Julia Dilley PhD MES Washington State - Healthy Schools Summit May 2008

1. ? ? Healthy Schools = Healthy Kids = Learning BetterORWhat is the relationship between school health policy and learning? Julia Dilley PhD MES Washington State - Healthy Schools Summit May 2008

2. Objectives Increase skills for: • Using WA Healthy Youth Survey to describe “healthy students” • Using WA School Health Profile data to describe “healthy schools” • Describing association between academic achievement & health • Describing association between school health policies and student health

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

4. Theoretical Model Students exhibit more healthy behaviors Pro-health school policies, procedures & environments School health programs Students Learn Better

5. Pro-health school policies, procedures & environments School health programs Students Learn Better Theoretical Model Students exhibit more healthy behaviors What are important health conditions? Who is at risk?

6. Washington State’s Healthy Youth Survey

7. Healthy Youth Survey (HYS) • Paper-based questionnaire given to 6th, 8th, 10th & 12th graders in fall of even years • Asks questions about • Risk & protective factors • Alcohol, drug & tobacco use • Health status • Next survey is Fall 2008: • Visit www.hys.wa.gov for materials, recruitment information, reports, link to online data analysis • Schools need to register by June 30 (it’s free)

8. Health Indicators of Interest • Smoking cigarettes • Using alcohol • Using marijuana • Obesity • Severe asthma • Poor nutrition: not eating breakfast • Poor nutrition: not enough fruit & veg • Poor nutrition: 2+ soda pop per day • Sedentary lifestyle: Insufficient exercise • Sedentary lifestyle: 3+ hours TV per day • Feeling unsafe at school • Mental distress/depression • Insufficient (<8 hours) sleep per night

9. Prevalence of Risk Factors

10. Health Indicator Trends • Most health status indicators are fairly stable • Smoking & marijuana have decreased in recent years • Obesity has increased in recent years • Local trends may be different – see your own reports

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

12. Health Disparities: Smoking Source: 2006 Healthy Youth Survey, full dataset, 10th grade

13. Health Disparities: Feeling Unsafe Source: 2006 Healthy Youth Survey, state sample only grades 8-10-12 combined.

14. Health Disparities: Feeling Unsafe Source: 2006 Healthy Youth Survey, full dataset, 10th grade

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

16. Health Disparities: Overweight Source: 2006 Healthy Youth Survey, full dataset, 10th grade

17. Summary: how are different students at-risk? • Race/ethnicity • Asian students and white non-Hispanic students tend to have lowest risk for a variety of factors • Native American, Black, Latino and Pacific Islander/Hawaiian students tend to have higher risk • Socio-Economic Status • Students in lower income families tend to have greater health risks

18. Students exhibit more healthy behaviors School health programs Students Learn Better Theoretical Model What is the status of school health policies in Washington? Pro-health school policies, procedures & environments

19. Washington StateSchool Health Profile Survey

20. School Health Profiles Survey • Paper-based questionnaire given to principals & lead health teachers in secondary schools • Given in spring of even-numbered years (in the field now!) • Asks about health-related policies and environments • Reports & more information: http://www.k12.wa.us/CoordinatedSchoolHealth/SchlHealthProfiles.aspx

21. School Health Policy Indicators • School Health Capacity • 52% have an advisory group • 65% have any health-related SIP goals/objectives (31% nutrition, 36% physical activity, 23% tobacco, 26% illness) • 59% have any staff wellness programs

22. School Health Policy Indicators • Asthma • 53% “no idle zone” policy for buses • 81% obtain asthma action plans • Nutrition • 27% policy to offer fruit & vegetable options when foods offered • Nutrition standards: 76% for vending, 74% for school store, 32% for parties, 29% fundraising • Labeling healthy food options: 30% cafeteria, 55% vending, 30% school store • Access to unhealthy competitive foods: 49% before class, 50% at lunch, 36% other hours during school

23. School Health Policy Indicators • Physical Activity • 32% required 4+ PE classes • 34% had staff who received training in fitness instruction • 50% promoted walking & biking to school • 38% have “safe route to school” partnerships • Tobacco • 89% posted “no-tobacco” signs • 87% enforced a “no-tobacco” zone near school property • 64% had supportive consequences

24. Associations: School Characteristics and Strong Policies • Schools with advisory groups tend to have stronger health policies • Larger schools tend to have stronger health policies • We are exploring whether having health-related SIP goals/objectives improves health policies • Staff wellness programs appear correlated with some improved policies and student behaviors

25. Students exhibit more healthy behaviors Pro-health school policies, procedures & environments School health programs Students Learn Better Theoretical Model Alignment of health with schools’ educational mission is critical

26. Student Health & Academic Achievement

27. Summarizing the Research • Building evidence base for associations • CDC DASH website: http://www.cdc.gov/HealthyYouth/health_and_academics/index.htm • California Study (Update 5) http://www.gettingresults.org/ • Active Living Research summary: http://www.activelivingresearch.org/alr/alr/files/Active_Ed.pdf • UW SDRG study linked WASL scores with school-level HYS (Arthur & Brown, 2005) • One study estimated that up to one-quarter of minority achievement gap due to health disparities (Currie, 2005)

28. Academic Risk • In HYS, self-reported as getting “mostly Cs, Ds, Fs” • 24% of 8th graders and 31% of 10th graders overall

29. Academic Risk & Race Source: 2006 Healthy Youth Survey, state sample only grades 8-10-12 combined.

30. Disparities in Achievement: Math WASL NOTE: on this graph “higher” is better

31. Academic Risk & Socio-economic Status Source: 2006 Healthy Youth Survey, state sample only grades 8-10-12 combined.

32. Academic Risk by Specific Health Indicators: 8th graders Source: 2006 Healthy Youth Survey

33. Academic Risk by Specific Health Indicators: 8th graders Source: 2006 Healthy Youth Survey

34. Which comes first?

35. Increasing Risks  Increasing Academic Challenges 2006 HYS: grades 8 and 10 combined

36. Average # Health Risks by Race • White NH: 3.1 • Asian: 3.0 • Native American: 3.8 • Black: 3.8 • Latino: 3.8 • Pac Islander/Native Hawaiian: 3.6

37. Increasing Risks & Race

38. Multivariate Statistical Models • We used a multivariate logistic regression model to simultaneously take all factors into account. • For those factors that are no longer significant, we can say that associations we originally observed can actually be attributed to other factors (those that remained significant). • For example, soda pop remains statistically significant in our full model – this means that for youth with all the same other factors (nutrition, overweight, exercise, safety, maternal education/SES, etc.) that drinking increasing numbers of soda pop per day is still is associated with increased academic risk.

39. Which are most important? • Strongest associations • Smoking, severe asthma, marijuana, no breakfast, depression • Moderate associations • Obesity, soda pop, insufficient exercise, TV, alcohol, feeling unsafe at school • Weakest associations • Sufficient fruit & veg, not enough sleep

40. Which health risks can we change with school-based interventions, and how? • Would be good to have interventions with broad influence, that reach race/ethnic minority and low SES students equitably • Would be good to have interventions that can include families, but do not rely on them or place any burden on them – things that can become “how the school works” or “what is normal”  Policy, Procedure, Systems

41. Students exhibit more healthy behaviors Pro-health school policies, procedures & environments School health programs Students Learn Better Theoretical Model This is currently the weakest link

42. What about Individual Interventions? • Individual interventions can change student health • Pros • Can be tailored to meet individual needs • Cons • Expensive/resource intensive to implement, difficult to sustain • May not always reach students in greatest need • Changing students one-by-one takes a long time

43. Policy & Environment-change Interventions • Policy interventions don’t cause individual behavior change, but they support other efforts • If the school was a garden, policy would be the fertile (or barren) soil where healthy ideas to grow • Pros • Broad influence, for a variety of students • Once implemented, need for resources to maintain may be less • Cons • Policies can’t be only on paper, they need promotion, buy-in and enforcement • Engaging diverse families may be difficult, but could be very helpful for implementation

44. School Policy & Nutrition

45. School Policy & Smoking Risk

46. School Policy & Physical Activity

47. Exploratory statistical models • We linked school policy data and student behavior data to describe changes in student behavior associated with changes in school policy • Reducing access to competitive foods was linked with decreases in student consumption of high-fat snacks and pop from school sources • Implementing more PE requirements increased student physical activity (this might be especially important for overweight students) • Lower SES schools had better PE participation, maybe due to fewer college-bound students seeking PE exemptions?

48. Disparities in Perception of Support Systems Source: 2006 Healthy Youth Survey

49. Disparities in Perceived Enforcement Source: 2006 Healthy Youth Survey, 10th grade

50. Possible Interpretation • The more individualized an intervention, the more critical cultural competence becomes