Healthy Schools = Healthy Kids = Learning Better OR What is the relationship between school health policy and learning? Julia Dilley PhD MES Washington

Healthy Schools = Healthy Kids = Learning BetterHealthy Schools = Healthy Kids = Learning Better

OROR

What is the relationship between school What is the relationship between school

health policy and learning?health policy and learning?

Julia Dilley PhD MESJulia Dilley PhD MESWashington State - Healthy Schools SummitWashington State - Healthy Schools Summit

May 2008May 2008

? ?

22

ObjectivesObjectives

Increase skills for: Increase skills for: Using WA Healthy Youth Survey to Using WA Healthy Youth Survey to

describe “healthy students”describe “healthy students” Using WA School Health Profile data to Using WA School Health Profile data to

describe “healthy schools”describe “healthy schools” Describing association between academic Describing association between academic

achievement & healthachievement & health Describing association between school Describing association between school

health policies and student healthhealth policies and student health

33

BackgroundBackground

From an ongoing project to merge From an ongoing project to merge Washington’s student-level health data Washington’s student-level health data and school-level policy dataand school-level policy data Some results are preliminary Some results are preliminary

44

Theoretical ModelTheoretical Model

Students Learn Better

Students exhibit more healthy behaviors

Pro-health school policies, procedures & environments

School health programs

55






What are importanthealth conditions?

Who is at risk?

66

Washington State’s Washington State’s Healthy Youth SurveyHealthy Youth Survey

77

Healthy Youth Survey Healthy Youth Survey (HYS)(HYS)

Paper-based questionnaire given to 6Paper-based questionnaire given to 6 thth, 8, 8thth, 10, 10thth & 12& 12thth graders in fall of even years graders in fall of even years

Asks questions about Asks questions about Risk & protective factorsRisk & protective factors Alcohol, drug & tobacco useAlcohol, drug & tobacco use Health statusHealth status

Next survey is Fall 2008:Next survey is Fall 2008: Visit Visit www.hys.wa.gov for materials, recruitment for materials, recruitment

information, reports, link to online data analysisinformation, reports, link to online data analysis Schools need to register by June 30 (it’s free)Schools need to register by June 30 (it’s free)

88

Health Indicators of InterestHealth Indicators of Interest

1.1. Smoking cigarettesSmoking cigarettes2.2. Using alcoholUsing alcohol3.3. Using marijuanaUsing marijuana4.4. Obesity Obesity 5.5. Severe asthmaSevere asthma6.6. Poor nutrition: not eating breakfastPoor nutrition: not eating breakfast7.7. Poor nutrition: not enough fruit & vegPoor nutrition: not enough fruit & veg8.8. Poor nutrition: 2+ soda pop per dayPoor nutrition: 2+ soda pop per day9.9. Sedentary lifestyle: Insufficient exerciseSedentary lifestyle: Insufficient exercise10.10. Sedentary lifestyle: 3+ hours TV per daySedentary lifestyle: 3+ hours TV per day11.11. Feeling unsafe at schoolFeeling unsafe at school12.12. Mental distress/depressionMental distress/depression13.13. Insufficient (<8 hours) sleep per nightInsufficient (<8 hours) sleep per night

99

Prevalence of Risk FactorsPrevalence of Risk Factors2006 WA Healthy Youth Survey 2006 WA Healthy Youth Survey 88thth grade grade 1010thth grade grade

SmokingSmoking 6%6% 14%14%

AlcoholAlcohol 17%17% 33%33%

MarijuanaMarijuana 7%7% 17%17%

ObesityObesity 10%10% 10%10%

Severe asthmaSevere asthma 0.3%0.3% 0.4%0.4%

No breakfastNo breakfast 34%34% 39%39%

Insufficient Fruit & VegInsufficient Fruit & Veg 71%71% 75%75%

Soda popSoda pop 16%16% 17%17%

Insufficient exerciseInsufficient exercise 18%18% 25%25%

Too much TVToo much TV 31%31% 28%28%

Feeling unsafe at schoolFeeling unsafe at school 18%18% 17%17%

Mental distressMental distress 24%24% 28%28%

Insufficient sleepInsufficient sleep 43%43% 65%65%

1010

Health Indicator TrendsHealth Indicator Trends

Most health status indicators are fairly Most health status indicators are fairly stablestable

Smoking & marijuana have decreased in Smoking & marijuana have decreased in recent yearsrecent years

Obesity has increased in recent yearsObesity has increased in recent years Local trends may be different – see your Local trends may be different – see your

own reportsown reports

1111

Health Disparities: SmokingHealth Disparities: Smoking

Cigarette Smoking by Race/Ethnicity

13.4%

6.6%

19.5%

14.4%11.6%

13.0%

0%

10%

20%

30%

White,non-

Hispanic

Asian NativeAmerican

Black/Af.Amer.

Hispanic/Latino

Nativ.Haw /Pac Isl.S

mo

ked

Cig

aret

tes

in P

ast

Mo

nth

*

**

Source: 2006 Healthy Youth Survey, state sample only grades 8-10-12 combined.

1212

Health Disparities: SmokingHealth Disparities: SmokingMaternal Education and Smoking

21.7

16.4

10.8

0

10

20

30

< HS HS graduate College +

% 1

0th

gra

der

s

smoking

Source: 2006 Healthy Youth Survey, full dataset, 10th grade

1313

Health Disparities: Feeling UnsafeHealth Disparities: Feeling Unsafe

Feel Unsafe at School by Race/Ethnicity

17.1%19.1%

25.0%

29.5%26.6%

23.6%

0%

10%

20%

30%

White, non-Hispanic


Black/Af.Amer.

Hispanic/Latino

Nativ.Haw /Pac Isl.

Fee

l U

nsa

fe a

t S

cho

ol

* * **


1414

Health Disparities: Feeling UnsafeHealth Disparities: Feeling Unsafe


Maternal Education and Feeling Unsafe at School

81.7 8076.1

0

20

40

60

80

100


% 1

0th

gra

der

s

1515

Health Disparities: Overweight Health Disparities: Overweight Overweight by Race/Ethnicity

9.4%6.9%

15.9%14.3% 13.8%

16.9%

0%

10%

20%

30%

White, non-Hispanic


Black/Af.Amer.

Hispanic/Latino

Nativ.Haw /Pac Isl.

Ove

rwei

gh

t b

y B

MI

**

**

*


1616

Health Disparities: OverweightHealth Disparities: Overweight


Maternal Education and Overweight

13.9

11.2

8.7

0

10

20

30


% 1

0th

gra

der

s

1717

Summary: how are different Summary: how are different students at-risk?students at-risk?

Race/ethnicityRace/ethnicity Asian students and white non-Hispanic Asian students and white non-Hispanic

students tend to have lowest risk for a variety students tend to have lowest risk for a variety of factorsof factors

Native American, Black, Latino and Pacific Native American, Black, Latino and Pacific Islander/Hawaiian students tend to have Islander/Hawaiian students tend to have higher riskhigher risk

Socio-Economic StatusSocio-Economic Status Students in lower income families tend to Students in lower income families tend to

have greater health riskshave greater health risks

1818






What is the status of school healthpolicies in Washington?

1919

Washington StateWashington StateSchool Health Profile SurveySchool Health Profile Survey

2020

School Health Profiles SurveySchool Health Profiles Survey

Paper-based questionnaire given to Paper-based questionnaire given to principals & lead health teachers in principals & lead health teachers in secondary schoolssecondary schools

Given in spring of even-numbered years Given in spring of even-numbered years (in the field now!)(in the field now!)

Asks about health-related policies and Asks about health-related policies and environmentsenvironments

Reports & more information: Reports & more information: http://www.k12.wa.us/CoordinatedSchoolHealth/SchlHealthProfiles.aspx

2121

School Health Policy IndicatorsSchool Health Policy Indicators

School Health CapacitySchool Health Capacity 52% have an advisory group52% have an advisory group 65% have any health-related SIP 65% have any health-related SIP

goals/objectives (31% nutrition, 36% physical goals/objectives (31% nutrition, 36% physical activity, 23% tobacco, 26% illness)activity, 23% tobacco, 26% illness)

59% have any staff wellness programs59% have any staff wellness programs

2222


AsthmaAsthma 53% “no idle zone” policy for buses53% “no idle zone” policy for buses 81% obtain asthma action plans 81% obtain asthma action plans

NutritionNutrition 27% policy to offer fruit & vegetable options when foods offered27% policy to offer fruit & vegetable options when foods offered Nutrition standards: 76% for vending, 74% for school store, 32% Nutrition standards: 76% for vending, 74% for school store, 32%

for parties, 29% fundraisingfor parties, 29% fundraising Labeling healthy food options: 30% cafeteria, 55% vending, 30% Labeling healthy food options: 30% cafeteria, 55% vending, 30%

school storeschool store Access to unhealthy competitive foods: 49% before class, 50% Access to unhealthy competitive foods: 49% before class, 50%

at lunch, 36% other hours during schoolat lunch, 36% other hours during school

2323


Physical ActivityPhysical Activity 32% required 4+ PE classes32% required 4+ PE classes 34% had staff who received training in fitness 34% had staff who received training in fitness

instructioninstruction 50% promoted walking & biking to school50% promoted walking & biking to school 38% have “safe route to school” partnerships38% have “safe route to school” partnerships

TobaccoTobacco 89% posted “no-tobacco” signs89% posted “no-tobacco” signs 87% enforced a “no-tobacco” zone near school 87% enforced a “no-tobacco” zone near school

propertyproperty 64% had supportive consequences64% had supportive consequences

2424

Associations: School Associations: School Characteristics and Strong PoliciesCharacteristics and Strong Policies

Schools with advisory groups tend to have Schools with advisory groups tend to have stronger health policiesstronger health policies

Larger schools tend to have stronger health Larger schools tend to have stronger health policiespolicies

We are exploring whether having health-related We are exploring whether having health-related SIP goals/objectives improves health policiesSIP goals/objectives improves health policies

Staff wellness programs appear correlated with Staff wellness programs appear correlated with some improved policies and student behaviorssome improved policies and student behaviors

2525






Alignment of health with schools’ educational mission is

critical

2626

Student Health & Academic AchievementStudent Health & Academic Achievement

2727

Summarizing the ResearchSummarizing the Research Building evidence base for associationsBuilding evidence base for associations

CDC DASH website: CDC DASH website: http://www.cdc.gov/HealthyYouth/health_and_academics/index.htm

California Study (Update 5) California Study (Update 5) http://www.gettingresults.org/ Active Living Research summary: Active Living Research summary:

http://www.activelivingresearch.org/alr/alr/files/Active_Ed.pdf UW SDRG study linked WASL scores with school-level HYS UW SDRG study linked WASL scores with school-level HYS

(Arthur & Brown, 2005)(Arthur & Brown, 2005) One study estimated that up to one-quarter of minority One study estimated that up to one-quarter of minority

achievement gap due to health disparities achievement gap due to health disparities (Currie, 2005)(Currie, 2005)

2828

Academic RiskAcademic Risk

In HYS, self-reported as getting “mostly In HYS, self-reported as getting “mostly Cs, Ds, Fs”Cs, Ds, Fs” 24% of 824% of 8thth graders and 31% of 10 graders and 31% of 10thth graders graders

overalloverall

2929

Academic Risk & RaceAcademic Risk & Race


Academic Risk by Race/Ethnicity

27.2%

16.6%

47.1%42.8% 40.1%

32.1%

0%

20%

40%

60%

White, non-Hispanic


Black/ Af.Amer. Hispanic/Latino

Nativ.Haw/ PacIsl.

Aca

dem

ic R

isk *

**

* * *

3030

Disparities in Achievement: Disparities in Achievement: Math WASLMath WASL

Percent of Students in Grade 10 Meeting Standard in 1999 and 2006 by Ethnicity

14.3

37.3

9.5 11.6

38.131.0

59.9

23.3 25.5

56.7

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

American Indian Asian/PacificIslander

Black Hispanic White

1999

2006

NOTE: on this graph “higher” is better

3131

Academic Risk & Socio-economic Academic Risk & Socio-economic StatusStatus

Academic Risk by Maternal Education

40.3%

30.1%

19.5%

0%

10%

20%

30%

40%

50%

no HS HS/GED Some college or more

Aca

dem

ic R

isk


3232

Academic Risk by Specific Health Academic Risk by Specific Health Indicators: 8Indicators: 8thth graders graders

0

20

40

60

80

CigaretteSmoking

Alcohol Use MarijuanaUse

Obesity SevereAsthma

Not EatingBreakfast

InsufficientFruit & Veg

% A

cad

emic

Ris

k

Without risk factor With risk factor

Source: 2006 Healthy Youth Survey

3333

Academic Risk by Specific Health Academic Risk by Specific Health Indicators: 8Indicators: 8thth graders graders

0

20

40

60

80

2+ SodaPop/Day

InsufficientExercise

3+ HoursTV/Day

Feels Unsafeat School

Depression <8 HoursSleep/Night

% A

cad

emic

Ris

k

Without risk factor With risk factor


3434

Which comes first?Which comes first?

3535

Increasing Risks Increasing Risks Increasing Increasing Academic ChallengesAcademic Challenges

0%

20%

40%

60%

80%

100%

0 1 2 3 4 5 6 7 8 9 10 11-12

Number of health risks

2006 HYS: grades 8 and 10 combined

3636

Average # Health Risks by RaceAverage # Health Risks by Race

White NH: 3.1White NH: 3.1 Asian: 3.0Asian: 3.0 Native American: 3.8Native American: 3.8 Black: 3.8Black: 3.8 Latino: 3.8Latino: 3.8 Pac Islander/Native Hawaiian: 3.6Pac Islander/Native Hawaiian: 3.6

3737

Increasing Risks & RaceIncreasing Risks & Race

0

20

40

60

80

100

120

0 1 2 3 4 5 6 7 8 9 10 11+

Native Amer

Asian

Pac Isl

Latino

White NH

Black

3838

Multivariate Statistical ModelsMultivariate Statistical Models We used a multivariate logistic regression model to We used a multivariate logistic regression model to

simultaneously take all factors into account.simultaneously take all factors into account.

For those factors that are no longer significant, we can For those factors that are no longer significant, we can say that associations we originally observed can actually say that associations we originally observed can actually be attributed to other factors (those that remained be attributed to other factors (those that remained significant). significant).

For example, soda pop remains statistically significant in For example, soda pop remains statistically significant in our full model – this means that for youth with all the our full model – this means that for youth with all the same other factors (nutrition, overweight, exercise, same other factors (nutrition, overweight, exercise, safety, maternal education/SES, etc.) that drinking safety, maternal education/SES, etc.) that drinking increasing numbers of soda pop per day is still is increasing numbers of soda pop per day is still is associated with increased academic risk.associated with increased academic risk.

3939

Which are most important?Which are most important?

Strongest associationsStrongest associations Smoking, severe asthma, marijuana, no Smoking, severe asthma, marijuana, no

breakfast, depressionbreakfast, depression Moderate associationsModerate associations

Obesity, soda pop, insufficient exercise, TV, Obesity, soda pop, insufficient exercise, TV, alcohol, feeling unsafe at school alcohol, feeling unsafe at school

Weakest associations Weakest associations Sufficient fruit & veg, not enough sleepSufficient fruit & veg, not enough sleep

4040

Which health risks can we change with Which health risks can we change with school-based interventions, and how?school-based interventions, and how?

Would be good to have interventions with Would be good to have interventions with broad influence, that reach race/ethnic broad influence, that reach race/ethnic minority and low SES students equitablyminority and low SES students equitably

Would be good to have interventions that Would be good to have interventions that can include families, but do not rely on can include families, but do not rely on them or place any burden on them – them or place any burden on them – things that can become “how the school things that can become “how the school works” or “what is normal”works” or “what is normal”

Policy, Procedure, SystemsPolicy, Procedure, Systems

4141






This is currently the weakest link

4242

What about Individual What about Individual Interventions?Interventions?

Individual interventions can change student Individual interventions can change student healthhealth

ProsPros Can be tailored to meet individual needsCan be tailored to meet individual needs

ConsCons Expensive/resource intensive to implement, Expensive/resource intensive to implement,

difficult to sustaindifficult to sustain May not always reach students in greatest needMay not always reach students in greatest need Changing students one-by-one takes a long timeChanging students one-by-one takes a long time

4343

Policy & Environment-change Policy & Environment-change InterventionsInterventions

Policy interventions don’t Policy interventions don’t causecause individual individual behavior change, but they behavior change, but they supportsupport other efforts other efforts If the school was a garden, policy would be the fertile If the school was a garden, policy would be the fertile

(or barren) soil where healthy ideas to grow(or barren) soil where healthy ideas to grow ProsPros

Broad influence, for a variety of students Broad influence, for a variety of students Once implemented, need for resources to maintain Once implemented, need for resources to maintain

may be lessmay be less ConsCons

Policies can’t be only on paper, they need promotion, Policies can’t be only on paper, they need promotion, buy-in and enforcementbuy-in and enforcement

Engaging diverse families may be difficult, but could Engaging diverse families may be difficult, but could be very helpful for implementationbe very helpful for implementation

4444

School Policy & NutritionSchool Policy & Nutrition

Trend in 5-a-day and unhealthy vending

0

20

40

60

80

100

2002 2004 2006

year

% 8th grademeeting 5-a-day

% schools withunhealthy opt

4545

School Policy & Smoking RiskSchool Policy & Smoking Risk

Trend in Susceptibility to Smoking & Supportive Policy Consequences

0

20

40

60

80

100

2002 2004 2006

year

% 10th gradesusceptible tosmoking

% schools w ith 10thgrade w ithsupportiveconsequences

4646

School Policy & Physical ActivitySchool Policy & Physical Activity

Trend in exercise and requiring PE

0

10

20

30

40

50

60

70

80

2002 2004 2006

year

% 10th grade gettingsuff icient exercise

% schools w ith 10thgrade requiring 4+ PEclasses

4747

Exploratory statistical modelsExploratory statistical models We linked school policy data and student We linked school policy data and student

behavior data to describe changes in student behavior data to describe changes in student behavior associated with changes in school behavior associated with changes in school policypolicy Reducing access to competitive foods was linked with Reducing access to competitive foods was linked with

decreases in student consumption of high-fat snacks decreases in student consumption of high-fat snacks and pop from school sourcesand pop from school sources

Implementing more PE requirements increased Implementing more PE requirements increased student physical activity (this might be especially student physical activity (this might be especially important for overweight students)important for overweight students)

Lower SES schools had better PE participation, Lower SES schools had better PE participation, maybe due to fewer college-bound students seeking maybe due to fewer college-bound students seeking PE exemptions?PE exemptions?

4848

Disparities in Perception of Disparities in Perception of Support SystemsSupport Systems

Access to ATOD Counselor by Race/Ethnicity

64.9%60.7% 58.6%

62.9% 64.2%70.0%

0%

20%

40%

60%

80%

White, non-Hispanic

Asian Native American Black/AfricanAmerican

Hispanic/Latino NativeHawaiian/Pacific

Islander

Pe

rce

nt

wh

o s

ay

sc

ho

ol p

rov

ide

s a

c

ou

ns

elo

r fo

r s

tud

en

ts

* * * * *


4949

Disparities in Perceived Disparities in Perceived EnforcementEnforcement

Policy Enforcement by Race/Ethnicity

21.9% 18.7%22.4%

18.0%22.7%

18.9%

0%

20%

40%

60%

White, non-Hispanic

Asian Native American Black/ Af.Amer. Hispanic/ Latino Nativ.Haw / PacIsl.

No

To

bac

co R

ule

s A

lway

s E

nfo

rced

**

* *

Source: 2006 Healthy Youth Survey, 10th grade

5050

Possible InterpretationPossible Interpretation

The more individualized an intervention, The more individualized an intervention, the more critical cultural competence the more critical cultural competence becomesbecomes

5151






You are here

5252

So now what???So now what???

5353

Summarizing what we knowSummarizing what we know

There is a strong association between health There is a strong association between health risks and academic risks, probably healthy risks and academic risks, probably healthy students learn better students learn better it certainly couldn’t hurt to help students be healthier!it certainly couldn’t hurt to help students be healthier!

Health disparities may play an important role in Health disparities may play an important role in minority & socio-economic achievement gapsminority & socio-economic achievement gaps

School policy interventions can have a modest School policy interventions can have a modest but broad-based, sustainable influence on but broad-based, sustainable influence on student health behaviorsstudent health behaviors

5454

Which Health Factors to Prioritize?Which Health Factors to Prioritize?

ConsiderConsider Prevalence of the health risk factor, number of Prevalence of the health risk factor, number of

students to influencestudents to influence Strength of association, logical direction of Strength of association, logical direction of

associationassociation Evidence for school-based interventionsEvidence for school-based interventions Resources for interventionsResources for interventions Potential reach and sustainability of outcomesPotential reach and sustainability of outcomes Political/community buy-in and opportunitiesPolitical/community buy-in and opportunities Building comprehensive capacity to address Building comprehensive capacity to address

health in schoolshealth in schools

5555

Thank you!Thank you!

Keep watching the research… Keep watching the research…

Julia DilleyJulia [email protected](360) 705-1358(360) 705-1358

Documents

Healthy Schools = Healthy Kids = Learning Better OR What is the relationship between school health policy and learning? Julia Dilley PhD MES Washington