HEALTH SERVICES UNDER THE ELEMENTARY AND SECONDARY EDUCATION ACT

VICTOR EISNER, M.D., RI.P.13.

Associate Clinical Professor of Maternal and Child Health, University of California School of Public Health, Berkeley, California 94720

Health program planners who want to establish comprehensive services for children need to iden- tify and use all of the resources they can find in a community. Despite recent legislation which has increased the availability of health care, many children still do not receive even basic health ser- vices. This paper describes a potential supple- ment to new or existing community health pro- grams. Title I of Public Law 89-750, the Ele- mentary and Secondary Education Act, provides innovative and remedial educational programs for childrnn in poverty areas. It permits a wide latitude in designing supporting services for these programs. It encourages the inclusion of health components (1) which can readily be incorporated into community health planning.

In 1968 the State of California’s Department of ICtlucntion developed a master plan for educat- ing the children of migrant agricultural workers. Under this plan, 176 school districts in 27 coun- ties organized 38 projects providing service to about 29,000 migrant children. The Bureau of Community Services and Rligrant Education, which administered the plan, developed in coop- eration with agencies in 21 states a uniform system of recording arid transmitting data from school to school. The Bureau based this system on :L record transfer form which they designed for eventual computerized data storage arid retrieval. The record transfer form had space for health data as well as for education data.

Kearly all of the migrant education projects in- cluded health components. These varied widely. For c>xample, some projects provided nurses within schools; others stationed nurses in the migrant camps, arid others depended upon nursing ser- vices provided by the local health department. The projects developed three methods of provid- ing medical services: referral to private practi- t ionm, provision of part-time school physicians, arid establishing new clinics for school children in the migrant camps. Very few projects in- cluded dental care.

To improve the effectivencss of these health coniponents, the Bureau of Community Services and Migrant Education requested consultation from the Farm Worker’s Health Service of the

State Department of Health. A medical con- sultant became available early in 1968, and spent approximately 10% of his time working with the program. The consultant prepared program guidelines, made consultation and follow-up visits to local projects, organized in-service education, and carried out a pilot program evaluc ‘I. t‘ 1011.

Preparation of Program Guidelines In initial conferences with program adminis-

trators, the consultant discovered that 110 obj t’c- tives had been set for the health component, of the program. Indeed, the first question :tsked of the consultant, was the proper extent of a school health program. In addition, the administrators wanted a cost estimate for each procedure which might be included.

A set of program guidelines \\’as prepared in April, 1968, by the Farm Worlter’s Health Ser- vice of the State Department of Health. ( 2 ) Thc guidelines suggested minimal and optini:il pro- gram objectives, as follows:

Minimal: The location and corrcction of cor- rectable health defects constituting a handicap to education.

Optimal: The location and correction of :dl correctable heallh defects whether or not thry constitute a handicap for education or em- ploy merit.

To implement these objectives, the guitlclincs recommended that each project should adopt :t health plan providing for medical examination and treatment, health education, dental care, and ancillary services, and they outlined require- ments for personnel, advisory committees, con- sultants, and records. Cost estimates, which ranged from $21 per child for a minimal program to $102 for an optimal program, were based on experience in similar programs in 1907. The guidelines also recommended ongoing progr:tm evaluation based on regularly collected service statistics.

Program administrators received the guidelines in May, 1968, a t a meeting with the coiisu1t:mt. Copies of the guidelines were distributed r:~pidly

464 The Journal of School Hecilth

to regional offices, but they did not reach all local programs until mid 1969.

Consultation Visits and Follow-up During the summer of 1968 and the following

autumn the consultant visited program adminis- trators and local projects in 12 counties. At these visits he endeavored to determine program pri- orities and to modify procedures for special cir- cumstances. The consultant initiated several planning conferences between administrators of the education projects and county health depart- ment personnel. These led to better utilization of existing facilities, and to cooperative efforts of health workers and school personnel.

Inservice Education In the late spring of 1969 a conference was held

for nurses and health aides from local projects. The conference was arranged cooperatively by the Bureau of Community Services and Migrant Education and by the Farm Worker’s Health Service. The latter agency prepared the pro- gram, and arranged for speakers: all other ar- rangements including invitations to participants were handled by the Bureau of Community Services and Migrant Education. The con- ference program included three subject areas: identifying children with health problems, cor- rection of health problems, and the use of the new interstate record transfer forms. Following the conference, written material developed at con- ference discussion sessions was sent to all participants.

Program Evaluation The consultant suggested that ongoing pro-

gram evaluation should be based on the record transfer forms. This method was readily adapt- able to computerization, and could be done with a minimum investment of staff time. More im- portant, the record transfer system will even- tually become the key to cont,inuity of care for migrant children. The program evaluation should emphasize that proper use of the form is an es- sential part of the program.

An evaluation based primarily on recorded cor- rection of health defects proved possible and use- ful although it needed supplementation by site visits. A pilot evaluation of these records was done in 1968 by personnel of the Farm Workers’ Health Service. It demonstrated low program effectiveness in the country selected for study. This was not expected by the program adminis- trators, and $0 the evaluation was repeated in another county, with similar results. It was

The Journul of School Health-November, 1970

found in the record study and by site visits that screening procedures, even those required by law for all students, had been done on less than half of the students. Many students remained in school only a short time, and the program itself was of short duration. Nevertheless, improve- ments in the coverage of screening procedures were possible. In addition, it was found that the follow-up of students with health defects had not been effective: school nurses frequently made referrals to appropriate sources of care but rarely made sure that the children actually were taken.

A repeat evaluation a year later, after the consultation and inservice education described above, showed considerable improvement in the correction of medical and dental defects, and in the immunization of children. However other program elements, especially follow-up of vision and hearing screening, had not been as successful as in the previous year.

The results of these studies were used by the consultant as stimuli for further improvements in the programs.

Discussion The experiences in California’s Migrant Edu-

cation Program illustrate the extent of the health services which can be provided under the Ele- mentary and Secondary Education Act. For example, in one county the project administrators established three clinics with project funds. The clinics were staffed by project nurses and aides, and by part time physicians. At these clinics, which met weekly, children from 2 to 17 years of age could receive health appraisals, im- munizations, and treatment of minor illnesses. Illnesses and health defects which could not be treated in the clinic were handled by referral to health department clinics for migrants, to private physicians, and to local hospitals. Project funds were used to pay for this treatment when neces- sary. The project also provided an outreach service through its nurses and aides, who were based in the migrant camps. The nurses and aides worked in the project schools and day care centers, but also visited all new families in the camps. An informal agreement between the camp nurses and the county public health nurses had reduced duplication of effort, so that the county nurses provided similar outreach services for migrant famiIies living outside of the camps. In addition, project funds had been used to finance dental treatment in a mobile four-chair experimental unit from the University of Cali-

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fornia School of Dentistry in San Francisco. The use of nurses, aides and teachers for intensive family orientation and education resulted in efficient use of the dental unit, and enabled complete restorative care to be given to nearly all of the children in camp when the unit arrived.

Such extensive health services will only appear within educational programs if health personnel take an active part in promoting them. Few educators are familiar with the details of planning effective health services nor do they generally know what outside health resources in a com- munity should be coordinated with school pro- gram. On the other hand, health personnel frequently are unaware of the new potential of school health services. Traditionally, school health services have emphasized casefinding and referral. In areas where children receive ade- quate health care outside of school, this has proven sufficient. In poverty areas, it usually is not. This is why Title I of the Elementary and Secondary Education Act provides funds for treatment and for necessary ancillary services. Project funds may pay for dental care, as in the example described, and they may be used to pay for service at existing facilities or to set up new

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facilities. They may also be used for supporting services, such as transportation and interpreta- tion. An investment of health personnel time in coordinating and improving these programs can result in substantial additions to the health care of children served by the projects.

The wide range of options allowed in these projects is at once their strength and their weak- ness. While it allows flexibility in meeting local needs, it carries the risk that programs will be poorly designed and therefore ineffective. We believe that health agencies can and should pro- vide support and guidance to these new school health programs. In turn, school health can be- come a valuable part of a community’s health resources.

REFERENCES

1. Ratchik, J. Evaluation of School Health Services for Disadvantaged Children under Title I, Elemen- tary and Secondary Education Act. J. Sch. €1. 38: 140-146: 1968.

2. Farm Workers’ Health Service. Guidelines for Health Services in Educational Programs for Migrant Children. California State Department of Public Health, Bureau of Maternal and Child Health 1625 Shattuck Street, Berkeley, California. Mhneo, 1968,9 pp.

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CHILD HEALTH IN A HARLEM ELEMENTARY SCHOOL

DORIS WETHERS, M.D.

Director of Pediatrics, Knickerbocker Hospital; Instrwtor in Pediatrics, Columbia University College of Physicians and Surgeons

and KENNETH COUBENS, M.D.

Boston Stale Hospital, BOSlOn, Mass. 02124

Public School 175 is one of several elementary schools in Central Harlem, and includes classes from Kindergarten through 5th grade. It is lo- cated one block from Harlem Hospital and two blocks from the New York City District Health Center. Basic health screening and referral ser- vices are provided for all students by the Bureau of School Health of the New York City Depart- ment of Health, and in Central Harlem about 90% of the physical examinations of students admitted to the elementary schools are completed by school physicians. (1)

Parents of children a t P.S.-175 complained that the health needs of the pupils were not being met, either in the school or in local hospitals

and health centers, With the advice and en- couragement of two medical students and two pediatricians from neighboring institutions, these parents channelled their concern into a school PTA health committee, which developed the idea of Project Health at P.S.-175. The purpose of the project was to document the nature and quality of health care received by children at- tending the school, and to recommend and initiate needed changes.

Necessary basic information was gathered over a 14-month period, 1967-1968. The plan in- cluded the offer of free medical evaluation for all the children at P.S.-175, with referral elsewhere of all those found to have a health problem; and

466 The Journtil yf School H P u I t A