SPECIAL TOPIC
Reframing School Dropout as a Public Health Issue

From: http://www.cdc.gov/pcd/issues/2007/oct/07_0063.htm

Nicholas Freudenberg, DrPH, Jessica Ruglis

Suggested citation for this article: Freudenberg N, Ruglis J. Reframing school dropout as a public health issue. Prev Chronic Dis 2007;4(4). http://www.cdc.gov/pcd/issues/2007/
oct/07_0063.htm. Accessed [date].

PEER REVIEWED

Abstract

Good education predicts good health, and disparities in health and in educational achievement are closely linked. Despite these connections, public health professionals rarely make reducing the number of students who drop out of school a priority, although nearly one-third of all students in the United States and half of black, Latino, and American Indian students do not graduate from high school on time. In this article, we summarize knowledge on the health benefits of high school graduation and discuss the pathways by which graduating from high school contributes to good health. We examine strategies for reducing school dropout rates with a focus on interventions that improve school completion rates by improving students’ health. Finally, we recommend actions health professionals can take to reframe the school dropout rate as a public health issue and to improve school completion rates in the United States.

Back to top

Introduction

If medical researchers were to discover an elixir that could increase life expectancy, reduce the burden of illness, delay the consequences of aging, decrease risky health behavior, and shrink disparities in health, we would celebrate such a remarkable discovery. Robust epidemiological evidence suggests that education is such an elixir. Yet health professionals have rarely identified improving school graduation rates as a major public health objective, nor have they systematically examined their role in achieving this objective. Seizing the opportunity to do so can improve health and reduce disparities.

Back to top

Impact of High School Graduation on Health

Education is one of the strongest predictors of health: the more schooling people have the better their health is likely to be. Although education is highly correlated with income and occupation, evidence suggests that education exerts the strongest influence on health (1-4). More formal education is consistently associated with lower death rates (4), while less education predicts earlier death. The less schooling people have, the higher their levels of risky health behaviors such as smoking, being overweight, or having a low level of physical activity (5). High school completion is a useful measure of educational attainment because its influence on health is well studied, and it is widely recognized as the minimum entry requirement for higher education and well-paid employment.

Although the beneficial effect of education varies by sex, age, and race/ethnicity, with blacks benefiting more than whites from more education (6), current policies exacerbate education-related health disparities, with women, whites, young adults, and United States–born residents having higher graduation rates than their respective counterparts (7). Moreover, the gap in health status between people who are well educated and those who are not has grown in recent decades (6).

Back to top

Pathways by Which Graduation Contributes to Improved Health

A good education leads to good health in several ways. First, the more schooling people have the more money they earn, enabling them to purchase better housing in safer neighborhoods, healthier food, better medical care and health insurance, and more education; each of these factors is associated with improved health (3,8,9). Each one allows individuals to move up the occupational and income ladder, giving them more prestige and power, both of which are associated with better health. High school completion is also the gateway into college, which offers even greater benefits than high school alone. Second, education facilitates healthier behavior choices by offering learners access to health information and tools to acquire help and resources such as smoking cessation programs. Third, education helps people to acquire social support, strengthen social networks, and mitigate social stressors (3,9,10). The more education people have the more social support they have (10). Education helps people to gain a sense of control over their lives (9), an outcome associated with better health.

According to a recent review by Cutler and Lleras-Muney (3), policies that increase educational attainment could have a large effect on population health. Moreover, estimates suggest that investments to improve educational achievement can save more lives than can medical advances (11). To realize these possibilities, public health researchers need to develop new conceptual and analytic approaches to studying the reciprocal relationships between health and education and consider education as an arena for intervention as well as a marker or moderator for social position (3,12).

Back to top

High School Graduation in the United States

In recent decades, educational attainment in the United States has improved significantly. From 1975 through 2000, the proportion of adults aged 25 years or older who completed high school increased from 63% to 84% (7). However, high dropout rates are increasingly concentrated among low-income and black and Latino students, and the rate at which students leave school between grades 9 and 10 has tripled (13). These trends indicate that more young adolescents are in jeopardy.

The Cumulative Promotion Index (CPI) (13) uses enrollment data to estimate the probability that a student entering 9th grade will graduate with a regular diploma in the traditional 4 years. Although many students finish high school in 5 or more years, the more narrowly defined CPI offers several advantages as a measure: it is commonly used, data are systematically collected, and it triggers the funding mandates set in the federal No Child Left Behind Act. The CPI method of calculating graduation shows that nearly one-third of students in the United States and half of black, Hispanic, and American Indian students who enter 9th grade do not graduate with a diploma in 4 years (Table 1).

Graduation rates in the nation’s largest cities are lower still. In 2001, 6 of the 10 largest cities in the United States had overall graduation rates of less than 50% (Table 2). In 2002, 18% of the nation’s 11,129 high schools promoted fewer than 60% of their students (15). Most of these schools with low promotion rates were concentrated in cities with low average incomes and with high proportions of blacks and Hispanics (15).

Back to top

Causes for School Dropout

Understanding why young people leave school can inform the design of polices that will increase school graduation rates. Although a comprehensive analysis of multidisciplinary studies of factors associated with school completion is beyond the scope of this article, Table 3 summarizes findings from social science and educational research on dropout rates, assessing the impact of factors from different levels of society (e.g., individual, community, school). The multiple factors associated with dropout rates suggest that no single type of intervention can end our nation’s dropout crisis.

Although much of the research on school completion focuses on the psychological traits of students and the organizational characteristics of teachers, schools, and school systems, some researchers have examined the impact of health. Health has direct and indirect effects on school dropout rates. Student health problems associated with dropping out are substance use; pregnancy; and psychological, emotional, and behavioral problems (27-30). Teenage pregnancy is the leading cause of dropping out of school for adolescent women; an estimated 30%–40% of female teenaged dropouts are mothers (29). Early parenting also affects young men who drop out to support a child.

Mental illness and emotional disturbance also account for a significant percentage of dropouts (31). Health problems also affect dropout rates indirectly by forcing young people, especially young women, to cope with family physical or mental illness, often imposing on teenagers responsibilities that can lead to their leaving school (32). The few researchers who examined the impact of addiction, mental illness, chronic diseases, or mortality among parents on students’ school achievement suggest it has a substantial effect (33,34).

Back to top

Health Interventions

Interventions to reduce school dropout rates seek to change individuals, families, schools, school systems, or public policies related to poverty, welfare, or employment. Most educational research has focused on evaluating interventions designed to alter the school curriculum, improve support for teachers, or change the institutional mindset in schools, as summarized in Table 4.

Interventions that have the potential to improve school achievement and reduce school dropout rates by improving the health of students are of particular interest to health professionals. These school-based interventions include coordinated school health programs; health clinics; mental health programs; substance abuse prevention and treatment programs; comprehensive sex education, human immunodeficiency virus infection prevention, and pregnancy prevention programs; special services for pregnant and parenting teens; violence prevention programs; and interventions to change the schools’ social climate (29,31,43-49). Table 5 lists the approaches that have the potential to reduce dropout rates. Although the focus here is on adolescents, these approaches are also used in elementary and middle schools. In addition, community-based programs can also promote adolescent health but are beyond the scope of this article.

Many schools offer several different types of health programs shown in Table 5. However, these activities are seldom coordinated, and they do not target reducing school dropout rates as an outcome. Few innovative or effective programs have gone beyond pilot studies or have been provided funding that assured sustainability. Evaluation studies that assess the impact of health programs on school dropout rates are rare, a disturbing gap given the importance of school dropout as a health, social justice, and economic issue. As a result, a comprehensive framework explaining the mechanisms by which various types of health programs reduce dropout rates is not available, making it difficult for school or health officials to select the most effective interventions for their setting.

Back to top

Recommendations

Although evidence shows that education is an important determinant of health and that changes in school policy can improve educational outcomes, public health professionals have seldom made improving school completion rates a health priority. In addition, poor health interferes with children’s capacity for education, and a variety of school-based health interventions have the potential to improve school achievement. With a few important exceptions, health providers have not developed lasting partnerships with schools, nor have researchers provided the evidence needed to improve or replicate health programs that can reduce school dropout rates.

Improving graduation rates is a specific objective that can bring health professionals and educators together for research, intervention, and advocacy to improve the lives and well-being of young people. We suggest five priorities for action. Local implementation will, of course, depend on which constituencies are mobilized, but every community can take some action to make the link between health and school completion a priority for action.

1. Target schools and cities with the most serious dropout problems for intensive intervention. In the United States, about 1000 high schools fail to graduate half their students, and in more than 20 cities at least three-quarters of high school students attend schools where fewer than 60% of students graduate (14). These appalling statistics undermine health, economic development, and social justice, and they serve as powerful generators of disparities in health. To reduce school dropout rates, the National Research Council Panel on High-Risk Youth recommended in 1993 that “the primary institutions that serve youth — health, schools, employment, training — are crucial and we must begin with helping them respond more effectively to contemporary adolescent needs. Effective responses will involve pushing the boundaries of these systems, encouraging collaborations between them and reducing the number of adolescents whose specialized problems cannot be met through primary institutions” (59, p. 193). A good first step would be to create state or municipal intersectoral dropout prevention councils in places where there is a disproportionate number of dropouts. Such councils could design, seek funding for, implement, and evaluate the educational, vocational, antipoverty, and health interventions at the intensity and scale needed to improve school completion rates in their areas.
2. Develop, implement, and evaluate health interventions to improve school completion rates. The paucity of research that explores the reciprocal connections between health and school achievement makes the development of a coordinated research agenda that will better identify health-related determinants of children dropping out of school an urgent priority. Such an agenda could guide the selection and evaluation of interventions to reduce dropout rates. Two promising avenues for research are studies of health interventions that better engage young people in their schools and that connect young people to caring adults. Schools that foster student engagement in their studies are more likely to graduate their students (35,60), and young people who feel connected to at least one adult in their school are much more likely to graduate (35). Some intervention research suggests that changes in school climate can increase students’ connection to adults and their level of engagement in their studies (58). Health interventions, including those targeted at sexual and reproductive health, healthy relationships, family health, violence prevention, substance use, and mental health, have the potential to engage young people in schooling and connect them to caring adults.
3. Strengthen support for health education teachers. Developing and implementing new approaches to school-based health education and health services that can reduce dropout rates will require well-trained school health education teachers, nurses, and mental health professionals, each currently in short supply. Better integration between health education and services in the school and community, consistent funding for school health education, partnerships between schools and universities, and strong professional preparation programs for health education teachers can help to reduce dropout rates by addressing student, family, and community health.
4. Advocate for evidence-based interventions that can improve health and reduce dropout rates. Health professionals can play a positive role in the contentious debates about providing services in schools addressing sex education; substance abuse; birth control, pregnancy, and parenting services; violence prevention; and mental health. By bringing evidence of effectiveness and public support into public deliberations on these issues, offering science-based arguments in support of interventions addressing these issues, joining coalitions that can compete effectively in the political arena, and explaining the links between health and education, health professionals can contribute to more informed public participation.
5. Put reducing high school dropout rates on the public health agenda. The public health community can bring its expertise in advocacy to the campaign to make improving graduation rates a high national priority. Simply reframing school dropout as a health issue has the potential to bring new players into the effort — parents, health institutions, young people, civil rights groups — and to encourage public officials to think of the dropout problem as central to community health and as a long-term solution beneficial to population health. Educating the public and policy makers about the long-term benefits of improved school completion (e.g., reductions in socioeconomic and racial/ethnic health disparities, lifetime health care costs, unhealthy behavior) can provide additional incentives for action. More specifically, public health professionals can advocate for good school health programs and can encourage administrators of these programs to make improving school completion a key objective. As citizens, taxpayers, parents, and advocates for social justice, public health professionals can join the fight for equitable funding and staffing of schools as well as advocating for school systems to be rated on their success in improving school completion through fair and equitable means.

Back to top

Conclusion

Seldom have health and education professionals been in a better position to work together to achieve common goals. Rarely has a single problem — high school dropout rates — contributed to so many adverse social, economic, and health conditions. Our nation’s young people deserve no less than a concerted effort to improve school completion rates and thus give young people a gateway to lifetime health and success.

It is not possible to eliminate health disparities without simultaneously reducing disparities in educational achievement. The populations that are most severely affected by the epidemics that have threatened this nation’s health in the last several decades are the populations most at risk of dropping out of school. By bringing together programs to improve health and school achievement and by making reducing school dropout rates a public health, educational, and human rights priority, public health professionals have the opportunity to make a lasting contribution to promoting population health and social justice.

Back to top

Author Information

Corresponding Author: Nicholas Freudenberg, DrPH, Distinguished Professor of Urban Public Health, Hunter College School of Health Sciences, City University of New York, 425 E 25th St, New York, NY 10010. Telephone: (212) 481-4363. E-mail: nfreuden@hunter.cuny.edu.

Author Affiliation: Jessica Ruglis, Graduate Center, City University of New York, New York, New York.

Back to top

References

1. Deaton A. Policy implications of the gradient of health and wealth. Health Aff (Millwood) 2002;21(2):13-30.
2. Winkleby M, Jatulis D, Frank E, Fortmann SP. Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease. Am J Public Health 1992;82(6):816-20.
3. Cutler DM, Lleras-Muney A. Education and health: evaluating theories and evidence. NBER working paper No. W12352. Cambridge (MA): National Bureau of Economic Research; 2006. http://papers.ssrn.com/sol3/papers.cfm?abstract_id=913315 *
4. Molla M, Madans J, Wagener D. Differentials in adult mortality and activity limitation by years of education in the United States at the end of the 1990s. Popul Dev Rev 2004;30:625-46.
5. Lantz PM, House JS, Lepkowski JM, Williams DR, Mero RP, Chen J. Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults. JAMA 1998;279(21):1703-8.
6. Crimmins EM, Saito Y. Trends in healthy life expectancy in the United States, 1970–1990: gender, racial, and educational differences. Soc Sci Med 2001;52(11):1629-41.
7. Educational attainment in the United States: March 2002. Washington (DC): U.S. Census Bureau. http://www.census.gov/population/pop-profile/dynamic/EdAttainment.pdf. Accessed December 1, 2006. Updated November 8, 2005.
8. Day J, Newburger E. The big payoff: educational attainment and synthetic estimates of work-life earnings. Current Population Reports. Washington (DC): U.S. Census Bureau; 2002.
9. Ross C, Wu C. The links between education and health. Am Sociol Rev 1995;60:719-45.
10. Ross CE, Mirowsky J. Explaining the social patterns of depression: control and problem solving — or support and talking? J Health Soc Behav 1989;30(2):209-19.
11. Woolf SH, Johnson RE, Phillips RL, Philipsen M. Giving everyone the health of the educated: an examination of whether social change would save more lives than medical advances. Am J Public Health 2007;97(4):679-83.
12. Thrane C. Explaining educational-related inequalities in health: mediation and moderator models. Soc Sci Med 2006;62(2):467-78.
13. Abrams L, Haney W. Accountability and the grade 9 to 10 transition: the impact on attrition and retention rates. In: Orfield G, ed. Dropouts in America: confronting the graduation rate crisis. Cambridge (MA): Harvard Education Press; 2004. p. 181-205.
14. Swanson CB. Who graduates? Who doesn’t? A statistical portrait of public high school graduation, class of 2001. Washington (DC): The Urban Institute; 2004. http://www.urban.org/UploadedPDF/410934_WhoGraduates.pdf *
15. Balfanz R, Legters NE. Locating the dropout crisis: which high schools produce the nation’s dropouts? In: Orfield G, ed. Dropouts in America: confronting the graduation rate crisis. Cambridge (MA): Harvard Education Press; 2004. p. 57-84.
16. Rumberger RW. Why students drop out of school. In: Orfield G, ed. Dropouts in America: confronting the graduation rate crisis. Cambridge (MA): Harvard Education Press; 2004. p. 131-56.
17. Rosenthal B. Nonschool correlates of drop-out: an integrative review of the literature. Child Youth Serv Rev 1998;20:413-33.
18. Ekstrom RB, Goertz ME, Pollack JM, Rock DA. Who drops out of high school and why? Findings from a national study. Teach Coll Rec 1986;87:356-73.
19. Lehr C, Hansen A, Sinclair M, Christenson S. Moving beyond dropout towards school completion: an integrative review of data-based interventions. School Psych Rev 2003;32:342-64.
20. National Dropout Prevention Center/Network. Why students drop out. Clemson (SC): Clemson University; 2002. www.dropoutprevention.org/stats/quick_facts/why_drop.htm.* Accessed June 8, 2006.
21. Ensminger ME, Lamkin RP, Jacobson N. School leaving: a longitudinal perspective including neighborhood effects. Child Dev 1996;67(5):2400-16.
22. Battin-Pearson S, Abbott RD, Hill KG, Catalano RF, Hawkins JD, Newcomb MD. Predictors of early high school dropout: a test of five theories. J Educ Psychol 2000;92:568-82.
23. Rumberger RW, Thomas SL. The distribution of dropout and turnover rates among urban and suburban high schools. Sociol Educ 2000;73:39-67.
24. Wehlage GG, Rutter RA. Dropping out: how much do schools contribute to the problem? Teach Coll Rec 1986;87:374-92.
25. Garcia-Reid P, Reid R, Peterson N. School engagement among Latino youth in an urban middle school context: valuing the role of social support. Educ Urban Soc 2005;37:257-75.
26. Rumberger RW, Palardy GJ. Does segregation still matter? The impact of student composition on academic achievement in high school. Teach Coll Rec 2005;107:1999-2045.
27. Lynskey M, Hall W. The effects of adolescent cannabis use on educational attainment: a review. Addiction 2000;95(11):1621-30.
28. Yamada T, Kendix M, Yamada T. The impact of alcohol consumption and marijuana use on high school graduation. Health Econ 1996;5(1):77-92.
29. Brindis C, Philliber S. Room to grow: improving services for pregnant and parenting teenagers in school settings. Educ Urban Soc 1998;30:242-60.
30. Brooks-Gunn J, Guo G, Furstenberg F. Who drops out of and who continues beyond high school? A 20-year follow-up of black urban youth. J Res Adolesc 1993;3:271-94.
31. Haynes NM. Addressing students’ social and emotional needs: the role of mental health teams in schools. J Health Soc Policy 2002;16(1-2):109-23.
32. Fine M, Zane N. Bein’ wrapped too tight: when low-income women drop out of high school. In: Weis L, Farrar E, Petrie H, eds. Dropouts from school: issues, dilemmas, and solutions. Albany (NY): State University of New York Press; 1989. p. 23-53.
33. Farahati F, Marcotte DE, Wilcox-Gok V. The effects of parents’ psychiatric disorders on children’s high school dropout. Econ Educ Rev 2003;22:167-78.
34. Fine M. Why urban adolescents drop into and out of public high school. Teach Coll Rec 1986;87:393-409.
35. National Research Council, Committee on Increasing High School Students’ Engagement and Motivation to Learn. Engaging schools: fostering high school students’ motivation to learn. Washington (DC): National Academies Press; 2004.
36. McPartland JM, Jordan WJ. Essential components of high school dropout-prevention reforms. In: Orfield G, ed. Dropouts in America: confronting the graduation rate crisis. Cambridge (MA): Harvard Education Press; 2004. p. 269-88.
37. Somers C, Piliawsky M. Drop-out prevention among urban, African American adolescents: program evaluation and practical implications. Preventing School Failure 2004;48:17-22.
38. Weis L, Farrar E, Petrie H, eds. Dropouts from school: issues, dilemmas, and solutions. Albany (NY): State University of New York Press; 1989.
39. Kerr KA, Legters NE. Preventing dropout: use and impact of organizational reforms designed to ease the transition to high school. In: Orfield G, ed. Dropouts in America: confronting the graduation rate crisis. Cambridge (MA): Harvard Education Press; 2004. p. 221-42.
40. Montecel M, Cortez J, Cortez A. Dropout-prevention programs: right intent, wrong focus, and some suggestions on where to go from here. Educ Urban Soc 2004;36:169-88.
41. Osher DM, Sandler S, Nelson CL. The best approach to safety is to fix schools and support children and staff. New Dir Youth Dev 2001;92:127-53.
42. Sellstrom E, Bremberg S. Is there a “school effect” on pupil outcomes? A review of multilevel studies. J Epidemiol Community Health 2006;60(2):149-55.
43. Coordinated school health programs. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. http://www.cdc.gov/healthyyouth/CSHP/. Accessed July 26, 2006.
44. Morone JA, Kilbreth EH, Langwell KM. Back to school: a health care strategy for youth. Health Aff (Millwood) 2001;20(1):122-36.
45. Elliott L, Orr L, Watson L, Jackson A. Secondary prevention interventions for young drug users: a systematic review of the evidence. Adolescence 2005;40(157):1-22.
46. Silva M. The effectiveness of school-based sex education programs in the promotion of abstinent behavior: a meta-analysis. Health Educ Res 2002;17(4):471-81.
47. Card JJ. Teen pregnancy prevention: do any programs work? Annu Rev Public Health 1999;20:257-85.
48. Mytton J, DiGuiseppi C, Gough DA, Taylor RS, Logan S. School-based violence prevention programs: systematic review of secondary prevention trials. Arch Pediatr Adolesc Med 2002;156(8):752-62.
49. Cohen J. Social, emotional, ethical and academic education: creating a climate for learning, participation in democracy and well-being. Harv Educ Rev 2006;76:201-37.
50. Stewart-Brown S. What is the evidence on school health promotion in improving health or preventing disease and, specifically, what is the effectiveness of the health promoting schools approach? Health Evidence Network report. Copenhagen (DK): WHO Regional Office for Europe; 2006. http://www.euro.who.int/document/e88185.pdf.* Accessed June 2, 2007.
51. Lear JG, Issacs SL, Knickman JR, Lavizzo-Mourey R, eds. School health services and programs. San Francisco (CA): Jossey-Bass; 2006.
52. Geierstanger SP, Amaral G, Mansour M, Walters SR. School-based health centers and academic performance: research, challenges, and recommendations. J Sch Health 2004;74(9):347-52.
53. Kratochwill TR, Albers CA, Shernoff ES. School-based interventions. Child Adolesc Psychiatr Clin N Am 2004;13(4):885-903, vi-vii.
54. Gottfredson D, Wilson D. Characteristics of effective school-based substance abuse prevention. Prev Sci 2003;4(1):27-38.
55. Kirby DB, Laris BA, Rolleri LA. Sex and HIV education programs: their impact on sexual behaviors of young people throughout the world. J Adolesc Health 2007;40(3):206-17.
56. Coren E, Barlow J. Individual and group-based parenting programmes for improving psychosocial outcomes for teenage parents and their children. Cochrane Database Syst Rev 2001;(3):CD002964.
57. Mytton J, DiGuiseppi C, Gough D, Taylor R, Logan S. School-based secondary prevention programmes for preventing violence. Cochrane Database Syst Rev 2006;3:CD004606.
58. Patton GC, Bond L, Carlin JB, Thomas L, Butler H, Glover S, et al. Promoting social inclusion in schools: a group-randomized trial of effects on student health risk behavior and well-being. Am J Public Health 2006;96(9):1582-7.
59. Panel on High-Risk Youth, Commission on Behavioral and Social Sciences and Education, National Research Council. Losing generations: adolescents in high-risk settings. Washington (DC): National Academies Press; 1993.
60. Bonny AE, Britto MT, Klostermann BK, Hornung RW, Slap GB. School disconnectedness: identifying adolescents at risk. Pediatrics 2000;106(5):1017-21.

Back to top