Public Policy Challenges

Concept to Action

Using Coordination, Partnerships, and Leadership to Plan and Implement CSHPs

Developing State Infrastructure: Essential Elements

Responding to Public Policy Challenges Facing Health and Education

Communications

Related Initiatives

Roles for Everyone

Action Steps

Current State and Local Initiatives

Responding to Public Policy Challenges Facing Health and Education

This section summarizes some contemporary challenges to public policy and programming in the related areas of health and education. It further indicates how the coordination of school health programs constitutes a solid strategy for dealing with such issues.

Health Disparities

The U.S. Department of Health and Human Services' Healthy People 2010 set the prevention agenda for the nation. Healthy People 2010 a statement of national health objectives designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats. It calls on community partnerships to achieve two goals: (1) to increase quality and years of healthy life, and (2) to eliminate health disparities among different segments of the population.

While remarkable improvements have occurred in the quality of life for Americans overall (e.g., life expectancy, reduced infant mortality), many Americans from some racial and ethnic groups have not enjoyed those gains. Studies consistently show that select minority populations have poorer health and reduced life expectancy as well as higher rates of infant mortality, diabetes, heart disease, HIV/AIDS, and mental health problems (U.S. Department of Health and Human Services, 2000).

These disparities exist because of differences in access to health and mental health care, differences in the quality of care received, different rates of lifestyle behaviors that affect health, the complex effects of poverty, and many other factors.

Health Disparities: A Few Facts

What do we mean by "health disparities"?
Health disparities are differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States.¹

Why talk about health disparities?²

Reducing health disparities is not only an essential goal for achieving justice and equity in our communities, our country, and our planet, but it is also now US federal policy.

US Department of Health and Human Services has articulated a goal to eliminate the disparities in six areas of health status (infant mortality, cancer, cardiovascular disease, diabetes, HIV infection, and immunizations) experienced by racial and ethnic minority populations.
These six health areas were selected for emphasis because they reflect areas of disparity that are known to affect multiple racial and ethnic minority groups at all life stages.
Each of the 27 institutes within the National Institutes of Health has developed a strategic plan for reducing health disparities
Healthy People 2010 has two overarching goals:

Increase quality and years of healthy life
Eliminate health disparities that occur by gender, race or ethnicity, education or income, disability, living in rural localities, or sexual orientation

Health disparities have implications for HHD's efficacy in promoting health, justice, and positive development
Dialogue can help us understand health disparities and examine how to address them in our work

What are examples of health disparities?

There are countless examples of health disparities to examine and address. The following is a mere snapshot of some striking points.

Gender

Men have a life expectancy that is 6 years less than women and have higher death rates for each of the 10 leading causes of death.
Men are two times more likely than women to die from unintentional injuries and 4 times more likely to die from firearm-related injuries.
Women have shown increased death rates over the past decade where men have shown declines, such as lung cancer.
Women are at a greater risk for Alzheimer's disease than men and are twice as likely as men to be affected by major depression.
Females have poorer outcomes following a heart attack than do males: 44 percent of females who have a heart attack die within a year, compared with 27 percent of males.
The proportion of AIDS cases in white men who have sex with men had declined, whereas the proportion in females and males in other racial and ethnic populations has increased.
Men are more likely to smoke than women (28 percent compared to 22 percent).

Race/Ethnicity

African Americans have substantially higher rates of death for infant mortality (100% higher), heart disease (40% higher), cancer (30% higher), HIV/AIDS (600% higher), homicide (500% higher) than Whites.
55 percent of all reported AIDS cases in the US have occurred among African Americans and Hispanics, even though they represent an estimated 13 percent and 12 percent, respectively, of the total US population.
An African-American baby is 2.5 times more likely to die in the first year of life than a White baby; a Hispanic baby is two times more likely and a Native American baby is 1.5 times more likely to die than a White baby.
African Americans are victims of homicide at 5.7 times the rate of Whites. Young African American men aged 15 to 24 are over 8 times more likely to be murdered than adult White men.
While suicidal behavior among all youth has increased, rates for African American youth have shown a greater increase.
Approximately 31 percent of Hispanics lack health insurance coverage, a rate that is double the national average of 14 percent. Mexican-Americans had one of the highest uninsured rates at 35 percent.
The recent decrease in breast cancer deaths in White women does not extend to African American women, whose breast cancer deaths are the highest among all groups and increasing.
Among adolescents, Whites and Hispanics are more likely than African Americans to use alcohol; Whites are more likely than African Americans and Hispanics to use tobacco and illicit drugs.
Asians and Pacific Islanders, on average, are one of the healthiest populations groups in the US. However, there is marked diversity within this group; e.g., Vietnamese women suffer from cervical cancer at nearly 5 times the rate for White women.

Income/Education

In general, population groups that suffer the worst health status are also those that have the highest poverty rates and least education.
Income inequality in the United States has increased over the past three decades. Recent health gains for the U.S. population as a whole appear to reflect achievements among the higher socioeconomic groups; lower socioeconomic groups continue to lag behind.
30 percent of those under the poverty level lack health insurance; 7 percent of those of middle/high income lack health insurance.
Poverty is strongly related to unsuccessful use of reversible contraceptive methods. Half of all females at risk for an unintended pregnancy who need subsidized family planning services are not getting them.
Individuals with 16 or more years of education have the lowest smoking rates (12 percent). Individuals below the poverty level are significantly more likely to smoke than individuals at or above it.
Lower income individuals have higher levels of obesity (29 percent) as compared to those with higher incomes (21 percent).
Women who are poor, have little formal education, and are on welfare or are unemployed are more likely to experience depression than other women.
Less than 10 percent of Whites live below the poverty level, while nearly 30 percent of Hispanics and African Americans are below the poverty level.

Sexual Orientation

Lesbian, gay, bisexual, and transgender (LGBT) populations have been among those for whom little or no national-level health data exist. Some State-level data from CDC's Youth Risk Behavioral Surveillance System and other research studies indicate that LGBT populations have health disparities related to sexual orientation or gender identity.³
Gay male adolescents are two to three times more likely than their peers to attempt suicide. Some evidence suggests lesbians have higher rates of smoking, obesity, alcohol abuse, and stress than heterosexual women.
Lesbian women are at a higher risk for breast cancer than heterosexual women.

1. National Institutes of Health. Addressing Health Disparities: The NIH Program of Action. http://healthdisparities.nih.gov/whatare.html

2. This section was excerpted and adapted from: U.S. Department of Health and Human Services. (2000). Healthy People 2010. Washington, DC: Author.

3. Gay and Lesbian Medical Association. (2001). A Healthy People 2010: Companion Document for Lesbian, Gay, Bisexual, and Transgender Health. http://www.glma.org/policy/hp2010/index.html

Disparities prevail in several areas, including the following:

Physical Inactivity
Obesity/Poor Nutrition
Tobacco Use
HIV, Other Sexually Transmitted Diseases (STDs), and Unintended Pregnancy

Physical Inactivity

Physical inactivity threatens to reverse the decades-long progress the country has made in reducing death from cardiovascular disease. Inactivity has contributed to an unprecedented epidemic of childhood obesity (see below). Numerous obstacles exist: dependence on cars, reductions in physical education requirements in schools, a proliferation of sedentary activities for children, and safety concerns that limit children's outdoor play (Secretary of Health and Human Services and Secretary of Education, 2000).

Physical inactivity is a problem for the vast majority of Americans, with only 22 percent of adults engaging regularly (i.e., a minimum of five times a week for at least 30 minutes) in sustained physical activity during leisure time. However, such inactivity is even more prevalent among women than men, among African Americans and Hispanics than whites, and among the less affluent than the more affluent (U.S. Department of Health and Human Services, 1996). Among young people, white students (67.4 percent) are significantly more likely than African American students (55.6 percent) to report vigorous physical activity, and white female students (59.7 percent) are significantly more likely than Hispanic and African American female students (49.5 and 47.2 percent, respectively) to report vigorous physical activity. This pattern holds true for moderate activity as well, with white students (28.8 percent) being more likely to report moderate levels of physical activity than Hispanic and African American students (21.4 and 20.9 percent, respectively) (Centers for Disease Control and Prevention, 2000).

CSHPs provide a strategy for increasing physical activity through physical education, particularly the "new PE," which emphasizes individual fitness rather than competition.

Obesity/Poor Nutrition

Childhood obesity has reached epidemic proportions, with 4.7 million youths, ages 6 to 17, now overweight or obese. (CITATION - See SHPN 1/2001)

"The environment we live in today makes obesity easy in several ways. We are surrounded by a virtually limitless supply of inexpensive, good-tasting foods that are easily accessible," according to a recent report of the International Life Sciences Institute. Unfortunately, the "limitless supply" is also available at most schools through vending machines, school stores, snack bars, and a la carte sales in cafeterias.

Obesity is closely associated with diabetes, a serious, costly, and increasingly common chronic disease that affects nearly 16 million Americans and contributes to almost 200,000 deaths a year. An estimated 10.3 million Americans have diagnosed diabetes, and another 5.4 million have undiagnosed diabetes. Among adults, the prevalence of diagnosed diabetes increased 33 percent from 1990 to 1998. Diabetes and its complications have their greatest impact on the elderly and on certain racial and ethnic populations. More than 18 percent of adults older than age 65 have diabetes; American Indians and Alaska Natives are 2.8 times more likely to have diagnosed diabetes than non-Hispanic whites of similar age. In addition, African Americans are two times more likely than whites to die of diabetes (Centers for Disease Control and Prevention, 2001).

Treatment of obesity in adults rarely meets with long-term success. Prevention is the best hope for decreasing the prevalence of this condition and its many resultant health problems. The roots of obesity for many adults can be traced back to childhood. The presence of obesity at any age will increase the risk of persistence at subsequent ages. Obese infants are at increased risk of becoming obese children, who are in turn more likely to become obese adolescents and adults (Moran, 1999).

A decade ago, the National School Lunch Program, based on principles of good nutrition, was the primary provider of foods for students at schools. Today, in middle/junior and senior high schools, commercial options prevail, with less nutritious offerings. Many schools and districts do not have policies or any formalized review process to evaluate food and beverage service.

CSHPs provide strategies for school districts to analyze these issues and to take action consistent with local concerns and health goals through Nutrition Services, Comprehensive School Health Education, Health Services, and Physical Education.

Tobacco

Tobacco use is the single leading preventable cause of death in the United States. According to the national Youth Risk Behavior Survey, frequent cigarette use among U.S. high school students increased from 12.7 percent in 1991 to 16.8 percent in 1999, while lifetime cigarette use fluctuated yet changed very little during this time period (70.1 percent in 1991 and 70.4 percent in 1999). Nationwide, 32.8 percent of students reported using tobacco on at least 1 of the 30 days prior to survey administration in the form of cigarettes, smokeless tobacco, or cigars. Overall, white and Hispanic students (36.2 and 31.3 percent respectively) were significantly more likely than black students (20.9 percent) to report current tobacco use (Centers for Disease Control and Prevention, 2000).

Among its many effects, tobacco use exacerbates asthma. "Today asthma affects 15 million people, including nearly 5 million under the age of 18, and it accounts for an estimated 10 million lost school days annually," said CDC health scientist Mary Vernon-Smiley. The impact of asthma is disproportionately felt among minority children, with African Americans being two to six times more likely to die from asthma than the general population (Centers for Disease Control, 2001).

To assist schools in tobacco prevention efforts, the Surgeon General, CDC/DASH and non-governmental organization have identified effective strategies and programs that combine education/curricula, school-community partnerships, and legal enforcement efforts. These are summarized in CDC's Best Practices for Tobacco Control Programs.

CSHP components that address comprehensive tobacco prevention include Family and Community Involvement, Comprehensive School Health Education, Health Services, and Healthy School Environment, as well as linkage and coordination with community initiatives.

HIV Infection, Other Sexually Transmitted Diseases (STDs), or Unintended Pregnancy

Sexual risk-taking activity that can lead to HIV, other STDs, and unintended pregnancy has reached epidemic proportions in many communities. Nowhere is this situation more serious than among adolescents in communities of color. Sexual risk-taking is complex, involving both the individuals themselves and their partners, friends, families and communities. These factors have a broad array of antecedents, many of which are some manifestation of poverty and social disorganization (Kirby, 1997).

The number of young people who contract HIV/AIDS has remained steady year after year, with half of new HIV infections in the United States occurring among those under age 25. Young Americans ages 13 to 25 continue to be infected at a rate of two new cases per hour, and public health officials estimate that 20,000 people in this age group are infected annually. Minority youth are disproportionately affected by HIV and AIDS. African Americans account for 49 percent of the AIDS cases among those ages 13 to 19, and 67 percent of HIV infections reported in this age group. Hispanics represent 20 percent of AIDS cases among adolescents (Office of National AIDS Policy, 2000).

Halting the spread of STDs, HIV, and unintended pregnancy requires multiple, integrated strategies for addressing the many-faceted risk and protective factors involved. Studies have concluded, for example, that strong educational programs combined with the provision of contraceptives may reduce high-risk sexual behavior among adolescents (Kirby, 1997).

CSHP components that address comprehensive sexuality education and disease prevention include Family and Community Involvement, Comprehensive School Health Education, and School Health Services.

Establishing Local and State Policies on Education and Health Challenges

Superintendents, principals, school board members, public health professionals, community leaders, family members, teachers, and state officials may develop specific local policies that address these national public policy challenges. They may take actions that implement one or more of the eight CSHP components or that bring community policies and practices in line with the CSHP message.

Schools can partner with local government, public agencies (e.g., social service departments, law enforcement), and private organizations (e.g., community action agencies, convenience stores) to effect policy changes (e.g., limit the availability of harmful substances and weapons) that impact the behavior of the young people they serve.

Although your community may need to create some new policies, many good policies are probably already in place and will primarily require work to promote consistent enforcement.

The National School Boards Association (NSBA) maintains the School Health Resource Database. It contains a sample of school district policies on a wide range of school health topics, including those listed above. At the NSBA School Health Programs website, you can do an online search of selected Database items and/or request staff to search the entire Database.

The National Association of State Boards of Education provides specific policy guidance on such subjects as health, at-risk students, and special education. It maintains policy updates on its website.

References

Centers for Disease Control and Prevention (June 2000). CDC surveillance summaries. MMWR 2000, 49 (SS-5).

Centers for Disease Control and Prevention (2001). Asthma: 10 million school days lost each year. Chronic Disease Notes & Reports, 14, 18.

Centers for Disease Control and Prevention (2001). Diabetes: A Serious Public Health Problem At A Glance 2001. Available online at: http://www.cdc.gov/diabetes/pubs/glance.htm#growing.

Kirby, D. (1997). No Easy Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, DC: National Campaign to Prevent Teen Pregnancy.

Moran, R. (February 1999). Evaluation and Treatment of Childhood Obesity. American Family Physician. Leawood, KS: American Academy of Family Physicians.

Office of National AIDS Policy (October 2000). Youth and HIV/AIDS 2000: A New American Agenda. Washington, DC: The White House, Office of National AIDS Policy.

Secretary of Health and Human Services & Secretary of Education (2000). Promoting Better Health for Young People Through Physical Activity and Sports: A Report to the President. Atlanta: CDC.

Team Nutrition (2001). Healthy School Nutrition Environments: Promoting Healthy Eating Behaviors. Available online at: http://www.fns.usda.gov/tn/Healthy/healthyeatingchallenge.html.

U.S. Department of Health and Human Services (1996). Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion.

U.S. Department of Health and Human Services (2000, November). Healthy People 2010: Understanding and Improving Health. 2^nd ed. Washington, DC: U.S. Government Printing Office.

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