Environmental justice at school: understanding research, policy, and practice to improve our children's health

BACKGROUND: No overarching federal agencies or policies are responsible for ensuring environmental health at schools in the United States, potentially allowing many inequities for low‐income and minority communities to persist. This article examines emergent research, policy, and practice‐based efforts that may be used to identify and address environmental justice at school. METHODS: A brief literature review was conducted to understand (1) major mental, behavioral, and physical outcomes associated with environmental risk for school‐aged children and (2) current research methods for assessing these relationships. Documents prepared by government agencies, school districts, and advocacy groups were also collected and synthesized to improve understanding of the state of planning and policies for maintaining or improving school environments. RESULTS: Environmental risk can manifest in diverse ways such as mold, poor air quality, poor community design, or contaminated playgrounds. Deeply rooted in national and state structures of school funding and planning, such risks can lead to outcomes including respiratory illness, poor performance in school, and reduced levels of physical activity. With growing attention to these concerns, methods for measuring environmental risks and underlying disparities have advanced tremendously in the last few decades, yet development of innovative research approaches may be necessary to further advance and evaluate appropriate interventions. CONCLUSIONS: Environmental injustice is generally unacknowledged during decision‐making in US school districts. Continued dialogue reflective of translatable science is necessary to support school districts with limited funding in ensuring safe, healthy environments for learning.     

Lessons learned while implementing a legislated school policy: body mass index assessments among Arkansas's public school students

BACKGROUND: To comprehensively address the childhood and adolescent obesity epidemic, Arkansas enacted Act 1220 of 2003. Among a series of community- and school-based interventions, the Act requires each public school student to have his/her body mass index (BMI) assessed and reported annually to parents. The process of implementing this policy on a statewide level and lessons learned are described in this article. METHODS: A confidential, standardized protocol to measure student BMIs and report results to parents was developed. Affordable, reliable, and durable equipment was selected and school personnel who conducted BMI assessments were trained to ensure standardization. To enhance the efficiency and ease of the measurement and reporting process and promote long-term and locally based sustainability, during the first 3 years of implementation, a transition from a paper-based system to a Web-based system was made. Confidential, individualized Child Health Reports have provided students' parents with information about the health of their children. RESULTS: Participation by schools and students has been high as a result of collaboration between the health and education communities and the students and their families. Childhood obesity has not increased since Act 1220 was passed into law. CONCLUSIONS: Parents, schools, school districts, and the state are able to better understand the obesity epidemic and track progress using detailed annual data. Providing a standardized measurement protocol, equipment, and efficient data entry and report generation options has enabled Arkansas to institutionalize the BMI assessment process in public schools.     

Ecological strategies to promote healthy body image among children

Background: Personal habits of children and adolescents related to healthy body image (BI) are influenced by various determinants in the micro‐ and macroenvironment. These include attitudes and behaviors about eating; exercise and physical appearance modeled by parents, teachers, and peers; as well as opportunities to learn new habits and social praise for healthy choices. The coordinated school health program (CSHP) is compatible with the 5 levels of an ecological approach to developing new health behaviors. Methods: Authors systematically applied the ecological model to all 8 components of coordinated school health. Next, strategies for each of the components were developed using the professional literature as well as author expertise in the areas of health education, exercise science, and dietetics. Results: For each strategy, applicable health and physical education standards, as well as goals for each strategy and additional Web resources, were provided to assist educators and administrators in supporting healthy BI among students. Conclusions: Educators may effectively use a coordinated approach to guide multiple intervention activities aimed at increasing healthy habits among adolescents and their families. The strength of the CSHP is its collaborative nature with active participation by students, faculty members, family caregivers, agency professionals, community residents, and health care providers.     

Condom use: slippage, breakage, and steps for proper use among adolescents in alternative school settings

BACKGROUND : School‐based human immunodeficiency virus (HIV)/sexually transmitted infection (STI), and pregnancy prevention programs often focus on consistent and correct condom use. Research on adolescents' experience using condoms, including condom slippage/breakage, is limited. This exploratory study examines proper condom use and the occurrence of condom slippage/breakage among alternative school youth. METHODS : Data are from an HIV/STI prevention trial for youth in continuation school settings (N = 776). Analyses included separate hierarchical logistic regression analyses to explore the relationship between potential correlates and each outcome variable. RESULTS : Students' use of steps for proper condom use varied—73.8% put on the condom before sexual contact, 71.1% squeezed air from the tip, and 92.0% unrolled the condom fully. Notably, 28.5% reported condom slippage/breakage. Results from the regression analyses showed that 4 sets of variables (demographic, substance use, sexual risk behaviors, and condom psychosocial factors) were associated with putting on a condom before sexual contact; none of the variable sets were associated with the other 2 condom steps measured. For slippage/breakage, the demographic and sexual risk behaviors were significant correlates; steps for proper condom use approached statistical significance (p = .058). CONCLUSIONS : This study extends the limited research on how adolescents use condoms, and highlights important targets for prevention interventions.     

Defining Standards and Policies for Promoting Physical Activity in Afterschool Programs

BACKGROUND: National guidelines exist that define “quality” afterschool programs (3–6 pm , ASP). No widely adopted national standards/policies exist, however, for ASP providers for the promotion of physical activity (PA). To address this gap, state-level ASP organizations have developed or adopted standards/policies related to PA. The extent to which standards and policies are uniform and disseminated is unclear. The purpose of this study was to review state-level ASP documentation to identify standards/policies for promoting PA within the ASP setting. METHODS: A systematic review of state-level ASP organizations' standards/policies was conducted to identify documentation that included language explicitly defining or related to the promotion of physical activity within ASP. State-level ASP organizations were identified from registries available from national ASP organizations. Documentation was retrieved from online sources and reviewed using a standardized content analysis protocol. RESULTS: Quality ASP definitions were retrieved from 47 states. Of these, 14 incorporated language related to the promotion of PA. This included the provision of adequate outdoor space for attendees to be active, provision of frequent PA opportunities, and promoting physical development. A total of 5 states had standards/policies that explicitly identified the amount of time for attendees to be physically active during ASP attendance, while 3 states outlined standards/policies regarding core competencies for ASP providers to promote PA. CONCLUSIONS: Overall, standards/polices related to promoting PA within ASP were largely absent. Those that do exist, however, can provide a foundation for future empirical tests. The testing of these standards/policies will assist in the development of national guidelines to promote PA within the ASP setting.     

Baseline Results of the First Healthy Schools Evaluation Among a Community of Young,Irish, Urban Disadvantaged Children and a Comparison of Outcomes With International Norms

BACKGROUND: In 2008, the Irish Government initiated a pilot Healthy Schools Programme based on the World Health Organization Health Promoting Schools Model among children attending schools officially designated as urban and disadvantaged. We present here the first results on physical and emotional health and the relationship between childhood depression and demographic and socioeconomic factors. METHODS: The Healthy Schools Programme evaluation was a 3‐year longitudinal outcome study among urban disadvantaged children aged 4 to 12 years. Physical and psychological health outcomes were measured using validated, international instruments at baseline. Outcomes at baseline were compared with international norms and where differences were found, results were statistically modeled to determine factors predicting poor outcomes. RESULTS: A total of 552 children responded at baseline, representing over 50% of all eligible children available to participate from 7 schools. Findings at baseline revealed that in general, children did not differ significantly from international norms. However, detailed analysis of the childhood depression scores revealed that in order of importance, psychological well‐being, the school environment, social support, and peer relations and age were statistically significant predictors of increased childhood depression in children under 12 years of age. CONCLUSION: Future health and well‐being studies in schools among urban disadvantaged children need to broaden their scope to include measures of depression in children under 12 years of age and be cognisant of the impact of the school environment on the mental and emotional health of the very young.     

Variation in school health policies and programs by demographic characteristics of US schools, 2006

BACKGROUND: To identify whether school health policies and programs vary by demographic characteristics of schools, using data from the School Health Policies and Programs Study (SHPPS) 2006. This study updates a similar study conducted with SHPPS 2000 data and assesses several additional policies and programs measured for the first time in SHPPS 2006. METHODS: SHPPS 2006 assessed the status of 8 components of the coordinated school health model using a nationally representative sample of public, Catholic, and private schools at the elementary, middle, and high school levels. Data were collected from school faculty and staff using computer-assisted personal interviews and then linked with extant data on school characteristics. RESULTS: Results from a series of regression analyses indicated that a number of school policies and programs varied by school type (public, Catholic, or private), urbanicity, school size, discretionary dollars per pupil, percentage of white students, percentage of students qualifying for free lunch funds, and, among high schools, percentage of college-bound students. Catholic and private schools, smaller schools, and those with low discretionary dollars per pupil did not have as many key school health policies and programs as did schools that were public, larger, and had higher discretionary dollars per pupil. However, no single type of school had all key components of a coordinated school health program in place. CONCLUSIONS: Although some categories of schools had fewer policies and programs in place, all had both strengths and weaknesses. Regardless of school characteristics, all schools have the potential to implement a quality school health program.     

Promoting Tobacco-Free School Policies Through a Statewide Media Campaign

Background:  Comprehensive, enforced tobacco-free school (TFS) policies lead to significant reductions in youth tobacco use. North Carolina is the first state in the United States to develop a statewide mass media campaign to promote the adoption of and compliance with TFS policies.
Methods:  In order to guide campaign development, researchers conducted a literature review as well as interviews with 45 TFS-policy experts, stakeholders, and North Carolina legislators. The experts included state and national TFS researchers and advocates, and the majority of stakeholders were North Carolina school administrators and personnel selected because of their personal knowledge of and experience with TFS policy. Interviewees provided information on messages they believed would be most salient to highlight in the media campaign and the best type of people to appear in ads.
Results:  Recommended themes included (1) a positive message about TFS becoming the norm in the state, (2) experiences of school districts that had successfully passed TFS policies, (3) the importance of adult role modeling, and (4) personal stories from youth about the importance of TFS policy. Recommended people to appear in ads included youth and adults with a personal connection to and experience with TFS policy. Using these recommended themes and people, the TFS media campaign began in the fall of 2006. In the 8 months following the campaign launch, 9 additional school districts adopted TFS policies, increasing the total from 78 to 87 (out of 115) by June 2007. In July 2007, the North Carolina legislature passed legislation mandating that all school districts adopt TFS policies by August 2008.
Conclusions:  Media campaigns can serve as part of a comprehensive strategy to advance TFS policies. Other states should consider these results in designing and evaluating a media campaign to promote adoption of and compliance with TFS policies.     

Frequent fliers, school phobias, and the sick student: school health personnel's perceptions of students who refuse school

BACKGROUND: This study explored school personnel's perceptions of school refusal, as it has been described as a “common educational and public health problem” that is less tolerated due to increasing awareness of the potential socioeconomic consequences of this phenomenon. METHODS: In‐depth interviews were conducted with school personnel at the middle school (N = 42), high school (N = 40), and district levels (N = 10). The findings focus on emergent themes from interviews with school health personnel (N = 12), particularly those themes related to their perceptions of and role in working with school‐refusing students. RESULTS: Personnel, especially school health services staff, constructed a typification of the school‐refusing student as “the sick student,” which conceptualized student refusal due to reasons related to illness. Personnel further delineated sick students by whether they considered the illness legitimate. School health personnel referenced the infamous “frequent fliers” and “school phobics” within this categorization of students. Overarching dynamics of this typification included parental control, parental awareness, student locus of control, blame, and victim status. These typifications influenced how personnel reacted to students they encountered, particularly in deciding which students need “help” versus “discipline,” thus presenting implications for students and screening of students. CONCLUSIONS: Overall, findings suggest school health personnel play a pivotal role in screening students who are refusing school as well as keeping students in school, underscoring policy that supports an increased presence of school health personnel. Recommendations for school health, prevention, and early intervention include the development of screening protocols and staff training.     

Changing nutrition standards in schools: the emerging impact on school revenue

BACKGROUND: Although great focus has been placed on nutritional and other consequences of changes in food-related policies within schools, few reports exist describing the impact of such changes on school revenue. This review provides an overview of the few revenue-related studies published recently, as well as information from a sampling of state reports on the subject. METHODS: A systematic review of the literature was conducted. Four peer-reviewed papers and 3 state-based reports were identified that assessed the impact on revenues of either targeted policy changes or overarching, district-wide changes in food-related policies. RESULTS: Thus far, few data exist to substantiate the concern that changes in nutrition standards in schools lead to a loss in total revenue. An interesting phenomenon of increased participation in the National School Lunch Program was noted in a number of reports and might play a role in buffering financial losses. CONCLUSIONS: A renewed focus on school policies related to health provides the opportunity for researchers to investigate how nutrition-related policy change can affect, if at all, food service and overall school revenues.     

Overheard in the halls: what adolescents are saying, and what teachers are hearing, about health issues

BACKGROUND: Schools have long been recognized as an excellent place to offer health education and supportive services. Teachers are among the most important influences in the lives of school-aged children and can provide valuable insight into the health issues important to adolescents. The purpose of this study was to examine the potential role general academic teachers may play in facilitating adolescent health promotion efforts. METHODS: To determine what teachers think about the role of health promotion in schools and what tools and topics they would find most helpful as critical advisers to students, we administered a 28-question survey at staff development meetings in 4 New York City schools. RESULTS: Teachers agreed that schools were an important venue for discussing and providing health messages. More than half of those surveyed reported having overheard student discussions about health once a week or more, and 70% stated that they had been actively approached by students 1-3 or more times per semester with reports of personal problems or health issues. Teachers expressed concern about their ability to handle student mental, behavioral, and reproductive health problems and desired additional staff development workshops to address these needs. CONCLUSIONS: Teachers felt that schools were important places to promote dialogue about health and accept the importance of playing a broader role in the lives of youth beyond education. To enhance the prospect of health-promoting interactions between teachers and students, attention must be paid to developing the overall skill and comfort level of teachers with respect to adolescent health concerns.     

Effects of a school-based nutrition program diffused throughout a large urban community on attitudes, beliefs, and behaviors related to fruit and vegetable consumption

BACKGROUND: Obesity among US children has increased in recent years. Although increased fruit and vegetable consumption has not been directly linked to obesity prevalence, it has been posited that more fruits and vegetables (FV) could reduce the consumption of high‐fat, energy‐dense foods and may protect against childhood illnesses including asthma and other respiratory diseases. The purpose of this current research was to assess the impact of a large public school district's hybrid approach to nutrition education programming on attitudes, beliefs, and behaviors related to fruit and vegetable consumption. METHODS: A total of 12 elementary schools from the Los Angeles Unified School District (9 intervention schools, 3 control schools) were randomly selected to participate in a “hybrid” school‐based nutrition education program. Data were collected at baseline (beginning of school year) and postintervention data (end of school year 9 months later). Linear mixed models were developed to assess the impact of the intervention. RESULTS: The intervention resulted in a significant change in teacher influence on students' attitudes toward FV (p < .05) and students' attitudes toward vegetables (p < .01), even after adjusting for gender, grade, and race/ethnicity. Although not statistically significant, there was a slight increase in fruit and vegetable consumption from pretest to posttest for both the intervention and control schools. CONCLUSION: The hybrid model reflects a more accurate representation of school‐based interventions. More research is needed to identify the specific components of this model that are most successful in impacting fruit and vegetable consumption among US children.     

Association of relative backpack weight with reported pain, pain sites, medical utilization, and lost school time in children and adolescents

BACKGROUND: There is debate about a 10% versus 15% of body weight cutoff point for safe weight of school backpacks. Estimation of the cutoff may be affected by use of survey methods and failure to assess pain experienced while wearing a backpack. Previous research also suggests that younger students and females are more at risk for developing backpack pain. METHODS: Five hundred and thirty-one 5th- to 12th-grade Northern California students and their backpacks were weighed. Students were individually interviewed about how often they experienced pain while carrying a backpack, the site of their pain, and if the pain had interfered with school activities or led to medical care. RESULTS: Data support the use of a 10% of body weight cutoff for safe use of backpacks for all grade levels. Younger students and females are more at risk due to relatively lower body weight while females also carry heavier backpacks than males. Greater relative backpack weight is associated with upper- and mid-back pain reports but not neck or lower back pain; it is also associated with lost school time, lost school sports time, and greater chiropractic utilization. CONCLUSIONS: The 10% cutoff is recommended along with a variety of practical methods to help schools achieve that goal for middle and high school students.