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Exploring the Role of the Health Sector in Supporting Educational Success and Improving Outcomes

In this session, panelists discussed more specifically how the health sector can contribute to improving educational outcomes and how public health and health care tools can be used to support educational success. Charles Basch of the Columbia University Teachers College opened the session with an overview of eight high-prevalence health barriers to learning and the pathways by which these barriers impact educational outcomes. The discussion that followed was moderated by Robert Kaplan of Stanford University.

A panel of five experts then presented current examples of the types of health interventions that are being deployed by or in the speakers’ organizations to improve educational outcomes. Megan Collins of Johns Hopkins University shared an example of school-based vision care delivery. Kimi Sakashita of the Alameda County Center for Healthy Schools and Communities discussed the implementation of school-based health centers in Alameda County, California. Jill Halterman of the University of Rochester School of Medicine and Dentistry discussed partnering with schools to improve asthma care for students (via videoconference). Heidi Schumacher of the District of Columbia Office of the State Superintendent of Education described engaging pediatricians in efforts to address chronic absenteeism, including sharing school attendance data with students’ health care providers. Jennifer Dillaha of the Arkansas Department of Health discussed how Arkansas has used school-based influenza (flu) vaccination as a tool to reduce school absenteeism. The discussion that followed the panel presentations was moderated by

Joaquin Tamayo of Stand for Children. (Highlights of this session are presented in Box 3-1.)

HOW THE HEALTH SECTOR CAN IMPROVE EDUCATIONAL OUTCOMES

Schools are one of the key social institutions that shape children’s lives, Basch said. As outlined by Woolf, education affects health, longevity, income, and employment. While the reverse connection between health and education might seem obvious, research to understand how health factors impact educational outcomes has essentially only taken place over the past two decades.

Regardless of how well prepared and effective the teachers are, how rigorous the curriculum is, how the school is organized and financed, or which measures of accountability are in place, the benefits of education will be limited if students are not motivated and ready to learn, Basch said. There are certain health problems that have profound and often overlooked effects on students’ motivation and ability to learn, he continued. The reciprocal relationships among health, education, and economic conditions exist within the larger context of the social determinants of health. These factors include racism and discrimination, parenting, community economic conditions, government policies, housing and segregation, media, and family and social support. For this workshop, Basch focused his discussion specifically on urban minority youth from low-income families, school-age youth, and health problems that can be feasibly and effectively addressed by schools.

Strategic Priorities

Schools cannot address all of the health needs of youth, Basch said, and strategic priorities could be selected based on

• prevalence of health disparities;
• evidence that certain health problems have causal effects on educational outcomes; and
• feasibility and effectiveness of school-based programs and policies to address these problems.

Based on these criteria, Basch selected eight high-prevalence health barriers to learning as strategic priorities: poor vision, poorly controlled asthma, teen pregnancy, aggression and violence, physical inactivity, skipping breakfast and hunger, attention-deficit/hyperactivity disorder (ADHD), and oral health problems (see Box 3-2). Basch added that there is a wide range of mental and emotional health problems that can be a cause or a consequence of these health barriers. For example, one survey reported that nearly 30 percent of high school students “felt so sad or hopeless almost every day for 2 or more weeks in a row that they stopped doing some usual activities” (Kann et al., 2016, p. 12). As mentioned by Woolf, adverse childhood experiences and toxic stress have long-term consequences for health, longevity, and overall quality of life.

Causal Pathways

There are five different causal pathways that affect educational outcome: sensory perceptions, cognition, school connectedness and engage-

ment, absenteeism, and temporary or permanent dropping out, Basch said. There are reciprocal causal relationships between these pathways. For example, a student who is struggling to succeed in school might feel less connected and might be less likely to attend, and chronic absenteeism leads to greater risk of dropping out. Basch briefly reviewed the five causal pathways (see Box 3-3) in relation to the eight priority health barriers.

Sensory Perception

• Good vision is key to foundational literacy and numeracy skills, Basch said, and poor visual acuity at a near distance is inversely

• associated with acquiring literacy skills. Inability to see at a far distance will affect students’ ability to read material on the board. Focusing ability is also important, as students must quickly look up and down, shifting their eyes from a far to a near distance. Tracking skills are essential for learning how to read words across a line and advance to the next line.
• Children with ADHD appear to have more ophthalmic problems and sensory impairments related to the perception of time and timing mechanisms, which are essential in completing a sequence of math steps and solving a problem, for example.

Cognition

Cognition involves thinking skills, such as working memory, focusing attention, completing tasks, listening and integrating information, organizing and planning, and regulating emotions. Six of the eight health factors are related to cognition, which demonstrates the multifactorial etiology of educational outcomes.

• Visual motor integration (the connections between one’s eyes and brain) are associated with reading, math, spelling, and standardized test scores.
• Aggression and violence are associated with intrusive thoughts, and the subconscious mind plays an important role in in learning, behavior, and performance. For example, worrying about being harassed or bullied affects learning ability both at school and at home. Disruptive behavior in the classroom influences teaching and learning.
• More than 2,000 years ago, the Greeks intuitively knew that a strong mind and a strong body were integrally related, Basch said. Recent advances in molecular biology and neuroscience elucidated the causal mechanisms through which physical activity influences brain chemistry and cognitive function. He lamented that, despite the evidence, physical education programs are being cut throughout the country to spend more time on improving standardized test scores.
• Skipping breakfast and hunger can affect alertness, focusing attention, memory, and problem solving. Basch said that the American Academy of Pediatrics’ analyses of longitudinal studies have shown that food insecurity in kindergarten students predicts reduced academic achievement in math and reading over a 4-year period.
• Poorly controlled asthma affects sleep, which is essential for brain health and memory consolidation.

• ADHD affects cognitive processing, memory, visual attention, recall of factual information, and comprehension.

Connectedness

School connectedness is about students’ relationships with peers and school staff such that they feel cared about and have a sense of belonging, Basch said. A sense of connectedness fosters attendance. Connectedness is affected by the same six health factors as cognition.

• Uncorrected vision problems cannot be overcome by trying harder. Young students trying to learn to read can become frustrated, demoralized, and disengaged.
• Children with poorly controlled asthma struggle in school. They tend to have more anxiety, more comorbidities, disrupted sleep, and difficulty succeeding in school.
• A school where bullying and aggression persist is not a place where students will want to be.
• Physical activity has significant potential to foster school connectedness by helping students learn about teamwork, cultivate relationships, support one another, persevere, and learn non-cognitive “soft” skills.
• Eating together is another way to foster a cohesive culture. Providing food for students at school can help to express caring and cultivate community.
• Students with ADHD have difficulty developing relationships with other students and often do not have many friends.

Absenteeism

Absenteeism is a major factor affecting school achievement, Basch said. Chronic absenteeism (missing 10 percent or more days per year) in the earliest grades leads to lower rates of reading on grade level, which in turn leads to higher dropout rates. Chronic absenteeism in middle and high school is a strong predictor of high school graduation. Six of the eight health factors also have an effect on absenteeism: asthma, aggression and violence, physical activity, breakfast, ADHD, and oral health problems.

Dropping Out of School

Temporarily or permanently, dropping out of school has both short- and long-term consequences.

• Teen pregnancy is strongly associated with dropping out of school. Even after adjusting for other known covariates, teen mothers are 10–12 percent less likely to complete high school and have 14–29 percent lower odds of attending college.
• Students with ADHD are more than twice as likely to drop out of school.

Overall, Basch summarized, if a child cannot see well or if the eyes do not integrate with the brain, then that child will have difficulty acquiring basic literacy and numeracy skills. If students’ ability to concentrate, memorize, and make decisions is impeded by ill nourishment, sedentary lifestyle, or distractions, it will be more difficult for them to learn in school. If their relationships with peers are negative, they will be less likely to feel connected and to want to attend. If they are not in school because of uncontrolled asthma, oral health problems, ADHD, or fear of aggression or violence, they will miss important learning opportunities. They are unlikely to succeed if they drop out, perhaps because they are failing or because they believe there will be no better opportunities even if they complete school, or if they became pregnant and there are no resources in place to help them complete school.

Evidence-Based Approaches and Effective Coordination

Many children are affected by multiple problems simultaneously, which may have additive and synergistic effects, Basch said. The most effective programs will be those that focus on multiple health barriers to learning. Schools need to focus on strategic priorities, high-quality evidence-based approaches, and effective coordination, he continued. Strategic priorities should be school specific, based on the magnitude and severity of the problems in the particular locality as well as the feasibility of potential solutions and acceptability of the program to parents, school board members, and the community. Basch noted the complexity of these issues and emphasized the need to use evidence-based programs and ensure that there is effective coordination. He also referred to the Centers for Disease Control and Prevention’s (CDC’s) Whole School, Whole Community, Whole Child initiative mentioned by Woolf, which strives to have a coordinated approach across policy, process, and practice and break down the silos that have traditionally existed across education, health, and social services. He mentioned the concept of data dashboards, which integrate key metrics to help schools identify which children need which services at which point in time. Schools cannot address health barriers to learning by themselves, Basch concluded. Help is needed from

families, health services providers, community organizations, philanthropies, government agencies, and institutions of higher education.

Discussion

Student Quality of Life

Kaplan suggested applying a value analogous to a quality-adjusted life year as a measure of how much quality of life is lost because students are afraid to go to school due to aggression and violence. Basch agreed that loss of quality of life is really the essence of the issue. Schools need to create a culture of kindness where students feel they are cared about and where they are not afraid of taking chances or of being stigmatized for being different. Aggression and violence are critical issues that relate to school culture. He noted that these disparities in health, education, and economics affect the same populations of young people, and a core issue is inequity in educational opportunity.

Hanh Cao Yu from The California Endowment said that many young people with whom the group has engaged talk about the pushout effect; that is, being denied educational opportunity due to various barriers and policies. To help address this, The California Endowment is working on issues such as restorative justice, culturally rooted healing practices, and implicit bias trainings because many of the social determinants of health are deeply rooted in structural inequalities, she said. She asked about the evidence base for the effectiveness of these types of approaches for improving student health and academic success. Basch said that academic achievement has a multifactorial etiology and that considering individual factors might not demonstrate success. For example, providing eyeglasses is a meaningful approach, but if the child is also hungry or has behavioral, mental, or emotional health issues because of exposure to violence, abuse, or neglect, improved vision might have no discernable effect on standardized test scores. He emphasized the need to do what is right and fair and find alternative milestones for measuring success. The participant agreed and said The California Endowment is assessing metrics, such as expulsion and suspension rates, that relate to absenteeism.

Broadening Partnerships and Community Engagement

The cross-sector nature of these issues and the importance of community engagement in addressing them was emphasized by Philip Alberti of the Association of American Medical Colleges. How inequities are measured (e.g., what the comparison group is) is important for how local policy is developed. For example, national health and education outcomes

data on teens who become pregnant show the role of inequities. However, when comparing a teen in a South Bronx school who becomes pregnant to a teen in the same school who does not, it is important to understand the community-level factors at play. Basch agreed with the need to focus on the local and state issues. He noted that the U.S. educational system is fairly unique in the world in that it is decentralized and funding is primarily at the state and local levels. He suggested that this is one reason that the status quo persists. Basch added that one of the only evidence-based teen pregnancy prevention programs in the United States was developed in the South Bronx by Carrera and colleagues at Children’s Aid. The program focuses on cultivating aspirations in young women through whole child education. The program includes academic tutoring, job assistance, financial literacy education, and opportunities for creative arts and lifetime sports.

Denise Chrysler of the University of Michigan School of Public Health said that previously, when she was a member of an urban school board, she was discouraged because she came to feel that the school district had the responsibility to address all of society’s problems at the same time as resources were being cut. She reiterated the point made by Basch that schools cannot address these issues by themselves. Basch agreed with the need for greater engagement of other social institutions within the community. Teachers and staff are overwhelmed, Basch added, and there is a need for additional investment in mental health professionals and school health coordinators, as well as linkages to community organizations that provide health services. He expressed disappointment that institutions of higher education, especially colleges of education, have not been more involved in working directly to address health barriers to learning.

James Allen from Chevron asked about a role for the private sector to invest in a productive workforce for the future. Basch said that business and industry have a vested interest and an important role to play in addressing these issues and that there are examples where industry has made great contributions.

Equity in Access to Education

Joaquin Tamayo of Stand for Children noted the strong American sense of individualism and “pull yourself up by your bootstraps” mentality. Young people are often told by elders that, despite their abilities or circumstances, the responsibility to achieve and succeed is on them. He asked how to balance this sense of agency and individual drive with the societal responsibility to provide effective support systems. The underlying issue, Basch responded, is equal access to education opportunity. Students dealing with any of the priority health barriers do not have equal

access to educational opportunities. It is important to show what can be done at the local and state levels when there is the political will to invest in addressing these issues. There are many examples from communities across the country, he said.

Maryjane Puffer of The Los Angeles Trust for Children’s Health was concerned about the impact of the privatization of education on perpetuating disparities. Basch noted his support for public education and was similarly concerned that the privatization of education has the potential to undermine public school efforts and infrastructure. He suggested that public charter schools can serve as laboratories for testing different ideas to determine what works.

USING PUBLIC HEALTH AND HEALTH CARE TOOLS TO SUPPORT EDUCATIONAL SUCCESS

Tamayo introduced a series of five presenters who shared five examples of collaboration between the health and education sectors, deploying public health and health care tools to improve not only health status but also educational outcomes. Speakers from Arkansas, California, Maryland, New York, and Washington, DC, shared brief case examples of interventions tackling asthma, immunization, behavior, vision, and overall health.

School-Based Vision Care Delivery

Collins, who is a pediatric ophthalmologist, said that focus groups with teachers across Baltimore and Chicago reported that students who are in need of glasses but do not wear any often fidget, squint, or come up to the front of the classroom, and some stop paying attention entirely. As discussed earlier, there is clear risk of impaired academic performance for students who cannot see clearly. Unfortunately, many children who need glasses do not have them, Collins said. From 2014 to 2016, the Baltimore Reading and Eye Disease Study examined 320 second- and third-grade students in 12 schools and provided glasses to those who needed them (Slavin et al., 2018). A surprising finding, Collins said, was that one-third of the students examined reported having worn glasses in the past, but only 6 percent still had them.

Vision problems in children are often first detected in school because most states mandate vision screenings. The State of Maryland, for example, screens students in the grade of first entry, in first grade, and in eighth grade. Seventy-five percent of children aged 13 years or younger do not know they have a vision problem, Collins said (Yawn et al., 1996). Children with vision problems primarily have refractive errors (e.g., near-

sightedness, farsightedness, astigmatism). Simply getting a pair of glasses can help to improve vision.

When a student fails a vision screening, a letter is usually sent home to the parents encouraging them to find an eye doctor in their community. This often involves a long appointment because the child’s eyes are dilated for examination, after which the family may need to go elsewhere to be fitted for glasses. Children often break those glasses, and the parents must go back again to get a new pair. There are challenges at every step, Collins said, and data suggest that, in high-poverty communities, as little as 5 percent of children who fail vision screening are actually getting care in the community. Surveys done by Wills Eye Hospital found that parents were not following up with vision care due to lack of communication (i.e., they did not receive the information from the school), inability to understand the information that was sent home (e.g., language barrier, did not understand the significance of vision for learning), or competing demands on their time and resources.

Vision for Baltimore

The city of Baltimore has been contemplating other ways to provide children with access to eye care. The Vision for Baltimore initiative, started in 2016, is a collaboration among the Baltimore City Health Department, Baltimore City Public Schools District, Johns Hopkins University, Vision to Learn (a nonprofit eye exam provider), and Warby Parker (an eye-wear retailer). The goal of Vision for Baltimore is to bring all aspects of vision care into the schools, Collins said. This includes vision screenings conducted by the health department for every child in the school system. For children who fail the vision screening, information is sent home to parents about how they can have their child’s eye exam done at school in Vision to Learn’s mobile clinic. Eye exams are performed by licensed optometrists, and eyeglasses are prescribed and dispensed as needed. Children can choose from an attractive selection of frames, and the glassed are delivered and fitted 2 to 4 weeks later. Finally, Collins said, there is a replacement program for lost or broken glasses, and there are efforts to educate and engage teachers and parents in monitoring and encouraging eyeglasses use.

As part of this initiative, Johns Hopkins is studying the long-term academic impact of school-based eye care on children’s performance in schools. A pilot study found that providing glasses to children who needed them had a statistically significant impact on reading scores (Slavin et al., 2018).

School-Based Health Centers in Alameda County, California

Alameda County is the sixth largest county in California and one of the most diverse, both culturally and economically. Place matters, Sakashita said, and she noted that African Americans born and living in Oakland’s Flatlands will die, on average, 15 years before whites born and living in the city’s most affluent areas (the Oakland Hills). She emphasized the point made by Woolf and Basch that the conditions that create this gap are complex. If one were to overlay maps of chronic absenteeism or asthma, for example, similar disparities would be observed.

These complex issues cannot be addressed with one intervention or by one organization, Sakashita said. There needs to be a common agenda with shared results across the health and education sectors to achieve measurable and lasting change, she continued. Sakashita envisions a county where all youth graduate from high school healthy and are ready for college and career. School health initiatives are results-driven and strive to ensure that children are physically, socially, and emotionally healthy; they are academically successful; their environments are safe; their families are supported and supportive; systems are integrated; and care is coordinated and equitable. The county works with hundreds of organizations and partners in education, health, businesses, and philanthropy to develop and implement these school health initiatives. Sakashita noted that the goal of these initiatives is not to “fix the kids,” but rather to change the adults. The school health initiatives focus on systems integration and partnerships.

Alameda County’s 29 school health centers are a key health initiative, Sakashita stated.¹ Each center receives a base allocation of around $100,000 per year, and they are required to provide medical, dental, health education, behavioral health, and youth development services. Sakashita said that a results-based accountability model is used to assess how much was done, how well it was done, and whether anyone is better off as a result. Data are collected using client surveys, including a specific module in the California Healthy Kids Survey. Responses from students indicate that the school health center helped them to have goals and plans for the future (91 percent), stay in school (87 percent), do better in school (84 percent), and have better attendance (78 percent).

Social and emotional health metrics can also be assessed through the California Healthy Kids Survey. Data are compared across high-frequency users, low-frequency users, and those who have not used the school health center regarding whether they know where to go for help if they are feeling stressed, nervous, sad, depressed, or angry; they have talked

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¹ See http://achealthyschools.org (accessed May 30, 2019).

to a doctor or nurse about moods or how school is going; and they always received counseling to help them deal with issues such as stress, sadness, family problems, or alcohol and drug use. High-frequency users of the student health center reported higher rates of knowing where to go for help, having talked about emotional health and academic progress with a provider, and always getting counseling when needed.

Another part of the initiative involved a trauma-informed care study at 15 Oakland school-based health centers. Each school health center implemented its own trauma screening, using a variety of methods. Sakashita pointed out that not everyone who screens positive for trauma will need intervention. Of the 35 percent of students who screened positive and needed follow-up care, 86 percent were connected to services, she said. A follow-up survey found that 83 percent of the trauma support group participants felt that it had helped them to stay in school.

In closing, Sakashita said that conversations about health results have to be in language that is relevant and important to educators. Moving this work forward depends on partnerships, relationships, and trust that all stakeholders are working toward shared results. The goal is that every child gets what he or she needs to thrive. It can appear that these initiatives are only serving a certain high-needs subpopulation, she said, but everyone will benefit from the improved coordination in services of a system that better supports those most in need.

Partnering with Schools to Improve Asthma Care

Asthma impacts 1 in 11 children in the United States, which is nearly 7 million children, and more than $50 billion in medical expenses are associated with asthma annually. The prevalence of asthma is higher among children living in poverty and those who are Puerto Rican and non-Hispanic African American. On average, 3 children in a classroom of 30 are likely to have asthma, and these rates are even higher in high-risk urban settings. Many students with asthma struggle to succeed in school. Asthma is the leading cause of missed school days for children (13.8 million days per year) and is also associated with poor sleep, limitation of activity, and poor school performance. Halterman added that asthma can impact all members of the school community. Halterman described Joshua, a 9-year-old student with asthma, as an example. Joshua has had multiple emergency room visits, has difficulty sleeping, is frequently absent from school, has poor attention when in school, and is inconsistent with adherence to his daily preventive medication, she said.

The national asthma guidelines from the National Heart, Lung, and Blood Institute recommend a daily preventive medication for all children with persistent symptoms and adjustments in medications for any child

who continues to have poor asthma control. These medications have been shown to improve outcomes and reduce asthma attacks that can lead to hospitalization. Unfortunately, inadequate therapy and poor control is common. A survey of nearly 1,000 children across the United States with persistent asthma found that only 20 percent were optimally controlled on a preventive medication, Halterman said. Forty-three percent of the children had poor asthma control despite reporting having a preventive medication, which she said is likely related to poor adherence, ongoing exposure to environmental triggers, or both. Another 37 percent continued to have persistent asthma and reported no use of a preventive medication. To address these gaps in care, Halterman’s team has based their work on Wagner’s chronic care model (Wagner, 1998). The model helps identify the elements of the health care system that encourage high-quality chronic disease care in the context of the community. The goal is to ensure access to services that improve outcomes (in this case, preventive medications that are known to work for children with persistent asthma).

The Preventive Care Program for Urban Children with Asthma

Halterman and others have previously shown that school-based programs can improve outcomes for children with persistent asthma. School-based programs provide opportunities to identify high-risk children and to build optimized systems of care where children spend most of their day. The Preventive Care Program for Urban Children with Asthma works in partnership with the Rochester, New York, school nurse program.² Preventive medications are administered to children daily through the school nurse’s office, with the possibility of dose adjustments during the year, if needed. This ensures adherence to preventive medications at least on the days the child goes to school.

The School-Based Asthma Therapy (SBAT) trial has shown a 25 percent reduction in symptom days, symptom nights, activity limitation, asthma attacks, and days absent from school, Halterman said. The program has now been implemented in more than 60 schools throughout the Rochester City School District (a high-risk urban district where most students are eligible for free or reduced-price lunches). Similar school-based asthma care programs are being implemented around the country, and the National Association of School Nurses now includes school-based care in its asthma care guidelines. Telemedicine has also been used to link children from school to the primary care provider for asthma assessments

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² See https://www.urmc.rochester.edu/pediatrics/jill-halterman-lab/research-overview.aspx (accessed May 30, 2019).

and prescribing purposes, which allows for better treatment of children who may have difficulty accessing care otherwise, she said.

In summary, Halterman reiterated that students with asthma may struggle to succeed and that despite the existence of guidelines, treatment often is suboptimal. Health care and school partnerships can lead to improved symptoms, which in turn can lead to improved participation in activities, decreased absenteeism, and enhanced school engagement and attention, ultimately leading to improved academic outcomes and school success.

Engaging Pediatricians in the Solution for Chronic Absenteeism

Chronic absenteeism is defined as missing 10 percent or more of the school year (18 days of an average 180-day school year). Many students are actually missing 2 or 3 days per month, but because these absences are scattered throughout the year, they often escape attention. Chronic absenteeism impacts the likelihood of academic success in a given school year, Schumacher said, but academic success in one year also predicts academic success in future years, which predicts the ultimate likelihood of graduation.

Educational outcomes and health outcomes are interrelated, and many of the reasons that children visit a health provider are also health barriers to learning, as discussed by Basch. In addition, the various factors that prevent children from attending school are the same factors that prevent children from making and keeping doctors’ appointments (e.g., social determinants of health, such as transportation issues, homelessness). There is a lack of alignment in how children are screened for the impact of social determinants of health, Schumacher noted, and how interventions are recommended.

The Chronic Absenteeism Reduction Effort (CARE) Pilot Program

Pediatric health providers have unique relationships with families, which can provide opportunities to address the social determinants of health, Schumacher said. Washington, DC, public schools sought a way to leverage pediatric health providers in addressing chronic absenteeism. It was determined that an infrastructure was needed where attendance data could be proactively shared between education and health providers. A health information exchange (HIE) system was already in place for providers to access patient data from hospitals, laboratories, and other sources, and so it was suggested that the DC public schools’ student information system be linked to the HIE. Student attendance data would be uploaded to the exchange and matched by the HIE to the students’

patient records. The HIE would then push biweekly reports to primary care doctors of how much school their patients had missed.

Based on this concept, the CARE pilot program was launched at several schools in the DC area in association with several area health care clinics.³ Schools were chosen based on diversity of student demographics and on the willingness of school leadership to invest the resources and staff time needed for the study. Prior to linking the attendance data to the HIE, consent from parents was required under the Family Educational Rights and Privacy Act. Guidance from the U.S. Department of Education was that a simple consent form would suffice. Parent and staff focus groups were held to gather feedback on the concept and the process (whether this program would be of value to them, how best to partner for data sharing, and development of the consent form and informational materials). Ultimately, a simple one-page letter and a consent form were included with the school enrollment packages, and Schumacher reported that about 75 percent of the families consented for attendance data to be shared with their pediatrician. In response to a question, Schumacher clarified that the forms were an opt-in, one-time consent (annual recertification is not needed).

The next step was to engage the pediatric health providers. Through the local chapter of the American Academy of Pediatrics, a survey of local pediatric providers was conducted regarding their knowledge about absenteeism. The results were used to develop training materials for the providers to help them understand not only the concept of chronic absenteeism but also what resources are available in the schools. Schumacher acknowledged the challenge of asking providers to add one more task during their brief visits with families. The goal was to engage not only the providers but also other clinic staff to create a “culture of attendance.”

The pilot study is under way, and Schumacher said that a process evaluation will be done to determine whether families consent, the demographics of populations that do and do not consent, whether the data are shared, and whether the clinics act on the data. The evaluation will also look for opportunities for greater collaboration. An outcomes evaluation will be done in years three through five of the pilot study to assess whether there are any reductions in rates of chronic absenteeism in these schools and how to develop more streamlined and aligned structures.

Influenza Vaccination as a Tool to Reduce Absenteeism

The state of Arkansas is largely rural, with a population of about 3 million people. Residents face significant challenges, including a low level

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³ See https://dcps.dc.gov/page/chronic-absenteeism-reduction-effort-care-pilot-program (accessed May 30, 2019).

of educational attainment, Dillaha said. Only 21 percent of adults have a college education, and 15 percent of adults have less than a high school education. There is a high level of poverty (63 percent of students qualify for free or reduced-price lunch) and poor health (the state ranked 48th out of 50 states in the 2017 America’s Health Rankings). She added that, in Arkansas, there is the political will to address these issues, and there are many people who are committed to making a genuine difference.

Arkansas has a centralized state health department that operates at least one local health unit in each of the 75 counties (there are no independent local health departments). The local health units offer childhood immunizations; Special Supplemental Nutrition Program for Women, Infants, and Children; family planning; prenatal care; and other population-based public health services, Dillaha said. In 2002, the Arkansas Department of Health’s Local Health Units began conducting community-based influenza vaccination clinics as a way to exercise their county mass dispensing plans as part of preparedness planning for public health emergencies.

In 2007, local health units began to partner with local school districts to conduct school-based vaccination clinics each fall. Dillaha explained that public health and school professionals collaborated to overcome various challenges related to planning, preparing materials (including vaccine information statements and consent forms in English and Spanish), verifying parental consent, transporting vaccine to the schools while maintaining the cold chain, and documenting the doses given for billing (when possible) and entry into the immunization registry. She noted that as many as 70 clinics might be held on a given day. For the 2017–2018 school year, there were close to 480,000 students enrolled in more than 1,000 Arkansas public schools. This past fall, flu vaccination clinics were held in 953 schools over a 2-month period. Around 120,000 flu vaccinations were given, which Dillaha noted represents an overall vaccination rate of about 25 percent.

Previous analyses have shown that increasing the vaccination rate decreased absenteeism (Gicquelais et al., 2016). However, Dillaha said, given the unusual severity of the most recent flu season, the Arkansas Department of Health conducted a repeat analysis, comparing the flu vaccination rates with all-cause absenteeism during the 8-week peak of the flu season. Absenteeism data were provided by the Arkansas Department of Education. The analysis showed that for every 10 percent increase in the flu vaccination rate, the mean absenteeism rate decreased by 0.23 percent. In closing, Dillaha stated that this translates to a reduction in school absenteeism of almost 45,000 school student days.

Discussion

Leadership

Moderator Tamayo asked the panelists to comment on the role of leadership in the programs they discussed, including what level of leadership is most critical (e.g., state, local, district, community, school). Leadership support for school-based influenza vaccination in Arkansas spans from the governor to the local school district superintendent, Dillaha said. When the program began, the governor dedicated a portion of the funding available through an increase in the tobacco excise tax to help cover the cost of vaccinations that were not otherwise reimbursed. She added that this support has been key to continuing to see these efforts grow.

Sakashita said that leadership at all levels is important for the school-based health centers, from the superintendent to the site administrators. Support has to start at the highest level, she said, but delivery of service requires the buy-in of the site administrator. She noted the impact of staff turnover and the importance of institutional memory. Letters of agreement outlining responsibilities are sent every year to all providers in the school setting. There are also master agreements with several school districts, she said, and the goal is to have a master agreement with all 18 school districts that defines the parameters of the relationship and sets the common agendas and common goals. Schumacher agreed and emphasized the value of having clinical champions with dedicated time at each clinic participating in the CARE pilot program.

Leadership for the Vision for Baltimore program, Collins said, included the Baltimore City Health Department, Baltimore City Public Schools District, and Johns Hopkins University coming together to think collectively about the strengths that each could offer in addressing poor vision in school children. She added that stakeholder engagement at every level is as important as leadership. There are many good ideas, but translating those ideas into practice in a busy school setting can be a challenge if no one has taken the time to build relationships at the school level.

Funding

Kelly Hall of Pembroke Policy Consulting asked about the possibility of sharing school absentee data with employers or insurers and whether that might help hold providers and other stakeholders accountable for children being in school. Schumacher noted that some employers are looking at such metrics, including when children use the school-based health center and their parents do not have to miss work. This metric could be leveraged to demonstrate the cost–benefit analysis of investment in these types of programs and to secure additional funding.

Participants discussed the funding of health sector initiatives to improve educational success. Rochelle Davis of the Healthy Schools Campaign asked about philanthropic versus sustainable sources of funding for the program examples, adding that philanthropic dollars do not necessarily promote system-level change. Collins explained that Vision for Baltimore is a 3-year pilot program supported initially by philanthropic funding but with a focus on ensuring financial sustainability through the creation of an infrastructure to bill Medicaid. Now, in the second year of the pilot, Medicaid is being billed for a portion of the students that are seen, she said. Sakashita agreed that philanthropy is an important source of funding, but these types of initiatives will not be sustained without public systems owning and buying into them. The school-based health centers in Alameda Country receive an allocation from the Tobacco Master Settlement Agreement. Such funding requires leadership from elected officials to invest flexible funding to implement models such as these, she said. For the CARE pilot program, Schumacher said, the infrastructure (the HIE) was already in place, and many of the other components, such as the consent forms, were low or no cost. The program is well situated for sustainability with minimal additional investment. The most significant costs for the pilot program are the evaluation and the dedicated time of the clinical partners. These are likely to be ongoing costs as the program is brought to scale. However, as the program is instituted in more clinics, it will hopefully become part of the routine workflow, she said. The vaccine for the school-based influenza vaccine clinics was primarily supported by the Vaccines for Children program and the state Children’s Health Insurance Program, Dillaha said. The program also received some grant funding from CDC. Private insurance is billed whenever possible, she continued, and state general revenue funds are used to cover any remaining costs. Halterman noted that the school-based asthma programs have been funded by research grants thus far. However, they have been purposefully designed to use existing infrastructure.

Root Causes

Lindsay Norris of Too Small to Fail asked panelists to elaborate on the root causes of the issues discussed and what the various agencies and organizations are doing to address them. Halterman said that the causes for disparities in asthma are multisectorial. There are known environmental triggers that exacerbate asthma, including pollutants in urban environments, allergens in the home, and ongoing exposure to smoke. There are many programs that are working to address the environmental causes of asthma. A challenge for remediation of triggers in the home, she said, is that many of the children move among multiple homes, and fami-

lies move frequently. Data suggest that many of the allergens impacting children with asthma are also in their schools. Halterman said that most of her work has focused on preventive medications because they are known to work and yet many children are not receiving them.

Collins said that 20–25 percent of children have vision problems, which is most commonly a correctable nearsightedness or farsightedness. A significant challenge in accessing vision care is that most children are largely asymptomatic and generally do not tell their teacher or parent that they cannot see. This results in a long delay before a vision problem is recognized through vision screening and corrected. Another challenge is that vision screenings tend to happen less frequently in high-poverty schools. There are also data on the impact of primary language, income, and highest education level in the household on whether children have a vision screening, she said (Ruderman, 2016).

Sakashita noted the challenges of interpreting the child that presents before you, adding that race often plays a factor in that interpretation. What is often seen as a social-emotional problem of acting out is really a child in distress from asthma or vision problems or dental decay. Correct early identification of children with any kind of health conditions can be very complicated, she said. Tamayo said that this highlights the importance of district- and school-level early warning systems that aggregate school-based metrics, such as absenteeism, behavior, or course completion. Those data can be used to help determine the deeper problem at the root of the behavior.

Increased School Revenue from Increased Attendance

Jeffrey Levi of The George Washington University observed that many of the interventions discussed result in increased school attendance and asked about any increased attendance-based revenues that school systems have saved or received. Sakashita said that one of the metrics for the school-based health centers is whether clients are sent back to class after being diagnosed and treated. She said that 80–90 percent of students are sent back to class after a visit and therefore did not miss a whole day of school, as might have happened if the child were to see an outside provider. This results in nearly $1 million in Average Daily Attendance payments saved, she said. Collins responded that a cost analysis of Vision for Baltimore is ongoing but those data are not yet available. Similarly, Dillaha said that state-level analyses are under way in Arkansas that will ultimately drive decision making and policies. Halterman noted that the school district has made reducing absenteeism a priority, but an exact dollar value has not been determined for the SBAT program. Tamayo referred participants to the work of the E3 Alliance in Austin, Texas, par-

ticularly a flu vaccination campaign that has saved millions of dollars as a result of students not missing school days due to flu.

Collaboration and Capacity

Sharfstein asked about the challenges of explaining the value of health initiatives designed to foster school success and about any unexpected sources of support or resistance when seeking funding. Schumacher said that because her program is focused on addressing chronic absenteeism specifically, there is a natural buy-in from educators. What has been more of a challenge, she noted, is explaining why the child health community is interested. Collins responded that poor vision is an issue that people understand, and most appreciate the simplicity of the intervention (giving a child a pair of glasses). The challenge is how to optimize this vision intervention in light of the fact that schools have so many different health intervention needs. Their capacity is often exhausted by the number of different programs offering these interventions, and she noted the need to synergize across programs.

Phyllis Meadows of The Kresge Foundation raised the corresponding issue of the capacity of pediatric practices. In Detroit, for example, concerns have been raised about the failure of the pediatric community to follow through on screening results. She asked about strategies to support pediatricians in these collaborative initiatives and how both sectors, health and education, can better balance their primary roles with the need to see the whole child. Collins reported that focus groups with parents and teachers in Baltimore and Chicago found that teachers were almost universally appreciative of the health-related opportunities to help students succeed in school. Teachers are held accountable for student performance and have little ability to address issues of poor vision or absenteeism due to asthma or flu, for example. Dillaha raised the issue of health literacy and noted that there are opportunities in the school setting, particularly in the school-based health clinics, to educate families and help them to develop the skills to manage their children’s health. Sakashita noted the value of a Coordination of Services Team in reviewing referrals of students to health and other support services. For example, the team can send mental health providers or social workers to support the teacher on how best to work with the student. This develops a relationship of trust across sectors, rather than an “us versus them” scenario. Tamayo stressed the importance of avoiding layering initiatives and programs on top of one another and expecting them to penetrate deeply into the education system. He also cautioned against blaming or shaming teachers under the guise of accountability. Rather, he said, the health sector needs to help school system leaders and educators understand the existing opportuni-

ties within the routine school day to amplify the effect of their work and improve both health and educational outcomes for students. Leveraging existing structures more effectively will help educators address student needs in a more holistic fashion.

Magnan asked in what other areas the health sector might contribute in the school setting. Schumacher suggested that there is an opportunity to address trauma and mental health concerns of parents and families. Data suggest that the health of the family, and specifically parents’ mental health, significantly impacts students’ attendance and academic performance, she said.

Changing the Culture

A participant from the Baltimore City Health Department observed that the focus on educating the whole family on the importance of health in educational success is similar to the work of the World Bank and the World Health Organization on the cost effectiveness of female education and its broader impact on public health. The evidence for the return on investment of education is significant in developing countries, she said, perhaps because it has been more studied than in developed countries. She asked how a health and education initiative might be built that could provide a similar level of return on investment for families, and more specifically women and mothers. Collins said these initiatives are not simply about point of service interventions but about changing the culture. Collectively, when teachers, administrators, parents, and students all work together on a particular health intervention, they influence each other. Students might remind each other to wear their glasses or remind their parents to sign the school eye exam form, for example. She emphasized the importance of these programs effectively engaging parents. Sakashita added that communication is essential and that schools need to be included as partners in the design of community public health initiatives.

In closing, moderator Tamayo said that cognitive science has shown that people learn most actively through the act of storytelling. He challenged participants to identify and develop at least one story, with the name of a real child or a real parent, that they can tell to illustrate to others why this work is so important and to amplify the ability to make a difference.