Leadings Causes of Death in the US

The 10 leading causes of death among adults in the United States account for as much as 80% of serious morbidity and premature mortality in the United States each year. These 10 major public health problems, listed in rank order are heart disease, cancer, cerebrovascular diseases, accidents, chronic obstructive lung disease, influenza/pneumonia, diabetes mellitus, suicide, cirrhosis of the liver, and arteriosclerosis. Of these diseases, only one — influenza/pneumonia — is a communicable disease. The remaining nine causes relate to lifestyle and personal health behavior.

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The importance of effective decision-making is highlighted by the fact that accidents, suicide, and homicide rank as leading causes of death for American teen-agers and young adults. AIDS also has emerged as a leading cause of death for males ages 24-35. Though AIDS is a communicable disease, lifestyle and health practices figure prominently both in the spread of disease and in efforts to control it.

Though most of these leading causes of death cannot be cured, they potentially can be prevented through health education that promotes positive lifestyles and develops effective decision-making skills. Therefore, the success of public health efforts to improve the health status of all Americans depends substantially on the success of such programs among children and adolescents.

Historically in the United States, health promotion activities have been incorporated into various aspects of public education. The three areas of school health services, school health instruction, and the healthful school environment traditionally comprise the total school health program. Recently, an expanded concept of the school health program including eight components has been proposed. In 1984, the National Professional School Health Education Organizations published a paper defining comprehensive school health education. According to the paper, such programs include instruction to promote health and not merely prevent disease or disability; activities to develop decision-making competencies; a planned, sequential K-12 curriculum; opportunities for students to develop and demonstrate knowledge, attitudes, and behavior; integration of the physical, mental, emotional, and social dimensions of health; specific program goals and objectives; formative and summative evaluation; effective management systems; and sufficient resources including curricular time, instructional materials, and adequate staff and teachers. Content areas for instruction include community health, consumer health, environmental health, family life, growth and development, nutritional health, personal health, prevention and control of disease and disorders, safety and accident prevention, and substance use and abuse.

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Though some consensus exists regarding the components of comprehensive school health education, several changes underway in the United States have influenced the health of all Americans, thus providing new challenges for school health. The elderly now out-number teenagers, guaranteeing an older population well into the next century. Also, while the fertility rate among white Americans has dropped to 1.7, the rate remains above 2.0 among certain minority groups. By the year 2020, ethnic minorities will constitute an estimated 48% of the school population for children ages 5-17. Likewise, the American family structure has changed, and some 50% of American children will live in a single parent home by age 18, usually with the mother. Since women earn less than men, the number of women and children living in poverty has increased.

American Youths Face Health Issues

American youth potentially face a variety of health problems including improper nutrition, inadequate physical fitness, depression and other emotional disorders, accidents and violence, substance abuse, and declining immunization levels. In addition, communicable diseases such as AIDS continue to pose a threat to health, particularly for young adults. The following data provide insight concerning the nature and extent of health problems confronting American youth:

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Chronic Disease. An estimated 7.5 million (12%) of the 62 million American children younger than age 18 have a chronic disease. Some 1.5 million (20%) have asthma, congenital heart disease, diabetes mellitus, cleft lip and palate, spina bifida, sickle cell anemia, chronic renal failure, or muscular dystrophy. Despite advances in medical technology, the number of children experiencing limitations in major activity increased from 1.1% in 1976 to 2.0% in 1980.

School Attendance. During 1980, American children missed an average of 5.3 days of school. Females missed 5.7 days, and males missed 4.8 days. Low income children missed almost twice as many days as upper income children.

Vision and Hearing. Refractory defects occur in an estimated 6% to 7% of six-year-olds and increases to 15% among 15-year-olds. Some 3% to 6% of children experience hearing loss. Only 31 states require periodic screening for hearing loss, and 29 states for loss of vision acuity.

Alcohol Use. Some 100,000 elementary schoolchildren get drunk at least once a week. Likewise, 26% of male and 21% of female adolescents report getting drunk from once a month to once a week or more.

Tobacco Use. While tobacco consumption has declined among the general population, some 19% of high school students report daily use of cigarettes.

Substance Use. Almost 60% of students try an illegal drug before graduation, and one in eight high school seniors report using cocaine during the year.

Nutrition. An estimated 10% to 20% of American youth are considered obese, while millions more practice poor dietary habits. In one study of some 2,000 children, only about 10% had acceptable diets, and 53% consumed sweet or salty snacks five or more times daily. Conversely, many American children lack sufficient food. An estimated 12 million children experience hunger at some time each month, and as many as 40% of American children attend school without eating a daily breakfast. About 3.7 million children receive breakfast at school through the National School Breakfast Program, and 89% receive the breakfast free or at a reduced price. Likewise, more than 24 million children receive lunch at school each day, and about 50% receive the lunch free or at a reduced price. Failure to receive adequate nutrition can produce apathy, inability to concentrate, disruptive behavior, and generally poor school performance.

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Physical Activity. Only 40% of students ages 10-18 participate in appropriate physical activity regularly throughout the year.

Emotional Health. Nationally, pediatricians report treating some 7% of their patients for emotional disorders. An estimated 20% of school-age children experience the symptoms of depression, though the symptoms are transitory and subside with age. Teachers report that 6% of students have serious conduct problems at school, and children with behavioral disorders are at increased risk for developing psychiatric disabilities as adults. Anorexia nervosa and bulimia are common emotional disorders, particularly for adolescent females ages 12-18. About one in 250 adolescents in this age range will develop anorexia with an estimated mortality rate of about 5%. An estimated 5% to 25% of adolescent females practice binging and purging. About two-thirds of adolescents with anorexia recover, while about one-third remain chronically ill.

Sexually Transmitted Diseases. Annually, some 2.5 million teen-agers contract a sexually transmitted disease. Sexually active adolescents ages 15-19 experience the highest overall rate of sexually transmitted diseases for any American population group.

Teen-age Pregnancy. More than 1 million teen-agers become pregnant annually, and about half these adolescents give birth. Pregnant teen-agers experience increased health complications during pregnancy and delivery, and their babies experience lower birth weights and increased morbidity and mortality, often due to lack of adequate prenatal care. Only about half of teen-age mothers graduate from high school. Consequently, these young women often must support their families on low incomes or with public assistance. More than 25% of teen-age mothers become pregnant again within two years, especially among black teenagers. Teen-age marriages usually end in divorce. Childbearing among teen-agers cost the United States more than $19 billion in 1987.

Seatbelt Use. Only 15% of American youth ages 13-17 always wear a seatbelt while riding in the front seat of an automobile.

Private Sector Initiatives

In response to this challenge, new child health initiatives are arising at the local, state, and national levels. Partnerships are emerging among parents, educators, health professionals, the private sector, and schools. For example, the Metropolitan Life Foundation, a private sector foundation supported by the Metropolitan Life Insurance Company, sponsors a national initiative called “Healthy Me” to promote comprehensive school health education. The initiative recognizes exemplary school health programs and community coalitions promoting school health, supports professional preparation partnerships between public schools and universities, promotes wellness programs for school faculty and staff, and provides educational materials concerning school health promotion.

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In 1988, the Metropolitan Life Foundation funded a national survey to examine the opinions of parents, teachers, and 4,738 public school students in grades three-12 concerning comprehensive health education. The survey addressed effects of comprehensive health education, relevance of health education, parental involvement, emotional health, curricular emphases, safety issues, and AIDS prevention. The survey represents the increasing contribution of the private sector in addressing child health problems and needs. Also, the survey findings provide more useful information for planning and promoting comprehensive school health programs. Highlights drawn from findings of the survey include:

Effects of Comprehensive Health Education

Students with comprehensive health education have more knowledge, better health-related attitudes, and more positive behavior than students with little or no health education. About 8 million public school students across the country have little or no health education.

Forty-three percent of students with one year of health education have a drink sometimes or more often; that proportion decreases to 33% for students who have had health education for at least three years.
Twenty percent of students with one year of health education smoke a cigarette sometimes or more often, as opposed to 14% among those having had health education for at least three years.

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Thirteen percent of students having received health education for one year have taken drugs a few times or more; only 6% of those with three or more years of health education have done so.

The proportion of those who have ridden with a driver who has been drinking decreases from 70% for students with one year of health education to 63% for students with at least three years of health education.

Relevance of Health Education

Thirty-two percent of students find health classes more interesting than other classes, and 45% say they are about the same as other classes.

Ninety-one percent of all students find health education classes useful.

Eighty-one percent of the “Healthy Me” school students and 74% of students who have had three years of health education report they have made changes to improve their health, compared to 62% of those who have not had health education.

Students who feel limited control over their own health tend to skip dinner more than students who report a lot of control over their own health (6% vs. 20%).

Eighty-one percent of students who feel a lot of control over their own health exercise or play outside of school three or more times a week; only 58% of those who feel little or no control do so.

Parental Involvement

Most parents endorse comprehensive health education; however, about half of parents do not know what is taught in health education.
Only 29% of parents say they have gotten involved in any way with their child’s school health education program.

Only 37% of teachers from the national sample say that parents give strong support to health education in their schools. However, in “Healthy Me” schools where health education seems to be highly successful, strong parental support rises sharply (63%).

Many parents do not know the extent of drinking, smoking, or drug-taking among students. They report all three behaviors to a much lesser degree than do students.

Though 36% of parents report that their child has had at least one alcoholic drink, 66% of students say that they have used alcohol at least once or twice.

Fourteen percent of parents report that their child has smoked a cigarette, compared to 41% of children who say that they have smoked a cigarette.


Five percent of parents say their child has used drugs, and 17% of students report that they have used drugs.

Emotional Health

A significant minority of students, more than one in three, report they feel very unhappy at least once a week. When unhappy, most children are likely to talk to their friends (61%). The proportion who talk to their mother is 59% for elementary school students, 37% for junior high school students, and 36% for senior high school students. On average, more than one in four say they would talk to no one about a problem.

Thirty-five percent of students say they have not learned about personal feelings, and 24% of junior and senior high school students have not learned about stress. Most teachers (74%) feel a great deal of emphasis should be placed on the subject of personal feelings; 59% feel emphasis should be placed on the subject of stress.

In “Healthy Me” schools, 95% of teachers devote a lot of time to teaching about self-esteem; the percentage decreases to 85% of teachers in other schools.

Though peer pressure often is viewed negatively, in this survey 87% of students report that friends help them do what they should do. Only 52% do things they do not want to do because their friends are doing them.

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Curricular Emphases

Eighty-seven percent of students report they have learned about drinking, yet only 70% think it is important they do not drink alcohol. Eighty-nine percent of students have learned about smoking; a somewhat lower 79% consider it important not to smoke.

In ranking health topics of personal interest, 60% of students rank not being overweight very important; only 52% rank not drinking as very important.

Eighty-five percent of teachers recommend classroom emphasis on alcohol or drug abuse, though only 47% feel that not drinking alcohol is personally important to them.

Safety Issues

Only 32% of students say they always follow traffic regulations when riding a bicycle. Only 4% say they wear a helmet when riding a bicycle.

Among students of legal drinking age, 48% have driven after having one drink. Among junior and senior high school students, 67% have ridden with a driver who has been drinking.

Only 34% of studens say they always wear a seatbelt in the front seat of an automobile.

AIDS Prevention

Many students are misinformed about the risks of safe behaviors. Three of 10 students believe not sharing a bathroom with an AIDS patient reduces their risk of getting AIDS, and 13% think not being in a classroom with someone who has AIDS reduces the risk.

Students in “Healthy Me” schools are more apt to be correct in recognizing risk-reducing behaviors. Of students with no health education, 81% identify taking drugs with needles as a risk; 92% of “Healthy Me” school students recognize this as a risk.


In identifying risk-reducing behaviors and AIDS, parents’ knowledge is more like that of students with no health education.

Federal Initiatives

During the past several years, the federal government also has recognized the need to develop public health programs emphasizing disease prevention and health promotion. Supporting what has been termed a second revolution in public health in the United States, the federal government in 1979 published the landmark report, Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention. The report noted the importance of health practices related to diet, exercise, alcohol and tobacco consumption, traffic safety, and medical screening in improving public health and identified five goals and 15 priority areas requiring action.

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Subsequently, the publication, Promoting Health/Preventing Disease: Objectives for the Nation specified 226 objectives within the 15 priority areas identified in Healthy People and set targets for their achievement. The 15 priority areas included high blood pressure control, family planning, pregnancy and infant health, immunization, sexually transmitted diseases, toxic agent control, occupational safety and health, accident prevention and injury control, fluoridation and dental health, surveillance and control of infectious diseases, smoking and health, misuse of alcohol and drugs, physical fitness and exercise, and control of stress and violent behavior. Objectives were specified for each of the 15 areas and substantial progress has been made toward achieving the objectives by 1990. Of the 226 public health objectives to be achieved by 1990, 67 objectives may be achieved either directly or indirectly through school-based initiatives, and substantial progress has been made toward achieving a number of goals for school-age youth.

In other developments at the federal level, a proposal was approved to establish a new Center for Chronic Diseases and Health Promotion as part of a reorganization for the Centers for Disease Control. Also, a new office of Comprehensive School Health Education within the U.S. Dept. of Education awaits final implementation. Both these changes reflect growing federal support for comprehensive school health programs.

As support for comprehensive school health programs gained momentum during the 1980s, increased attention was focused on planning and implementing quality programs and on demonstrating the effectiveness of such programs. During that period, research projects such as the School Health Program Evaluation demonstrated scientifically the benefits of quality health instruction. Some 3,000 fourth-seventh grade students in 1,071 classrooms from 20 states participated in an evaluation of four health education curricula. The evaluation determined that optimally 50 hours of health instruction was required annually to maximally influence student knowledge, attitude, and behavior. Such efforts have strengthened the case for a planned, sequential approach to comprehensive health education.

School health programs have been, and will continue to be, an important component of public health activity in the United States. Historically, school-based efforts in health instruction and health services contributed significantly to the control of communicable diseases. Today, school-based initiatives are focusing on a variety of contemporary health problems related to lifestyle and health behavior. Whether combating contagious diseases from the past, or the personal and social diseases of the present, school health programs contribute directly to public health by serving the current needs of school-age children. Since school-age children constitute some 25% of the American population, school health programs contribute both to the current and future health of the American public. Professionals in school health and public health remain committed to meeting the needs of children and adolescents, and a dialogue continues concerning how to best meet those needs.


American society includes a unique blend of some 250 million people representing virtually every religion, culture, nationality, and ethnic group. Based historically on the principles of private enterprise, the system emphasizes personal freedom and the rights and responsibilities of the individual. Yet, through a series of social and fiscal programs, society also provides a level of support for those in need. As the nature and scope of need continues to change, American society faces the challenge of maintaining an historical and philosophical devotion to individualism and private enterprise while assisting the needy.

The public health concerns currently confronting the United States, and the ultimate success of efforts to address those concerns, have implications for the entire world. The American experience can serve as one example for other nations as they plan to deal with increasing prosperity and the attendant social changes that inherently accompany such progress.