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Public Health and Education: Working Collaboratively Across Sectors to Improve High School Graduation as a Means to Eliminate Health Disparities
Policy Date: 11/9/2010
Policy Number: 20101
Public Health and Education: Working Collaboratively Across Sectors to Improve High School Graduation as a Means to Eliminate Health Disparities
APHA policy statement 2004-09: Promoting public health and education goals through coordinated school health programs1
APHA policy statement 2000-27: Encourage healthy behavior by adolescents2
APHA policy statement 94-18: Children with special health care needs under health care reform policy3
Health and education are inextricably intertwined, and a lack of education is one of the social determinants of poor health.4 Two of the overarching goals for the public health community in Healthy People, 2010,5 were to increase quality and years of healthy life and to eliminate health disparities. Current evidence suggests that improving graduation rates to reduce health disparities and improve health may be more cost-effective than investing only in medical interventions.6–8
High school graduates have better health and lower medical costs than high school dropouts do, and college graduates have even better health and lower medical costs than high school graduates do.6,9 Graduation from high school is associated with an increase in average lifespan of 6 to 9 years.10 Further, high school graduates are less likely to commit crimes,11 rely on government health care,12 or use public services such as food stamps or housing assistance13 and are more likely to raise healthier, better-educated children.14
Every school day, 7,000 students drop out of high school approximately 1.2 million students each year,15 with poor and minority students most at risk for dropping out. However, three fourths of minority students attend high poverty/high minority schools, whereas only one third of Whites attend high poverty/high minority schools.16 These high poverty/high minority schools often are in inadequate, rundown facilities,14,18 receive lower per-pupil spending allocations,17,19,20 have fewer advanced placement courses,17,21,22 have less credentialed and qualified teachers17,21,23 who are absent more often,16,17 experience higher teacher turnover,17,21,22 have larger class sizes,16,17 have less technology-assisted instruction,16 and lack school safety.16,24
The reasons that students drop out include both school and nonschool factors. The specific school factors that have been identified include lack of rigor in the curriculum; lack of teacher preparation, experience, and attendance; large class size; and lack of school safety16; as well as poor teacher–student relationships, absenteeism,25and lack of careful monitoring of student progress.25 For all grades, the lower the family income is, the higher absenteeism will be.27 Absenteeism is related to lower academic achievement and failure to graduate.25 The nonschool factors contributing to lower student achievement include poverty,17,18,21–23 lack of parent participation in schooling, low birth weight, lead poisoning, hunger and poor nutrition, lack of being read to, increased television watching, lack of parent availability, frequent residence and school changes,16 and health conditions that affect learning and attendance.6,27,28
Certain health conditions can directly affect cognitive function and reduce student achievement, including diabetes, sickle cell anemia, epilepsy,27 disabilities,17 lead poisoning, nutrition and hunger,16,29 and mental health problems.17 Health-risk behaviors such as substance use, violence, and physical inactivity are consistently linked to academic failure and often affect students’ school attendance, grades, test scores, and ability to pay attention in class. Adolescent students who are engaging in health risk behaviors are more likely to receive grades of “Ds” and “Fs” in school.30 Further, exposure to adverse childhood traumatic stressors substantially increases the likelihood of initiating risky, unhealthy behaviors during early adolescence. Specifically, exposure to adverse childhood events such as abuse, neglect, and family dysfunction are strongly associated with early initiation of smoking,31 alcohol use,32 illicit drug use,33 sexual intercourse,34 adolescent pregnancies,35 and adolescent suicide attempts.36
Lack of access to health care, including preventive health care, is a major issue for low-income students.37 Lack of care for a health problem can directly influence attendance rates and ultimately affect passing a course or passing to the next grade.
Early childhood education programs for low-income children that address health needs as well as developmental needs, including programs such as public health nurses’ visiting fist-time mothers38 and head start,39 provide long-term benefits.38–42 These benefits include fewer referrals for remedial classes or special education in K–12, less absenteeism, fewer retentions in grade school, higher grades, higher graduation rates, and increased attendance in postsecondary education.40,41 These benefits provide some protection against high-risk behaviors in adolescence, including a lower incidence of unplanned pregnancies, drug abuse, and delinquent acts.39
School health programs are increasingly recognized as vital players in children’s health,43 particularly for low-income students without a medical home. Further, emerging evidence demonstrates that the various components of a high-quality school health program have the potential to increase academic achievement, including nutrition services, health services, physical education, parent involvement, counseling and psychological services, a healthy school environment,44–46 and health education44–47 (particularly instruction in personal and social skills).47 Some schools providing medical services in conjunction with other important services (e.g., mentoring, tutoring) have reduced absenteeism,48 drop-out rates,48–51 and behavioral problems52 and raised students’ grade point averages48 and graduation rates.48 Having a full-time school nurse in the school has been shown to improve attendance of poor and minority students.53 A decrease in rescue treatments for asthma has been shown when a school-based asthma intervention was implemented.51,52
When education and health sectors have been linked in initiatives such as a school-based clinic,53 full-service schools,54 community schools,55 or educational improvement initiatives that include health services,56 health, academic, or school outcomes for students have improved,
Linking health and education resources at the state level through interagency collaboration, such as children’s cabinets addressing state policy, or at the local level through child-integrated data system such as Philadelphia’s Kids Integrated Data System57 allows state and local planners to be targeted in continuous efforts to improve the health, education, and well-being of children
Therefore, be it resolved that the American Public Health Association increase the public’s awareness of the factors that contribute to the achievement gap and health disparities, as well as the solutions that decrease education inequities, improve graduation rates, and improve health for all students, especially poor and minority students. Therefore, the American Public Health Association—
1. Urges local health departments to collaborate with local education agencies and other community agencies to improve high school graduation rates as a means to reduce health disparities by linking school health and community health services, as well as linking community health databases and school indicator databases.
2. Encourages local health departments and local education agencies to establish school health coordinating councils that engage families and representatives from other community agencies, including faith-based organizations, businesses, and mental health and health care organizations to collaboratively promote the health, well-being, and achievement of children and youth by engaging in a process of continuous improvement, including linking community health databases and school indicator databases.
3. Encourages local health departments and local education agencies to establish school health teams at all schools, particularly high poverty schools, to engage families, students, and representatives from other community agencies, including faith-based organizations, business, and service clubs, to collaboratively promote the health, well-being, and achievement of children and youth in their neighborhood.
4. Encourages state health departments and state education agencies to establish interagency collaborating councils (children’s cabinets) that engage representatives from other state agencies, including state parent–teacher organizations, professional health associations, voluntary health associations, faith-based organizations, businesses, and mental health and health care organizations to collaboratively promote the health, well-being, and achievement of state’s children and youth through policy, resources, and data tracking systems that can serve to coordinate systems of continuous improvement.
5. Encourages state coordinating councils, local coordinating councils, and other community agencies, such as postsecondary institutions, to—
• Document and disseminate information about the link between education and health58
• Promote evidence-based early interventions for low-income families that address health needs as well as growth and development needs such as participating in early childhood education programs39 and public health nurses’ providing home visits first-time mothers from the prenatal period to age 2.38,39
• Link early childhood programs with K–12 standards and programming to ensure school readiness
• Promote high-quality schooling as a means to reduce health disparities4,28 by supporting the equitable allocation of educational resources communitywide
• Encourage the implementation of those health interventions that may contribute to improved school completion rates, including provision of a high-quality school health program,7,28 school-based clinic, mental health programs, substance abuse prevention and treatment programs, HIV infection and pregnancy prevention programs, services for pregnant and parenting girls, violence prevention programs, and school climate improvement programs,7,28 and ensure access to appropriate supporting staff, such as school counselors, social workers, and nurses59
• Encourage efforts to promote school wellness by increasing participation in US Department of Agriculture’s child nutrition programs in school, after school, and summer settings; adhere to guidelines for healthy competitive (a la carte) foods; and promote high-quality physical education, opportunities for classroom physical activities throughout the school day, and annual fitness testing for grades 4–12
• Encourage schools to incorporate lessons in workplace health and safety as part of the high school curriculum, such as the California Resource Network for Young Workers and the Washington State Department of Labor and Industries Teen Workers program (e.g., www. Youngworkers.org, www.teenworkers.lni.wa.gov)
• Implement community schools initiatives that ensure that students from vulnerable communities have access to health care services and equitable educational resources55
• Support after-school programs that promote student success and well-being
6. Supports high-quality early childhood programs, particularly for vulnerable children; high-quality school health programs, including a medical, mental health, vision and eye health, and dental home to increase children’s access to healthcare and school health and community programs that reduce health risk behaviors and increase health enhancing behaviors
7. Encourages both education and public health professional associations to collaborate at the national, state, and local levels to address improving high school graduation rates as both an education and public health priority
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2. American Public Health Association. APHA policy statement 2000-27: Encourage healthy behavior by adolescents. Washington, DC: American Public Health Association; 2000. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=234. Accessed January 31, 2011.
3. American Public Health Association. APHA policy statement 94-18: Children with Special Health Care Needs under Health Care Reform Policy. Washington, DC: American Public Health Association; 1994. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=84. Accessed January 31, 2011.
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