Schools play a critical role in promoting the health and safety of young people and helping them establish lifelong healthy behavior patterns. Schools can promote student health through a variety of strategies including health education and physical education classes; nutritious school meals and snacks; opportunities to participate in physical activity before, during, and after school; health, mental health, psychological, and counseling services; a safe and supportive physical and social climate; and health promotion activities for families.
A strong and growing body of evidence has emerged in recent decades, documenting the positive impact that school policies and practices can have on youth health behaviors and outcomes. A number of school-based policies and practices are recommended by the Task Force on Community Preventive Services,1–5 and a series of evidence-based, school health guidance documents have been released by Institute of Medicine panels,6–9 the US Centers for Disease Control and Prevention,10–13 and a collaboration of multiple federal agencies and national, non-governmental organizations.14
Despite increasing evidence of the effectiveness of school health programs and growing concern over critical health problems affecting youth, such as obesity, CDC's School Health Policies and Programs Study has found that most US schools spend insufficient time on health education15 and physical education;16 fail to provide recommended levels of nursing17 and mental health services;18 commonly provide students with ready access to high calorie, low-nutrient foods and beverages;19 and generally fall far short of the school health practices recommended by public health authorities.20
Advocates for school health programs have expressed concern that these programs have become increasingly marginalized in US schools, particularly since the 2001 passage of the No Child Left Behind Act.21 This legislation expanded the federal role in holding schools accountable for increasing the academic achievement of all students, as measured by performance on standardized tests, primarily in mathematics and language arts. Increasing pressures for accountability are believed to have led educators to narrow the curriculum and neglect topics that have typically not been part of the high stakes testing process, such as health education and physical education.22 Despite the vastly expanded emphasis on accountability and a host of national, state, and local efforts at school reform, a substantial achievement gap remains between Black and White students23 and between Hispanic and White students.24
Public health professionals naturally focus on the role school health programs play in improving health outcomes. However, Kolbe has identified promoting academic achievement as one of the four fundamental outcomes of modern school health programs.25 A key tenet of good health promotion practice is that we must understand the priorities of our target audience and present the benefits of behavior change in terms that appeal to their priority interests. For educational policy makers and school administrators, their priority interests, now more than ever, involve improving academic achievement. Therefore, it is imperative that we document for them the positive impact that school health programs can have on academic achievement and, in particular, reducing the educational achievement gap.
A number of literature reviews have summarized some of the existing evidence of the impact of health behaviors and school health programs on academic achievement.26–30 However, the articles by Basch in this issue of the Journal of School Health represent the most comprehensive, authoritative, and compelling summary of why addressing health-related barriers to learning needs to be a fundamental component of school reform efforts. Basch does a masterful job of synthesizing a vast array of research from diverse fields including education, public health, neurosciences, and child development. Perhaps the greatest contribution to the literature is the clear delineation of the causal pathways by which specific health problems are linked to critical educational risks and poor educational outcomes.
Basch's work is not merely academic, but is clearly designed to influence the current debates over school reform. He understands that educators are overwhelmed with an extraordinary array of challenges and cannot possibly address all of the critical health issues that public health professionals would like to see addressed in the school setting. He, therefore, prioritizes those health issues that are most important to address if the overriding goal is to improve the educational outcomes of low-income, urban minority youth. His criteria for establishing these strategic priorities are sound: they include the extent of the problem; the extent to which low-income, urban minority youth are disproportionately affected by the problem; the strength of the evidence showing causal effects of the health problem on educational outcomes; and the strength of the evidence showing that specific school policies and practices can reduce the prevalence of the health problem. Some high priority public health problems, such as tobacco, alcohol, and other drug use, are not included on Basch's list of priority health problems, because they do not disproportionately affect low-income, urban minority youth compared with other youth. While some may disagree with the specific health problems selected—vision problems, asthma, teen pregnancy, violence, physical inactivity, failure to eat breakfast, and hyperactivity—Basch provides strong evidence that each of these problems meets the criteria established and needs to be addressed if schools are to make genuine progress in reducing the educational achievement gap.
It is important to emphasize that this set of papers was not produced by faculty at a school of public health, but rather by a professor at the Nation's oldest graduate school of education, Teachers College, Columbia University; and that the development of these papers was sponsored by the Campaign for Educational Equity, an initiative solely focused on exploring innovative approaches to reducing the educational achievement gap. The argument that implementing school health programs will improve academic achievement will have enhanced credibility if it comes from the educational sector itself, rather than the public health sector.
At the same time, however, strong school health policies and programs need to be supported for more than just the boost they can give to standardized test scores. The case for school health needs to be 2-fold: healthy students are better learners, as Basch has ably documented, but schools also need to be active centers of health promotion to meet vital needs of our society unrelated to traditional measures of academic achievement.
Many educators are calling for a national debate on the role of education in our society. One of the largest education associations, ASCD, has called for a “new compact to educate the whole child” that identifies health promotion as one of the essential components of the new compact for our schools.31 A strong emphasis on health promotion is evident in the educational frameworks of a number of prominent school reform coalitions, including the Partnership for 21st Century Skills, which is supported by some of the Nation's largest technology corporations.32 This integration of health promotion into the fundamental mission of schools is not a new idea; in fact, it is entirely consistent with the vision of early leaders of the public school movement in the United States. The 19th century education advocate Horace Mann, considered to be “the father of American public education,” wrote, “In the great work of education, our physical condition, if not the first step in point of importance, is the first in order of time. On the broad and firm foundation of health alone can the loftiest and most enduring structures of the intellect be reared.”33 With rising health care costs threatening our Nation's economic strength and high obesity rates threatening our military's ability to recruit physically fit soldiers, our societal need for promoting health through schools is powerful.
The value of Basch's work is much greater than his detailed descriptions of the connection between health and learning. He also makes a strong case for why health promotion needs to be a fundamental part of elementary and secondary education and identifies a clear set of policy actions that need to be taken at the federal, state, and local levels to support effective and efficient school health problems. The US Centers for Disease Control and Prevention has long supported a coordinated approach to school health that epitomizes the high-quality, evidence-based, strategically planned, and effectively coordinated effort recommended by Basch.34
Many different strategies have been employed, with limited success, to address the educational achievement gap. Basch's work makes a compelling case that these efforts are likely to continue to be futile until addressing health-related barriers to learning is included as one of the fundamental components of school reform. The evidence accumulated by Basch on the role of school health programs in reducing the educational achievement gap needs to be widely disseminated to state and local education agencies, school board members and legislators, superintendents and principals, teachers, parents, students, and the general public.
The findings and conclusions in this article are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.