption and implementation of policy and practice supporting the WSCC model. Successful utilization of the WSCC model has led to substantial positive changes in school health environments, policies, and practices.

CONCLUSIONS

Collaboration among health and education sectors to integrate and align services may lead to improved efficiencies and better health and education outcomes for students.

A small body of research has demonstrated the critical links that exist between health and education, highlighting the importance of health to educational outcomes, and the importance of educational attainment to health.[ 1-6] Despite these strong connections however, the health and education sectors have, for the most part, grown, developed, and established their influence independent of each other. Yet, they are often serving the same child, in the same location, often attending separately to similar issues.

The alignment, integration, and collaboration across health and education sectors hold the potential for greater efficiency, reduced resource consumption, and improved outcomes for both sectors. However, alignment, collaboration, and integration between 2 of the sectors that are of primary importance to children-education and health-can be a challenge. Local school districts often do not have a working relationship with their local health districts, rarely share information and data, and develop interventions without cross-sector collaboration and partnerships. At the state level, health and education departments can struggle to reach beyond their respective agencies, successfully manipulate funding streams and navigate authority structures to actively collaborate and align initiatives. Policymakers also miss opportunities to integrate health into state and local education policy and practice, and vice versa, as health and education have distinct accountability measures, and pressures to achieve short-term gains can make it challenging to take a more integrated, long-term approach.[ 7]

Whole School, Whole Community, Whole Child Model

The Whole School, Whole Community, Whole Child (WSCC) model (Figure 1), developed by ASCD (formerly the Association for Supervision and Curriculum Development) and the US Centers for Disease Control (CDC), provides a framework and a call for the health and education sectors to work toward greater alignment and coordination of policy, process, and practice. The WSCC model, released in 2014, was developed to ensure that school-community and education-health sector alignments are front and center. The model expands the traditional 8-component coordinated school health (CSH) approach and deliberately places it inside the larger community in order to emphasize this connection and role. This includes not only an increase in the number of school health components from 8 to 10 but also the alignment of an education focus with a health focus. The new model calls for a greater collaboration across the community, school, and health and education sectors to meet the needs and support the full potential of each child.[ 8]

The benefits of collaboration, alignment, and integration between health and education can best be viewed in 3 key areas: leveraging resources, utilizing resources efficiently, and improving both health and education outcomes. A 2010 report from the Coalition of Community Schools cited 5 key ways that schools can efficiently leverage resources.[ 9] This includes collaborative efforts to strengthen the core instructional mission of schools, leveraging community-wide financial resources, developing collaborative leadership structures and ownership, enhancing public/private partnerships, and providing coordination between and across systems. In terms of more efficient utilization, increased integration of health and education can improve usage of facilities and resources. Leveraging resources from across the community, as illustrated in the WSCC model, can aid both the establishment of school-community connections and health and educational outcomes. Examples include shared use agreements that can lead to improved community access to facilities for physical activity[ 10, 11] and school-based health centers that have been shown to reduce a community's inappropriate emergency room use, increase use of primary care, and result in fewer hospitalizations among regular users.[ 12-14] Finally, strengthening the integration and collaboration between health and education benefits both sectors because research suggests that educational attainment is important to achieving better health outcomes,[ 15, 16] and health is key to better educational outcomes.[ 2, 3]

Operationalizing WSCC requires moving from theoretical model to practical implementation through the development of state and local school policies and practices. Although the model is new, a number of states and local school districts have made significant strides over the last few years in their efforts to better align health and education by building a collaborative, integrated approach. Arkansas, Kentucky, Colorado, Maine Regional School Unit #22, and Denver Public Schools (DPS) all provide valuable examples of states and local districts that embraced WSCC's core vision of aligning health and education through the adoption of integrated policies and initiatives. Their trailblazing efforts demonstrate both the feasibility of implementing the WSCC model and the visionary leadership required to do so.

METHODS

We conducted a search of the health and education department's websites in Arkansas, Colorado, and Kentucky, and the school districts' websites in Maine Regional School Unit #22, and DPS for materials demonstrating adoption and implementation of CSH and its respective components or the WSCC model. We also conducted a search of the respective state legislative databases, state health and education department websites, and local school district websites for adopted policy relevant to CSH and the WSCC model. We searched PubMed, Web of Science, and Academic Search Premier and for relevant peer-reviewed articles around the implementation of aspects of CSH or WSCC in the 4 states and 2 local school districts. In addition, we searched online for news articles and gray literature highlighting the implementation of CSH or the WSCC model, or aspects of them, in each state and local school district.

Secondarily, we conducted informal reinforcing interviews via phone with 1 person in a key school health leadership role related to the promotion and implementation of the WSCC model in each district and state: Arkansas, Kentucky, and Colorado, Maine Regional School Unit #22 and DPS. The interviews were conducted between September and December 2014. The interviews were recorded and transcribed.

RESULTS

Applying the WSCC Model at the State Level

In Arkansas, the state health and education departments have a long history of working collaboratively and with partners to improve the health of students. The 2 agencies have jointly operated the Coordinated School Health Program (CSHP) for over 2 decades, working together to expand CSH in school districts across the state. They have been supported by a series of state laws that have created a strong and long-lasting foundation for their actions.

In 2003, the Arkansas legislature adopted Act 1220, landmark legislation addressing multiple areas of a healthy school environment.[ 17] The legislation included requirements for body mass index (BMI) screening in schools; the establishment of a state-level Child Health Advisory Committee (CHAC) to develop rules and regulations for school nutrition, physical education (PE), and physical activity, and to make recommendations to the Arkansas State Board of Education and Board of Health; and the establishment of a wellness committee in each local school district. Act 1220 also created positions for regional community health promotion specialists (CHPS) specifically to assist schools and led to new standards for competitive foods and physical activity in schools, created by the Arkansas CHAC. Act 201 followed in 2007 to make modifications to the BMI screening and grade level requirements, provide a parental opt-out clause, and require the Department of Health to assign regional community health nurse specialists (CHNS) to work with schools to ensure appropriate protocols and follow up. Act 317 (2007) later strengthened the CHAC recommended physical activity requirements and required a half credit of PE for high school graduation.[ 18]

In 2009, Act 180 (Tobacco Excise Tax) made possible a state-level Joint Use Agreement Grant program collaboratively run by the Arkansas Department of Education (ADE), the Arkansas Department of Health (ADH), and the Arkansas Center for Health Improvement.[ 19] The program assists schools in the adoption and implementation of shared use policies and the formation of collaborative community partnerships to increase opportunities for physical activity. Act 180 also provided funding for an annual School-Based Health Center Grant, a collaboration among ADE, ADH, the Arkansas Department of Human Services, and Medicaid in the Schools. This funding led to the establishment of 22 school-based health centers across the state, providing on-site clinical services for students and connecting them with community partners in an effort to meet their needs better.

Together, the impact of these laws has been considerable. To date, post-implementation data indicate that Act 1220 and the related policies have resulted in substantial positive changes in school health environments, policies, and practices, with widespread parental support and no increase in negative consequences such as weight-based teasing.[ 20-22] Among the changes are improved nutrition environments in school districts across the state, including reduced access to less healthy competitive foods and beverages and increased access to healthier options, and stronger policies to promote physical activity and recess.[ 20, 21, 23-27] The CHPS, employed by the State Health Department but housed in regional educational cooperatives, have worked together with CHNS to support local school districts, including assisting with the creation of wellness committees and policies, administering the School Health Index, and developing strategies to improve nutrition, physical activity, and health environment policies and programs. The state health and education departments have worked collaboratively, with initiatives guided by a School Health Services Team comprised of staff from various areas in each agency, including school health services, human immunodeficiency virus infection/acquired immune deficiency syndrome, mental health, Arkansas Medicaid in the Schools, the state school nurse consultant, Act 1220, and CSH. Team members provide ongoing support, training, and professional development to school districts throughout the state and to the CHPS and CHNS on topics such as wellness policies and administration of the School Health Index.

Kentucky provides another valuable example of a state that has worked to integrate health and education through the alignment of policy at the state level. Kentucky's state health and education departments have enjoyed a strong, collaborative relationship in recent years. Together, staff from each agency have worked together to increase awareness of CSH among education leaders across the state, including superintendents, principals, and school board members. They have collaborated with state associations including the Kentucky Association of School Councils, Kentucky School Nutrition Association, Kentucky Family Resource Youth Service Centers, and Kentucky Association of Health, Physical Education, Recreation, and Dance to promote understanding, adoption, and implementation of CSH at the local level. The state agencies have focused on helping education leaders make the connection between the CSH components and educational outcomes of academic achievement, discipline, and attendance. This foundation, along with strong relationships with state-level organizations including the Kentucky School Boards Association and the Kentucky Superintendents Association, has facilitated the adoption of education policies that support healthier schools and students.

An example of this can be seen in Kentucky's Program Review process. In 2009, the Kentucky legislature adopted Senate Bill 1, which established Program Review as a part of a new assessment and accountability model.[ 28] In addition to ensuring district and school accountability for student achievement, the annual program reviews are designed to both audit and provide feedback and recommendations focused on improving the quality of educational experiences available to students. The Program Review includes a Practical Living/Career Studies component, encompassing health education and PE. The state health and education departments worked collaboratively to draft the Program Review rubric for the Practical Living/Career Studies component, setting a high baseline to support and strengthen the integration of health into school-level policies and practices.

Schools receive one of 4 designations during the Program Review process: No Implementation, Needs Improvement, Proficient, and Distinguished. To achieve the Proficient level for health education in the Practical Living/Career Studies Program Review, a school must have a CSH committee that is used as a support and resource for collaboration and integration of Health Education instruction in the school environment (Table 1). Similarly, to achieve Proficient in the Practical Living/Administrative Leadership/Support and Monitoring component, a school must convene its CSH committee at least twice a year, implement the district-level wellness policy via a school-level wellness policy reviewed annually, and include goals for school wellness in the Comprehensive School Improvement Plan (CSIP). For PE, the CSH committee of a Proficient school must utilize a Comprehensive School Physical Activity program (CSPAP) to increase quality PE and physical activity opportunities, and integrate the PE curriculum, providing opportunities for cross-disciplinary connections (Table 1). Whereas schools may go beyond these standards to achieve the Distinguished level, setting high requirements for the Proficient level has greatly incentivized the establishment of Coordinated School Health Committees in schools across the state, creation of school-level wellness policies, integration of wellness goals into the school improvement plans, and expansion of CSPAP. Using a common sense approach, Kentucky has intentionally and thoughtfully woven health into education measures, and in doing so, has taken a major step toward ensuring better integration of health and education at the local level.

Curriculum and Instruction Demonstrator 1. Health Education Students Have Equitable Access to High Quality, Rigorous Health Education Curriculum

To what extent does the school ensure a Coordinated School Heath Committee is used as a support and resource for collaboration and integration of health education instruction throughout the school environment?

There is no Coordinated School Health Committee.

A Coordinated School Health committee is in place but is not used to inform instructional practices.

A Coordinated School Heath Committee is used as a support and resource for collaboration and integration of health education instruction throughout the school environment.

A Coordinated School Health committee annually collects and analyzes data to create/review the school wellness policy and utilizes the policy to guide collaboration and integration of health education instruction throughout the school environment.

Curriculum and Instruction Demonstrator 2. Physical Education Students Have Equitable Access to High Quality, Rigorous Physical Education Curriculum

To what extent does the school ensure a Coordinated School Heath Committee is used as a support and resource for collaboration and integration of health education instruction throughout the school environment?

There is no Coordinated School Health Committee.

A Coordinated School Health committee is in place but is not used to inform instructional practices and/or increase physical activity opportunities within the school environment.

A Coordinated School Health committee utilizes a Comprehensive School Physical Activity Program (CSPAP) to increase the quality of the physical education instruction as well as increase physical activity opportunities throughout the school environment.

A Coordinated School Health committee annually collects and analyzes data to create/review the school wellness policy, including all components of CSPAP in the policy, to increase the quality of the physical education instruction as well as specific time allocated daily for physical activity opportunities throughout the school environment.

To what extent does the school ensure the physical education curriculum is integrated and includes regular opportunities for cross-disciplinary connections to meet the physical activity needs of all students?

There is no integration of the physical education curriculum.

School has limited integration opportunities of the physical education curriculum.

School ensures the physical education curriculum is integrated and includes regular opportunities for cross-disciplinary connections to meet the physical activity needs of all students.

School ensures the physical education curriculum is frequently integrated into all content areas to meet the physical activity needs of all students

Administrative/Leadership Support and Monitoring Demonstrator 1: Policies and Monitoring School Leadership Establishes and Monitors Implementation of Policies, Provides Adequate Resources, Facilities, Space, and Instructional Time to Support Highly Effective PLCS Instructional Programs

To what extent does school leadership ensure that Committees (Coordinated School Health committees, Career and Technical Education [CTE] program advisory committees) meet a minimum of twice per school year to ensure quality PLCS programming policies?

Advisory Committees do not exist.

Advisory Committees are implemented but do not collaborate to ensure quality PLCS programming policies.

Committees (Coordinated School Health, CTE program advisory committees) meet a minimum of twice per school year to ensure quality PLCS programming policies.

Advisory Committees (Coordinated School Health, CTE program advisory committees) meet at least quarterly throughout the school year to ensure quality PLCS programming policies.

To what extent does school leadership ensure that the school is implementing the district-level wellness policy via a school-level wellness policy that is reviewed annually; and goals for school wellness are included in the Comprehensive School Improvement Plan (CSIP)?

Only a district-level wellness policy is in place.

A school-level wellness policy is developed but not reviewed annually.

School is implementing the district-level wellness policy via a school-level wellness policy that is reviewed annually; and goals for school wellness are included in the CSIP.

School is implementing the district-level wellness policy via a school-level wellness policy that is reviewed annually; the school utilizes collection of body mass index percentile data in their annual wellness policy review process; and goals for school wellness are included in the CSIP and Comprehensive District Improvement Plan.

In Colorado, strong collaboration and leadership between health and education partners, both public and private, have been instrumental in advancing the integration of health and education across the state. Cooperative relationships have been created by aligning the priorities of local foundations with state-level initiatives rather than passing policy. In addition to a solid working partnership between the state health and education agencies, the state has benefitted from the strategic support of local foundations and organizations including: The Colorado Education Initiative, RMC Health, the Colorado Health Foundation, and Kaiser Permanente. In 2010, these partners came together to develop and disseminate the Healthy School Champion Score Card, a voluntary online school-level assessment tool and associated statewide recognition program that provides financial incentives for creating healthy schools (Tables 2 and 3). The Score Card's design incorporated input from nearly 500 Colorado leaders. It includes 80 questions structured around the 8 components of CSH. Whereas the design is based on the School Health Index, it also takes into consideration Colorado legislation and policies. The use of the Score Card grew significantly from its initiation in 2010, when 100 schools participated. In the 2013-2014 school year, 216 schools, covering over 100,000 students, participated.[ 29, 30]

1

Description of coordinated school health efforts

2

Assessment of community, family, and student involvement

3

Assessment of health education

4

Assessment of health services

5

Assessment of nutrition

6

Assessment of physical education/physical activity

7

Assessment of staff wellness

8

Assessment of school counseling, psychological and social work services

9

Assessment of school environment

Does your school have an individual who coordinates school health and wellness activities and programs?

Schools that answer "fully in place" have designated a staff member who has been formally designated as part of his/her job description to coordinate school health and wellness activities and programs.

In schools that answer "partially in place" have a staff member(s) coordinating school health and wellness activities and programs, but it is NOT a part of their job description.

Schools that answer "not in place" do not have a staff member(s) whose formal responsibilities include coordinating school health and wellness activities and programs.

Does your school have a team that focuses on improving school health and wellness?

Schools that answer "fully in place" have a designated team whose members have assumed responsibility for coordinating school health and wellness activities and programs.

In schools that answer "partially in place:" existing teams informally assume these responsibilities.

Schools that answer "not in place" do not have a designated team whose formal responsibilities include coordinating school health and wellness activities and programs.

If your school has a school health team, are members representative of all School Health component areas?

Schools that answer "fully in place" have a designated team whose members include representatives from each of the 8 Coordinated School Health component areas.

In schools that answer "partially in place," the team has representation from some but not all of the 8 Coordinated School Health component areas.

Schools that answer "not in place" do not have a designated team who coordinate school health and wellness activities and programs.

To what extent does the principal of your school support the school health and wellness activities that are under way?

In schools that answer "fully in place," the principal demonstrates support for the school health and wellness activities by encouraging staff involvement, giving priority to health activities, promoting wellness, modeling healthy behavior, and providing resource support.

In schools that answer "partially in place," the principal has taken some actions to support the school health and wellness activities that are under way.

In schools that answer "not in place," the principal has not taken any actions to support the school health and wellness activities that are under way.

To what extent does your school collect, utilize and present data and other information to identify the populations and health issues to be addressed in your school health efforts?

In schools that answer "fully In place," data are actively used to prioritize the populations and health issues addressed in school health efforts.

In schools that answer "partially in place," data actions are limited because information is not updated or complete, or not all priorities are set using data.

In schools that answer "not in place," no actions are under way to collect, utilize, and/or present data and other information to identify the populations and health issues to be addressed in your school health efforts.

Colorado is working to build on the success of the Score Card by developing the next phase of a district- and school-level assessment and implementation tool for health policies and practices, called Healthy Schools Smart Source. This effort is funded by Kaiser Permanente, in partnership with the Colorado Department of Education, the Colorado Department of Public Health and the Environment, The Colorado Education Initiative, and the Colorado Coalition for Healthy Schools. The goal of Smart Source is to create a single assessment tool that will incorporate questions from the Score Card and other statewide school health assessments, streamlining data collection and submission for schools.[ 31] To create the assessment, partners conducted an extensive literature review and convened over 200 stakeholders in order to determine the correct data points. A pilot of Smart Source was launched in the 2014-2015 school year with 90 schools. By the 2016-2017 school year, Smart Source will collect and synthesize data about school and district health policies and practices into a statewide system. Smart Source will provide schools with school-level reports that offer objective, meaningful comparisons to the aggregated results from all respondents statewide. These reports are designed to provide useful, actionable data as well as recommendations for implementing best practices related to health and wellness (Table 4). Reports will provide school- and district-level leaders with a more robust picture of the effect their school health efforts have on student performance and classroom behavior, informing the school improvement planning process.[ 31, 32]

Smart Source will decrease duplicative data collection by streamlining multiple survey efforts and recognize exemplar schools and districts in order to replicate best practices. It will also provide a far more robust picture of the effects of their school health efforts through tailored technical assistance and school-level reports.

For statewide funders, organizations, and agencies, it will help assess whether they are "moving the needle" on health and wellness in schools, allocate resources, and inform statewide decisions and legislation.

A school- and district-level tool that collects data about health policies and practices.

A student-level tool that collects data on student attitudes and behaviors. Student-level data are collected via the Healthy Kids Colorado Survey.

A system that allows schools and districts to assess their own policy and practices in order to improve school health.

A monitoring system holding schools accountable for implementing school health policies and practices.

A tool that reduces the burden on schools by streamlining multiple school health policy and practice data collections into one system.

One of many school-level tools that assess school health policy and practice.

A vehicle to help secure funding and resources to improve school health.

A vehicle to highlights schools and districts that are not engaged in health and wellness efforts.

An opportunity to recognize schools for the great work they do in health and wellness and replicate best practices.

An opportunity for schools and districts to be penalized for not emphasizing health and wellness efforts.

A way to provide reports to schools and districts with meaningful and actionable data.

A system that provides little to no usable data.

In addition to the Smart Source initiative, collaborating partners have also launched the Colorado Healthy Schools Collective Impact (HSCI), a purposeful and strategic effort to define healthy schools, prioritize school health-related work in the state, minimize duplication of initiatives, and better leverage resources and funding for healthy schools. Healthy Schools Collective Impact members include 20 foundations and nearly 100 community organizations, state agencies, school districts and schools, and nonprofits that are all interested in strengthening the school health environment. The 4 focus areas, each represented by a work group that meets monthly, are PE and physical activity, nutrition, behavioral health (social, emotional, and mental), and student health services. Healthy Schools Collective Impact's objectives are to (1) coordinate efforts and ensure resources are allocated based on identified needs; (2) engage those impacted by the work, including districts and schools, parents, students, funders, and organizations that champion healthy schools; (3) gather consistent data by coordinating surveys and systems to collect data from schools; (4) use consistent communication by creating a shared definition of a healthy school, possibly producing a one-stop shop for data and resources related to priority school health strategies; (5) support core capacity for schools and districts; and (6) develop shared policy priorities.[ 33]

Applying the WSCC Model at the Local Level

At the local level, many school districts nationally have embraced the importance of addressing the whole child through better alignment and integration of health and education. Two districts that provide strong examples of application and implementation of Coordinated School Health and/or the WSCC model include Maine Regional School Unit (RSU) #22 and Denver Public Schools in Colorado. Both have benefited from the leadership of superintendents and local school boards that have embraced the importance of educating the whole child.

Maine Regional School Unit #22

Maine Regional School Unit #22, located in the Hampden area, began to intentionally focus on the health and wellness of students and staff in 1991. The vision to strengthen school health and wellness has been driven by Rick Lyons, district superintendent since 1992. The district began by forming a Wellness Team long before the concept had gained widespread popularity. The Wellness Team, comprised administrators, faculty, support staff, and community members, has been a key factor behind the district's school health achievements since its establishment. In 2001, the district also founded a School Health Advisory Council (SHAC) comprised of administrators, healthcare professionals, and community members. The SHAC oversees the CSHP, which is headed by a School Health Coordinator employed by the district. Given RSU #22's small size (approximately 2,200 students and 375 employees), the financial commitment to support a full-time school health coordinator speaks to the high priority that school health has in this district.

Over the last 20 years, RSU #22 has taken many proactive steps toward strengthening school health in each of its 6 schools. The district adopted a tobacco policy in 1994, followed by a nutrition policy. It increased the number of positions and staffing time for health education teachers, nurses, and guidance counselors and forged partnerships with behavioral health providers. The district promotes active transport to school with a "walking school bus," works with the Hampden Town Council to repair bike lanes and install street lights, and partners with the Hampden Recreation Department to provide before- and after-school programming. Regional School Unit #22 implemented a comprehensive K-12 Health/PE curriculum focusing on lifelong activities (such as weight training, aerobics, bicycling, and running) along with activities such as skiing, tennis, snowshoeing, and swimming and uses Recess Rocks® in K-2 classrooms. In 2002, the Wellness Coordinator and Nutrition Director worked with students and suppliers to change the content of all food offered in vending machines to healthy choices. Regional School Unit #22's schools offer salad bars at lunch, and the food service director strives to use locally sourced foods as much as possible. In 2010, parents, students, the district's food service director, wellness coordinator, and community partners collaborated to plant apple orchards and a vegetable garden.

Leadership from school board members and the superintendent has been key in RSU #22's transformation into a district where health and wellness is a top priority and a value embraced by the school employees and the community. The SHAC, Wellness Team, and school health coordinator have also been integral to the process. They have worked together to facilitate the integration of health and education in numerous areas, including the district's strategic plan and the interview process for prospective employees, which includes questions about their thoughts on the district's wellness priorities. The district has focused on improving student and staff health and dedicated significant financial resources to both. The local school board allocates approximately $40,000 per year for employee wellness incentives for those who did not use more than 3 sick days the previous year, and 60% of staff members have qualified for this reward. Regional School Unit #22 promotes periodic wellness challenges for staff and a 7-week "total health" track through Adult Education. In 2012, it opened a new high school that includes a fitness center, track, and tennis courts open to students, staff, and the community. As a result of these efforts, the Wellness Council of America awarded the district their Gold Level Workplace Wellness award.

Denver Public Schools

Superintendent leadership also has been critical to the success of DPS' strategic inclusion of student health in the district's overall priorities and plan. Since being appointed to the position by the Board of Education in 2009, Superintendent Tom Boasberg has managed the district's 183 schools, which serve a diverse population of over 90,000 children. Seventy-two percent of students qualify for free or reduced-price lunch, and 41% speak a language other than English at home.[ 34] The district has also committed significant resources to student health, and made it a part of the district's strategic planning process.

In 2010, Boasberg oversaw the Denver School Health Advisory Council's creation of the DPS Health Agenda 2015, which outlines the districts' health priorities.[ 35] The district has since invested over $22 million toward its health goals, including the addition of 6 full-time district-funded employees. Some of the significant accomplishments include dramatically increasing the number of schools that serve breakfast after the bell; adding PE teachers to elementary schools, which has led to an additional 22 minutes per week of PE classes; and increasing the number of school counselors, which has corresponded with a decrease in expulsion and suspension rates. Denver Public School has also added a school-based health center every year since 2010, with a fifth scheduled to open in 2015.

In August 2014, DPS released the current version of its 5-year strategic plan, Denver Plan 2020. This version, which was developed with the input of nearly 3,000 educators, parents, students, community partners, and city leaders, includes "Support for the Whole Child" as one of 5 goals. Using the WSCC model as a backbone, an advisory committee is assessing DPS' activities, and will present recommendations for creating a metric to determine future progress in early 2015.[ 36] Denver Public School is also working on the development of the next generation of their health agenda, DPS Health Agenda 2020. The district has solicited input from students, parents, and community members through a widely disseminated survey about health issues that most impact students. Survey topics include asthma, vision, oral health, nutrition, physical activity, social/emotional health, substance abuse, teen pregnancy, and school culture. Denver Public School plans to use the results of this survey to improve student health and wellness going forward.

IMPLICATIONS FOR SCHOOL HEALTH

The WSCC model provides a framework for the health and education sectors at the state and local levels to work toward stronger alignment, integration, and collaboration. As Lloyd Kolbe stated, the WSCC model provides a new opportunity, impetus, and sense of purpose for both sectors: "If we prudently could unite the expertise, perspectives, resources, communication, visibility, and political support of national education, health, and related organizations to help schools and colleges implement a WSCC approach, we synergistically could increase the impact of each sector, each organization involved; we could build a lasting national base for new means to improve both education and health; we could accomplish that which we otherwise cannot."[ 37]

Whereas the WSCC model is new, having been launched in March 2014, many states and local school districts are already in the process of adapting and adjusting practices and processes to suit the expanded version of CSH. The 3 states and 2 school districts highlighted all provide strong examples of implementation of various aspects of the WSCC model. They demonstrate that it is possible to prioritize student health within the education system, for the purpose of better addressing the needs of the whole child. They also demonstrate the importance of strategic leadership at the state and local level, including support from policymakers, superintendents, local school boards, and community organizations that recognize and seize opportunities to integrate and better align the health and education sectors.

Moving forward, state and local health and education agencies should focus greater attention toward ensuring the adoption and implementation of policies that serve both sectors and students, and promote the formation of collaborative partnerships. Policymakers need to focus on adoption and implementation of policies and practices that build on the connection between the school health components and educational outcomes, both academic and behavioral. When those in decision-making roles understand and embrace the WSCC model, they are able to create programs and policies that lead to collaboration and more effective use of resources, creating healthier school environments that address the needs of the whole child.

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REFERENCES

1 Fedewa AL, Ahn S. The effects of physical activity and physical fitness on children's achievement and cognitive outcomes: a meta-analysis. Res Q Exerc Sport. 2011;82(3):521-535.

3 Basch C. Healthier Students Are Better Learners: A Missing Link in Efforts to Close the Achievement Gap. New York, NY: Columbia University; 2010. Available at: http://www.equitycampaign.org/i/a/document/12557_ EquityMattersVol6_Web03082010.pdf. Accessed February 2, 2015.

5 Bradley BJ, Greene AC. Do health and education agencies in the United States share responsibility for academic achievement and health? A review of 25 years of evidence about the relationship of adolescents' academic achievement and health behaviors. J Adolesc Health. 2013;52(5):523-532.

7 Institute of Medicine. Exploring Opportunities for Collaboration between Health and Education to Improve Population Health: Workshop Summary. Washington, DC: The National Academies Press; 2014.

8 ASCD, Centers for Disease Control and Prevention. Whole School, Whole Community, Whole Child: A Collaborative Approach to Learning and Health. Alexandria, VA: ASCD; 2014. Available at: http://www.ascd.org/ASCD/pdf/siteASCD/publications/wholechild/wscc-a-collaborative-approach.pdf. Accessed January 15, 2015.

11 Maddock J, Choy LB, Nett B, McGurk MD, Tamashiro R. Increasing access to places for physical activity through a joint use agreement: a case study in urban Honolulu. Prev Chronic Dis. 2008;5(3):A91.

17 An act to create a child health advisory committee. 2003; Act 1220 (Arkansas 84th General Assembly).

18 An act to increase academic instruction time in public schools; to limit physical activity requirements for public school students; and for other purposes. 2007; Act 317(Arkansas 86th General Assembly).

19 An act to increase the tax on cigarettes and other tobacco products; to authorize the department of finance and administration to pay the commission to the stamp deputies for certain cigarette taxes; and for other purposes. 2009; Act 180 (Arkansas 87th General Session).

28 An act relating to student assessment. 2009; Senate Bill 1 (Kentucky 09 Regular Session).

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GENERAL ARTICLE

Authors

Rachelle Johnsson Chiang MPH,

Senior Consultant, Corresponding author

School Health, National Association of Chronic Disease Directors, Atlanta, GA 30345

Address correspondence to: Rachelle Johnsson Chiang, Senior Consultant, ( rchiang@chronicdisease.org), School Health, National Association of Chronic Disease Directors, 2200 Century Parkway, Suite 250, Atlanta, GA 30345.

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Whitney Meagher MSW,

Senior Associate

The Pew Charitable Trusts, Washington, DC 20004
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Sean Slade MEd

Director

Whole Child Programs, ASCD, Alexandria, VA 22311-1714
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ABSTRACT

BACKGROUND

The Whole School, Whole Community, Whole Child (WSCC) model calls for greater collaboration across the community, school, and health sectors to meet the needs and support the full potential of each child. This article reports on how 3 states and 2 local school districts have implemented aspects of the WSCC model through collaboration, leadership and policy creation, alignment, and implementation.

METHODS

We searched state health and education department websites, local school district websites, state legislative databases, and sources of peer-reviewed and gray literature to identify materials demonstrating adoption and implementation of coordinated school health, the WSCC model, and associated policies and practices in identified states and districts. We conducted informal interviews in each state and district to reinforce the document review.

RESULTS

States and local school districts have been able to strategically increase collaboration, integration, and alignment of health and education through the adoption and implementation of policy and practice supporting the WSCC model. Successful utilization of the WSCC model has led to substantial positive changes in school health environments, policies, and practices.

CONCLUSIONS

Collaboration among health and education sectors to integrate and align services may lead to improved efficiencies and better health and education outcomes for students.

Whole School, Whole Community, Whole Child Model

The Whole School, Whole Community, Whole Child (WSCC) model (Figure 1), developed by ASCD (formerly the Association for Supervision and Curriculum Development) and the US Centers for Disease Control (CDC), provides a framework and a call for the health and education sectors to work toward greater alignment and coordination of policy, process, and practice. The WSCC model, released in 2014, was developed to ensure that school-community and education-health sector alignments are front and center. The model expands the traditional 8-component coordinated school health (CSH) approach and deliberately places it inside the larger community in order to emphasize this connection and role. This includes not only an increase in the number of school health components from 8 to 10 but also the alignment of an education focus with a health focus. The new model calls for a greater collaboration across the community, school, and health and education sectors to meet the needs and support the full potential of each child.[ 8]

The benefits of collaboration, alignment, and integration between health and education can best be viewed in 3 key areas: leveraging resources, utilizing resources efficiently, and improving both health and education outcomes. A 2010 report from the Coalition of Community Schools cited 5 key ways that schools can efficiently leverage resources.[ 9] This includes collaborative efforts to strengthen the core instructional mission of schools, leveraging community-wide financial resources, developing collaborative leadership structures and ownership, enhancing public/private partnerships, and providing coordination between and across systems. In terms of more efficient utilization, increased integration of health and education can improve usage of facilities and resources. Leveraging resources from across the community, as illustrated in the WSCC model, can aid both the establishment of school-community connections and health and educational outcomes. Examples include shared use agreements that can lead to improved community access to facilities for physical activity[ 10, 11] and school-based health centers that have been shown to reduce a community's inappropriate emergency room use, increase use of primary care, and result in fewer hospitalizations among regular users.[ 12-14] Finally, strengthening the integration and collaboration between health and education benefits both sectors because research suggests that educational attainment is important to achieving better health outcomes,[ 15, 16] and health is key to better educational outcomes.[ 2, 3]

Operationalizing WSCC requires moving from theoretical model to practical implementation through the development of state and local school policies and practices. Although the model is new, a number of states and local school districts have made significant strides over the last few years in their efforts to better align health and education by building a collaborative, integrated approach. Arkansas, Kentucky, Colorado, Maine Regional School Unit #22, and Denver Public Schools (DPS) all provide valuable examples of states and local districts that embraced WSCC's core vision of aligning health and education through the adoption of integrated policies and initiatives. Their trailblazing efforts demonstrate both the feasibility of implementing the WSCC model and the visionary leadership required to do so.

Applying the WSCC Model at the State Level

In Arkansas, the state health and education departments have a long history of working collaboratively and with partners to improve the health of students. The 2 agencies have jointly operated the Coordinated School Health Program (CSHP) for over 2 decades, working together to expand CSH in school districts across the state. They have been supported by a series of state laws that have created a strong and long-lasting foundation for their actions.

In 2003, the Arkansas legislature adopted Act 1220, landmark legislation addressing multiple areas of a healthy school environment.[ 17] The legislation included requirements for body mass index (BMI) screening in schools; the establishment of a state-level Child Health Advisory Committee (CHAC) to develop rules and regulations for school nutrition, physical education (PE), and physical activity, and to make recommendations to the Arkansas State Board of Education and Board of Health; and the establishment of a wellness committee in each local school district. Act 1220 also created positions for regional community health promotion specialists (CHPS) specifically to assist schools and led to new standards for competitive foods and physical activity in schools, created by the Arkansas CHAC. Act 201 followed in 2007 to make modifications to the BMI screening and grade level requirements, provide a parental opt-out clause, and require the Department of Health to assign regional community health nurse specialists (CHNS) to work with schools to ensure appropriate protocols and follow up. Act 317 (2007) later strengthened the CHAC recommended physical activity requirements and required a half credit of PE for high school graduation.[ 18]

In 2009, Act 180 (Tobacco Excise Tax) made possible a state-level Joint Use Agreement Grant program collaboratively run by the Arkansas Department of Education (ADE), the Arkansas Department of Health (ADH), and the Arkansas Center for Health Improvement.[ 19] The program assists schools in the adoption and implementation of shared use policies and the formation of collaborative community partnerships to increase opportunities for physical activity. Act 180 also provided funding for an annual School-Based Health Center Grant, a collaboration among ADE, ADH, the Arkansas Department of Human Services, and Medicaid in the Schools. This funding led to the establishment of 22 school-based health centers across the state, providing on-site clinical services for students and connecting them with community partners in an effort to meet their needs better.

Together, the impact of these laws has been considerable. To date, post-implementation data indicate that Act 1220 and the related policies have resulted in substantial positive changes in school health environments, policies, and practices, with widespread parental support and no increase in negative consequences such as weight-based teasing.[ 20-22] Among the changes are improved nutrition environments in school districts across the state, including reduced access to less healthy competitive foods and beverages and increased access to healthier options, and stronger policies to promote physical activity and recess.[ 20, 21, 23-27] The CHPS, employed by the State Health Department but housed in regional educational cooperatives, have worked together with CHNS to support local school districts, including assisting with the creation of wellness committees and policies, administering the School Health Index, and developing strategies to improve nutrition, physical activity, and health environment policies and programs. The state health and education departments have worked collaboratively, with initiatives guided by a School Health Services Team comprised of staff from various areas in each agency, including school health services, human immunodeficiency virus infection/acquired immune deficiency syndrome, mental health, Arkansas Medicaid in the Schools, the state school nurse consultant, Act 1220, and CSH. Team members provide ongoing support, training, and professional development to school districts throughout the state and to the CHPS and CHNS on topics such as wellness policies and administration of the School Health Index.

Kentucky provides another valuable example of a state that has worked to integrate health and education through the alignment of policy at the state level. Kentucky's state health and education departments have enjoyed a strong, collaborative relationship in recent years. Together, staff from each agency have worked together to increase awareness of CSH among education leaders across the state, including superintendents, principals, and school board members. They have collaborated with state associations including the Kentucky Association of School Councils, Kentucky School Nutrition Association, Kentucky Family Resource Youth Service Centers, and Kentucky Association of Health, Physical Education, Recreation, and Dance to promote understanding, adoption, and implementation of CSH at the local level. The state agencies have focused on helping education leaders make the connection between the CSH components and educational outcomes of academic achievement, discipline, and attendance. This foundation, along with strong relationships with state-level organizations including the Kentucky School Boards Association and the Kentucky Superintendents Association, has facilitated the adoption of education policies that support healthier schools and students.

An example of this can be seen in Kentucky's Program Review process. In 2009, the Kentucky legislature adopted Senate Bill 1, which established Program Review as a part of a new assessment and accountability model.[ 28] In addition to ensuring district and school accountability for student achievement, the annual program reviews are designed to both audit and provide feedback and recommendations focused on improving the quality of educational experiences available to students. The Program Review includes a Practical Living/Career Studies component, encompassing health education and PE. The state health and education departments worked collaboratively to draft the Program Review rubric for the Practical Living/Career Studies component, setting a high baseline to support and strengthen the integration of health into school-level policies and practices.

Schools receive one of 4 designations during the Program Review process: No Implementation, Needs Improvement, Proficient, and Distinguished. To achieve the Proficient level for health education in the Practical Living/Career Studies Program Review, a school must have a CSH committee that is used as a support and resource for collaboration and integration of Health Education instruction in the school environment (Table 1). Similarly, to achieve Proficient in the Practical Living/Administrative Leadership/Support and Monitoring component, a school must convene its CSH committee at least twice a year, implement the district-level wellness policy via a school-level wellness policy reviewed annually, and include goals for school wellness in the Comprehensive School Improvement Plan (CSIP). For PE, the CSH committee of a Proficient school must utilize a Comprehensive School Physical Activity program (CSPAP) to increase quality PE and physical activity opportunities, and integrate the PE curriculum, providing opportunities for cross-disciplinary connections (Table 1). Whereas schools may go beyond these standards to achieve the Distinguished level, setting high requirements for the Proficient level has greatly incentivized the establishment of Coordinated School Health Committees in schools across the state, creation of school-level wellness policies, integration of wellness goals into the school improvement plans, and expansion of CSPAP. Using a common sense approach, Kentucky has intentionally and thoughtfully woven health into education measures, and in doing so, has taken a major step toward ensuring better integration of health and education at the local level.

Curriculum and Instruction Demonstrator 1. Health Education Students Have Equitable Access to High Quality, Rigorous Health Education Curriculum

To what extent does the school ensure a Coordinated School Heath Committee is used as a support and resource for collaboration and integration of health education instruction throughout the school environment?

There is no Coordinated School Health Committee.

A Coordinated School Health committee is in place but is not used to inform instructional practices.

A Coordinated School Heath Committee is used as a support and resource for collaboration and integration of health education instruction throughout the school environment.

A Coordinated School Health committee annually collects and analyzes data to create/review the school wellness policy and utilizes the policy to guide collaboration and integration of health education instruction throughout the school environment.

Curriculum and Instruction Demonstrator 2. Physical Education Students Have Equitable Access to High Quality, Rigorous Physical Education Curriculum

To what extent does the school ensure a Coordinated School Heath Committee is used as a support and resource for collaboration and integration of health education instruction throughout the school environment?

There is no Coordinated School Health Committee.

A Coordinated School Health committee is in place but is not used to inform instructional practices and/or increase physical activity opportunities within the school environment.

A Coordinated School Health committee utilizes a Comprehensive School Physical Activity Program (CSPAP) to increase the quality of the physical education instruction as well as increase physical activity opportunities throughout the school environment.

A Coordinated School Health committee annually collects and analyzes data to create/review the school wellness policy, including all components of CSPAP in the policy, to increase the quality of the physical education instruction as well as specific time allocated daily for physical activity opportunities throughout the school environment.

To what extent does the school ensure the physical education curriculum is integrated and includes regular opportunities for cross-disciplinary connections to meet the physical activity needs of all students?

There is no integration of the physical education curriculum.

School has limited integration opportunities of the physical education curriculum.

School ensures the physical education curriculum is integrated and includes regular opportunities for cross-disciplinary connections to meet the physical activity needs of all students.

School ensures the physical education curriculum is frequently integrated into all content areas to meet the physical activity needs of all students

Administrative/Leadership Support and Monitoring Demonstrator 1: Policies and Monitoring School Leadership Establishes and Monitors Implementation of Policies, Provides Adequate Resources, Facilities, Space, and Instructional Time to Support Highly Effective PLCS Instructional Programs

To what extent does school leadership ensure that Committees (Coordinated School Health committees, Career and Technical Education [CTE] program advisory committees) meet a minimum of twice per school year to ensure quality PLCS programming policies?

Advisory Committees do not exist.

Advisory Committees are implemented but do not collaborate to ensure quality PLCS programming policies.

Committees (Coordinated School Health, CTE program advisory committees) meet a minimum of twice per school year to ensure quality PLCS programming policies.

Advisory Committees (Coordinated School Health, CTE program advisory committees) meet at least quarterly throughout the school year to ensure quality PLCS programming policies.

To what extent does school leadership ensure that the school is implementing the district-level wellness policy via a school-level wellness policy that is reviewed annually; and goals for school wellness are included in the Comprehensive School Improvement Plan (CSIP)?

Only a district-level wellness policy is in place.

A school-level wellness policy is developed but not reviewed annually.

School is implementing the district-level wellness policy via a school-level wellness policy that is reviewed annually; and goals for school wellness are included in the CSIP.

School is implementing the district-level wellness policy via a school-level wellness policy that is reviewed annually; the school utilizes collection of body mass index percentile data in their annual wellness policy review process; and goals for school wellness are included in the CSIP and Comprehensive District Improvement Plan.

In Colorado, strong collaboration and leadership between health and education partners, both public and private, have been instrumental in advancing the integration of health and education across the state. Cooperative relationships have been created by aligning the priorities of local foundations with state-level initiatives rather than passing policy. In addition to a solid working partnership between the state health and education agencies, the state has benefitted from the strategic support of local foundations and organizations including: The Colorado Education Initiative, RMC Health, the Colorado Health Foundation, and Kaiser Permanente. In 2010, these partners came together to develop and disseminate the Healthy School Champion Score Card, a voluntary online school-level assessment tool and associated statewide recognition program that provides financial incentives for creating healthy schools (Tables 2 and 3). The Score Card's design incorporated input from nearly 500 Colorado leaders. It includes 80 questions structured around the 8 components of CSH. Whereas the design is based on the School Health Index, it also takes into consideration Colorado legislation and policies. The use of the Score Card grew significantly from its initiation in 2010, when 100 schools participated. In the 2013-2014 school year, 216 schools, covering over 100,000 students, participated.[ 29, 30]

1

Description of coordinated school health efforts

2

Assessment of community, family, and student involvement

3

Assessment of health education

4

Assessment of health services

5

Assessment of nutrition

6

Assessment of physical education/physical activity

7

Assessment of staff wellness

8

Assessment of school counseling, psychological and social work services

9

Assessment of school environment

Does your school have an individual who coordinates school health and wellness activities and programs?

Schools that answer "fully in place" have designated a staff member who has been formally designated as part of his/her job description to coordinate school health and wellness activities and programs.

In schools that answer "partially in place" have a staff member(s) coordinating school health and wellness activities and programs, but it is NOT a part of their job description.

Schools that answer "not in place" do not have a staff member(s) whose formal responsibilities include coordinating school health and wellness activities and programs.

Does your school have a team that focuses on improving school health and wellness?

Schools that answer "fully in place" have a designated team whose members have assumed responsibility for coordinating school health and wellness activities and programs.

In schools that answer "partially in place:" existing teams informally assume these responsibilities.

Schools that answer "not in place" do not have a designated team whose formal responsibilities include coordinating school health and wellness activities and programs.

If your school has a school health team, are members representative of all School Health component areas?

Schools that answer "fully in place" have a designated team whose members include representatives from each of the 8 Coordinated School Health component areas.

In schools that answer "partially in place," the team has representation from some but not all of the 8 Coordinated School Health component areas.

Schools that answer "not in place" do not have a designated team who coordinate school health and wellness activities and programs.

To what extent does the principal of your school support the school health and wellness activities that are under way?

In schools that answer "fully in place," the principal demonstrates support for the school health and wellness activities by encouraging staff involvement, giving priority to health activities, promoting wellness, modeling healthy behavior, and providing resource support.

In schools that answer "partially in place," the principal has taken some actions to support the school health and wellness activities that are under way.

In schools that answer "not in place," the principal has not taken any actions to support the school health and wellness activities that are under way.

To what extent does your school collect, utilize and present data and other information to identify the populations and health issues to be addressed in your school health efforts?

In schools that answer "fully In place," data are actively used to prioritize the populations and health issues addressed in school health efforts.

In schools that answer "partially in place," data actions are limited because information is not updated or complete, or not all priorities are set using data.

In schools that answer "not in place," no actions are under way to collect, utilize, and/or present data and other information to identify the populations and health issues to be addressed in your school health efforts.

Colorado is working to build on the success of the Score Card by developing the next phase of a district- and school-level assessment and implementation tool for health policies and practices, called Healthy Schools Smart Source. This effort is funded by Kaiser Permanente, in partnership with the Colorado Department of Education, the Colorado Department of Public Health and the Environment, The Colorado Education Initiative, and the Colorado Coalition for Healthy Schools. The goal of Smart Source is to create a single assessment tool that will incorporate questions from the Score Card and other statewide school health assessments, streamlining data collection and submission for schools.[ 31] To create the assessment, partners conducted an extensive literature review and convened over 200 stakeholders in order to determine the correct data points. A pilot of Smart Source was launched in the 2014-2015 school year with 90 schools. By the 2016-2017 school year, Smart Source will collect and synthesize data about school and district health policies and practices into a statewide system. Smart Source will provide schools with school-level reports that offer objective, meaningful comparisons to the aggregated results from all respondents statewide. These reports are designed to provide useful, actionable data as well as recommendations for implementing best practices related to health and wellness (Table 4). Reports will provide school- and district-level leaders with a more robust picture of the effect their school health efforts have on student performance and classroom behavior, informing the school improvement planning process.[ 31, 32]

Smart Source will decrease duplicative data collection by streamlining multiple survey efforts and recognize exemplar schools and districts in order to replicate best practices. It will also provide a far more robust picture of the effects of their school health efforts through tailored technical assistance and school-level reports.

For statewide funders, organizations, and agencies, it will help assess whether they are "moving the needle" on health and wellness in schools, allocate resources, and inform statewide decisions and legislation.

A school- and district-level tool that collects data about health policies and practices.

A student-level tool that collects data on student attitudes and behaviors. Student-level data are collected via the Healthy Kids Colorado Survey.

A system that allows schools and districts to assess their own policy and practices in order to improve school health.

A monitoring system holding schools accountable for implementing school health policies and practices.

A tool that reduces the burden on schools by streamlining multiple school health policy and practice data collections into one system.

One of many school-level tools that assess school health policy and practice.

A vehicle to help secure funding and resources to improve school health.

A vehicle to highlights schools and districts that are not engaged in health and wellness efforts.

An opportunity to recognize schools for the great work they do in health and wellness and replicate best practices.

An opportunity for schools and districts to be penalized for not emphasizing health and wellness efforts.

A way to provide reports to schools and districts with meaningful and actionable data.

A system that provides little to no usable data.

In addition to the Smart Source initiative, collaborating partners have also launched the Colorado Healthy Schools Collective Impact (HSCI), a purposeful and strategic effort to define healthy schools, prioritize school health-related work in the state, minimize duplication of initiatives, and better leverage resources and funding for healthy schools. Healthy Schools Collective Impact members include 20 foundations and nearly 100 community organizations, state agencies, school districts and schools, and nonprofits that are all interested in strengthening the school health environment. The 4 focus areas, each represented by a work group that meets monthly, are PE and physical activity, nutrition, behavioral health (social, emotional, and mental), and student health services. Healthy Schools Collective Impact's objectives are to (1) coordinate efforts and ensure resources are allocated based on identified needs; (2) engage those impacted by the work, including districts and schools, parents, students, funders, and organizations that champion healthy schools; (3) gather consistent data by coordinating surveys and systems to collect data from schools; (4) use consistent communication by creating a shared definition of a healthy school, possibly producing a one-stop shop for data and resources related to priority school health strategies; (5) support core capacity for schools and districts; and (6) develop shared policy priorities.[ 33]

Applying the WSCC Model at the Local Level

At the local level, many school districts nationally have embraced the importance of addressing the whole child through better alignment and integration of health and education. Two districts that provide strong examples of application and implementation of Coordinated School Health and/or the WSCC model include Maine Regional School Unit (RSU) #22 and Denver Public Schools in Colorado. Both have benefited from the leadership of superintendents and local school boards that have embraced the importance of educating the whole child.

Maine Regional School Unit #22

Maine Regional School Unit #22, located in the Hampden area, began to intentionally focus on the health and wellness of students and staff in 1991. The vision to strengthen school health and wellness has been driven by Rick Lyons, district superintendent since 1992. The district began by forming a Wellness Team long before the concept had gained widespread popularity. The Wellness Team, comprised administrators, faculty, support staff, and community members, has been a key factor behind the district's school health achievements since its establishment. In 2001, the district also founded a School Health Advisory Council (SHAC) comprised of administrators, healthcare professionals, and community members. The SHAC oversees the CSHP, which is headed by a School Health Coordinator employed by the district. Given RSU #22's small size (approximately 2,200 students and 375 employees), the financial commitment to support a full-time school health coordinator speaks to the high priority that school health has in this district.

Over the last 20 years, RSU #22 has taken many proactive steps toward strengthening school health in each of its 6 schools. The district adopted a tobacco policy in 1994, followed by a nutrition policy. It increased the number of positions and staffing time for health education teachers, nurses, and guidance counselors and forged partnerships with behavioral health providers. The district promotes active transport to school with a "walking school bus," works with the Hampden Town Council to repair bike lanes and install street lights, and partners with the Hampden Recreation Department to provide before- and after-school programming. Regional School Unit #22 implemented a comprehensive K-12 Health/PE curriculum focusing on lifelong activities (such as weight training, aerobics, bicycling, and running) along with activities such as skiing, tennis, snowshoeing, and swimming and uses Recess Rocks® in K-2 classrooms. In 2002, the Wellness Coordinator and Nutrition Director worked with students and suppliers to change the content of all food offered in vending machines to healthy choices. Regional School Unit #22's schools offer salad bars at lunch, and the food service director strives to use locally sourced foods as much as possible. In 2010, parents, students, the district's food service director, wellness coordinator, and community partners collaborated to plant apple orchards and a vegetable garden.

Leadership from school board members and the superintendent has been key in RSU #22's transformation into a district where health and wellness is a top priority and a value embraced by the school employees and the community. The SHAC, Wellness Team, and school health coordinator have also been integral to the process. They have worked together to facilitate the integration of health and education in numerous areas, including the district's strategic plan and the interview process for prospective employees, which includes questions about their thoughts on the district's wellness priorities. The district has focused on improving student and staff health and dedicated significant financial resources to both. The local school board allocates approximately $40,000 per year for employee wellness incentives for those who did not use more than 3 sick days the previous year, and 60% of staff members have qualified for this reward. Regional School Unit #22 promotes periodic wellness challenges for staff and a 7-week "total health" track through Adult Education. In 2012, it opened a new high school that includes a fitness center, track, and tennis courts open to students, staff, and the community. As a result of these efforts, the Wellness Council of America awarded the district their Gold Level Workplace Wellness award.

Denver Public Schools

Superintendent leadership also has been critical to the success of DPS' strategic inclusion of student health in the district's overall priorities and plan. Since being appointed to the position by the Board of Education in 2009, Superintendent Tom Boasberg has managed the district's 183 schools, which serve a diverse population of over 90,000 children. Seventy-two percent of students qualify for free or reduced-price lunch, and 41% speak a language other than English at home.[ 34] The district has also committed significant resources to student health, and made it a part of the district's strategic planning process.

In 2010, Boasberg oversaw the Denver School Health Advisory Council's creation of the DPS Health Agenda 2015, which outlines the districts' health priorities.[ 35] The district has since invested over $22 million toward its health goals, including the addition of 6 full-time district-funded employees. Some of the significant accomplishments include dramatically increasing the number of schools that serve breakfast after the bell; adding PE teachers to elementary schools, which has led to an additional 22 minutes per week of PE classes; and increasing the number of school counselors, which has corresponded with a decrease in expulsion and suspension rates. Denver Public School has also added a school-based health center every year since 2010, with a fifth scheduled to open in 2015.

In August 2014, DPS released the current version of its 5-year strategic plan, Denver Plan 2020. This version, which was developed with the input of nearly 3,000 educators, parents, students, community partners, and city leaders, includes "Support for the Whole Child" as one of 5 goals. Using the WSCC model as a backbone, an advisory committee is assessing DPS' activities, and will present recommendations for creating a metric to determine future progress in early 2015.[ 36] Denver Public School is also working on the development of the next generation of their health agenda, DPS Health Agenda 2020. The district has solicited input from students, parents, and community members through a widely disseminated survey about health issues that most impact students. Survey topics include asthma, vision, oral health, nutrition, physical activity, social/emotional health, substance abuse, teen pregnancy, and school culture. Denver Public School plans to use the results of this survey to improve student health and wellness going forward.

Human Subjects Approval Statement

Information contained in this article was not deemed to involve human subjects, and therefore, was considered exempt from institutional review board examination.

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REFERENCES

1 Fedewa AL, Ahn S. The effects of physical activity and physical fitness on children's achievement and cognitive outcomes: a meta-analysis. Res Q Exerc Sport. 2011;82(3):521-535.

3 Basch C. Healthier Students Are Better Learners: A Missing Link in Efforts to Close the Achievement Gap. New York, NY: Columbia University; 2010. Available at: http://www.equitycampaign.org/i/a/document/12557_ EquityMattersVol6_Web03082010.pdf. Accessed February 2, 2015.

5 Bradley BJ, Greene AC. Do health and education agencies in the United States share responsibility for academic achievement and health? A review of 25 years of evidence about the relationship of adolescents' academic achievement and health behaviors. J Adolesc Health. 2013;52(5):523-532.

7 Institute of Medicine. Exploring Opportunities for Collaboration between Health and Education to Improve Population Health: Workshop Summary. Washington, DC: The National Academies Press; 2014.

8 ASCD, Centers for Disease Control and Prevention. Whole School, Whole Community, Whole Child: A Collaborative Approach to Learning and Health. Alexandria, VA: ASCD; 2014. Available at: http://www.ascd.org/ASCD/pdf/siteASCD/publications/wholechild/wscc-a-collaborative-approach.pdf. Accessed January 15, 2015.

11 Maddock J, Choy LB, Nett B, McGurk MD, Tamashiro R. Increasing access to places for physical activity through a joint use agreement: a case study in urban Honolulu. Prev Chronic Dis. 2008;5(3):A91.

17 An act to create a child health advisory committee. 2003; Act 1220 (Arkansas 84th General Assembly).

18 An act to increase academic instruction time in public schools; to limit physical activity requirements for public school students; and for other purposes. 2007; Act 317(Arkansas 86th General Assembly).

19 An act to increase the tax on cigarettes and other tobacco products; to authorize the department of finance and administration to pay the commission to the stamp deputies for certain cigarette taxes; and for other purposes. 2009; Act 180 (Arkansas 87th General Session).

28 An act relating to student assessment. 2009; Senate Bill 1 (Kentucky 09 Regular Session).

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GENERAL ARTICLE

Authors

Rachelle Johnsson Chiang MPH,

Senior Consultant, Corresponding author

School Health, National Association of Chronic Disease Directors, Atlanta, GA 30345

Address correspondence to: Rachelle Johnsson Chiang, Senior Consultant, ( rchiang@chronicdisease.org), School Health, National Association of Chronic Disease Directors, 2200 Century Parkway, Suite 250, Atlanta, GA 30345.

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Whitney Meagher MSW,

Senior Associate

The Pew Charitable Trusts, Washington, DC 20004
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Sean Slade MEd

Director

Whole Child Programs, ASCD, Alexandria, VA 22311-1714
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In Arkansas, the state health and education departments have a long history of working collaboratively and with partners to improve the health of students. The 2 agencies have jointly operated the Coordinated School Health Program (CSHP) for over 2 decades, working together to expand CSH in school districts across the state. They have been supported by a series of state laws that have created a strong and long-lasting foundation for their actions.

In 2003, the Arkansas legislature adopted Act 1220, landmark legislation addressing multiple areas of a healthy school environment.[ 17] The legislation included requirements for body mass index (BMI) screening in schools; the establishment of a state-level Child Health Advisory Committee (CHAC) to develop rules and regulations for school nutrition, physical education (PE), and physical activity, and to make recommendations to the Arkansas State Board of Education and Board of Health; and the establishment of a wellness committee in each local school district. Act 1220 also created positions for regional community health promotion specialists (CHPS) specifically to assist schools and led to new standards for competitive foods and physical activity in schools, created by the Arkansas CHAC. Act 201 followed in 2007 to make modifications to the BMI screening and grade level requirements, provide a parental opt-out clause, and require the Department of Health to assign regional community health nurse specialists (CHNS) to work with schools to ensure appropriate protocols and follow up. Act 317 (2007) later strengthened the CHAC recommended physical activity requirements and required a half credit of PE for high school graduation.[ 18]

In 2009, Act 180 (Tobacco Excise Tax) made possible a state-level Joint Use Agreement Grant program collaboratively run by the Arkansas Department of Education (ADE), the Arkansas Department of Health (ADH), and the Arkansas Center for Health Improvement.[ 19] The program assists schools in the adoption and implementation of shared use policies and the formation of collaborative community partnerships to increase opportunities for physical activity. Act 180 also provided funding for an annual School-Based Health Center Grant, a collaboration among ADE, ADH, the Arkansas Department of Human Services, and Medicaid in the Schools. This funding led to the establishment of 22 school-based health centers across the state, providing on-site clinical services for students and connecting them with community partners in an effort to meet their needs better.

Together, the impact of these laws has been considerable. To date, post-implementation data indicate that Act 1220 and the related policies have resulted in substantial positive changes in school health environments, policies, and practices, with widespread parental support and no increase in negative consequences such as weight-based teasing.[ 20-22] Among the changes are improved nutrition environments in school districts across the state, including reduced access to less healthy competitive foods and beverages and increased access to healthier options, and stronger policies to promote physical activity and recess.[ 20, 21, 23-27] The CHPS, employed by the State Health Department but housed in regional educational cooperatives, have worked together with CHNS to support local school districts, including assisting with the creation of wellness committees and policies, administering the School Health Index, and developing strategies to improve nutrition, physical activity, and health environment policies and programs. The state health and education departments have worked collaboratively, with initiatives guided by a School Health Services Team comprised of staff from various areas in each agency, including school health services, human immunodeficiency virus infection/acquired immune deficiency syndrome, mental health, Arkansas Medicaid in the Schools, the state school nurse consultant, Act 1220, and CSH. Team members provide ongoing support, training, and professional development to school districts throughout the state and to the CHPS and CHNS on topics such as wellness policies and administration of the School Health Index.

Kentucky provides another valuable example of a state that has worked to integrate health and education through the alignment of policy at the state level. Kentucky's state health and education departments have enjoyed a strong, collaborative relationship in recent years. Together, staff from each agency have worked together to increase awareness of CSH among education leaders across the state, including superintendents, principals, and school board members. They have collaborated with state associations including the Kentucky Association of School Councils, Kentucky School Nutrition Association, Kentucky Family Resource Youth Service Centers, and Kentucky Association of Health, Physical Education, Recreation, and Dance to promote understanding, adoption, and implementation of CSH at the local level. The state agencies have focused on helping education leaders make the connection between the CSH components and educational outcomes of academic achievement, discipline, and attendance. This foundation, along with strong relationships with state-level organizations including the Kentucky School Boards Association and the Kentucky Superintendents Association, has facilitated the adoption of education policies that support healthier schools and students.

An example of this can be seen in Kentucky's Program Review process. In 2009, the Kentucky legislature adopted Senate Bill 1, which established Program Review as a part of a new assessment and accountability model.[ 28] In addition to ensuring district and school accountability for student achievement, the annual program reviews are designed to both audit and provide feedback and recommendations focused on improving the quality of educational experiences available to students. The Program Review includes a Practical Living/Career Studies component, encompassing health education and PE. The state health and education departments worked collaboratively to draft the Program Review rubric for the Practical Living/Career Studies component, setting a high baseline to support and strengthen the integration of health into school-level policies and practices.

Schools receive one of 4 designations during the Program Review process: No Implementation, Needs Improvement, Proficient, and Distinguished. To achieve the Proficient level for health education in the Practical Living/Career Studies Program Review, a school must have a CSH committee that is used as a support and resource for collaboration and integration of Health Education instruction in the school environment (Table 1). Similarly, to achieve Proficient in the Practical Living/Administrative Leadership/Support and Monitoring component, a school must convene its CSH committee at least twice a year, implement the district-level wellness policy via a school-level wellness policy reviewed annually, and include goals for school wellness in the Comprehensive School Improvement Plan (CSIP). For PE, the CSH committee of a Proficient school must utilize a Comprehensive School Physical Activity program (CSPAP) to increase quality PE and physical activity opportunities, and integrate the PE curriculum, providing opportunities for cross-disciplinary connections (Table 1). Whereas schools may go beyond these standards to achieve the Distinguished level, setting high requirements for the Proficient level has greatly incentivized the establishment of Coordinated School Health Committees in schools across the state, creation of school-level wellness policies, integration of wellness goals into the school improvement plans, and expansion of CSPAP. Using a common sense approach, Kentucky has intentionally and thoughtfully woven health into education measures, and in doing so, has taken a major step toward ensuring better integration of health and education at the local level.

Curriculum and Instruction Demonstrator 1. Health Education Students Have Equitable Access to High Quality, Rigorous Health Education Curriculum

To what extent does the school ensure a Coordinated School Heath Committee is used as a support and resource for collaboration and integration of health education instruction throughout the school environment?

There is no Coordinated School Health Committee.

A Coordinated School Health committee is in place but is not used to inform instructional practices.

A Coordinated School Heath Committee is used as a support and resource for collaboration and integration of health education instruction throughout the school environment.

A Coordinated School Health committee annually collects and analyzes data to create/review the school wellness policy and utilizes the policy to guide collaboration and integration of health education instruction throughout the school environment.

Curriculum and Instruction Demonstrator 2. Physical Education Students Have Equitable Access to High Quality, Rigorous Physical Education Curriculum

To what extent does the school ensure a Coordinated School Heath Committee is used as a support and resource for collaboration and integration of health education instruction throughout the school environment?

There is no Coordinated School Health Committee.

A Coordinated School Health committee is in place but is not used to inform instructional practices and/or increase physical activity opportunities within the school environment.

A Coordinated School Health committee utilizes a Comprehensive School Physical Activity Program (CSPAP) to increase the quality of the physical education instruction as well as increase physical activity opportunities throughout the school environment.

A Coordinated School Health committee annually collects and analyzes data to create/review the school wellness policy, including all components of CSPAP in the policy, to increase the quality of the physical education instruction as well as specific time allocated daily for physical activity opportunities throughout the school environment.

To what extent does the school ensure the physical education curriculum is integrated and includes regular opportunities for cross-disciplinary connections to meet the physical activity needs of all students?

There is no integration of the physical education curriculum.

School has limited integration opportunities of the physical education curriculum.

School ensures the physical education curriculum is integrated and includes regular opportunities for cross-disciplinary connections to meet the physical activity needs of all students.

School ensures the physical education curriculum is frequently integrated into all content areas to meet the physical activity needs of all students

Administrative/Leadership Support and Monitoring Demonstrator 1: Policies and Monitoring School Leadership Establishes and Monitors Implementation of Policies, Provides Adequate Resources, Facilities, Space, and Instructional Time to Support Highly Effective PLCS Instructional Programs

To what extent does school leadership ensure that Committees (Coordinated School Health committees, Career and Technical Education [CTE] program advisory committees) meet a minimum of twice per school year to ensure quality PLCS programming policies?

Advisory Committees do not exist.

Advisory Committees are implemented but do not collaborate to ensure quality PLCS programming policies.

Committees (Coordinated School Health, CTE program advisory committees) meet a minimum of twice per school year to ensure quality PLCS programming policies.

Advisory Committees (Coordinated School Health, CTE program advisory committees) meet at least quarterly throughout the school year to ensure quality PLCS programming policies.

To what extent does school leadership ensure that the school is implementing the district-level wellness policy via a school-level wellness policy that is reviewed annually; and goals for school wellness are included in the Comprehensive School Improvement Plan (CSIP)?

Only a district-level wellness policy is in place.

A school-level wellness policy is developed but not reviewed annually.

School is implementing the district-level wellness policy via a school-level wellness policy that is reviewed annually; and goals for school wellness are included in the CSIP.

School is implementing the district-level wellness policy via a school-level wellness policy that is reviewed annually; the school utilizes collection of body mass index percentile data in their annual wellness policy review process; and goals for school wellness are included in the CSIP and Comprehensive District Improvement Plan.

In Colorado, strong collaboration and leadership between health and education partners, both public and private, have been instrumental in advancing the integration of health and education across the state. Cooperative relationships have been created by aligning the priorities of local foundations with state-level initiatives rather than passing policy. In addition to a solid working partnership between the state health and education agencies, the state has benefitted from the strategic support of local foundations and organizations including: The Colorado Education Initiative, RMC Health, the Colorado Health Foundation, and Kaiser Permanente. In 2010, these partners came together to develop and disseminate the Healthy School Champion Score Card, a voluntary online school-level assessment tool and associated statewide recognition program that provides financial incentives for creating healthy schools (Tables 2 and 3). The Score Card's design incorporated input from nearly 500 Colorado leaders. It includes 80 questions structured around the 8 components of CSH. Whereas the design is based on the School Health Index, it also takes into consideration Colorado legislation and policies. The use of the Score Card grew significantly from its initiation in 2010, when 100 schools participated. In the 2013-2014 school year, 216 schools, covering over 100,000 students, participated.[ 29, 30]

1

Description of coordinated school health efforts

2

Assessment of community, family, and student involvement

3

Assessment of health education

4

Assessment of health services

5

Assessment of nutrition

6

Assessment of physical education/physical activity

7

Assessment of staff wellness

8

Assessment of school counseling, psychological and social work services

9

Assessment of school environment

Does your school have an individual who coordinates school health and wellness activities and programs?

Schools that answer "fully in place" have designated a staff member who has been formally designated as part of his/her job description to coordinate school health and wellness activities and programs.

In schools that answer "partially in place" have a staff member(s) coordinating school health and wellness activities and programs, but it is NOT a part of their job description.

Schools that answer "not in place" do not have a staff member(s) whose formal responsibilities include coordinating school health and wellness activities and programs.

Does your school have a team that focuses on improving school health and wellness?

Schools that answer "fully in place" have a designated team whose members have assumed responsibility for coordinating school health and wellness activities and programs.

In schools that answer "partially in place:" existing teams informally assume these responsibilities.

Schools that answer "not in place" do not have a designated team whose formal responsibilities include coordinating school health and wellness activities and programs.

If your school has a school health team, are members representative of all School Health component areas?

Schools that answer "fully in place" have a designated team whose members include representatives from each of the 8 Coordinated School Health component areas.

In schools that answer "partially in place," the team has representation from some but not all of the 8 Coordinated School Health component areas.

Schools that answer "not in place" do not have a designated team who coordinate school health and wellness activities and programs.

To what extent does the principal of your school support the school health and wellness activities that are under way?

In schools that answer "fully in place," the principal demonstrates support for the school health and wellness activities by encouraging staff involvement, giving priority to health activities, promoting wellness, modeling healthy behavior, and providing resource support.

In schools that answer "partially in place," the principal has taken some actions to support the school health and wellness activities that are under way.

In schools that answer "not in place," the principal has not taken any actions to support the school health and wellness activities that are under way.

To what extent does your school collect, utilize and present data and other information to identify the populations and health issues to be addressed in your school health efforts?

In schools that answer "fully In place," data are actively used to prioritize the populations and health issues addressed in school health efforts.

In schools that answer "partially in place," data actions are limited because information is not updated or complete, or not all priorities are set using data.

In schools that answer "not in place," no actions are under way to collect, utilize, and/or present data and other information to identify the populations and health issues to be addressed in your school health efforts.

Colorado is working to build on the success of the Score Card by developing the next phase of a district- and school-level assessment and implementation tool for health policies and practices, called Healthy Schools Smart Source. This effort is funded by Kaiser Permanente, in partnership with the Colorado Department of Education, the Colorado Department of Public Health and the Environment, The Colorado Education Initiative, and the Colorado Coalition for Healthy Schools. The goal of Smart Source is to create a single assessment tool that will incorporate questions from the Score Card and other statewide school health assessments, streamlining data collection and submission for schools.[ 31] To create the assessment, partners conducted an extensive literature review and convened over 200 stakeholders in order to determine the correct data points. A pilot of Smart Source was launched in the 2014-2015 school year with 90 schools. By the 2016-2017 school year, Smart Source will collect and synthesize data about school and district health policies and practices into a statewide system. Smart Source will provide schools with school-level reports that offer objective, meaningful comparisons to the aggregated results from all respondents statewide. These reports are designed to provide useful, actionable data as well as recommendations for implementing best practices related to health and wellness (Table 4). Reports will provide school- and district-level leaders with a more robust picture of the effect their school health efforts have on student performance and classroom behavior, informing the school improvement planning process.[ 31, 32]

Smart Source will decrease duplicative data collection by streamlining multiple survey efforts and recognize exemplar schools and districts in order to replicate best practices. It will also provide a far more robust picture of the effects of their school health efforts through tailored technical assistance and school-level reports.

For statewide funders, organizations, and agencies, it will help assess whether they are "moving the needle" on health and wellness in schools, allocate resources, and inform statewide decisions and legislation.

A school- and district-level tool that collects data about health policies and practices.

A student-level tool that collects data on student attitudes and behaviors. Student-level data are collected via the Healthy Kids Colorado Survey.

A system that allows schools and districts to assess their own policy and practices in order to improve school health.

A monitoring system holding schools accountable for implementing school health policies and practices.

A tool that reduces the burden on schools by streamlining multiple school health policy and practice data collections into one system.

One of many school-level tools that assess school health policy and practice.

A vehicle to help secure funding and resources to improve school health.

A vehicle to highlights schools and districts that are not engaged in health and wellness efforts.

An opportunity to recognize schools for the great work they do in health and wellness and replicate best practices.

An opportunity for schools and districts to be penalized for not emphasizing health and wellness efforts.

A way to provide reports to schools and districts with meaningful and actionable data.

A system that provides little to no usable data.

In addition to the Smart Source initiative, collaborating partners have also launched the Colorado Healthy Schools Collective Impact (HSCI), a purposeful and strategic effort to define healthy schools, prioritize school health-related work in the state, minimize duplication of initiatives, and better leverage resources and funding for healthy schools. Healthy Schools Collective Impact members include 20 foundations and nearly 100 community organizations, state agencies, school districts and schools, and nonprofits that are all interested in strengthening the school health environment. The 4 focus areas, each represented by a work group that meets monthly, are PE and physical activity, nutrition, behavioral health (social, emotional, and mental), and student health services. Healthy Schools Collective Impact's objectives are to (1) coordinate efforts and ensure resources are allocated based on identified needs; (2) engage those impacted by the work, including districts and schools, parents, students, funders, and organizations that champion healthy schools; (3) gather consistent data by coordinating surveys and systems to collect data from schools; (4) use consistent communication by creating a shared definition of a healthy school, possibly producing a one-stop shop for data and resources related to priority school health strategies; (5) support core capacity for schools and districts; and (6) develop shared policy priorities.[ 33]

Maine Regional School Unit #22

Maine Regional School Unit #22, located in the Hampden area, began to intentionally focus on the health and wellness of students and staff in 1991. The vision to strengthen school health and wellness has been driven by Rick Lyons, district superintendent since 1992. The district began by forming a Wellness Team long before the concept had gained widespread popularity. The Wellness Team, comprised administrators, faculty, support staff, and community members, has been a key factor behind the district's school health achievements since its establishment. In 2001, the district also founded a School Health Advisory Council (SHAC) comprised of administrators, healthcare professionals, and community members. The SHAC oversees the CSHP, which is headed by a School Health Coordinator employed by the district. Given RSU #22's small size (approximately 2,200 students and 375 employees), the financial commitment to support a full-time school health coordinator speaks to the high priority that school health has in this district.

Over the last 20 years, RSU #22 has taken many proactive steps toward strengthening school health in each of its 6 schools. The district adopted a tobacco policy in 1994, followed by a nutrition policy. It increased the number of positions and staffing time for health education teachers, nurses, and guidance counselors and forged partnerships with behavioral health providers. The district promotes active transport to school with a "walking school bus," works with the Hampden Town Council to repair bike lanes and install street lights, and partners with the Hampden Recreation Department to provide before- and after-school programming. Regional School Unit #22 implemented a comprehensive K-12 Health/PE curriculum focusing on lifelong activities (such as weight training, aerobics, bicycling, and running) along with activities such as skiing, tennis, snowshoeing, and swimming and uses Recess Rocks® in K-2 classrooms. In 2002, the Wellness Coordinator and Nutrition Director worked with students and suppliers to change the content of all food offered in vending machines to healthy choices. Regional School Unit #22's schools offer salad bars at lunch, and the food service director strives to use locally sourced foods as much as possible. In 2010, parents, students, the district's food service director, wellness coordinator, and community partners collaborated to plant apple orchards and a vegetable garden.

Leadership from school board members and the superintendent has been key in RSU #22's transformation into a district where health and wellness is a top priority and a value embraced by the school employees and the community. The SHAC, Wellness Team, and school health coordinator have also been integral to the process. They have worked together to facilitate the integration of health and education in numerous areas, including the district's strategic plan and the interview process for prospective employees, which includes questions about their thoughts on the district's wellness priorities. The district has focused on improving student and staff health and dedicated significant financial resources to both. The local school board allocates approximately $40,000 per year for employee wellness incentives for those who did not use more than 3 sick days the previous year, and 60% of staff members have qualified for this reward. Regional School Unit #22 promotes periodic wellness challenges for staff and a 7-week "total health" track through Adult Education. In 2012, it opened a new high school that includes a fitness center, track, and tennis courts open to students, staff, and the community. As a result of these efforts, the Wellness Council of America awarded the district their Gold Level Workplace Wellness award.

Denver Public Schools

Superintendent leadership also has been critical to the success of DPS' strategic inclusion of student health in the district's overall priorities and plan. Since being appointed to the position by the Board of Education in 2009, Superintendent Tom Boasberg has managed the district's 183 schools, which serve a diverse population of over 90,000 children. Seventy-two percent of students qualify for free or reduced-price lunch, and 41% speak a language other than English at home.[ 34] The district has also committed significant resources to student health, and made it a part of the district's strategic planning process.

In 2010, Boasberg oversaw the Denver School Health Advisory Council's creation of the DPS Health Agenda 2015, which outlines the districts' health priorities.[ 35] The district has since invested over $22 million toward its health goals, including the addition of 6 full-time district-funded employees. Some of the significant accomplishments include dramatically increasing the number of schools that serve breakfast after the bell; adding PE teachers to elementary schools, which has led to an additional 22 minutes per week of PE classes; and increasing the number of school counselors, which has corresponded with a decrease in expulsion and suspension rates. Denver Public School has also added a school-based health center every year since 2010, with a fifth scheduled to open in 2015.

In August 2014, DPS released the current version of its 5-year strategic plan, Denver Plan 2020. This version, which was developed with the input of nearly 3,000 educators, parents, students, community partners, and city leaders, includes "Support for the Whole Child" as one of 5 goals. Using the WSCC model as a backbone, an advisory committee is assessing DPS' activities, and will present recommendations for creating a metric to determine future progress in early 2015.[ 36] Denver Public School is also working on the development of the next generation of their health agenda, DPS Health Agenda 2020. The district has solicited input from students, parents, and community members through a widely disseminated survey about health issues that most impact students. Survey topics include asthma, vision, oral health, nutrition, physical activity, social/emotional health, substance abuse, teen pregnancy, and school culture. Denver Public School plans to use the results of this survey to improve student health and wellness going forward.

Ancillary

Article Information

Format Available

Full text: HTML | PDF

© 2015 The Authors. Journal of School Health published by Wiley Periodicals, Inc. on behalf of American School Health Association.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.
Request Permissions

REFERENCES

1 Fedewa AL, Ahn S. The effects of physical activity and physical fitness on children's achievement and cognitive outcomes: a meta-analysis. Res Q Exerc Sport. 2011;82(3):521-535.

3 Basch C. Healthier Students Are Better Learners: A Missing Link in Efforts to Close the Achievement Gap. New York, NY: Columbia University; 2010. Available at: http://www.equitycampaign.org/i/a/document/12557_ EquityMattersVol6_Web03082010.pdf. Accessed February 2, 2015.

5 Bradley BJ, Greene AC. Do health and education agencies in the United States share responsibility for academic achievement and health? A review of 25 years of evidence about the relationship of adolescents' academic achievement and health behaviors. J Adolesc Health. 2013;52(5):523-532.

7 Institute of Medicine. Exploring Opportunities for Collaboration between Health and Education to Improve Population Health: Workshop Summary. Washington, DC: The National Academies Press; 2014.

8 ASCD, Centers for Disease Control and Prevention. Whole School, Whole Community, Whole Child: A Collaborative Approach to Learning and Health. Alexandria, VA: ASCD; 2014. Available at: http://www.ascd.org/ASCD/pdf/siteASCD/publications/wholechild/wscc-a-collaborative-approach.pdf. Accessed January 15, 2015.

11 Maddock J, Choy LB, Nett B, McGurk MD, Tamashiro R. Increasing access to places for physical activity through a joint use agreement: a case study in urban Honolulu. Prev Chronic Dis. 2008;5(3):A91.

17 An act to create a child health advisory committee. 2003; Act 1220 (Arkansas 84th General Assembly).

18 An act to increase academic instruction time in public schools; to limit physical activity requirements for public school students; and for other purposes. 2007; Act 317(Arkansas 86th General Assembly).

19 An act to increase the tax on cigarettes and other tobacco products; to authorize the department of finance and administration to pay the commission to the stamp deputies for certain cigarette taxes; and for other purposes. 2009; Act 180 (Arkansas 87th General Session).

28 An act relating to student assessment. 2009; Senate Bill 1 (Kentucky 09 Regular Session).

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# data[].attributes.attachment_link.title
How the Whole School, Whole Community, Whole Child Model Works: Creating Greater Alignment, Integration, and Collaboration Between Health and Education

# data[].attributes.attachment_link.description
GENERAL ARTICLE Senior Consultant, Corresponding author School Health, National Association of Chronic Disease Directors, Atlanta, GA 30345 Address correspondence to: Rachelle Johnsson Chiang, Senior Consultant, ( rchiang@chronicdisease.org), School Health, National Association of Chronic Disease Directors, 2200 Century Parkway, Suite 250, Atlanta, GA 30345.

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The Whole School, Whole Community, Whole Child Model: A New Approach for Improving Educational Attainment and Healthy Development for Students†

Authors

Theresa C. Lewallen MA, CHES

Holly Hunt MA

William Potts-Datema MS,

Stephanie Zaza MD, MPH,

Wayne Giles MD, MS

# data[].attributes.attachment_link.readable_text
GENERAL ARTICLE

Authors

Theresa C. Lewallen MA, CHES,

Chief Constituent Services Officer, Corresponding author

Constituent Services, ASCD, Alexandria, VA 22311

Address correspondence to: Theresa C. Lewallen, Chief Constituent Services Officer, ( tlewalle@ascd.org), ASCD, 1703 N. Beauregard Street, Alexandria, VA 22311.

Search for more papers by this author

†Indicates that continuing education hours are available. Visit www.ashaweb.org and click on Continuing Education for more information.

Since 1987, the coordinated school health (CSH) approach has served as the foundation for addressing health promotion among youth in our nation's schools. The model, originally conceptualized by Lloyd Kolbe and Diane Allensworth, in the seminal article "The Comprehensive School Health Program: Exploring an Expanded Concept"[ 1] has been viewed as the essential public health framework for school health, though it has not resonated as strongly with the education sector. While the US Centers for Disease Control and Prevention (CDC) was supporting the implementation of the CSH approach, ASCD (formerly known as the Association for Supervision and Curriculum Development) launched the Commission on the Whole Child and challenged the education community to focus attention on ensuring that all students are healthy and feel supported, challenged, engaged, and safe.[ 2] While both of these approaches address the physical and emotional needs of the student, neither have resulted in a unified approach supported by both health and education sectors.[ 3]

METHODS

Expert Panel

During spring 2013, ASCD and CDC convened a group of experts from education, public health, and academia to discuss lessons learned from implementation of both approaches and to explore the revision and development of a model that would incorporate the knowledge gained through implementation to date. A series of meetings were held and outcomes from the discussions were vetted with a review group made up of additional experts and stakeholders (Box 1).

CDC and ASCD Core Group

Diane D. Allensworth, PhD

Professor Emeritus, Kent State University

Laura Rooney, MPH

Adolescent Health Program Manager, Ohio Department of Health

Elaine Auld, MPH, MCHES, CEO, SOPHE

David Birch, PhD, Department Chair, University of Alabama

Marty Blank, Exec. Director, Coalition of Community Schools

Maurice Elias, PhD, Professor, Rutgers University

Susan Goekler, PhD, MCHES, Executive Director, DHPE

Dave Lohrmann, PhD, Department Chair, Indiana University

Donna J. Mazyck, RN, MS, NCSN, Executive Director, NASN

Douglas McCall, Executive Director, International School Health Network

Robert Valois, PhD, Professor, University of South Carolina

Summary of the Whole Child and CSH Approaches

In The Learning Compact Redefined: A Call to Action, ASCD implored communities, educators, and key decision makers to work together to ensure the implementation of policies that would result in successful learners who are knowledgeable, emotionally and physically healthy, civically active, artistically engaged, prepared for economic self-sufficiency, and ready for adulthood.[ 2] The Whole Child approach responds to this call with 5 tenets that make the student the focal point:

Each student enters school healthy and learns about and practices a healthy lifestyle.

Each student learns in an environment that is physically and emotionally safe for students and adults.

Each student is actively engaged in learning and is connected to the school and broader community.

Each student has access to personalized learning and is supported by qualified, caring adults.

Each student is challenged academically and prepared for success in college or further study and for employment and participation in a global environment.

The CSH approach follows a systems-based approach addressing 8 components of the school as a venue for health promotion and disease prevention:

Health education

Physical education

School health services

Healthy and safe school environment

Counseling, psychological, and social services

Family and community involvement

Health promotion for staff

Nutrition services.[4]

RESULTS

As a result of these deliberations the Whole School, Whole Community, Whole Child (WSCC) model was established. The WSCC approach combines and builds on the elements of the Whole Child model and the CSH approach to create a unified model that supports a systematic, integrated, and collaborative approach to health and learning. The WSCC model is designed to provide a shared framework and approach for decision making and action for both sectors to work together (Figure 1).

The WSCC model incorporates the 5 tenets of the Whole Child model by putting the student at the center and making her/him the focal point. Surrounding the child/student is a ring that stresses the need for coordination among policy, process, and practice. While much focus has been given to coordination among components, the previous approaches did not explicitly describe the critical role of day-to-day practices and processes or the essential role of policy in sustaining a school environment that supports both health and learning.

The outer ring of the WSCC model reflects greater integration and alignment between health and education by incorporating the components of the CSH approach and emphasizing the school as an integral part of the community.[ 3] In addition, the model's incorporation of the important context of community and the role of coordination for policy, process, and practice is consistent with findings of an evaluation of strong CSH programs conducted by CDC's Division of Adolescent and School Health.[ 4] The importance of sectors and individuals working together to implement policies, practice, and process is now prominent in this integrated approach that addresses health and learning.

Some of the original CSH components have been expanded to better reflect current evidence and practice. Specifically, the healthy and safe school environment component is now separated into "social and emotional climate" and "physical environment" giving greater attention to each. The family and community involvement component is now separated into "community involvement" to emphasize the role of community, businesses, agencies, and organizations, and "family engagement" to place a greater emphasis on the critical role that families play. Health promotion for staff has been changed to "employee wellness" to reflect a broader approach that addresses learning new life skills and becoming aware of and making conscious choices toward a more balanced and healthy lifestyle.[ 5] The nutrition services component has been expanded to include the nutrition environment. Physical education is now expanded to include physical activity.

In addition to these structural changes, the definitions and descriptions of each component of the outer ring (Figure 1) have been updated and revised to better reflect the current evidence. Definitions were developed by subject matter experts and vetted with experts in the field ( http://www.cdc.gov/healthyyouth/wscc/components.htm).

Health Education

Formal, structured health education consists of any combination of planned learning experiences that provide the opportunity to acquire information and the skills students need to make quality health decisions. When provided by qualified, trained teachers, health education helps students acquire the knowledge, attitudes, and skills they need for making health-promoting decisions, achieving health literacy, adopting health-enhancing behaviors, and promoting the health of others. Comprehensive school health education includes curricula and instruction for students in pre-K to grade 12 that address a variety of topics such as alcohol and other drug use and abuse, healthy eating/nutrition, mental and emotional health, personal health and wellness, physical activity, safety and injury prevention, sexual health, tobacco use, and violence prevention. Health education curricula and instruction should address the National Health Education Standards and incorporate the characteristics of an effective health education curriculum. Health education, based on an assessment of student health needs and planned in collaboration with the community, ensures reinforcement of health messages that are relevant for students and meet community needs. Students might also acquire health information through education that occurs as part of a patient visit with a school nurse, through posters or public service announcements, or through conversations with family and peers.

Nutrition Environment and Services

The school nutrition environment provides students with opportunities to learn about and practice healthy eating through available foods and beverages, nutrition education, and messages about food in the cafeteria and throughout the school campus. Students may have access to foods and beverages in a variety of venues at school including the cafeteria, vending machines, grab 'n' go kiosks, schools stores, concession stands, classroom rewards, classroom parties, school celebrations, and fundraisers.

School nutrition services provide meals that meet federal nutrition standards for the National School Lunch and Breakfast Programs, accommodate the health and nutrition needs of all students, and help ensure that foods and beverages sold outside of the school meal programs (competitive foods) meet Smart Snacks in School nutrition standards. School nutrition professionals should meet minimum education requirements and receive annual professional development and training to ensure that they have the knowledge and skills to provide these services. All individuals in the school community support a healthy school nutrition environment by marketing and promoting healthier foods and beverages, encouraging participation in the school meal programs, role-modeling healthy eating behaviors, and ensuring that students have access to free drinking water throughout the school day. Healthy eating has been linked in studies to improved learning outcomes and helps ensure that students are able to reach their potential.

Employee Wellness

Schools are not only places of learning, but they are also worksites. Fostering school employees' physical and mental health protects school staff, and by doing so, helps to support students' health and academic success. Healthy school employees-including teachers, administrators, bus drivers, cafeteria and custodial staff, and contractors-are more productive and less likely to be absent. They serve as powerful role models for students and may increase their attention to students' health. Schools can create work environments that support healthy eating, adopt active lifestyles, be tobacco free, manage stress, and avoid injury and exposure to hazards (such as mold or asbestos). A comprehensive school employee wellness approach is a coordinated set of programs, policies, benefits, and environmental supports designed to address multiple risk factors (including lack of physical activity and tobacco use) and health conditions (such as diabetes or depression) to meet the health and safety needs of all employees. Partnerships between school districts and their health insurance providers can help offer resources, including personalized health assessments and flu vaccinations. Employee wellness programs and healthy work environments can improve a district's bottom line by decreasing employee health insurance premiums, reducing employee turnover, and cutting costs of substitutes.

Social and Emotional School Climate

Social and emotional school climate refers to the psychosocial aspects of students' educational experience that influence their social and emotional development. The social and emotional climate of a school can impact student engagement in school activities; relationships with other students, staff, family, and community; and academic performance. A positive social and emotional school climate is conducive to effective teaching and learning. Such climates promote health, growth, and development by providing a safe and supportive learning environment.

Physical Environment

A healthy and safe physical school environment promotes learning by ensuring the health and safety of students and staff. The physical school environment encompasses the school building and its contents, the land on which the school is located, and the area surrounding it. A healthy school environment will address a school's physical condition during normal operation as well as during renovation (including ventilation, moisture, temperature, noise, or natural and artificial lighting), and protect occupants from physical threats (such as crime, violence, traffic, or injuries) and biological and chemical agents in the air, water, or soil as well as those purposefully brought into the school (including pollution, mold, hazardous materials, pesticides, or cleaning agents).

Health Services

School health services intervene with actual and potential health problems, including providing first aid, emergency care and assessment, and planning for the management of chronic conditions (such as asthma or diabetes). In addition, wellness promotion, preventive services and staff, and student and parent education complement the provision of care coordination services. These services are also designed to ensure access and/or referrals to the medical home or private healthcare provider. Health services connect school staff, students, families, community, and healthcare providers to promote the health care of students and a healthy and safe school environment. School health services actively collaborate with school and community support services to increase the ability of students and families to adapt to health and social stressors, such as chronic health conditions or social and economic barriers to health, and to be able to manage these stressors and advocate for their own health and learning needs. Qualified professionals such as school nurses, nurse practitioners, dentists, health educators, physicians, physician assistants, and allied health personnel provide these services.

Counseling, Psychological, and Social Services

These prevention and intervention services support the mental, behavioral, and social-emotional health of students and promote success in the learning process. Services include psychological, psychoeducational, and psychosocial assessments; direct and indirect interventions to address psychological, academic, and social barriers to learning, such as individual or group counseling and consultation; and referrals to school and community support services as needed. Additionally, systems-level assessment, prevention, intervention, and program design by school-employed mental health professionals contribute to the mental and behavioral health of students as well as to the health of the school environment. These services can be accomplished through resource identification and needs assessments, school-community-family collaboration, and ongoing participation in school safety and crisis response efforts. Additionally, school-employed professionals can provide skilled consultation with other school staff and community resources and community providers. School-employed mental health professionals ensure that services provided in school reinforce learning and help to align interventions provided by community providers with the school environment. Professionals such as certified school counselors, school psychologists, and school social workers provide these services.

Community Involvement

Community groups, organizations, and local businesses create partnerships with schools, share resources, and volunteer to support student learning, development, and health-related activities. The school, its students, and their families benefit when leaders and staff at the district or school solicits and coordinates information, resources, and services available from community-based organizations, businesses, cultural and civic organizations, social service agencies, faith-based organizations, health clinics, colleges and universities, and other community groups. Schools, students, and their families can contribute to the community through service-learning opportunities and by sharing school facilities with community members such as school-based community health centers or fitness facilities.

Family Engagement

Families and school staff work together to support and improve the learning, development, and health of students. Family engagement with schools is a shared responsibility of both school staff and families. School staff members are committed to making families feel welcomed, engaging families in a variety of meaningful ways, and sustaining family engagement. Families are committed to actively supporting their child's learning and development. This relationship between school staff and families cuts across and reinforces student health and learning in multiple settings-at home, in school, in out-of-school programs, and in the community. Family engagement should be continuous across a child's life and requires an ongoing commitment as children mature into young adulthood.

Physical Education and Physical Activity

Schools can create an environment that offers many opportunities for students to be physically active throughout the school day. A comprehensive school physical activity program (CSPAP) is the national framework for physical education and youth physical activity. A CSPAP reflects strong coordination across 5 components: physical education, physical activity during school, physical activity before and after school, staff involvement, and family and community engagement. Physical education serves as the foundation of a CSPAP and is an academic subject characterized by a planned, sequential K-12 curriculum (course of study) that is based on the national standards for physical education. Physical education provides cognitive content and instruction designed to develop motor skills, knowledge, and behaviors for healthy active living, physical fitness, sportsmanship, self-efficacy, and emotional intelligence. A well-designed physical education program provides the opportunity for students to learn key concepts and practice critical skills needed to establish and maintain physically active lifestyles throughout childhood, adolescence, and into adulthood. Teachers should be certified or licensed, and endorsed by the state to teach physical education.

DISCUSSION

A Holistic Health and Education Model

Inherent in the WSCC model is a holistic view of students, schools, and communities. The model builds on other socioecological models used in health and education, including Bronfenbrenner's "Ecological Framework for Human Development,"[ 6] public health and health promotion models,[ 7] and Lohrmann's "Ecological Model of the Coordinated School Health Program."[ 8] Each segment and layer of the WSCC model is interdependent on the others; the model is designed to emphasize the whole to support the development of each child and youth most effectively. The focus of the WSCC model is a socioecological approach that is directed at the whole school, with the school, in turn, drawing its resources and influences from the whole community and serving to address the needs of the whole child. ASCD and the CDC encourage use of the model as a framework for improving students' learning and health.[ 3]

The model is based on health and education research, including research that addresses the need to engage students as active participants in their learning and health. The figure of the child represents children and youth who should be at the center of decisions made by policymakers and practitioners from the education and health sectors. In addition, the child is a reminder of the powerful outcomes that can be achieved by giving voice to children and youth about their education, their health and their communities. To be successful adults, students must be provided a variety of opportunities to learn, including in the community, and to put into practice their learning through peer leadership and educational choices, as well as their involvement in peer education and youth development.

After years of observing the CSH approach in action in local schools and districts, the consultation team noted that without coordination, policies, practices, and processes in place, the model would not be effective in achieving its intended outcomes. Administrator support, particularly the support of principals, has been shown to be a key factor in the success of the integration of learning and health in schools.[ 9] District and school policies that promote health and learning, practices that reinforce the policies and desired behaviors of staff and students, and processes that ensure that coordination, planning, use of data, and continuous improvement all must work in concert with the other pieces of the model.

How the WSCC Model Advances School Health

Improves the uptake of CSH principles

The original CSH components serve as the primary organizing framework through which school health educators, physical education teachers, school nurses, and other staff work to support students within the context of the school. Furthermore, this approach encourages schools and communities to come together to address the health needs of students to support their physical, cognitive, and emotional development. Overall, the CSH approach supports positive academic outcomes through its foci on health promotion and on reducing barriers to learning.

However, CSH has had scattered adoption across the United States. School health coordinating councils often have not had their work included into School Improvement Plans, a key requirement for successful integration and sustainability of any effort undertaken within individual schools and school districts. Pressures on school administrators to improve student academic outcomes measured primarily through test scores have increased since the last reauthorization of the Elementary and Secondary Education Act in 2002. While educators have recognized the need for students to be healthy and safe in order to learn, declines in school budgets and punitive measures taken against schools that do not meet standards have also had a negative impact on administrators' adoption of CSH in schools and districts across the country.[ 10]

Directly addresses the relationship between education and health

To further the integration of health and education, the consultation team recognized the need to align the new model with the role that social determinants such as education play in the lifelong health of individuals and of populations. Public health recognizes that a range of personal, social, economic, and environmental factors contribute to individual and population health. The CDC and the World Health Organization have identified place-based settings that contribute to population and individual health. These 5 determinants include: (1) economic stability; (2) education; (3) social and community context; (4) health and health care; and (5) neighborhood and built environment.[ 11]

The WSCC approach incorporates all of the determinants and acknowledges their impact on the cognitive, physical, and emotional development of children and youth. The integration of health and education within the model provides educators with a holistic framework for integrating education and health. Schools are situated in social and community contexts. The model addresses social determinants of health, encourages the provision of health and health care, and emphasizes coordination and planning with the surrounding community and the local neighborhood through the lenses of the education and health sectors.

In line with the strong focus on social determinants of health, the WSCC further emphasizes the connectedness between health and academic outcomes. Proficient academic skills are associated with lower rates of risky behaviors and higher rates of healthy behaviors.[ 12-14] High school graduation leads to lower rates of health problems[ 15-18] and risk for incarceration, as well as enhanced financial stability during adulthood.[ 19, 20] The school social environment affects students' attendance,[ 21] academic achievement, and behavior.[ 22] A safe and healthy school environment promotes student engagement[ 23] and protects against risky behaviors[ 24-26] and dropping out.[ 12] School administrators are required to focus on the long-term educational outcomes for students. Many also recognize the need to address immediate health-related factors to support educational outcomes. Studies demonstrate that when children's basic nutritional and fitness needs are met, they attain higher achievement levels.[ 14, 27-38] Similarly, the use of school-based and school-linked health centers ensuring access to needed physical, mental, and oral health care improves attendance,[ 39] behavior,[ 40-45] and achievement.[ 46-49] The development of connected and supportive school environments benefits teaching and learning, engages students, and enhances positive learning outcomes. The development of a positive social and emotional climate increases academic achievement, reduces stress, and improves positive attitudes toward self and others.[ 50, 51] Academic achievement is an excellent indicator for the overall well-being of youth and a primary predictor and determinant of adult health outcomes. Individuals with more education are likely to live longer; experience better health outcomes; and practice health-promoting behaviors such as exercising regularly, refraining from smoking, and obtaining timely healthcare checkups and screenings.[ 52-54] These positive outcomes are why many of the nation's leading educational organizations recognize the close relationship between health[ 55-57] and education, as well as the need to foster health and well-being within the educational environment for all students.[ 2, 58-60] Conversely, education and public health recognize that a range of health-related factors can lead to poor school performance. Health-risk behaviors are linked to poor grades and lower educational attainment.[ 14]

Although the education and health sectors are both keenly interested in student achievement and health, the specific goals and accountability standards for achieving these outcomes can be different. The new WSCC model is designed to provide a shared framework and approach for decision making and action for both sectors to work together.

Through the development of the WSCC model, the goals of the education and health sectors are combined and integrated. As the next evolution of CSH, the model speaks to leaders and practitioners of both sectors on the local level. However, the model's use is not intended to be confined to a school, a district, or a community. The consultation and review groups also recognized that within the federal government a myriad of initiatives focus on school health issues. The WSCC model offers an overarching framework and a holistic approach to program coordination and integration within and across agencies.

IMPLICATIONS FOR SCHOOL HEALTH

The key to moving from model to action is collaborative development of local school policies, processes, and practices. The day-to-day practices within each sector require examination and collaboration so that they work in tandem, with appropriate complementary processes guiding each decision and action. Developing joint and collaborative policy is half the challenge; putting it into action and making it routine completes the task. To develop joint or collaborative policies, processes, and practices, all parties involved should start with a common understanding about the interrelatedness of learning and health. From this understanding, current and future systems and actions can be adjusted, adapted, or crafted to jointly achieve both learning and health outcomes.[ 3]

School health coordinators and school health teams have been the facilitators of CSH in many schools and districts across the United States. That work has been most successful when the work has been viewed as integral to the mission of the school. When the district and school-based wellness teams work closely with the school administrator, both sectors' goals are combined and met most effectively.

As previously mentioned, schools are situated within the contexts of neighborhoods and communities. The relationship between the school and the community affects the entire community, not just the students attending the school. The WSCC model includes these contexts because research has shown their impact on education and health outcomes. When schools and their communities work together, their resources are used most effectively and the needs of the entire community can be identified and met more cost-effectively. The model recognizes that schools and communities have a shared responsibility for the health and education of children and youth. The model calls for this shared responsibility, acknowledging that schools are fiscally supported through the community and that they must work together to provide services and a positive quality of life.

While the WSCC model is designed for application in schools, it was developed to be relevant to a wide variety of individuals and groups who work with schools or whose work affects schools.

School administrators and those who provide service within the component areas of the model (educators, school nurses, counselors, and those who provide support services in nutrition, physical environment, employee wellness, family engagement, and community involvement) will find direct, practical applications. The model's emphases on coordinating policy, process, and practice and integration of the community can enhance all aspects of the work of the school.

School districts and schools can use the model as a framework for school improvement plans and initiatives. School improvement teams can be structured using representation from each of the components utilized in the model. Doing so can ensure integration of critical outcomes in education and health for students.

Higher education programs that prepare school administrators, teachers, counselors, nurses, and other staff who work in school districts and schools may design coursework and professional development preservice and in-service events directed toward effective implementation of the model.

Local, state, and national-level philanthropic organizations may develop initiatives that emphasize the community engagement aspects of the model and encourage its focus on coordinating policy, process, and practice in school districts and schools.

Governmental agencies such as state education departments and state health departments can use the model as a framework for establishing accountability measures that address both education and health. They may also consider the model in design of specific programs designed to support local districts, including funding opportunity announcements.

Federal agencies can utilize the framework as a foundation for official guidance, funding opportunity announcements, technical assistance initiatives, and professional development opportunities. Likewise, national governmental agencies in other countries may wish to consider the model in development of their own health-promoting schools initiatives.

Policymakers and opinion leaders will find the approach helpful as a comprehensive view of necessary supports in schools and how they may be effectively organized. This view may be useful in development of policy initiatives that efficiently address learning and health.

Finally, the public, including parents, can more effectively connect with school districts and schools as integral parts of the model. Building these collaborations will provide increased school connectedness and family connectedness, which are both critically important for student success. The efficiency of the model and interactivity of its components should provide efficiencies that can improve the work of schools.

The implementation of the model brings together all stakeholders to engage with the education and health issues present in the community, including collaborative identification of the college and career readiness skills required by businesses and higher education. Community agencies, educators, families, policymakers, children, and youth all play a role. Through the full implementation of all of the pieces included in the model, schools and communities have worked together. Schools are now sites for community health centers and fitness centers. Community agencies provide educational supports and student engagement programs. The model is designed to initiate conversation and activate research- and evidence-based practices that support lifelong health, cognitive development and economic success.

It is important to be clear, however, that the model is a framework and not an intervention. It identifies the sectors, stakeholders, contexts, and elements that need to be considered when fully integrating health and education. Each element of the model has supporting research, evidence, and best practices that can be used for implementation. However, the specific interventions, curricula, classroom practices, and resources brought together to put the framework into action will be dependent on the local context.

Conclusion

The WSCC model represents an evolution of organizational thinking in schools. In the marriage of the two leading models addressing healthy schools, the Whole Child Initiative and the CSH approach, the WSCC approach provides a comprehensive framework for school districts and schools. The important changes within components and emphases on critical facilitative factors including community engagement, policies, processes, and practices build upon the assets of both approaches and effectively address the needs of modern schools.

By focusing on children and youth as students, addressing critical education and health outcomes, organizing collaborative actions and initiatives that support students, and strongly engaging community resources, the WSCC approach offers important opportunities for school improvements that will advance educational attainment and healthy development for students.

Human Subjects Approval Statement

This paper involved no human subjects, and therefore, was exempt from examination by an Institutional Review Board.

Disclaimer

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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REFERENCES

10 Basch CE. Healthier Students Are Better Learners: A Missing Link in School Reforms to Close the Achievement Gap. New York, NY: Columbia University; 2010. (Equity Matters: Research Review No. 6) Available at: http://www.equitycampaign.org/i/a/document/12557_EquityMattersVol6_Web03082010.pdf. Accessed February 6, 2015.

18 Muennig P. The economic value of health gains associated with education interventions. Paper prepared for the Equity Symposium on The Social Costs of Inadequate Education; 2005 Oct 24-25; Teachers College, Columbia University, New York, NY; 2005. Available at: http://www.schoolfunding.info/news/policy/Muennig%20-%20Health%20and%20Education.pdf. Accessed February 20, 2015.

21 Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance-United States, 2009. MMWR Surveill Summ. 59(SS05):1-142. Available at: http://www.cdc.gov/mmwr/pdf/ss/ss5905.pdf. Accessed February 20, 2015.

25 Henderson M, Ecob R, Wight D, Abraham C. What explains between-school differences in rates of smoking? BMC Public Health. 2008;8:218. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442834/pdf/1471-2458-8-218.pdf or http://www.biomedcentral.com/1471-2458/8/218. Accessed February 20, 2015.

27 Bradley B, Green AC. Do health and education agencies in the United States share responsibility for academic achievement and health? A review of 25 years of evidence about the relationship of adolescents' academic achievement and health behaviors. J Adolesc Health. 2013;52(5):523-532.

28 Murphy JM, Pagano ME, Nachmani J, Sperling P, Kane S, Kleinman RE. The relationship of school breakfast to psychosocial and academic functioning: cross-sectional and longitudinal observations in an inner-city school sample. Arch Pediatr Adolesc Med. 1998;152(9):899-907.

29 Rampersaud GC, Pereira MA, Girard BL, Adams J, Metzl JD. Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents. J Am Diet Assoc. 2005;105(5):743-760, quiz 761-762.

32 Widenhorn-Müller K, Hille K, Klenk J, Weiland U. Influence of having breakfast on cognitive performance and mood in 13- to 20-year-old high school students: results of a crossover trial. Pediatrics. 2008;122(2):279-284.

33 Alaimo K, Olson CM, Frongillo EA Jr. Food insufficiency and American school-aged children's cognitive, academic, and psychosocial development. Pediatrics. 2001;108(1):44-53.

48 Dean S. Hearts and Minds: A Public School Miracle. Toronto, ON, Canada: Penguin Canada; 2001.

59 American Association of School Administrators (AASA). Position statement 3: getting children ready for success in school, July 2006; Position statement 18: Providing a safe and nurturing environment for students, July 2007. AASA Position Statements. Available at: http://www.aasa.org/uploadedFiles/About/_files/AASAPositionStatements072408.pdf. Accessed February 20, 2015.

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GENERAL ARTICLE

Authors

Theresa C. Lewallen MA, CHES,

Chief Constituent Services Officer, Corresponding author

Constituent Services, ASCD, Alexandria, VA 22311

Address correspondence to: Theresa C. Lewallen, Chief Constituent Services Officer, ( tlewalle@ascd.org), ASCD, 1703 N. Beauregard Street, Alexandria, VA 22311.

Search for more papers by this author

†Indicates that continuing education hours are available. Visit www.ashaweb.org and click on Continuing Education for more information.

ABSTRACT

BACKGROUND

The Whole Child approach and the coordinated school health (CSH) approach both address the physical and emotional needs of students. However, a unified approach acceptable to both the health and education communities is needed to assure that students are healthy and ready to learn.

METHODS

During spring 2013, the ASCD (formerly known as the Association for Supervision and Curriculum Development) and the US Centers for Disease Control and Prevention (CDC) convened experts from the field of education and health to discuss lessons learned from implementation of the CSH and Whole Child approaches and to explore the development of a new model that would incorporate the knowledge gained through implementation to date.

RESULTS

As a result of multiple discussions and review, the Whole School, Whole Community, Whole Child (WSCC) approach was developed. The WSCC approach builds upon the traditional CSH model and ASCD's Whole Child approach to learning and promotes greater alignment between health and educational outcomes.

CONCLUSION

By focusing on children and youth as students, addressing critical education and health outcomes, organizing collaborative actions and initiatives that support students, and strongly engaging community resources, the WSCC approach offers important opportunities that will improve educational attainment and healthy development for students.

Since 1987, the coordinated school health (CSH) approach has served as the foundation for addressing health promotion among youth in our nation's schools. The model, originally conceptualized by Lloyd Kolbe and Diane Allensworth, in the seminal article "The Comprehensive School Health Program: Exploring an Expanded Concept"[ 1] has been viewed as the essential public health framework for school health, though it has not resonated as strongly with the education sector. While the US Centers for Disease Control and Prevention (CDC) was supporting the implementation of the CSH approach, ASCD (formerly known as the Association for Supervision and Curriculum Development) launched the Commission on the Whole Child and challenged the education community to focus attention on ensuring that all students are healthy and feel supported, challenged, engaged, and safe.[ 2] While both of these approaches address the physical and emotional needs of the student, neither have resulted in a unified approach supported by both health and education sectors.[ 3]

METHODS

Expert Panel

During spring 2013, ASCD and CDC convened a group of experts from education, public health, and academia to discuss lessons learned from implementation of both approaches and to explore the revision and development of a model that would incorporate the knowledge gained through implementation to date. A series of meetings were held and outcomes from the discussions were vetted with a review group made up of additional experts and stakeholders (Box 1).

CDC and ASCD Core Group

Diane D. Allensworth, PhD

Professor Emeritus, Kent State University

Laura Rooney, MPH

Adolescent Health Program Manager, Ohio Department of Health

Elaine Auld, MPH, MCHES, CEO, SOPHE

David Birch, PhD, Department Chair, University of Alabama

Marty Blank, Exec. Director, Coalition of Community Schools

Maurice Elias, PhD, Professor, Rutgers University

Susan Goekler, PhD, MCHES, Executive Director, DHPE

Dave Lohrmann, PhD, Department Chair, Indiana University

Donna J. Mazyck, RN, MS, NCSN, Executive Director, NASN

Douglas McCall, Executive Director, International School Health Network

Robert Valois, PhD, Professor, University of South Carolina

Summary of the Whole Child and CSH Approaches

In The Learning Compact Redefined: A Call to Action, ASCD implored communities, educators, and key decision makers to work together to ensure the implementation of policies that would result in successful learners who are knowledgeable, emotionally and physically healthy, civically active, artistically engaged, prepared for economic self-sufficiency, and ready for adulthood.[ 2] The Whole Child approach responds to this call with 5 tenets that make the student the focal point:

Each student enters school healthy and learns about and practices a healthy lifestyle.

Each student learns in an environment that is physically and emotionally safe for students and adults.

Each student is actively engaged in learning and is connected to the school and broader community.

Each student has access to personalized learning and is supported by qualified, caring adults.

Each student is challenged academically and prepared for success in college or further study and for employment and participation in a global environment.

The CSH approach follows a systems-based approach addressing 8 components of the school as a venue for health promotion and disease prevention:

Health education

Physical education

School health services

Healthy and safe school environment

Counseling, psychological, and social services

Family and community involvement

Health promotion for staff

Nutrition services.[4]

RESULTS

As a result of these deliberations the Whole School, Whole Community, Whole Child (WSCC) model was established. The WSCC approach combines and builds on the elements of the Whole Child model and the CSH approach to create a unified model that supports a systematic, integrated, and collaborative approach to health and learning. The WSCC model is designed to provide a shared framework and approach for decision making and action for both sectors to work together (Figure 1).

The WSCC model incorporates the 5 tenets of the Whole Child model by putting the student at the center and making her/him the focal point. Surrounding the child/student is a ring that stresses the need for coordination among policy, process, and practice. While much focus has been given to coordination among components, the previous approaches did not explicitly describe the critical role of day-to-day practices and processes or the essential role of policy in sustaining a school environment that supports both health and learning.

The outer ring of the WSCC model reflects greater integration and alignment between health and education by incorporating the components of the CSH approach and emphasizing the school as an integral part of the community.[ 3] In addition, the model's incorporation of the important context of community and the role of coordination for policy, process, and practice is consistent with findings of an evaluation of strong CSH programs conducted by CDC's Division of Adolescent and School Health.[ 4] The importance of sectors and individuals working together to implement policies, practice, and process is now prominent in this integrated approach that addresses health and learning.

Some of the original CSH components have been expanded to better reflect current evidence and practice. Specifically, the healthy and safe school environment component is now separated into "social and emotional climate" and "physical environment" giving greater attention to each. The family and community involvement component is now separated into "community involvement" to emphasize the role of community, businesses, agencies, and organizations, and "family engagement" to place a greater emphasis on the critical role that families play. Health promotion for staff has been changed to "employee wellness" to reflect a broader approach that addresses learning new life skills and becoming aware of and making conscious choices toward a more balanced and healthy lifestyle.[ 5] The nutrition services component has been expanded to include the nutrition environment. Physical education is now expanded to include physical activity.

In addition to these structural changes, the definitions and descriptions of each component of the outer ring (Figure 1) have been updated and revised to better reflect the current evidence. Definitions were developed by subject matter experts and vetted with experts in the field ( http://www.cdc.gov/healthyyouth/wscc/components.htm).

Health Education

Formal, structured health education consists of any combination of planned learning experiences that provide the opportunity to acquire information and the skills students need to make quality health decisions. When provided by qualified, trained teachers, health education helps students acquire the knowledge, attitudes, and skills they need for making health-promoting decisions, achieving health literacy, adopting health-enhancing behaviors, and promoting the health of others. Comprehensive school health education includes curricula and instruction for students in pre-K to grade 12 that address a variety of topics such as alcohol and other drug use and abuse, healthy eating/nutrition, mental and emotional health, personal health and wellness, physical activity, safety and injury prevention, sexual health, tobacco use, and violence prevention. Health education curricula and instruction should address the National Health Education Standards and incorporate the characteristics of an effective health education curriculum. Health education, based on an assessment of student health needs and planned in collaboration with the community, ensures reinforcement of health messages that are relevant for students and meet community needs. Students might also acquire health information through education that occurs as part of a patient visit with a school nurse, through posters or public service announcements, or through conversations with family and peers.

Nutrition Environment and Services

The school nutrition environment provides students with opportunities to learn about and practice healthy eating through available foods and beverages, nutrition education, and messages about food in the cafeteria and throughout the school campus. Students may have access to foods and beverages in a variety of venues at school including the cafeteria, vending machines, grab 'n' go kiosks, schools stores, concession stands, classroom rewards, classroom parties, school celebrations, and fundraisers.

School nutrition services provide meals that meet federal nutrition standards for the National School Lunch and Breakfast Programs, accommodate the health and nutrition needs of all students, and help ensure that foods and beverages sold outside of the school meal programs (competitive foods) meet Smart Snacks in School nutrition standards. School nutrition professionals should meet minimum education requirements and receive annual professional development and training to ensure that they have the knowledge and skills to provide these services. All individuals in the school community support a healthy school nutrition environment by marketing and promoting healthier foods and beverages, encouraging participation in the school meal programs, role-modeling healthy eating behaviors, and ensuring that students have access to free drinking water throughout the school day. Healthy eating has been linked in studies to improved learning outcomes and helps ensure that students are able to reach their potential.

Employee Wellness

Schools are not only places of learning, but they are also worksites. Fostering school employees' physical and mental health protects school staff, and by doing so, helps to support students' health and academic success. Healthy school employees-including teachers, administrators, bus drivers, cafeteria and custodial staff, and contractors-are more productive and less likely to be absent. They serve as powerful role models for students and may increase their attention to students' health. Schools can create work environments that support healthy eating, adopt active lifestyles, be tobacco free, manage stress, and avoid injury and exposure to hazards (such as mold or asbestos). A comprehensive school employee wellness approach is a coordinated set of programs, policies, benefits, and environmental supports designed to address multiple risk factors (including lack of physical activity and tobacco use) and health conditions (such as diabetes or depression) to meet the health and safety needs of all employees. Partnerships between school districts and their health insurance providers can help offer resources, including personalized health assessments and flu vaccinations. Employee wellness programs and healthy work environments can improve a district's bottom line by decreasing employee health insurance premiums, reducing employee turnover, and cutting costs of substitutes.

Social and Emotional School Climate

Social and emotional school climate refers to the psychosocial aspects of students' educational experience that influence their social and emotional development. The social and emotional climate of a school can impact student engagement in school activities; relationships with other students, staff, family, and community; and academic performance. A positive social and emotional school climate is conducive to effective teaching and learning. Such climates promote health, growth, and development by providing a safe and supportive learning environment.

Physical Environment

A healthy and safe physical school environment promotes learning by ensuring the health and safety of students and staff. The physical school environment encompasses the school building and its contents, the land on which the school is located, and the area surrounding it. A healthy school environment will address a school's physical condition during normal operation as well as during renovation (including ventilation, moisture, temperature, noise, or natural and artificial lighting), and protect occupants from physical threats (such as crime, violence, traffic, or injuries) and biological and chemical agents in the air, water, or soil as well as those purposefully brought into the school (including pollution, mold, hazardous materials, pesticides, or cleaning agents).

Health Services

School health services intervene with actual and potential health problems, including providing first aid, emergency care and assessment, and planning for the management of chronic conditions (such as asthma or diabetes). In addition, wellness promotion, preventive services and staff, and student and parent education complement the provision of care coordination services. These services are also designed to ensure access and/or referrals to the medical home or private healthcare provider. Health services connect school staff, students, families, community, and healthcare providers to promote the health care of students and a healthy and safe school environment. School health services actively collaborate with school and community support services to increase the ability of students and families to adapt to health and social stressors, such as chronic health conditions or social and economic barriers to health, and to be able to manage these stressors and advocate for their own health and learning needs. Qualified professionals such as school nurses, nurse practitioners, dentists, health educators, physicians, physician assistants, and allied health personnel provide these services.

Counseling, Psychological, and Social Services

These prevention and intervention services support the mental, behavioral, and social-emotional health of students and promote success in the learning process. Services include psychological, psychoeducational, and psychosocial assessments; direct and indirect interventions to address psychological, academic, and social barriers to learning, such as individual or group counseling and consultation; and referrals to school and community support services as needed. Additionally, systems-level assessment, prevention, intervention, and program design by school-employed mental health professionals contribute to the mental and behavioral health of students as well as to the health of the school environment. These services can be accomplished through resource identification and needs assessments, school-community-family collaboration, and ongoing participation in school safety and crisis response efforts. Additionally, school-employed professionals can provide skilled consultation with other school staff and community resources and community providers. School-employed mental health professionals ensure that services provided in school reinforce learning and help to align interventions provided by community providers with the school environment. Professionals such as certified school counselors, school psychologists, and school social workers provide these services.

Community Involvement

Community groups, organizations, and local businesses create partnerships with schools, share resources, and volunteer to support student learning, development, and health-related activities. The school, its students, and their families benefit when leaders and staff at the district or school solicits and coordinates information, resources, and services available from community-based organizations, businesses, cultural and civic organizations, social service agencies, faith-based organizations, health clinics, colleges and universities, and other community groups. Schools, students, and their families can contribute to the community through service-learning opportunities and by sharing school facilities with community members such as school-based community health centers or fitness facilities.

Family Engagement

Families and school staff work together to support and improve the learning, development, and health of students. Family engagement with schools is a shared responsibility of both school staff and families. School staff members are committed to making families feel welcomed, engaging families in a variety of meaningful ways, and sustaining family engagement. Families are committed to actively supporting their child's learning and development. This relationship between school staff and families cuts across and reinforces student health and learning in multiple settings-at home, in school, in out-of-school programs, and in the community. Family engagement should be continuous across a child's life and requires an ongoing commitment as children mature into young adulthood.

Physical Education and Physical Activity

Schools can create an environment that offers many opportunities for students to be physically active throughout the school day. A comprehensive school physical activity program (CSPAP) is the national framework for physical education and youth physical activity. A CSPAP reflects strong coordination across 5 components: physical education, physical activity during school, physical activity before and after school, staff involvement, and family and community engagement. Physical education serves as the foundation of a CSPAP and is an academic subject characterized by a planned, sequential K-12 curriculum (course of study) that is based on the national standards for physical education. Physical education provides cognitive content and instruction designed to develop motor skills, knowledge, and behaviors for healthy active living, physical fitness, sportsmanship, self-efficacy, and emotional intelligence. A well-designed physical education program provides the opportunity for students to learn key concepts and practice critical skills needed to establish and maintain physically active lifestyles throughout childhood, adolescence, and into adulthood. Teachers should be certified or licensed, and endorsed by the state to teach physical education.

DISCUSSION

A Holistic Health and Education Model

Inherent in the WSCC model is a holistic view of students, schools, and communities. The model builds on other socioecological models used in health and education, including Bronfenbrenner's "Ecological Framework for Human Development,"[ 6] public health and health promotion models,[ 7] and Lohrmann's "Ecological Model of the Coordinated School Health Program."[ 8] Each segment and layer of the WSCC model is interdependent on the others; the model is designed to emphasize the whole to support the development of each child and youth most effectively. The focus of the WSCC model is a socioecological approach that is directed at the whole school, with the school, in turn, drawing its resources and influences from the whole community and serving to address the needs of the whole child. ASCD and the CDC encourage use of the model as a framework for improving students' learning and health.[ 3]

The model is based on health and education research, including research that addresses the need to engage students as active participants in their learning and health. The figure of the child represents children and youth who should be at the center of decisions made by policymakers and practitioners from the education and health sectors. In addition, the child is a reminder of the powerful outcomes that can be achieved by giving voice to children and youth about their education, their health and their communities. To be successful adults, students must be provided a variety of opportunities to learn, including in the community, and to put into practice their learning through peer leadership and educational choices, as well as their involvement in peer education and youth development.

After years of observing the CSH approach in action in local schools and districts, the consultation team noted that without coordination, policies, practices, and processes in place, the model would not be effective in achieving its intended outcomes. Administrator support, particularly the support of principals, has been shown to be a key factor in the success of the integration of learning and health in schools.[ 9] District and school policies that promote health and learning, practices that reinforce the policies and desired behaviors of staff and students, and processes that ensure that coordination, planning, use of data, and continuous improvement all must work in concert with the other pieces of the model.

How the WSCC Model Advances School Health

Improves the uptake of CSH principles

The original CSH components serve as the primary organizing framework through which school health educators, physical education teachers, school nurses, and other staff work to support students within the context of the school. Furthermore, this approach encourages schools and communities to come together to address the health needs of students to support their physical, cognitive, and emotional development. Overall, the CSH approach supports positive academic outcomes through its foci on health promotion and on reducing barriers to learning.

However, CSH has had scattered adoption across the United States. School health coordinating councils often have not had their work included into School Improvement Plans, a key requirement for successful integration and sustainability of any effort undertaken within individual schools and school districts. Pressures on school administrators to improve student academic outcomes measured primarily through test scores have increased since the last reauthorization of the Elementary and Secondary Education Act in 2002. While educators have recognized the need for students to be healthy and safe in order to learn, declines in school budgets and punitive measures taken against schools that do not meet standards have also had a negative impact on administrators' adoption of CSH in schools and districts across the country.[ 10]

Directly addresses the relationship between education and health

To further the integration of health and education, the consultation team recognized the need to align the new model with the role that social determinants such as education play in the lifelong health of individuals and of populations. Public health recognizes that a range of personal, social, economic, and environmental factors contribute to individual and population health. The CDC and the World Health Organization have identified place-based settings that contribute to population and individual health. These 5 determinants include: (1) economic stability; (2) education; (3) social and community context; (4) health and health care; and (5) neighborhood and built environment.[ 11]

The WSCC approach incorporates all of the determinants and acknowledges their impact on the cognitive, physical, and emotional development of children and youth. The integration of health and education within the model provides educators with a holistic framework for integrating education and health. Schools are situated in social and community contexts. The model addresses social determinants of health, encourages the provision of health and health care, and emphasizes coordination and planning with the surrounding community and the local neighborhood through the lenses of the education and health sectors.

In line with the strong focus on social determinants of health, the WSCC further emphasizes the connectedness between health and academic outcomes. Proficient academic skills are associated with lower rates of risky behaviors and higher rates of healthy behaviors.[ 12-14] High school graduation leads to lower rates of health problems[ 15-18] and risk for incarceration, as well as enhanced financial stability during adulthood.[ 19, 20] The school social environment affects students' attendance,[ 21] academic achievement, and behavior.[ 22] A safe and healthy school environment promotes student engagement[ 23] and protects against risky behaviors[ 24-26] and dropping out.[ 12] School administrators are required to focus on the long-term educational outcomes for students. Many also recognize the need to address immediate health-related factors to support educational outcomes. Studies demonstrate that when children's basic nutritional and fitness needs are met, they attain higher achievement levels.[ 14, 27-38] Similarly, the use of school-based and school-linked health centers ensuring access to needed physical, mental, and oral health care improves attendance,[ 39] behavior,[ 40-45] and achievement.[ 46-49] The development of connected and supportive school environments benefits teaching and learning, engages students, and enhances positive learning outcomes. The development of a positive social and emotional climate increases academic achievement, reduces stress, and improves positive attitudes toward self and others.[ 50, 51] Academic achievement is an excellent indicator for the overall well-being of youth and a primary predictor and determinant of adult health outcomes. Individuals with more education are likely to live longer; experience better health outcomes; and practice health-promoting behaviors such as exercising regularly, refraining from smoking, and obtaining timely healthcare checkups and screenings.[ 52-54] These positive outcomes are why many of the nation's leading educational organizations recognize the close relationship between health[ 55-57] and education, as well as the need to foster health and well-being within the educational environment for all students.[ 2, 58-60] Conversely, education and public health recognize that a range of health-related factors can lead to poor school performance. Health-risk behaviors are linked to poor grades and lower educational attainment.[ 14]

Although the education and health sectors are both keenly interested in student achievement and health, the specific goals and accountability standards for achieving these outcomes can be different. The new WSCC model is designed to provide a shared framework and approach for decision making and action for both sectors to work together.

Through the development of the WSCC model, the goals of the education and health sectors are combined and integrated. As the next evolution of CSH, the model speaks to leaders and practitioners of both sectors on the local level. However, the model's use is not intended to be confined to a school, a district, or a community. The consultation and review groups also recognized that within the federal government a myriad of initiatives focus on school health issues. The WSCC model offers an overarching framework and a holistic approach to program coordination and integration within and across agencies.

IMPLICATIONS FOR SCHOOL HEALTH

The key to moving from model to action is collaborative development of local school policies, processes, and practices. The day-to-day practices within each sector require examination and collaboration so that they work in tandem, with appropriate complementary processes guiding each decision and action. Developing joint and collaborative policy is half the challenge; putting it into action and making it routine completes the task. To develop joint or collaborative policies, processes, and practices, all parties involved should start with a common understanding about the interrelatedness of learning and health. From this understanding, current and future systems and actions can be adjusted, adapted, or crafted to jointly achieve both learning and health outcomes.[ 3]

School health coordinators and school health teams have been the facilitators of CSH in many schools and districts across the United States. That work has been most successful when the work has been viewed as integral to the mission of the school. When the district and school-based wellness teams work closely with the school administrator, both sectors' goals are combined and met most effectively.

As previously mentioned, schools are situated within the contexts of neighborhoods and communities. The relationship between the school and the community affects the entire community, not just the students attending the school. The WSCC model includes these contexts because research has shown their impact on education and health outcomes. When schools and their communities work together, their resources are used most effectively and the needs of the entire community can be identified and met more cost-effectively. The model recognizes that schools and communities have a shared responsibility for the health and education of children and youth. The model calls for this shared responsibility, acknowledging that schools are fiscally supported through the community and that they must work together to provide services and a positive quality of life.

While the WSCC model is designed for application in schools, it was developed to be relevant to a wide variety of individuals and groups who work with schools or whose work affects schools.

School administrators and those who provide service within the component areas of the model (educators, school nurses, counselors, and those who provide support services in nutrition, physical environment, employee wellness, family engagement, and community involvement) will find direct, practical applications. The model's emphases on coordinating policy, process, and practice and integration of the community can enhance all aspects of the work of the school.

School districts and schools can use the model as a framework for school improvement plans and initiatives. School improvement teams can be structured using representation from each of the components utilized in the model. Doing so can ensure integration of critical outcomes in education and health for students.

Higher education programs that prepare school administrators, teachers, counselors, nurses, and other staff who work in school districts and schools may design coursework and professional development preservice and in-service events directed toward effective implementation of the model.

Local, state, and national-level philanthropic organizations may develop initiatives that emphasize the community engagement aspects of the model and encourage its focus on coordinating policy, process, and practice in school districts and schools.

Governmental agencies such as state education departments and state health departments can use the model as a framework for establishing accountability measures that address both education and health. They may also consider the model in design of specific programs designed to support local districts, including funding opportunity announcements.

Federal agencies can utilize the framework as a foundation for official guidance, funding opportunity announcements, technical assistance initiatives, and professional development opportunities. Likewise, national governmental agencies in other countries may wish to consider the model in development of their own health-promoting schools initiatives.

Policymakers and opinion leaders will find the approach helpful as a comprehensive view of necessary supports in schools and how they may be effectively organized. This view may be useful in development of policy initiatives that efficiently address learning and health.

Finally, the public, including parents, can more effectively connect with school districts and schools as integral parts of the model. Building these collaborations will provide increased school connectedness and family connectedness, which are both critically important for student success. The efficiency of the model and interactivity of its components should provide efficiencies that can improve the work of schools.

The implementation of the model brings together all stakeholders to engage with the education and health issues present in the community, including collaborative identification of the college and career readiness skills required by businesses and higher education. Community agencies, educators, families, policymakers, children, and youth all play a role. Through the full implementation of all of the pieces included in the model, schools and communities have worked together. Schools are now sites for community health centers and fitness centers. Community agencies provide educational supports and student engagement programs. The model is designed to initiate conversation and activate research- and evidence-based practices that support lifelong health, cognitive development and economic success.

It is important to be clear, however, that the model is a framework and not an intervention. It identifies the sectors, stakeholders, contexts, and elements that need to be considered when fully integrating health and education. Each element of the model has supporting research, evidence, and best practices that can be used for implementation. However, the specific interventions, curricula, classroom practices, and resources brought together to put the framework into action will be dependent on the local context.

Conclusion

The WSCC model represents an evolution of organizational thinking in schools. In the marriage of the two leading models addressing healthy schools, the Whole Child Initiative and the CSH approach, the WSCC approach provides a comprehensive framework for school districts and schools. The important changes within components and emphases on critical facilitative factors including community engagement, policies, processes, and practices build upon the assets of both approaches and effectively address the needs of modern schools.

By focusing on children and youth as students, addressing critical education and health outcomes, organizing collaborative actions and initiatives that support students, and strongly engaging community resources, the WSCC approach offers important opportunities for school improvements that will advance educational attainment and healthy development for students.

Human Subjects Approval Statement

This paper involved no human subjects, and therefore, was exempt from examination by an Institutional Review Board.

Disclaimer

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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REFERENCES

10 Basch CE. Healthier Students Are Better Learners: A Missing Link in School Reforms to Close the Achievement Gap. New York, NY: Columbia University; 2010. (Equity Matters: Research Review No. 6) Available at: http://www.equitycampaign.org/i/a/document/12557_EquityMattersVol6_Web03082010.pdf. Accessed February 6, 2015.

18 Muennig P. The economic value of health gains associated with education interventions. Paper prepared for the Equity Symposium on The Social Costs of Inadequate Education; 2005 Oct 24-25; Teachers College, Columbia University, New York, NY; 2005. Available at: http://www.schoolfunding.info/news/policy/Muennig%20-%20Health%20and%20Education.pdf. Accessed February 20, 2015.

21 Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance-United States, 2009. MMWR Surveill Summ. 59(SS05):1-142. Available at: http://www.cdc.gov/mmwr/pdf/ss/ss5905.pdf. Accessed February 20, 2015.

25 Henderson M, Ecob R, Wight D, Abraham C. What explains between-school differences in rates of smoking? BMC Public Health. 2008;8:218. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442834/pdf/1471-2458-8-218.pdf or http://www.biomedcentral.com/1471-2458/8/218. Accessed February 20, 2015.

27 Bradley B, Green AC. Do health and education agencies in the United States share responsibility for academic achievement and health? A review of 25 years of evidence about the relationship of adolescents' academic achievement and health behaviors. J Adolesc Health. 2013;52(5):523-532.

28 Murphy JM, Pagano ME, Nachmani J, Sperling P, Kane S, Kleinman RE. The relationship of school breakfast to psychosocial and academic functioning: cross-sectional and longitudinal observations in an inner-city school sample. Arch Pediatr Adolesc Med. 1998;152(9):899-907.

29 Rampersaud GC, Pereira MA, Girard BL, Adams J, Metzl JD. Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents. J Am Diet Assoc. 2005;105(5):743-760, quiz 761-762.

32 Widenhorn-Müller K, Hille K, Klenk J, Weiland U. Influence of having breakfast on cognitive performance and mood in 13- to 20-year-old high school students: results of a crossover trial. Pediatrics. 2008;122(2):279-284.

33 Alaimo K, Olson CM, Frongillo EA Jr. Food insufficiency and American school-aged children's cognitive, academic, and psychosocial development. Pediatrics. 2001;108(1):44-53.

48 Dean S. Hearts and Minds: A Public School Miracle. Toronto, ON, Canada: Penguin Canada; 2001.

59 American Association of School Administrators (AASA). Position statement 3: getting children ready for success in school, July 2006; Position statement 18: Providing a safe and nurturing environment for students, July 2007. AASA Position Statements. Available at: http://www.aasa.org/uploadedFiles/About/_files/AASAPositionStatements072408.pdf. Accessed February 20, 2015.

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GENERAL ARTICLE

Authors

Theresa C. Lewallen MA, CHES,

Chief Constituent Services Officer, Corresponding author

Constituent Services, ASCD, Alexandria, VA 22311

Address correspondence to: Theresa C. Lewallen, Chief Constituent Services Officer, ( tlewalle@ascd.org), ASCD, 1703 N. Beauregard Street, Alexandria, VA 22311.

Search for more papers by this author

†Indicates that continuing education hours are available. Visit www.ashaweb.org and click on Continuing Education for more information.

ABSTRACT

BACKGROUND

The Whole Child approach and the coordinated school health (CSH) approach both address the physical and emotional needs of students. However, a unified approach acceptable to both the health and education communities is needed to assure that students are healthy and ready to learn.

METHODS

During spring 2013, the ASCD (formerly known as the Association for Supervision and Curriculum Development) and the US Centers for Disease Control and Prevention (CDC) convened experts from the field of education and health to discuss lessons learned from implementation of the CSH and Whole Child approaches and to explore the development of a new model that would incorporate the knowledge gained through implementation to date.

RESULTS

As a result of multiple discussions and review, the Whole School, Whole Community, Whole Child (WSCC) approach was developed. The WSCC approach builds upon the traditional CSH model and ASCD's Whole Child approach to learning and promotes greater alignment between health and educational outcomes.

CONCLUSION

By focusing on children and youth as students, addressing critical education and health outcomes, organizing collaborative actions and initiatives that support students, and strongly engaging community resources, the WSCC approach offers important opportunities that will improve educational attainment and healthy development for students.

Since 1987, the coordinated school health (CSH) approach has served as the foundation for addressing health promotion among youth in our nation's schools. The model, originally conceptualized by Lloyd Kolbe and Diane Allensworth, in the seminal article "The Comprehensive School Health Program: Exploring an Expanded Concept"[ 1] has been viewed as the essential public health framework for school health, though it has not resonated as strongly with the education sector. While the US Centers for Disease Control and Prevention (CDC) was supporting the implementation of the CSH approach, ASCD (formerly known as the Association for Supervision and Curriculum Development) launched the Commission on the Whole Child and challenged the education community to focus attention on ensuring that all students are healthy and feel supported, challenged, engaged, and safe.[ 2] While both of these approaches address the physical and emotional needs of the student, neither have resulted in a unified approach supported by both health and education sectors.[ 3]

METHODS

Expert Panel

During spring 2013, ASCD and CDC convened a group of experts from education, public health, and academia to discuss lessons learned from implementation of both approaches and to explore the revision and development of a model that would incorporate the knowledge gained through implementation to date. A series of meetings were held and outcomes from the discussions were vetted with a review group made up of additional experts and stakeholders (Box 1).

CDC and ASCD Core Group

Diane D. Allensworth, PhD

Professor Emeritus, Kent State University

Laura Rooney, MPH

Adolescent Health Program Manager, Ohio Department of Health

Elaine Auld, MPH, MCHES, CEO, SOPHE

David Birch, PhD, Department Chair, University of Alabama

Marty Blank, Exec. Director, Coalition of Community Schools

Maurice Elias, PhD, Professor, Rutgers University

Susan Goekler, PhD, MCHES, Executive Director, DHPE

Dave Lohrmann, PhD, Department Chair, Indiana University

Donna J. Mazyck, RN, MS, NCSN, Executive Director, NASN

Douglas McCall, Executive Director, International School Health Network

Robert Valois, PhD, Professor, University of South Carolina

Summary of the Whole Child and CSH Approaches

In The Learning Compact Redefined: A Call to Action, ASCD implored communities, educators, and key decision makers to work together to ensure the implementation of policies that would result in successful learners who are knowledgeable, emotionally and physically healthy, civically active, artistically engaged, prepared for economic self-sufficiency, and ready for adulthood.[ 2] The Whole Child approach responds to this call with 5 tenets that make the student the focal point:

Each student enters school healthy and learns about and practices a healthy lifestyle.

Each student learns in an environment that is physically and emotionally safe for students and adults.

Each student is actively engaged in learning and is connected to the school and broader community.

Each student has access to personalized learning and is supported by qualified, caring adults.

Each student is challenged academically and prepared for success in college or further study and for employment and participation in a global environment.

The CSH approach follows a systems-based approach addressing 8 components of the school as a venue for health promotion and disease prevention:

Health education

Physical education

School health services

Healthy and safe school environment

Counseling, psychological, and social services

Family and community involvement

Health promotion for staff

Nutrition services.[4]

RESULTS

As a result of these deliberations the Whole School, Whole Community, Whole Child (WSCC) model was established. The WSCC approach combines and builds on the elements of the Whole Child model and the CSH approach to create a unified model that supports a systematic, integrated, and collaborative approach to health and learning. The WSCC model is designed to provide a shared framework and approach for decision making and action for both sectors to work together (Figure 1).

The WSCC model incorporates the 5 tenets of the Whole Child model by putting the student at the center and making her/him the focal point. Surrounding the child/student is a ring that stresses the need for coordination among policy, process, and practice. While much focus has been given to coordination among components, the previous approaches did not explicitly describe the critical role of day-to-day practices and processes or the essential role of policy in sustaining a school environment that supports both health and learning.

The outer ring of the WSCC model reflects greater integration and alignment between health and education by incorporating the components of the CSH approach and emphasizing the school as an integral part of the community.[ 3] In addition, the model's incorporation of the important context of community and the role of coordination for policy, process, and practice is consistent with findings of an evaluation of strong CSH programs conducted by CDC's Division of Adolescent and School Health.[ 4] The importance of sectors and individuals working together to implement policies, practice, and process is now prominent in this integrated approach that addresses health and learning.

Some of the original CSH components have been expanded to better reflect current evidence and practice. Specifically, the healthy and safe school environment component is now separated into "social and emotional climate" and "physical environment" giving greater attention to each. The family and community involvement component is now separated into "community involvement" to emphasize the role of community, businesses, agencies, and organizations, and "family engagement" to place a greater emphasis on the critical role that families play. Health promotion for staff has been changed to "employee wellness" to reflect a broader approach that addresses learning new life skills and becoming aware of and making conscious choices toward a more balanced and healthy lifestyle.[ 5] The nutrition services component has been expanded to include the nutrition environment. Physical education is now expanded to include physical activity.

In addition to these structural changes, the definitions and descriptions of each component of the outer ring (Figure 1) have been updated and revised to better reflect the current evidence. Definitions were developed by subject matter experts and vetted with experts in the field ( http://www.cdc.gov/healthyyouth/wscc/components.htm).

Health Education

Formal, structured health education consists of any combination of planned learning experiences that provide the opportunity to acquire information and the skills students need to make quality health decisions. When provided by qualified, trained teachers, health education helps students acquire the knowledge, attitudes, and skills they need for making health-promoting decisions, achieving health literacy, adopting health-enhancing behaviors, and promoting the health of others. Comprehensive school health education includes curricula and instruction for students in pre-K to grade 12 that address a variety of topics such as alcohol and other drug use and abuse, healthy eating/nutrition, mental and emotional health, personal health and wellness, physical activity, safety and injury prevention, sexual health, tobacco use, and violence prevention. Health education curricula and instruction should address the National Health Education Standards and incorporate the characteristics of an effective health education curriculum. Health education, based on an assessment of student health needs and planned in collaboration with the community, ensures reinforcement of health messages that are relevant for students and meet community needs. Students might also acquire health information through education that occurs as part of a patient visit with a school nurse, through posters or public service announcements, or through conversations with family and peers.

Nutrition Environment and Services

The school nutrition environment provides students with opportunities to learn about and practice healthy eating through available foods and beverages, nutrition education, and messages about food in the cafeteria and throughout the school campus. Students may have access to foods and beverages in a variety of venues at school including the cafeteria, vending machines, grab 'n' go kiosks, schools stores, concession stands, classroom rewards, classroom parties, school celebrations, and fundraisers.

School nutrition services provide meals that meet federal nutrition standards for the National School Lunch and Breakfast Programs, accommodate the health and nutrition needs of all students, and help ensure that foods and beverages sold outside of the school meal programs (competitive foods) meet Smart Snacks in School nutrition standards. School nutrition professionals should meet minimum education requirements and receive annual professional development and training to ensure that they have the knowledge and skills to provide these services. All individuals in the school community support a healthy school nutrition environment by marketing and promoting healthier foods and beverages, encouraging participation in the school meal programs, role-modeling healthy eating behaviors, and ensuring that students have access to free drinking water throughout the school day. Healthy eating has been linked in studies to improved learning outcomes and helps ensure that students are able to reach their potential.

Employee Wellness

Schools are not only places of learning, but they are also worksites. Fostering school employees' physical and mental health protects school staff, and by doing so, helps to support students' health and academic success. Healthy school employees-including teachers, administrators, bus drivers, cafeteria and custodial staff, and contractors-are more productive and less likely to be absent. They serve as powerful role models for students and may increase their attention to students' health. Schools can create work environments that support healthy eating, adopt active lifestyles, be tobacco free, manage stress, and avoid injury and exposure to hazards (such as mold or asbestos). A comprehensive school employee wellness approach is a coordinated set of programs, policies, benefits, and environmental supports designed to address multiple risk factors (including lack of physical activity and tobacco use) and health conditions (such as diabetes or depression) to meet the health and safety needs of all employees. Partnerships between school districts and their health insurance providers can help offer resources, including personalized health assessments and flu vaccinations. Employee wellness programs and healthy work environments can improve a district's bottom line by decreasing employee health insurance premiums, reducing employee turnover, and cutting costs of substitutes.

Social and Emotional School Climate

Social and emotional school climate refers to the psychosocial aspects of students' educational experience that influence their social and emotional development. The social and emotional climate of a school can impact student engagement in school activities; relationships with other students, staff, family, and community; and academic performance. A positive social and emotional school climate is conducive to effective teaching and learning. Such climates promote health, growth, and development by providing a safe and supportive learning environment.

Physical Environment

A healthy and safe physical school environment promotes learning by ensuring the health and safety of students and staff. The physical school environment encompasses the school building and its contents, the land on which the school is located, and the area surrounding it. A healthy school environment will address a school's physical condition during normal operation as well as during renovation (including ventilation, moisture, temperature, noise, or natural and artificial lighting), and protect occupants from physical threats (such as crime, violence, traffic, or injuries) and biological and chemical agents in the air, water, or soil as well as those purposefully brought into the school (including pollution, mold, hazardous materials, pesticides, or cleaning agents).

Health Services

School health services intervene with actual and potential health problems, including providing first aid, emergency care and assessment, and planning for the management of chronic conditions (such as asthma or diabetes). In addition, wellness promotion, preventive services and staff, and student and parent education complement the provision of care coordination services. These services are also designed to ensure access and/or referrals to the medical home or private healthcare provider. Health services connect school staff, students, families, community, and healthcare providers to promote the health care of students and a healthy and safe school environment. School health services actively collaborate with school and community support services to increase the ability of students and families to adapt to health and social stressors, such as chronic health conditions or social and economic barriers to health, and to be able to manage these stressors and advocate for their own health and learning needs. Qualified professionals such as school nurses, nurse practitioners, dentists, health educators, physicians, physician assistants, and allied health personnel provide these services.

Counseling, Psychological, and Social Services

These prevention and intervention services support the mental, behavioral, and social-emotional health of students and promote success in the learning process. Services include psychological, psychoeducational, and psychosocial assessments; direct and indirect interventions to address psychological, academic, and social barriers to learning, such as individual or group counseling and consultation; and referrals to school and community support services as needed. Additionally, systems-level assessment, prevention, intervention, and program design by school-employed mental health professionals contribute to the mental and behavioral health of students as well as to the health of the school environment. These services can be accomplished through resource identification and needs assessments, school-community-family collaboration, and ongoing participation in school safety and crisis response efforts. Additionally, school-employed professionals can provide skilled consultation with other school staff and community resources and community providers. School-employed mental health professionals ensure that services provided in school reinforce learning and help to align interventions provided by community providers with the school environment. Professionals such as certified school counselors, school psychologists, and school social workers provide these services.

Community Involvement

Community groups, organizations, and local businesses create partnerships with schools, share resources, and volunteer to support student learning, development, and health-related activities. The school, its students, and their families benefit when leaders and staff at the district or school solicits and coordinates information, resources, and services available from community-based organizations, businesses, cultural and civic organizations, social service agencies, faith-based organizations, health clinics, colleges and universities, and other community groups. Schools, students, and their families can contribute to the community through service-learning opportunities and by sharing school facilities with community members such as school-based community health centers or fitness facilities.

Family Engagement

Families and school staff work together to support and improve the learning, development, and health of students. Family engagement with schools is a shared responsibility of both school staff and families. School staff members are committed to making families feel welcomed, engaging families in a variety of meaningful ways, and sustaining family engagement. Families are committed to actively supporting their child's learning and development. This relationship between school staff and families cuts across and reinforces student health and learning in multiple settings-at home, in school, in out-of-school programs, and in the community. Family engagement should be continuous across a child's life and requires an ongoing commitment as children mature into young adulthood.

Physical Education and Physical Activity

Schools can create an environment that offers many opportunities for students to be physically active throughout the school day. A comprehensive school physical activity program (CSPAP) is the national framework for physical education and youth physical activity. A CSPAP reflects strong coordination across 5 components: physical education, physical activity during school, physical activity before and after school, staff involvement, and family and community engagement. Physical education serves as the foundation of a CSPAP and is an academic subject characterized by a planned, sequential K-12 curriculum (course of study) that is based on the national standards for physical education. Physical education provides cognitive content and instruction designed to develop motor skills, knowledge, and behaviors for healthy active living, physical fitness, sportsmanship, self-efficacy, and emotional intelligence. A well-designed physical education program provides the opportunity for students to learn key concepts and practice critical skills needed to establish and maintain physically active lifestyles throughout childhood, adolescence, and into adulthood. Teachers should be certified or licensed, and endorsed by the state to teach physical education.

DISCUSSION

A Holistic Health and Education Model

Inherent in the WSCC model is a holistic view of students, schools, and communities. The model builds on other socioecological models used in health and education, including Bronfenbrenner's "Ecological Framework for Human Development,"[ 6] public health and health promotion models,[ 7] and Lohrmann's "Ecological Model of the Coordinated School Health Program."[ 8] Each segment and layer of the WSCC model is interdependent on the others; the model is designed to emphasize the whole to support the development of each child and youth most effectively. The focus of the WSCC model is a socioecological approach that is directed at the whole school, with the school, in turn, drawing its resources and influences from the whole community and serving to address the needs of the whole child. ASCD and the CDC encourage use of the model as a framework for improving students' learning and health.[ 3]

The model is based on health and education research, including research that addresses the need to engage students as active participants in their learning and health. The figure of the child represents children and youth who should be at the center of decisions made by policymakers and practitioners from the education and health sectors. In addition, the child is a reminder of the powerful outcomes that can be achieved by giving voice to children and youth about their education, their health and their communities. To be successful adults, students must be provided a variety of opportunities to learn, including in the community, and to put into practice their learning through peer leadership and educational choices, as well as their involvement in peer education and youth development.

After years of observing the CSH approach in action in local schools and districts, the consultation team noted that without coordination, policies, practices, and processes in place, the model would not be effective in achieving its intended outcomes. Administrator support, particularly the support of principals, has been shown to be a key factor in the success of the integration of learning and health in schools.[ 9] District and school policies that promote health and learning, practices that reinforce the policies and desired behaviors of staff and students, and processes that ensure that coordination, planning, use of data, and continuous improvement all must work in concert with the other pieces of the model.

How the WSCC Model Advances School Health

Improves the uptake of CSH principles

The original CSH components serve as the primary organizing framework through which school health educators, physical education teachers, school nurses, and other staff work to support students within the context of the school. Furthermore, this approach encourages schools and communities to come together to address the health needs of students to support their physical, cognitive, and emotional development. Overall, the CSH approach supports positive academic outcomes through its foci on health promotion and on reducing barriers to learning.

However, CSH has had scattered adoption across the United States. School health coordinating councils often have not had their work included into School Improvement Plans, a key requirement for successful integration and sustainability of any effort undertaken within individual schools and school districts. Pressures on school administrators to improve student academic outcomes measured primarily through test scores have increased since the last reauthorization of the Elementary and Secondary Education Act in 2002. While educators have recognized the need for students to be healthy and safe in order to learn, declines in school budgets and punitive measures taken against schools that do not meet standards have also had a negative impact on administrators' adoption of CSH in schools and districts across the country.[ 10]

Directly addresses the relationship between education and health

To further the integration of health and education, the consultation team recognized the need to align the new model with the role that social determinants such as education play in the lifelong health of individuals and of populations. Public health recognizes that a range of personal, social, economic, and environmental factors contribute to individual and population health. The CDC and the World Health Organization have identified place-based settings that contribute to population and individual health. These 5 determinants include: (1) economic stability; (2) education; (3) social and community context; (4) health and health care; and (5) neighborhood and built environment.[ 11]

The WSCC approach incorporates all of the determinants and acknowledges their impact on the cognitive, physical, and emotional development of children and youth. The integration of health and education within the model provides educators with a holistic framework for integrating education and health. Schools are situated in social and community contexts. The model addresses social determinants of health, encourages the provision of health and health care, and emphasizes coordination and planning with the surrounding community and the local neighborhood through the lenses of the education and health sectors.

In line with the strong focus on social determinants of health, the WSCC further emphasizes the connectedness between health and academic outcomes. Proficient academic skills are associated with lower rates of risky behaviors and higher rates of healthy behaviors.[ 12-14] High school graduation leads to lower rates of health problems[ 15-18] and risk for incarceration, as well as enhanced financial stability during adulthood.[ 19, 20] The school social environment affects students' attendance,[ 21] academic achievement, and behavior.[ 22] A safe and healthy school environment promotes student engagement[ 23] and protects against risky behaviors[ 24-26] and dropping out.[ 12] School administrators are required to focus on the long-term educational outcomes for students. Many also recognize the need to address immediate health-related factors to support educational outcomes. Studies demonstrate that when children's basic nutritional and fitness needs are met, they attain higher achievement levels.[ 14, 27-38] Similarly, the use of school-based and school-linked health centers ensuring access to needed physical, mental, and oral health care improves attendance,[ 39] behavior,[ 40-45] and achievement.[ 46-49] The development of connected and supportive school environments benefits teaching and learning, engages students, and enhances positive learning outcomes. The development of a positive social and emotional climate increases academic achievement, reduces stress, and improves positive attitudes toward self and others.[ 50, 51] Academic achievement is an excellent indicator for the overall well-being of youth and a primary predictor and determinant of adult health outcomes. Individuals with more education are likely to live longer; experience better health outcomes; and practice health-promoting behaviors such as exercising regularly, refraining from smoking, and obtaining timely healthcare checkups and screenings.[ 52-54] These positive outcomes are why many of the nation's leading educational organizations recognize the close relationship between health[ 55-57] and education, as well as the need to foster health and well-being within the educational environment for all students.[ 2, 58-60] Conversely, education and public health recognize that a range of health-related factors can lead to poor school performance. Health-risk behaviors are linked to poor grades and lower educational attainment.[ 14]

Although the education and health sectors are both keenly interested in student achievement and health, the specific goals and accountability standards for achieving these outcomes can be different. The new WSCC model is designed to provide a shared framework and approach for decision making and action for both sectors to work together.

Through the development of the WSCC model, the goals of the education and health sectors are combined and integrated. As the next evolution of CSH, the model speaks to leaders and practitioners of both sectors on the local level. However, the model's use is not intended to be confined to a school, a district, or a community. The consultation and review groups also recognized that within the federal government a myriad of initiatives focus on school health issues. The WSCC model offers an overarching framework and a holistic approach to program coordination and integration within and across agencies.

IMPLICATIONS FOR SCHOOL HEALTH

The key to moving from model to action is collaborative development of local school policies, processes, and practices. The day-to-day practices within each sector require examination and collaboration so that they work in tandem, with appropriate complementary processes guiding each decision and action. Developing joint and collaborative policy is half the challenge; putting it into action and making it routine completes the task. To develop joint or collaborative policies, processes, and practices, all parties involved should start with a common understanding about the interrelatedness of learning and health. From this understanding, current and future systems and actions can be adjusted, adapted, or crafted to jointly achieve both learning and health outcomes.[ 3]

School health coordinators and school health teams have been the facilitators of CSH in many schools and districts across the United States. That work has been most successful when the work has been viewed as integral to the mission of the school. When the district and school-based wellness teams work closely with the school administrator, both sectors' goals are combined and met most effectively.

As previously mentioned, schools are situated within the contexts of neighborhoods and communities. The relationship between the school and the community affects the entire community, not just the students attending the school. The WSCC model includes these contexts because research has shown their impact on education and health outcomes. When schools and their communities work together, their resources are used most effectively and the needs of the entire community can be identified and met more cost-effectively. The model recognizes that schools and communities have a shared responsibility for the health and education of children and youth. The model calls for this shared responsibility, acknowledging that schools are fiscally supported through the community and that they must work together to provide services and a positive quality of life.

While the WSCC model is designed for application in schools, it was developed to be relevant to a wide variety of individuals and groups who work with schools or whose work affects schools.

School administrators and those who provide service within the component areas of the model (educators, school nurses, counselors, and those who provide support services in nutrition, physical environment, employee wellness, family engagement, and community involvement) will find direct, practical applications. The model's emphases on coordinating policy, process, and practice and integration of the community can enhance all aspects of the work of the school.

School districts and schools can use the model as a framework for school improvement plans and initiatives. School improvement teams can be structured using representation from each of the components utilized in the model. Doing so can ensure integration of critical outcomes in education and health for students.

Higher education programs that prepare school administrators, teachers, counselors, nurses, and other staff who work in school districts and schools may design coursework and professional development preservice and in-service events directed toward effective implementation of the model.

Local, state, and national-level philanthropic organizations may develop initiatives that emphasize the community engagement aspects of the model and encourage its focus on coordinating policy, process, and practice in school districts and schools.

Governmental agencies such as state education departments and state health departments can use the model as a framework for establishing accountability measures that address both education and health. They may also consider the model in design of specific programs designed to support local districts, including funding opportunity announcements.

Federal agencies can utilize the framework as a foundation for official guidance, funding opportunity announcements, technical assistance initiatives, and professional development opportunities. Likewise, national governmental agencies in other countries may wish to consider the model in development of their own health-promoting schools initiatives.

Policymakers and opinion leaders will find the approach helpful as a comprehensive view of necessary supports in schools and how they may be effectively organized. This view may be useful in development of policy initiatives that efficiently address learning and health.

Finally, the public, including parents, can more effectively connect with school districts and schools as integral parts of the model. Building these collaborations will provide increased school connectedness and family connectedness, which are both critically important for student success. The efficiency of the model and interactivity of its components should provide efficiencies that can improve the work of schools.

The implementation of the model brings together all stakeholders to engage with the education and health issues present in the community, including collaborative identification of the college and career readiness skills required by businesses and higher education. Community agencies, educators, families, policymakers, children, and youth all play a role. Through the full implementation of all of the pieces included in the model, schools and communities have worked together. Schools are now sites for community health centers and fitness centers. Community agencies provide educational supports and student engagement programs. The model is designed to initiate conversation and activate research- and evidence-based practices that support lifelong health, cognitive development and economic success.

It is important to be clear, however, that the model is a framework and not an intervention. It identifies the sectors, stakeholders, contexts, and elements that need to be considered when fully integrating health and education. Each element of the model has supporting research, evidence, and best practices that can be used for implementation. However, the specific interventions, curricula, classroom practices, and resources brought together to put the framework into action will be dependent on the local context.

Conclusion

The WSCC model represents an evolution of organizational thinking in schools. In the marriage of the two leading models addressing healthy schools, the Whole Child Initiative and the CSH approach, the WSCC approach provides a comprehensive framework for school districts and schools. The important changes within components and emphases on critical facilitative factors including community engagement, policies, processes, and practices build upon the assets of both approaches and effectively address the needs of modern schools.

By focusing on children and youth as students, addressing critical education and health outcomes, organizing collaborative actions and initiatives that support students, and strongly engaging community resources, the WSCC approach offers important opportunities for school improvements that will advance educational attainment and healthy development for students.

Human Subjects Approval Statement

This paper involved no human subjects, and therefore, was exempt from examination by an Institutional Review Board.

Disclaimer

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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REFERENCES

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9 Valois RF, Slade S, Ashford E. The Healthy School Communities Model: Aligning Health and Education in the School Setting. Alexandria, VA: ASCD; 2011.

10 Basch CE. Healthier Students Are Better Learners: A Missing Link in School Reforms to Close the Achievement Gap. New York, NY: Columbia University; 2010. (Equity Matters: Research Review No. 6) Available at: http://www.equitycampaign.org/i/a/document/12557_EquityMattersVol6_Web03082010.pdf. Accessed February 6, 2015.

18 Muennig P. The economic value of health gains associated with education interventions. Paper prepared for the Equity Symposium on The Social Costs of Inadequate Education; 2005 Oct 24-25; Teachers College, Columbia University, New York, NY; 2005. Available at: http://www.schoolfunding.info/news/policy/Muennig%20-%20Health%20and%20Education.pdf. Accessed February 20, 2015.

21 Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance-United States, 2009. MMWR Surveill Summ. 59(SS05):1-142. Available at: http://www.cdc.gov/mmwr/pdf/ss/ss5905.pdf. Accessed February 20, 2015.

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ASCD is the global leader in developing and delivering innovative programs, products, and services that empower educators to support the success of each learner. Comprising 125,000 members-superintendents, principals, teachers, professors, and advocates from more than 138 countries-the ASCD community also includes 56 affiliate organizations.

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ASCD is a passionate community of life-changing educators. Our community is empowered to be equity and instructional warriors who transform vision into practice. For 75 years we have worked side by side with educators from every level in all 50 states and more than 200 countries to help them find their people and amplify their voice to reach many.

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