|Concept to Action
Using Coordination, Partnerships, and Leadership to Plan and
Infrastructure: Essential Elements
Responding to Public Policy Challenges
Facing Health and Education
Roles for Everyone
Current State and Local
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.
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
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
What do we mean by "health
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
- 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
- Healthy People 2010 has two
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
- Increase quality and years of healthy
- Eliminate health disparities that
occur by gender, race or ethnicity, education or income, disability, living in rural
localities, or sexual orientation
What are examples of health
There are countless examples of
health disparities to examine and address. The following is a mere snapshot of some
- 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
- Men are two times more likely than
women to die from unintentional injuries and 4 times more likely to die from
- 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
- 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).
- 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
- 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.
- In general, population groups that
suffer the worst health status are also those that have the highest poverty rates and
- 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
- 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.
- 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 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
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
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
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
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.
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
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.
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
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:
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:
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. 2nd ed. Washington, DC: U.S. Government