Healthier Students are Better Learners: Building a research strategy and agenda for improving health and K-12 education outcomes No matter what improvements are made in … read mater off slide ... The educational benefits to students will be limited if they are not motivated and able to learn. Charles E. Basch

Strategies to Improve Educational Outcomes Standards and accountability Revising school financing Teacher preparation Rigorous curricula Charter schools Reducing educationally relevant health disparities

Reciprocal Relationships Health Education Poverty There are reciprocal causal relationships between children’s health educational attainments and underlying economic and social conditions. The focus today is on how certain health problems influence academic achievement and educational attainment.

Criteria for Selecting Strategic Priorities Extent of health disparities Causal effects on educational outcomes Feasibility of school-based programs and policies School can’t address all health problems. Leaders need a way to prioritize. In my work, I have used three criteria to establish priorities: read 3 criteria on slide.

8 Priority, Educationally Relevant Health Factors Vision Asthma Teen pregnancy Aggression and violence Physical activity Breakfast ADHD Oral health problems Based on these criteria, there are 8 health problems that warrant consideration as priorities. Further, mental and emotional health must be addressed thematically since it is a cause and/or consequence of all the other problems. This list is not meant to say that every school must address all of these problems, or that other problems not included on this list may not be priorities. The intent is that, based on the criteria outlined previously, these health problems warrant consideration as priorities.

Mental and Emotional Health … cause and/or consequence of each health issue And students who are affected by one problem are also more likely to be affected by others, which is why it’s so important for school based initiatives to focus on multiple problems simultaneously

High Prevalence Visual problems: ~20% of low-income youth Asthma: ~13% of youth <18 Teen pregnancy: 6% of 15 to 19 year-olds annually Violence: 20% of high school students bullied at school annually Physical activity: ~2 in 3 don’t get enough Breakfast: ~14% of high school students skip it ADHD: ~12.2% of 12-17 year-olds diagnosed Untreated caries: 23% of 2- to 11-year-olds olds Read material on slide. Then note that all of these health problems disproportionately affect low-income urban minority youth.

Rates of Visual Impairment in US Among Persons Age 12 and Above, by Race/Ethnicity and Income Compared with whites, Blacks and Hispanics high higher rates of visual impairment. People with low-come have higher rates as well. *Income below poverty level; **Income >2X poverty level Source: NHANES 1999-2002

Asthma Prevalence for Youth in US, Ages 5 – 14, by Race/Ethnicity For youth aged 5-14, compared with whites, the prevalence of asthma for Blacks is twice as high (18.8% versus 9.4%). The last two bars in the histogram indicate the importance of disaggregating the Hispanic population. These same disparities exist for poorly controlled asthma, as indicated by overuse of emergency departments for asthma care and underuse of efficacious medications. Source: CDC, National Surveillance of Asthma: US, 2008 - 2010

Birth Rates Per 1,000 Among 15 – 17 Year Olds in US, by Race/Ethnicity 21.9 Percent 8.4 While teen birth rates have declined dramatically over the past several decades, the U.S. still has high teen birth rates compared with many other nations. Source: National Vital Statistics Reports, 2012

Percentage of High School Students in US Who Were in a Physical Fight, Percentage of High School Students in US Who Were in a Physical Fight,* by Race/Ethnicity** 34.7 28.4 20.9 Percent These data, which are nationally representative of high school students in the U.S. show that, compared with white high school students, Black and Hispanic high school students are considerably more likely to have been in a physical fight during the 12 months preceding the YRBD survey, which is conducted biennially by the U.S. Centers for Disease Control and Prevention. *One or more times during the 12 months before the survey. ** B > H > W Source: CDC, National Youth Risk Behavior Survey, 2013

Percentage of High School Students in US Who Did Not Go to School Because They Felt Unsafe at School or On Their Way to or From School,* by Race/Ethnicity** 7.9 Percent 5.6 This slide show the percentage of high school students that have missed one or more days of school in the past 30 days, and indicates that almost 1 in 10 Hispanic high school students report that they have missed one or more days of school in the past month because they felt unsafe at school or traveling to or from school. We have made very little progress in changing this metric. *On at least 1 day during the 30 days before the survey. **H >B > W Source: CDC, National Youth Risk Behavior Survey, 2013

Percentage of Female High School Students in US Who Did Not Participate in Physical Activity,* by Race/Ethnicity** 27.3 20.3 16.1 Percent Compared with white female high school students, almost 70% more Black female high school students and over 25% more Hispanic female high school students did not participate in in physical activity (for 60 minutes on at least 1 day during the 7 days before being surveyed). *Did not participate in 60 or more minutes of any kind of physical activity that increased their heart rate and made them breathe hard some of the time on at least 1 day during the 7 days before the survey **B > H > W Source: CDC, National Youth Risk Behavior Survey, 2013

Percentage of White and Black Girls Who Consumed Breakfast on All 3 Days Assessed At Age 9 This slide, based on the NHLBI longitudinal Growth and Health Survey, shows that, while 77% of white 9 year-old children consumed breakfast on all 3 days assess, only 57% of black children did so. The proportion of both white and Black children who consumed breakfast on all 3 days assessed declined in both groups. Nevertheless, compared with white children, a lower proportion of Black children consumed breakfast on all 3 days assessed. Note that while the absolute differences between white youth and black youth decline as youth grow older (from 20 percentage points to 10 percentage points), the relative differences between whites and Blacks increased. Source: NHLBI, Longitudinal Growth and Health Survey; n = 1166 white and 1213 black girls

Prevalence of ADHD Among 3 -17 Year Olds in US, by Family Status and Income 12.4 11.7 8.8 8.3 Percent Compared with youth in families with both parents and with higher incomes, youth in single mother families and in families with household income < $35,000 have higher rates of ADHD. Source: National Health Interview Survey, 2012

Prevalence of Sealants on Permanent Teeth Among Youth 6 -11 Years of Age, 1999 - 2004 40.1 36.1 24.2 21.3 20.9 % with Sealants These same patterns are seen with respect to sealants on permanent teeth among youth aged 6 to 11. Source: CDC, Vital Statistics, April 2007. Trends in Oral Health Status: United States, 1988 – 1994 and 1999 - 2004

Causal Pathways Sensory perceptions Cognition School connectedness and engagement Absenteeism Temporary or permanent dropping out There are at least 5 causal pathways through which health problems affect educational outcomes. … Read list and comment on each…

Inattention & Hyperactivity Slide 18 Visual Problems Inattention & Hyperactivity Sensory Perceptions Educational Outcomes Give examples based on research of how each health problem affects the causal pathway

Inattention & Hyperactivity Slide 19 Visual Problems Asthma Aggression & Violence Physical Activity Breakfast Inattention & Hyperactivity Oral Health Problems Cognition Educational Outcomes Give examples based on research of how each health problem affects the causal pathway

Inattention & Hyperactivity Slide 20 Visual Problems Asthma Aggression & Violence Physical Activity Inattention & Hyperactivity Oral Health Problems Educational Outcomes Connectedness Give examples based on research of how each health problem affects the causal pathway

Inattention & Hyperactivity Slide 21 Asthma Aggression & Violence Physical Activity Inattention & Hyperactivity Oral Health Problems Educational Outcomes Breakfast Absenteeism Give examples based on research of how each health problem affects the causal pathway

Inattention & Hyperactivity Slide 22 Teen Pregnancy Inattention & Hyperactivity Dropping Out of School Educational Outcomes Give examples based on research of how each health problem affects the causal pathway

Synergistic Effects And students who are affected by one problem are also more likely to be affected by others, which is why it’s so important for school based initiatives to focus on multiple problems simultaneously

Our Children Are NOT Served Well by the Silo Approach SOCIAL SERVICES In too many cases, funding streams, policies, programs and services are in silos. And there are even silos with siloes. This does not serve students well. HEALTH EDUCATION

Silos Within Each Silo Funding Policies Programs Personnel

Limited Returns on Investments of Social Resources Efforts are not strategically planned Poor quality programs Efforts are not effectively coordinated But most efforts appear to be insufficiently financed, are not strategically planned, in too many instances in the past have relied on programs with no evidence of effectiveness, and are not coordinated effectively.

Strategies for Supporting School Efforts to Address Priority Health Disparities Communication Policy mandates and accountability Financial support Guidance, technical assistance, and professional development Research There are many examples of policies that can help … read material on slide

Policy Development Integrate health-related measures into accountability systems for school improvement efforts…if we don’t measure it, it must not be important Augment early warning systems with health information Include health data on school “report cards” There are many examples of policies that can help … read material on slide

Research Develop a national research agenda to put into practice what we already know Determine ways to cultivate political will among elected officials and educational stakeholders to address persistent health barriers to learning Conduct cluster randomized trials of strategic, high quality, effectively coordinated programs versus categorical efforts Identify existing health and education data systems to inform research, policy and practice, and gaps in data While we will always need research to produce new discoveries, what we need now is research to put into practice what we already know.

Research Assess workforce preparedness to address health priorities Evaluate effects of health policies (e.g., school discipline) Develop reliable, valid and practical measures of social- emotional and self-regulation skills, grit, collaboration, and school connectedness for young children Build consensus around metrics that warrant inclusion in education accountability structures While we will always need research to produce new discoveries, what we need now is research to put into practice what we already know.

Research (continued) What are school and community (neighborhood) characteristics that help students learn and practice health behaviors that increase their odds for learning and achievement? While we will always need research to produce new discoveries, what we need now is research to put into practice what we already know.

Slide 32 While there is a tremendous need, this is an opportune time for school health.