School Health Policy Opportunities to Nurture Healthier Students Who Are Ready to Learn

ABSTRACT

Background

Children's health and educational outcomes are interconnected, and unmet health needs affect youths' readiness to learn. Comprehensive school health (CSH) systems are designed to promote academic success and well‐being for all youth. State and local health and education leaders benefit from guidance on how to build, fund, and sustain effective CSH systems to support the whole child.

Contributions to Theory

In this article, we offer core areas for CSH policy development with recommendations for enhancing the quality and scale of CSH systems.

Implications for School Health Policy, Practice, and Equity

Several key policy opportunities and strategies aligned with core features of a CSH are identified, including (1) adoption of a CSH framework, (2) enhancement of cross‐sector coordination and collaboration, (3) use of standardized metrics to enhance CSH system quality, (4) engagement of youth and families in system building, (5) use of innovative strategies to enhance workforce capacity and development, and (6) establishment of a strategic funding plan.

Conclusions

State and local health and education departments are challenged to act upon key policy opportunities to build, fund, and sustain CSH systems to promote student success, health, and well‐being.

1. Introduction

The academic achievement of K‐12 students in the United States has been declining for decades, with national reports revealing decreased levels of reading and math proficiency for students from kindergarten to high school [1, 2]. In a seminal article on school health policy, Dr. Charles Basch outlined strategies for promoting student health to enhance their readiness to learn as a mechanism to address the educational crisis [3]. Since 2014, school health research has evolved, including an increased focus on the role of health promotion and education on child wellness and academic success [4]. However, the educational crisis continues, and it is influenced by interrelated social and environmental factors, including social determinants of health (SDoH). SDoH are the conditions in which people live, grow, work, and play [5]. Exposure to detrimental SDoH and adverse childhood experiences (ACEs), such as food and housing instability, familial and community violence, racism, and discrimination, are connected to poorer health from childhood through late adulthood [6, 7]. Poor health weakens youths' potential to reach their greatest academic, emotional, and social potential [8, 9]. Schools are a critical setting for promoting student well‐being by fostering safety, school connectedness, and positive relationships, and offering evidence‐based mental health interventions [6, 7]. Given the well‐established effects of children's health on educational outcomes, CSH systems that employ a public health approach to health promotion, are critical to nurturing healthy youth who are ready to learn [10, 11]. Youth of color and those living in poverty experience disproportionate rates of exposure to detrimental conditions that harm health and contribute to barriers to learning [3, 12, 13]. As such, it is critical that CSH systems address health disparities to promote wellness and success for all youth.

Schools are a natural setting to offer comprehensive systems to support student health. Schools are a central part of the ecological microsystem affecting child development [14, 15]. Alongside families, friends, neighbors, and workplaces, schools are well‐positioned to promote healthy child development [16, 17]. Additionally, providing health services in schools exemplifies the principle of meeting youth where they are to improve accessibility to care. However, many schools lack the funding, staffing, and infrastructure necessary to effectively implement CSH services. As such, state health and education departments are challenged to work with local school districts to ensure schools and districts have the resources required to implement high‐quality CSH systems.

Basch outlined school health strategies that can be applied and expanded to address current contexts to nurture healthy students who are ready to learn [3]. This article on promoting school health policy is part of a Journal of School Health Special Issue on Healthier Students are Better Learners. These articles offer updates to Basch's article [3] to identify and review current evidence on health topics affecting educational success. This article describes six recommended school health policy focuses and strategies that include: (1) CSH framework adoption, (2) cross‐sector collaboration and coordination, (3) use of integrated data systems and standardized metrics to support quality improvement, (4) youth and family engagement, (5) capacity building and workforce development, and (6) funding strategies. The policy strategies outlined align with Basch's framework, address the core features of a system of support for well‐being in schools, and the CDC's guidance for how states can support coordinated school health [3, 18, 19]. The article serves as a renewed call to action for school health to state and local leaders across health, public health, education, and related systems affecting children's health and well‐being.

2. Policy Opportunity: Adopt a Comprehensive School Health (CSH) Framework

The CDC established the Whole School, Whole Community, Whole Child (WSCC) framework as a model of what it looks like to support student health in schools (see Figure 1) [20]. The WSCC model is student‐centered and emphasizes the connection between health and learning, the need for strong school‐community partnership, and implementation of evidence‐based school policies to promote health and success. The model aligns with guiding principles of a public health approach, such as community engagement, health equity, evidence‐based practice (EBP), and prevention. It also uses a whole child approach, recognizing that the social, emotional, physical, cognitive, and psychological aspects of a child are all connected, and all must be supported to nurture healthy and successful youth. WSCC incorporates 10 components, including Health Education; Physical Education/Activity; Nutrition Environment; Health Services; Counseling/Social Services; Social/Emotional Climate; Physical Environment; Employee Wellness; Community Involvement; and Family Engagement, which schools can address through coordinated policies, processes, and practices.

FIGURE 1.

Whole School, Whole Community, Whole Child (WSCC) Framework [16].

An early step in building a CSH system is adopting an established framework, like WSCC, that offers shared language and targets for school health promotion. The WSCC model offers a comprehensive conceptualization of student health. It encourages policy influencers to view health beyond somatic health to include mental health and social and emotional learning along with other health domains that are not consistently addressed in health initiatives, such as employee wellness, school health services, health education, physical education, and physical activity [21]. This comprehensive perspective extends the focus to the whole child. It also helps advance a public health approach to promoting child wellness through a full continuum of care that treats disease, emphasizes prevention, and promotes wellness.

The Multi‐Tiered Systems of Support (MTSS) model is a complementary framework to the WSCC model. MTSS is recognized as the ideal for academic, behavioral, physical, and emotional health, specifically because it uses a public health approach that emphasizes a continuum of prevention through intervention services and has increasingly become integrated into school‐based health frameworks that are guided by universal screening and supported by progress monitoring of evidence‐based services [22, 23, 24]. MTSS is implemented through several core components including: high‐quality differentiated instruction; meaningful assessment, screening, and progress monitoring; identifying and selecting prevention and intervention programs and strategies; intervention fidelity; identifying, selecting, translating, and evaluating EBP; and professional development (PD) [25]. A comprehensive MTSS for student health includes services and supports from universal health promotion and prevention strategies (e.g., health education, vision screening, and classroom movement breaks) through triaged early and intensive health intervention (e.g., mental health services and substance use treatment) [22].

3. Policy Opportunity: Enhance Coordinated Cross‐Sector Teaming

It takes a coordinated cross‐sector team to build and continuously improve CSH systems and the policies and practices that uphold them. Patchwork efforts across child‐serving sectors create barriers to system‐building [26]. The CDC identified School Health Councils (SHCs), along with coordinators to lead the team, as essential to implementing CSH systems [15]. School health teams are responsible for visioning, planning, implementation, evaluation, and funding of CSH systems [27]. Ideally councils involve major sectors affecting children's health, including education, health, juvenile justice, social services, housing, technology, and transportation [18]. However, representation among some critical sectors (i.e., juvenile justice) as well as groups focused on historically marginalized communities tend to be lacking in federal interagency SHCs [12, 21].

States and districts can establish SHCs that ensure representation of all key informants. School nurses are a critical resource to councils, serving as school health coordinators who lead school‐based health teams and coordinate school‐wide wellness programs. School nurses provide education, screening, and other preventive interventions. CSH teams can leverage the expertise of school nurses and other health professionals (e.g., health educators, psychologists) to bridge health service provision and educational policies (e.g., HIPAA and FERPA). District and school teams may include health services directors, principals, educators, and local community health directors and providers. CSH teams can also seek participation from youth and families who represent the various perspectives, preferences, and needs of the school community [28].

The National Center for School Mental Health (NCSMH) outlined responsibilities of a comprehensive school mental health team that can be applied to CSH teams [27]. These core functions and responsibilities include: (1) shaping school health policy and practice; (2) training, coaching, and supporting school teams; (3) serving as a liaison between state educational agencies (SEAs) and local schools; and (4) collecting student, family, and community partners' perspectives on health needs and strategies [27]. As it relates to shaping school health policy, district‐level teams set expectations for data collection methods, student health assessment tools, and interventions in schools. They may also set up processes to ensure consistent standards of support are met districtwide. District teams often provide on‐going technical assistance (TA) and resources to enhance school and community employed staff capacity to implement high‐quality school health services. District leaders can serve as liaisons between SEAs and schools to ensure that state departments of education, health, and behavioral health leverage schools as a setting for implementing health education and intervention. Finally, district CSH teams can help coordinate the integration of key informant perspectives on health priorities into CSH plans [27].

4. Policy Opportunity: Leverage Integrated Data Systems and Standardized Metrics to Support CSH Quality

Use of EBPs is an indicator of the quality of school‐based services; however, few school health providers report using EBPs [29]. Fortunately, there are dozens of EBPs for promoting healthy behaviors and addressing health risks and conditions that commonly affect children, such as asthma, diabetes, depression, and obesity [30]. The MTSS framework is a gold‐standard model for data‐driven triaging, evidence‐based programming, and progress monitoring to meet student needs and influence quality improvement efforts [22].

Using data on health and educational needs is a natural early step to support data‐driven decision‐making to guide school health programming. A couple examples of national surveys that offer state‐level youth health data include the Youth Risk Behavior Surveillance System and the National Survey of Children's Health [31, 32]. Public schools in the US collect attendance and academic performance data with schools receiving federal funding also collecting disciplinary and school climate data [33, 34]. These data sources can be used to investigate the connection between health and educational outcomes to guide CSH policies and programming. FERPA and HIPAA regulations can make it challenging to integrate data systems. Fortunately, there are examples of how to do this successfully. For instance, the Maryland Department of Health, in partnership with the University of Maryland, established a CDC‐funded Healthy Schools Dashboard that linked academic and health data to track student outcomes, inform school improvement activities, and collect and share aggregated data between schools and child and community health‐serving organizations [35]. The team identified a local school district, which was already using a data system with integration capabilities, to conduct targeted analyses of student health and academic performance. They successfully linked education data with health data obtained from the SBHC using student identification numbers, with required data security measures in place. This example highlights the potential that exists when states leverage cross‐agency partnerships, school health funding mechanisms, and integrated data systems, to support CSH system goals.

Standardized measures of school health systems can also inform CSH quality improvement efforts. The School Health Assessment and Performance Evaluation (SHAPE) System and the School Health Index (SHI) are two standardized performance measurement tools that can be used to self‐assess health‐related policies and practices and identify system‐level strengths and weaknesses to inform goals and action plans for improvement [36, 37]. CSH teams are advised to set SMART (specific, measurable, achievable, relevant, time‐bound) goals or other methods of methodical goal setting and monitoring that can link how desired educational outcomes can be achieved through attention to student health [38]. Community‐Based Participatory Research (CBPR) principles are recommended in a quality improvement process that is rooted in shared‐leadership with youth and families [39].

It is important that selected EBPs are appropriate for the specific populations served, such that they are both developmentally appropriate and culturally grounded, and that program delivery adheres to recommended implementation guidelines. School health leaders may find it helpful to engage in Learning Collaboratives to enhance their quality improvement efforts. LCs offer shared learning with other schools and districts and the provision of TA from experts [40].

5. Policy Opportunity: Center Youth and Family Perspectives and Leadership

Meaningful youth and family engagement in system‐building processes aligns with the CDC's position on youth involvement as well as Youth Participatory Action Research (YPAR), a form of CBPR [41]. The WSCC framework centers youth and incorporates family engagement as a core component of child health promotion. Youth and families with health risks and conditions may offer useful feedback to guide quality improvement processes. Some schools and districts are engaging youth as co‐leaders in system building initiatives [42]. Youth provide insight into peer experiences and needs to enhance the relevance of interventions [43]. YPAR positions youth as co‐investigators rather than subjects, promoting their agency to enact positive change [44]. YPAR is especially powerful in school settings, where youth have often been excluded from decision‐making processes [45]. There is evidence that youth leadership helps promote social and emotional skill development [42, 46].

SHCs and CSH teams can leverage the expertise of youth and families to build, sustain, and improve CSH systems. Methods of engagement should be responsive to the needs, preferences, languages, and abilities of youth and family advisors. It is best practice to prioritize youth and family preferences for participation, use shared decision‐making processes, offer peer support and connection, fairly compensate advisors, connect families to well‐being supports as needed, and offer gradual leadership opportunities in engagement initiatives [47, 48, 49]. Schools and districts can identify personnel to help facilitate meaningful engagement.

6. Policy Opportunity: Use Innovative Strategies to Enhance Capacity and Support a Healthy and Well‐Trained School Workforce

A robust, healthy, and well‐trained school workforce is necessary to build capacity to offer a full array of school health education and services [50, 51]. Educators and school staff are key personnel in CSH systems. They lead or support universal health promotion activities in classrooms. This includes health education interventions, which increase student physical activity‐ and nutrition‐related knowledge, attitudes and perceptions [52]. Educators and school staff are also sources of health referrals in schools. School nurses and other related service professionals, such as school psychologists and social workers, are essential to implementing CSH systems. They facilitate early intervention, intensive treatment, and crisis management. Notably, schools often lack adequate school‐employed healthcare staffing (e.g., nurses, mental health providers) to adopt and implement a CSH system via a MTSS. State health and education departments are challenged to ensure student‐to‐health provider staffing ratios align with practice‐based standards. Relatedly, it is critical that there is a full‐time school nurse in every school [53]. School nurses are situated at the intersection of health and education and are well‐positioned to serve as school health coordinators due to their unique role and expertise. School‐Based Health Centers (SBHCs) and partnerships between schools and community health organizations can be leveraged to place providers in schools and serve as referral sources for students who require higher levels of care. These types of partnerships increase care coordination, close gaps in MTSS service provision, and increase access to care [28, 54]. States and districts are called upon to employ existing and innovative solutions to address workforce shortages. Leaders can strategically build school‐community partnerships to augment health service provision in schools. Schools and districts that are new to building partnerships may benefit from TA on identifying service gaps, vetting partners, establishing Memoranda of Understanding, and using CSH teaming processes to delineate provider roles to ensure team efficiency. Some districts partner with universities to develop school health provider workforce pipelines, where they expand training programs and establish streamlined credentialing and certification pathways for school health professionals. Additionally, loan repayment programs and monetary support for graduate education expenses, such as tuition, practicum placements, and licensing and credentialing costs are strategies to recruit and retain school health educators and providers. Categorization of nursing, social work, and other health graduate degrees as “professional degrees” historically made these professionals eligible for incentives, for example, loan repayment programs, that build the health workforce. Retaining this categorization is one strategy to increase the CSH workforce.

Given the challenge of limited implementation of EBPs in schools, state and district leaders (i.e., director or designated personnel within divisions of student services, child and adolescent behavioral health, prevention and health promotion, etc.) can offer TA to school administrators to establish PD plans that enhance staff capacity to use EBPs and programs. On‐going coaching, PD, and consultation for educators and providers is critical to supporting MTSS delivery [55]. CSH teams can establish menus of available free/low‐cost training resources to equip staff with necessary skills. For example, the CDC has an online catalog of guidance documents to enhance knowledge and skills for implementing the WSCC model, including a Healthy Schools Virtual School, an interactive resource that demonstrates applicability of each WSCC component. Additionally, Classroom WISE is a free, online training that can be offered in PD plans to help educators use strategies that promote well‐being [56].

States are encouraged to enact policies that enhance wellness for the school health workforce. Employee wellness is a core WSCC component. There are several system‐level factors that negatively affect staff well‐being. One study found that 45% of school nurses experience mental health symptoms, and greater risk was associated with working more than 40 h a week, inadequate compensation, poor leadership and peer support, and experiences with stigma, discrimination, and job‐related harassment [57]. Educators report high levels of burnout and benefit from district‐provided supports including mental health resources and opportunities to connect with others [58]. This suggests the need to conduct comprehensive assessments to evaluate system‐level factors that affect staff well‐being [58].

The Organizational Well‐Being Inventory for Schools (OWBI‐S) can be used to gather staff input on domains of organizational well‐being [59]. The OWBI‐S can guide plans to improve school climate, leadership, and other factors that affect employee well‐being. Partnerships between universities and local districts have demonstrated an efficacious method of using system‐wide data to develop PD offerings that address district staff‐reported needs [59, 60].

7. Policy Opportunity: Establish a Strategic CSH Funding Plan

The work to build and sustain high quality CSH systems requires stable funding. Core CSH system components requiring funding include: school‐based health personnel; CSH services and supports; evidence‐based training, TA, and coaching; data and evaluation systems. Funding sources include state appropriations, school funding models, earmarked tax revenue, Medicaid, federal grants, and philanthropic partnerships. Federal funding has supported building the foundation of CSH systems. Recent reductions in funding for Medicaid and federal health and education agencies warrant increased state‐level effort to identify alternative and/or supplemental funding for CSH.

State and districts are advised to develop funding strategies that braid funding sources, while intentionally accounting for economic and political factors that affect funding availability [61]. As an early step CSH teams can focus on optimizing their use of Medicaid to fund school‐based services. States can receive guidance from the Medicaid School‐Based Services TA Center to better understand how to get Medicaid reimbursement for school health services. Both Medicaid and private insurance reimbursement can help support financial sustainability of school health services. Additionally, many states are leveraging Health Services Initiatives, state‐designed projects (funded through Children's Health Insurance Program [CHIP]) that allow states to use up to 10% of their CHIP administrative funding to support public health programs, to fund school health services such as asthma interventions [62]. The CDC has established cooperative agreements with state health departments and nongovernmental organizations (e.g., the National Association of School Nurses, the American Academy of Pediatrics) to support the adoption of the WSCC model through provision of training, TA, and resource dissemination to states and districts. States have historically leveraged funding from opportunities, such as the Substance Abuse and Mental Health Services Administration and the Elementary and Secondary School Emergency Relief (ESSER) Fund to implement EBPs, hire school health providers, and improve the quality of services.

Given the ever‐changing nature of the federal funding landscape, states are encouraged to build financing plans that include long‐term state funding models and foundation and philanthropic partnerships to sustain CSH. The Blueprint for Maryland's Future is an example of a joint state and local jurisdictional long‐term funding plan that addresses student health by expanding SBHCs, promoting community schools that offer wraparound services (including health, vision, and dental care), and supporting MTSS for student mental health [63]. States and districts seeking innovative funding solutions, are encouraged to craft compelling messages about the needs and benefit for supporting whole child health. CSH teams are also encouraged to build relationships with national and local organizations that value children's health and well‐being to enhance opportunities to build strategic partnerships. CSH teams can use data on current school health system effectiveness, gaps in service access and utilization, and student success stories for integration in their messaging and in funding proposals.

8. Discussion

8.1. Implications for School Health Research

There are numerous barriers to CSH system building that can be addressed by future research. For one, the instability of federal funding requires that states and districts seek multiple funding mechanisms, and this work requires coordination, strategy, and time that may significantly stretch existing capacity. CSH funding deficits for school health workforce development programming weaken system capacity to fill critical staffing gaps required to meet student needs and reduce burden on the existing workforce. Future examination of strategies that maintain service quality and are both low‐cost and scalable for schools with limited funding is needed. Other noteworthy opportunities for future research in CSH system development relate to the work of SHCs. First, cross‐sector SHCs, which necessarily include cross‐sector representatives with varying perspectives and priorities, may find it difficult to come to consensus on goals and action steps. Additionally, once plans are established, CSH teams must carry out the effortful work of using health and education data to guide policy development, measure impact, and support continuous quality improvement. SHCs can use existing guidance documents with evidence‐based strategies to address these barriers. SHCs can also partner with national TA centers that offer expert training, coaching, and CSH implementation support. Evaluating the effectiveness of these proposed strategies would be beneficial in improving collaboration and consensus among cross‐sector representatives in SHCs.

8.2. Implications for School Health Policy, Practice, and Equity

CSH systems offer a promising path toward establishing services that promote wellness for the whole child and prevent and respond to health risks and existing conditions. State and local leaders in child‐serving systems are challenged to meaningfully partner with youth and families in a manner that honors their voices and choices as they together promote equitable and evidence‐based policies and practices that build, enhance quality of, and fiscally sustain CSH systems. Through adoption of the WSCC framework, SHCs can establish measurable goals and actionable steps to build and sustain CSH. To support high‐quality CSH systems, the health and wellness of school‐based staff must be prioritized. Adults benefit from support through wellness and school climate strategies that offer choice, build on their strengths, and are responsive to their concerns. Standardized CSH assessment tools that collect data on indicators of school health quality can be used to inform decision‐making related to supports.

9. Conclusion

Students' unmet health needs remain a barrier to their readiness to learn, highlighting the need for effective CSH systems. This requires coordinated action among state and local leaders in health and education sectors to advance the recommended policy opportunity areas that support the implementation and sustainability of CSH systems. This will help ensure that schools are equipped to meet students' health needs and support their capacity to learn and thrive.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.