A Complementary Ecological Model of the Coordinated School Health Program
DAVID K. LOHRMANN, PhD, CHES, FASHA
ABSTRACT
BACKGROUND: A complementary ecological model of the coordinated school health program (CSHP) reflecting 20 years of evolved changes is proposed. Ecology refers to the complex interrelationship between intrapersonal factors, interpersonal processes and primary groups, institutional factors, community factors, and public policy.
METHODS: Public health and child development theories that incorporate the influence of personal and social environments on health behavior, along with models that incorporate the influence of ecology, were consulted.
RESULTS: Concepts from several models were combined with the 8 components of
CSHP to formulate an ecological model involving 6 program and services components in an inner circle surrounded by 4 concentric rings representing the healthy school environment, essential structures of CSHP, local school district governance, and family and community involvement.
CONCLUSION: This complementary ecological model is intended to serve as an additional conceptual approach to CSHP practice, evaluation, and research, and should prove especially useful to practitioners and researchers who already have a fundamental understanding of CSHP.
Keywords: marketing; advocacy for coordinated school health programs; child;
adolescent health; public health.
Citation: Lohrmann DK. A complementary ecological model of the coordinated school
health program. Public Health Reports. 2008; 123(6):695–703. Reprinted with
permission. Association of Schools of Public Health.
Received on August 31, 2009
Accepted on September 2, 2009
Professor, (dlohrman@indiana.edu), Department of AppliedHealth Science, IndianaUniversity, Bloomington, IN47405.
Address correspondence to: David K. Lohrmann, Professor, (dlohrman@indiana.edu), Department of AppliedHealth Science, IndianaUniversity, HPER Room116, Bloomington, IN
47405.
Journal of School Health • January 2010, Vol. 80, No. 1 • © 2010, American School Health Association • 1
In 1987, Kolbe and Allensworth introduced the 8
components of a coordinated school health program
(CSHP), an innovation that strongly influenced
school health over the ensuing years. Previously,
the operative conceptualization of school health was
the ‘‘3-legged stool’’ of health education, health
services, and the healthy school environment.1 The
new approach retained these components and added
food and nutrition services; health promotion for
staff; physical education; counseling, psychological,
and social services; and family and community
involvement.
The 8-components approach was adopted and
recommended by the Centers for Disease Control
and Prevention, Division of Adolescent and School
Health (CDC/DASH) and, via CDC/DASH-funded
national organizations and state and local education
agencies, became the operative framework in the
United States.2,3 By the late 1990s, a version had
been adopted by the World Health Organization
under its health-promoting schools initiative and
implemented in countries across the globe.4 The 8-
components approach, and variants of it, is a very
successful innovation that has enjoyed an impressive
dissemination and adoption curve.
Coordinated school health program is commonly
depicted as a series of 8 connected bubbles in orbit
around 2 generic students (Figure 1).5 The lines connecting
the component bubbles connote coordination.
By implication, the components seem to have equal
status and all function in a single dimension.
Somewhat in contrast, the expanded CSHP
approach was originally depicted through a diagram
(Figure 2) that illustrated the direct impact of 7 components
on student health-related behaviors and,
subsequently, their health status, cognitive performance,
and educational achievement.1 The eighthcomponent
health-promotion program for faculty and
staff is shown as initially influencing employee health
behaviors, health status, and cognitive performance
and then, via healthy and high-performing employees,
student health and educational outcomes. This
diagram portrayed true health promotion because it
clearly involved health education plus policy, regulatory,
organizational, social, economic, and/or political
interventions that support actions and conditions of
living6 across all components and, thereby, enhanced
health, educational, and social outcomes of students
and school employees.7
The bubble visual of CSHP has proven very
functional in conveying a general impression of CSHP.
Most peoplewho see it have attended US public schools
and readily recognize the majority of components.
They have all been in physical education or gym,
were served by the ‘‘lunch ladies,’’ have visited the
school nurse, spoken to a counselor, experienced
some lessons about health, and recognize school as
a physical building. Because much of the visual is
readily grasped by school administrators, school board
members, community leaders, and others, it is wellsuited
for introducing CSHP to these audiences.
The bubble visual also has shortcomings. The socialemotional
climate aspect of the school environment,
along with the family and community involvement
and health promotion for staff components, is less
familiar to individuals not steeped in school health.
Neither the social-emotional climate8 nor school safety
and security systems9 subsumed in the ‘‘healthy
school environment’’ are specifically identified in the
visual. Many schools do not have health-promotion
programs for staff and, within the visual, family
and community involvement can be simplistically
interpreted as parents and community members
serving on health committees or as guest speakers.
The bubble visual also does not: (1) readily convey
the strong emphasis on health promotion projected
in the 1987 diagram; (2) include aspects of CSHP
developed over the ensuing years, such as the essential
structures of a school health coordinator, school health
council, and school health team;10 (3) recognize that
the CSHP in every school should be supported by
local school district organizational infrastructure;11,12
or (4) incorporate the recently evolved and expanded
importance and impact of both family and community
involvement.13
To account for these and other aspects of CSHP, a
new, complementary depiction of CSHP is warranted.
An alternative depiction could clearly recognize the
various spheres within the lives of students and
school staff that influence health behaviors and
educational achievement, as well as distinguish CSHP
components that provide programs and services from
those that are more contextual. Such a model could
explicitly include the much wider array of strategies
for involving families as well as broader community
networks capable of providing the programs, services,
and resources for students, staff, and families14–16
that should be engaged to fully implement and
institutionalize CSHP within school systems. The goal
of a complementary model would be to represent
a truly health-promoting school—one that enables,
motivates, supports, and reinforces student and staff
adoption and practice of healthy behaviors.16
THE ROLE OF ECOLOGY IN HEALTH
The health status of humans is determined by a
mix of factors as illustrated by the current obesity
epidemic.17 While body weight is partially dependent
on genetics, historically most people have been
able to maintain a normal weight through relatively
healthy eating and exercise behaviors. Within the past
3 decades, the environmental factors that influence
weight have changed, making it more difficult for
2 • Journal of School Health • January 2010, Vol. 80, No. 1 • © 2010, American School Health Association
Figure 1. ‘‘Bubble’’ Depiction of a Coordinated School Health Program (Adapted from [5])
Comprehensive school
health education
Family and community
involvement in school
health
Physical education
School-site health School health services
promotion for staff
Healthy school
environment
School counseling,
psychological, and
social services
School nutrition services
many individuals to maintain a healthy weight despite
having little biological predisposition to obesity.17
Environmental changes that influence consumption
patterns include availability of abundant food along
with processed foods that are high in fat and sugar
and, for many low-income families, limited availability
of fresh fruits, vegetables, and other whole foods,
aggressive marketing of food products, hectic lifestyles
conducive to fast-food consumption, and increased
portion sizes served in restaurants.17,18 Environmental
changes that impact exercise include communities
designed for vehicle traffic, inadequate or unsafe facilities
for routine physical activity such as walking, and
passive entertainment such as television and computer
games. Together, these and other environmental
changes encourage the overconsumption of food and
sedentary living that contribute to obesity and related
diseases including type II diabetes.17
Most of the environmental changes that negatively
impact body weight also occurred in the schools,
surrounding neighborhoods, and homes of children,
youth, and school employees.18 Like obesity, many of
the myriad health problems experienced by children
and youth today are influenced by their ecology—the
complex interrelationship among intrapersonal factors,
interpersonal processes and primary groups,
institutional factors, community factors, and public
policy.19
ECOLOGICAL MODELS
The influence of environmental factors within
human ecology is acknowledged in health education
and health-promotion theories and models. For
example, in his social cognitive theory, Bandura recognized
the reciprocal determinism of an individual’s
personal factors and self-control with environment.20
Personal factors such as past history, self-efficacy, and
behavioral capacity, and self-control mechanisms such
as locus of control, self-observation, self-judgment,
and self-reaction, are influenced by the environmental
factors of observational learning. And behavioral
reinforcement or inhibition is moderated by real or
perceived consequences to self or others. Further, Bandura
proposed several teaching and learning strategies
designed to influence this interaction.
In their precede/proceed model, Green and Kreuter
contend that 3 types of factors affect health behavior.
Predisposing factors are antecedents to behavioral or
environmental changes that provide the motivation
for behavior, enabling factors are antecedents to
behavioral or environmental changes related to policy,
and reinforcing factors provide reward or incentive to
Journal of School Health • January 2010, Vol. 80,No. 1 • © 2010, American School Health Association • 3
Figure 2. School Health-Promotion Components and Outcomes (Adapted from [1])
Program
components
Immediate
outcomes
Short-term
outcomes
Long-term
outcomes
(1) School health
services
Health status
Health status
(2) School health
education
Student healthrelated
behaviors Cognitive
performance
Educational
achievement
(3) School health
environment
(4) Integrated school
and community health
promotion efforts
(5) School physical
education
(6) School food service
(7) School counseling
Health status
(8) School-site health
promotion program
for faculty and staff
Faculty and staff
health-related
behaviors
Cognitive
performance
persistent repetition of a behavior. They contend that
health education and health-promotion programs can
be designed to modify these factors, thereby positively
influencing health behaviors and/or environments
and, ultimately, enhancing the quality of life. One
phase of this model involves both educational
and ecological assessments intended to ‘‘examine
the highest-priority behavioral and environmental
conditions linked to health status or quality of life
concerns to determine what causes them.’’21
Hovel, Wahlgreen, and Gehrman proposed a behavioral
ecological model (BEM) based on principles of
respondent and operant conditioning, as well as concepts
of social cognitive theory, which posits that the
interaction of physical and social contingencies can
explain and control behavior. Behavioral ecological
model follows a hierarchy of contingencies ranging
from highly individualized to generic that include
individual physical and social characteristics, local
networks made up of friends and coworkers, community
contingencies that include policies and laws, and
culturally specific and nationality-related societal contingencies.
Interventions designed to influence health
behavior are implemented through social institutions
including schools and families using a variety of media
and social marketing strategies.22
Through their synthesis of the various ecological
models of health behavior, Sallis and Owen devised 7
guiding principles: (1) multiple levels of factors influence
health behaviors; (2) multiple types of environmental
influences affect health behavior; (3) behaviorspecific
ecological models can be useful; (4) multilevel
interventions may be most effective; (5) multilevel
interventions are most easily implemented by multisectorial
groups; (6) ecological interventions should
be evaluated and their implementation should be
monitored to assess changes in mediators at multiple
levels; and (7) political dynamics can limit ecological
interventions. They provide examples of successful
health interventions based on these principles and
recommend their use for guiding both intervention
development and research.19
Bronfenbrenner’s ecological systems theory provides
a widely accepted explanation of the impact of
environment on children and adolescents. This theory
holds that a child’s development is affected by multiple
layers of influencers identified as the microsystem
that includes direct influencers such as family, school,
4 • Journal of School Health • January 2010, Vol. 80,No. 1 • © 2010, American School Health Association
neighborhood, and childcare: the mesosystem that
connects the structures of themicrosystem; the exosystem
that constitutes the larger, indirect social system
including parental workplace and community-based
resources; the macrosystem that includes values, customs,
and laws; and the chronosystem that denotes the
relationship between time and timing of external life
events and internal processes related to physical maturation.
Key concepts include the bidirectional influences
across layers and the premise that children are
both products and producers of their environments.23
PROPOSED ECOLOGICAL MODEL OF CSHP PROMOTION
Clearly, multiple authorities recognize the impact
of ecology on health behavior, and several commonly
applied health theories and theory-basedmodels incorporate
an ecological approach to health promotion.
Additionally, at least one ecological theory of child
and adolescent development exists.23 Based on these
precedents, the levels of influence on child and adolescent
health and health behavior can be envisioned.
The depiction in Figure 3 includes concepts from the
ecological models and theories previously described
and, especially, incorporates the layers of influence
from ecological systems theory,23 with the microsystem
and mesosystem represented by health education
classrooms, the whole school, family structure and culture,
and neighborhood spheres, and the exosystem
and macrosystem represented by the popular culture
sphere. Figure 3 subsumes the following concepts:
1. In health classrooms (commonly the general
education classroom at the elementary level),
students learn essential knowledge and skills
they can employ to engage in healthy behaviors.
24 Instruction about health can be provided
through other CSHP components including physical
education, school counseling, and school
health services and can be integrated into other
subjects such as science.
2. The entire school constitutes an immediate environment
that supports or impedes students’
inclinations and abilities to engage in healthy
behaviors.10,18
3. Family and neighborhood are additional environments
that support or impede students’
inclinations and abilities to engage in healthy
behaviors.10
4. The greater community constitutes a proximal
context and health-related resource for individuals,
health educators, schools and school systems,
families, and neighborhoods.10
5. Popular culture provides the overarching values,
customs, and laws, including those related to
health, and influences students’ health-related
behaviors, especially through the many types of
Figure 3. Spheres of Ecological Influences on Child and Adolescent Health Behavior and Health From the School Perspective
Health
education
classrooms
Whole
school
Family
culture
Neighborhood
Popular
culture
Greater community
Journal of School Health • January 2010, Vol. 80, No. 1 • © 2010, American School Health Association • 5
Figure 4. Coordinated School Health Program (CSHP) Ecological Model
media.17 (While this probably cannot be influenced
by a CSHP, students can be taught how
to recognize and counteract negative cultural
influences.24)
6. For school health education to be effective in
influencing students to behave in healthy ways,
the lessons they learn must be supported and
reinforced throughout the school as well as by
the family and neighborhood.7,10,16
An ecological model specific to CSHP emerges
(Figure 4) by telescoping the first 5 spheres from
Figure 3 and combining them with the 8 components
from Figure 1.5 In this new model, the 6 components
that comprise programs and services provided to students
and school employees are located in the center
circle. These 6 are fully described elsewhere.10,14,25 The
outcomes derived from them are the same as indicated
in Figure 2.1
The major differences between the model in
Figure 4 and the visual in Figure 1 that it is intended
to complement are found in the 4 concentric rings
that surround the middle 6 components—the healthy
school environment (inner ring), essential governance
structures of a CSHP (second ring), local school
system infrastructure within which a CSHP exists
and functions (third ring), and family and community
involvement (outer ring). The ‘‘chutes’’ running from
the outer ring through the 3 adjacent rings to the
inner circle are meant to convey coordination across
all layers, as well as the concept that family members
and a diverse, wide array of community organizations
and agencies can be involved bidirectionally in any and
all other components and/or provide resources at any
and all levels of the CSHP. (Note that the many major
categories of community organizations attached to the
outer ring can be further delineated; for example,
local, state, and national government can include
many entities such as city councils, police departments,
courts and probation departments, child protective
services, parks, and recreation departments.)
Ecological Model Advantages
This ecological model has several advantages. First,
it more closely represents CSHP as the originally
intended health-promotion strategy by explicitly
including the mechanisms through which policy,
regulatory, organizational, social, economic, and/or
political changes can occur.1 It clearly shows that a
CSHP exists within and is dependent on the overall
6 • Journal of School Health • January 2010, Vol. 80, No. 1 • © 2010, American School Health Association
local school district infrastructure, including school
board policies, administrative procedures, budgetary
resources, and operating systems.12 Therefore, it
is subject to and influenced by decision makers
and stakeholders whose vision and mission may be
more focused on traditional educational outcomes10
than on health outcomes or who may not readily
recognize the strong relationship among students’
and school staffs’ physical, mental, emotional, and
social health status and educational outcomes.1,7 For
CSHP to be implemented and sustained over time,
this relationship to local school district infrastructure,
indicative of strong administrative support, must be
recognized and continuously nurtured.11,12 Second,
the 3 essential structures of a CSHP that evolved over
the past 8 to 10 years are included. The composition,
roles, functions, and responsibilities of the health
coordinator, coordinating council, and team have been
fully described and are recognized as necessary to the
effective functioning of a CSHP.10,26,27 Therefore, it is
appropriate to include these structures in any current
CSHP model.
The third ring also includes a ‘‘champion.’’
Emanating from diffusion of innovation theory, a
champion is defined as ‘‘a charismatic individual who
throws his or her weight behind an innovation, thus
overcoming indifference and resistance that the new
idea may provoke in an organization.’’28 Champions
are recognized as seminal to the implementation and
institutionalization of school health programming and
can be external (eg, local physician, activist parent, or
director of a voluntary health agency) or internal (e.g.,
school board member, central office administrator,
school principal, school nurse, or influential teacher)
to a school district.29,30
Finally, the healthy school environment and
family and community involvement components are
distinguished from the other 6 direct program and
services components because, in reality, they are
different. Ecologically, the healthy school environment
provides the overall context enveloping students and
school employees. As the component in which the
within-school components and all other aspects of
schooling function, it constitutes the innermost ring.
This ring signifies the higher level of importance
that the healthy school environment merits and more
explicitly portrays its true complexity.31 The correlation
of a healthy school environment with learning
and school success is clearly recognized by the
‘‘education establishment.’’9 And something as seemingly
inconsequential as natural daylight in classrooms
is highly correlated with faster math and reading
skill development.31 Complexity is demonstrated by
ring segmentation into 4 distinct parts—psychosocial
climate, safety, facilities, and transportation—all of
which are crucial to establishing and maintaining
a school culture in which all students can be safe,
secure, and successful.9 To further illustrate, just one
of the 4 segments—the psychosocial climate—can be
separated into the whole school climate and individual
classroom climate.16 The former can further be
delineated as (1) expectations for students and staff,
(2) ownership and bonding, and (3) conduct and discipline,
and the latter as (1) opportunity to learn,
(2) classroom tone, (3) student self-management, and
(4) classroom management.16
Family and community involvement is likewise different
from the 6 inner components as it represents an
aspect of the children’s and adolescents’ microsystem
(family) and their entire exosystem of communitybased
resources that can complement and support a
CSHP. Although they may be inclined to favor initiation
of CSHP in their schools, education decision
makers may not feel they have the resources to do so.
The importance of capturing and focusing sufficient,
untapped resources that may be present in the greater
community has been demonstrated via numerous case
studies.13 Beyond the issue of resources, however,
involvement of the greater community in CSHP is crucial
to initiation and maintenance of healthy behaviors
as well as desired health and educational outcomes.32
Three examples illustrate this point.
Involving the Community in CSHP
Implementation of CSHP in a small southern school
district over several years was shown to positively
impact both education and health indicators, including
improved standardized test scores and graduation
rates, decreased dropout rates, reduced juvenile
crime rates, and substantial reductions in second
pregnancies for teenage mothers.33 Initially, district
leaders asked the community constituents to answer
3 questions: (1) What do they not like about the
district? (2) What do they want the district to be
like? and (3) What should be done to get there?
The answers showed community commitment to
development of the ‘‘whole child’’ and provided the
impetus for enhanced school health programming
coordinated with programming provided by medical,
social, and criminal justice agencies in the community.
This school-community approach is credited with
generating positive education and health outcomes.33
Researchers in Minnesota were successful in
establishing the efficacy of a health education
curriculum that resulted in less onset and lower use
of alcohol in intervention vs control school districts.34
These successes were attributed to several aspects of
the curriculum including adequate instructional time,
fidelity in implementation, peer leader involvement,
and a focus on social influences, life skills, and peerresistance
skills accompanied by school-based demand
reduction efforts. Key to the curriculum effect was
the ability to influence perceived alcohol use norms
Journal of School Health • January 2010, Vol. 80,No. 1 • © 2010, American School Health Association • 7
by involving parents, peers, and the community.
In particular, a task force was established in each
intervention community to focus on policies and
activities to reduce the availability of alcohol to minors
in the community and provide alcohol-free activities
for teens.34
One Midwest suburban community was also
successful at reducing use of gateway drugs by adolescents,
but via a somewhat different approach.35 Utilizing
the precede/proceed model,21 program planners
organized risk and protective factors within predisposing,
enabling, and reinforcing categories. They then
identified which factors in each category could best be
influenced by schools, families, and the community.
This exercise demonstrated that, while school-based
programs were vital, most of the risk factors could
best be influenced by families and the greater community.
Over time, a multilevel school-family-community
prevention program, including a very broad-based
community coalition, was implemented and resulted
in substantial reductions in alcohol, tobacco, and marijuana
use that were sustained beyond a decade.35
Besides highlighting the importance of family and
community involvement, these 3 examples suggest the
evolution of CSHP into a community organization and
community-building approach that potentially could
involve all aspects of the community.36
CONCLUSION
In summary, the 8-components model of CSHP
first introduced in 1987 realized tremendous success
in influencing school health programs and practices
in the United States and around the globe. Coordinated
school health program has traditionally been
represented by a bubble visual that is readily interpreted
by school personnel and parents, and for this
reason should continue to be used as a means of
introducing CSHP to na¨ıve audiences. Nevertheless,
multiple developments and features of CSHP and in
the field of health promotion, which evolved over the
ensuing years, are not represented in the traditional
visual. Thus, a complementary model based primarily
on ecological systems theory23 and consistent with
the 7 guiding principles of public health ecological
modeling19 is proposed as an additional conceptual
approach to CSHP practice, evaluation, and research.
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