Addressing social determinants to ensure on-time graduation

Abstract

Over the years, APHA has addressed many systemic barriers to on-time high school graduation through various policy positions, including working collaboratively with the education sector to improve high school graduation as a means of eliminating health disparities, promoting the need for coordinated school health programs, and advocating for reductions in violence. A gap remains, however, in integrating social inequity and place-based inequities to break the cycle of failure and ensure on-time high school graduation. This policy statement addresses the social determinants that affect on-time graduation. Educational attainment is a leading social determinant of health (and economic viability), yet analyses of place-based statistics indicate that other social determinants such as housing and employment, food security, access to health care, neighborhood and built environment characteristics, and violence are also significant factors in on-time graduation rates. While a deficit in any single determinant is not the cause of high dropout rates, a combination of factors contributes to the end result. Barriers preventing individuals and communities from reaching their full potential create inequities. The aim is to achieve both health and educational equity, especially among low-income African Americans, Hispanic Americans, American Indians, Native Hawaiians, Alaska Natives, and immigrants (in particular, refugees), and reach healthiest nation status by ensuring that all students graduate from high school.

Relationship to Existing APHA Policy Statements

• APHA Policy Statement 20101: Public Health and Education: Working Collaboratively Across Sectors to Improve High School Graduation as a Means to Eliminate Health Disparities
• APHA Policy Statement 20142: Reduction of Bullying to Address Health Disparities among LGBT Youth
• APHA Policy Statement 20049: Promoting Public Health and Education Goals through Coordinated School Health Programs
• APHA Policy Statement 9508: Full Employment and Public Health
• APHA Policy Statement 20131: Endorsing Caring for Our Children: National Health and Safety Performance Standards: Guidelines for Early Care and Education Programs, Third Edition
• APHA Policy Statement 20121: Supporting the National Physical Activity Plan
• APHA Policy Statement 9708: Minimizing Adverse Public Health Consequences of the 1996 Welfare Reform Act
• APHA Policy Statement 200027: Encouraging Healthy Behavior by Adolescents
• APHA Policy Statement 8705: Expansion and Funding of Comprehensive School-Based Clinics
• APHA Policy Statement 7905: Health of School-Age Children
• APHA Policy Statement 201415: Support for Social Determinants of Behavioral Health and Pathways for Integrated and Better Public Health
• APHA Policy Statement 201013: American Public Health Association Child Health Policy for the United States
• APHA Policy Statement 20137: Improving Health and Wellness through Access to Nature
• APHA Policy Statement 200914: Building Public Health Infrastructure for Youth Violence Prevention
• APHA Policy Statement 201210: Promoting Health Impact Assessment to Achieve Health in All Policies
• APHA Policy Statement 9718(PP): Supporting a National Priority to Eliminate Homelessness

Problem Statement

Both Healthy People 2020 and the Community Preventive Services Task Force have identified on-time graduation from high school as a leading health indicator or social determinant of health.[1–3] As noted in APHA Policy 20101 (Public Health and Education: Working Collaboratively Across Sectors to Improve High School Graduation as a Means to Eliminate Health Disparities): “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.[4,5] Graduation from high school is associated with an increase in average lifespan of 6 to 9 years.[6] Further, high school graduates are less likely to commit crimes,[7] rely on government health care,[8] or use public services such as food stamps or housing assistance[9] and are more likely to raise healthier, better-educated children.”[10]

Although APHA already has in place statements that call for collaboration between the public health and education sectors, those statements do not address more systemic issues such as poverty, affordable housing, structural racism, and the “school to prison pipeline,” all of which contribute to school dropout. According to one study, 58.4% of the relative influence on student learning is attributable to the home environment, parental support, community socioeconomic level, and community influences.[11] Making a real difference in achieving on-time high school graduation requires addressing inputs (i.e., what students bring into the classroom as well as what happens in school) rather than simply assessing outputs (what students achieve)[12]; namely, a broader reach and a more systemic approach are needed.

More than a third of African American, Latino, and American Indian students in the United States do not graduate from high school on time.[13,14] African American and Hispanic youths are still more than 16 percentage points away from the Healthy People 2020 graduation target of 82.4%, lagging behind their Caucasian peers by more than 10%.[14] The rate among Native Americans is even lower.[15] These disparities begin as early as the womb, with African Americans much more likely than others to be born with a low birthweight, which has lifelong consequences for success.[12] The importance of addressing such disparities at a young age is the rationale for the American Academy of Pediatrics recommendation that pediatricians “screen for risk factors within social determinants of health during patient encounters.”[16]

Charles Basch has identified health issues that affect academic outcomes. These issues include unmet health needs (e.g., relating to vision and asthma), teenage pregnancy, hunger, lack of physical activity, and chronic stress and trauma caused by living in conditions of poverty and by exposure to aggression and violence. Each of these health issues disproportionately affects low-income, urban minority youths as measured by incidence, prevalence, and educationally relevant consequences.[17] Rates of diagnosed inattention and hyperactivity, as well as other inappropriate social behaviors that often result in a mental health diagnosis and/or school removal, are much higher among urban minority youths than among their peers in other groups.[13,17]

Analyses of place-based statistics indicate that social determinants of health such as housing, income, food security, access to health care, neighborhood and built environment characteristics, and violence are also significant determinants of on-time graduation rates.[2,3,12–14,17] Most of those who drop out of school live in high-poverty communities and attend schools with high concentrations of other disadvantaged minority students. Child poverty rates among Latinos (29%) and African Americans (29%) are approximately three times the rate among Caucasians (10%).[18,19] In California, rates of poverty are highest among Hmong and Cambodian children (42% and 33%, respectively), slightly higher than their Black and Latino counterparts.[20] In more than 20 cities, at least three quarters of students attend schools where fewer than 60% of students graduate on time.[14] While a deficit in any one area does not predict high school dropout, a combination of these factors contributes to the end result.

The effects of poverty on cognitive, language, and socioemotional skills are evident as early as the age of 3 years, with wider gaps at kindergarten and increasing gaps each year of schooling among African American children.[19] Poverty contributes to the stated reasons a large number of young people offer for dropping out of school, such as family financial worries, out-of-school employment, caregiving needs, family instability, and teen pregnancies.[21] According to the National Center for Education Statistics, 41% of boys drop out of school to get a job and approximately 33% of girls drop out as a result of becoming a parent.[22]

While poverty clearly plays a strong role in on-time graduation rates, a body of evidence shows that structural racism is also a factor. Structural racism contributes to inequities in school disciplinary practices, housing security, food security, economic stability, violence, access to health care, and school resource levels.[18,22–26] Inequities in school disciplinary practices lead to “pushing students out.” The Civil Rights Data Collection, conducted by the US Department of Education’s Office of Civil Rights, showed that African American students are suspended or expelled more than three times as often as their peers who are Caucasian. Disparities in discipline begin in preschool, with African Americans comprising 42% of students with an out-of-school suspension and 48% of students with multiple out-of-school suspensions even though they account for only 18% of the preschool population.[12,21,22] In addition, more than 50% of students who are involved in school-related arrests or referred to law enforcement by school authorities are Hispanic or African American.[12,21,22]

Thus, Hispanic and African American students are losing important instructional time due to exclusionary disciplinary practices, leading to their falling behind academically and giving up. A correlation exists between exclusionary discipline policies and practices and an array of educational, economic, and social problems including school avoidance and diminished educational engagement, decreased academic achievement, increased behavior problems, an increased likelihood of dropping out, substance abuse, and involvement with juvenile justice systems.[12,21–23]

Other issues that contribute to high school dropout and that stem from living in high-poverty areas and/or areas with structural racism are housing insecurity, food insecurity, economic instability, violence, lack of access to health care, and underresourced schools.[12,18,23] In most US cities, “redlining,” a pattern of discriminatory housing practices that began in the 1930s and continued through 1968, created highly segregated neighborhoods. African American children are more likely to live in households that are extremely poor, are food insecure, or receive long-term welfare support. African American children are less likely than Caucasian or Hispanic children to live in households where at least one parent has secure employment, and rates of homelessness are highest among these children. Nearly 25% of African American parents, as compared with 7% of Caucasian parents, report that their children live in unsafe neighborhoods.[18,23–25]

Segregation related to poverty and race has created a system of unequal schools. Schools in high-poverty, predominantly African American and Hispanic neighborhoods receive on average $902 less per pupil[18] because of a lower property tax base. As a consequence, these schools cannot provide educational opportunities comparable to those offered in affluent communities with a higher tax base.[23,26] Nor can they spend as much on cleaning, routine maintenance, or even land acquisition. The poorest children often attend the facilities that are in the poorest condition and that pose the greatest threats to health because of inadequate maintenance or siting near hazards such as highways, waste transfer stations, or industrial facilities.[27] Poor air quality is a major contributor to asthma, the cause of 10.5 million missed school days each year and, in fact, the greatest cause of school absenteeism due to illness.[28] Lost school days result in students falling behind academically and becoming at risk for dropping out altogether.

Thus, improving on-time high school graduation rates requires working collaboratively across sectors to implement policies that address social and place-based inequities.[12,29,30]

Opposing Arguments

Many US residents believe that structural racism no longer exists, as evidenced by a Wall Street Journal editorial published just after the racially motivated shooting that killed nine members of a historically Black church in Charleston, South Carolina; according to that editorial, “Today the system and philosophy of institutionalized racism identified by Dr. King no longer exists.”[31] While the Wall Street Journal’s editorial provides no evidence base, detractors studying actions intended to end structural racism (e.g., school integration and increased funding targeted to underresourced schools) have attempted to make an evidence-based case against those actions.[18,26] Early data from the beginning of school integration revealed little, no, or a negative impact on the achievement of minority students.[26] However, more recent research has disproven those findings and led to a theory of “stereotype threat” that accounts for lowered achievement in situations in which minorities perceive negative stereotypes attributed to them.[26,32,33]

Some studies have suggested that increased funding to underresourced schools did little to improve the academic achievement of students. A meta-analytic study assessing the effects of school resources on student performance showed that achievement is more dependent on how money is spent than on how much is spent.[34] Another finding of that investigation, however, was that many nonschool factors were confounding variables and probably negated some of the effects of school resources. This study provides support for a coordinated approach addressing multiple determinants, including food access and health coupled with increased resources, to improve academic success.[1,2,18,19,30]

The federal No Child Left Behind legislation used vouchers and charter schools to punish low-performing schools. The assumption was that if parents had choices, they would use market forces to improve the schools their children attended. Some students did perform better when they exercised school choice. That success, however, reinforces the need for a comprehensive approach. Regardless of family income, students attending schools where a majority of students were from low-income families performed more poorly.[12] Parental engagement is another predictor of achievement, and students opting for school choice almost by definition have engaged families.[11,12,21]

Evidence-Based Strategies to Address the Problem

The integration of a comprehensive set of policies aimed at addressing social inequity and place-based inequities will require multiple approaches. For example, Berliner concluded that improving educational outcomes in schools serving disadvantaged communities will require policies addressing out-of-school factors that negatively affect students: “Poverty limits student potential; inputs to schools affect outputs from them.”[12] Berliner suggested that the following out-of-school factors significantly affect school success:

• Low birthweight
• Drug or alcohol abuse (a risk factor for low birthweight and for failure as a student)
• Exposure to pollutants and toxins
• Lack of medical care
• Food insecurity
• Family violence, especially in low-income neighborhoods
• Poor mental health
• Concentrated low-income housing
• Children’s mobility and absenteeism rates
• Lack of a high-quality preschool
• Summer losses in academic achievement that are greater among those in underresourced communities and impoverished families

Poverty and structural racism underlie most of these factors.

Equity in all policies: Addressing social determinants of health through a cross-sectoral approach can prevent chronic disease[29,35,36] and has led to advocacy for “health in all policies.” Evidence suggests the same for approaches designed to increase on-time high school graduation rates,[12] so perhaps a focus on “equity in all policies” would serve to improve both health and educational outcomes. Addressing the interrelationships among poverty, racism, and school dropout requires collaboration among sectors.[13,18,28,35] A comprehensive set of policies at the school, district, and state levels that address social and place-based inequities can ensure on-time high school graduation and break the poverty cycle.[12–14,18,25,29,35–37]

Neighborhood/housing integration: Inclusionary zoning practices increase affordable housing because they require mixed-income development,[25] thus reducing the concentration of poverty in a school community. Such practices also tend to reduce exposure to pollutants, because those with more political capital are affected when polluting industries or toxic dumps are proposed for an area.[12,27,28]

Equitable resources: Although resources alone do not predict academic success, poorly resourced schools often have difficulty recruiting and retaining effective teachers and providing the support that disadvantaged students need to succeed.[3] School financing policies tend to increase inequities because of an overreliance on property taxes, which do not generate enough funds for schools in high-poverty communities to provide the same educational opportunities as those in affluent communities with a higher tax base.[18,23,25] On average (as noted), schools in poor, urban districts receive $902 per pupil less than schools in more affluent areas[14] because of differences in property tax income, which is the primary funding mechanism for schools in most states. Equitable resources include access to the quality and quantity of resources available in other schools as well as well-qualified, experienced teachers and other staff. When high-poverty and high-minority schools have access to the same resources as other schools, the achievement gap narrows.[14,25] Health services in schools: High-quality early education programs, such as Head Start, and full-day preschool programs can narrow gaps in school readiness and later achievement among minority and disadvantaged children.[12] School-based health services and behavioral health support starting in kindergarten and continuing through 12th grade can address the social and emotional effects of poverty on learning, behavior, and health,[12,17] and school-based health centers can reduce dropout rates in high schools serving disadvantaged and minority youths.[38]

Young people in low-income, minority communities are at increased risk of experiencing or witnessing violence and other traumatic events,[12,17,39,40] and trauma-informed care approaches have been shown to improve academic performance among students in these communities.[41–43] Access to food and physical activity in schools: The National Center for Chronic Disease Prevention and Health Promotion has established clear evidence of the importance of access to food and physical activity for students.[44] School breakfasts, snacks, and access to fresh fruits and vegetables can improve cognitive functioning and/or increase academic performance among low-income students.[45–47] Physical activity is associated with better grades, better attendance, and better behavior.[48] School discipline policies and the “school to prison pipeline”: Prevention and intervention programs such as in-school suspensions are far more effective than out-of-school suspensions and expulsions with respect to keeping students in school. Furthermore, prevention and intervention are more cost effective than funneling youths into the juvenile justice system.[43,49]

Action Steps

Improving on-time graduation rates requires a cross-sectoral approach that addresses multiple social determinants of health. As noted in the National Prevention Strategy,[35] the field of public health shares the responsibility for the nation’s health with many other sectors. A similar approach is necessary with respect to increasing on-time high school graduation rates. APHA proposes that:

• Researchers include per pupil spending, educational attainment, and other indicators of school resources and effectiveness in measures of community health.
• Planning bodies adopt inclusionary zoning practices that reduce concentrated poverty and ensure affordable and adequate housing for all.
• School boards, parents, and community members monitor and evaluate implementation of the reauthorized Elementary and Secondary Education Act[50] at the local level to ensure equity in school resources, health services, healthy food access, and educator training across communities and to ensure that quality health education and adequate physical education are core school components.
• School food services staff, school administrators, and families ensure that foods available as part of school meals and competitive foods meet guidelines for healthy food and beverages and provide backpacks of food over weekends and school holidays for those who are food insecure.
• Schools working with health care providers, insurers, and civic leaders ensure that physical and mental health services are available in schools, especially in the communities most in need, and that they include trauma-informed approaches as appropriate.
• School administrators and teachers use alternative disciplinary strategies that eliminate or reduce out-of-school suspensions and expulsions, thus keeping students in a learning environment.
• As specified, the action steps recommended in APHA Policy 20101 (Public Health and Education: Working Collaboratively Across Sectors to Improve High School Graduation as a Means to Eliminate Health Disparities) be fully implemented.
• Citizens advocate for year-round, universal school breakfast, lunch, and snack or dinner funding, especially in schools with high proportions of students receiving subsidized meals; increased federal, state, and local funding to ensure equity in the quality and quantity of resources at all schools; and school funding that does not discriminate against poorly resourced communities by relying on property taxes.
• Public health, education, and civic leaders include multiple sectors such as education, employment, housing, and criminal justice in coalitions seeking to improve health through educational attainment.

These actions can help ensure that all students graduate from high school and thus further health equity.

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