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SPECIAL TOPIC
Reframing School Dropout as a Public Health Issue
Nicholas Freudenberg, DrPH, Jessica Ruglis
Suggested citation for this article: Freudenberg N, Ruglis J. Reframing school dropout as a public health issue. Prev Chronic Dis 2007;4(4).
http://www.cdc.gov/pcd/issues/2007/
oct/07_0063.htm. Accessed [date].
PEER REVIEWED
Abstract
Good education predicts good health, and disparities in health and in educational achievement are closely linked. Despite these connections, public health professionals rarely make reducing the number of students who drop out of school a priority, although nearly one-third of all students in the United States and half of black, Latino, and American Indian students do not
graduate from high school on time. In this article, we summarize knowledge on the health benefits of high school graduation and discuss the pathways by which
graduating from high school contributes to good health. We examine strategies for reducing school dropout
rates with a focus on interventions that improve school completion rates by improving
students’ health. Finally, we recommend actions health professionals can take to reframe
the
school dropout rate as a public health issue and to improve school completion
rates in the United States.
If medical researchers were to discover an elixir that could increase life expectancy, reduce the burden of illness, delay the consequences of aging, decrease risky health behavior, and shrink disparities in health, we would celebrate such a remarkable discovery. Robust epidemiological evidence suggests that education
is such an elixir. Yet health professionals have
rarely identified improving school graduation rates as a major public health objective, nor have they systematically examined their role in achieving this
objective. Seizing the opportunity to do so can improve health and reduce disparities.
Education is one of the strongest predictors of health: the more schooling
people have the better their health is likely to be. Although education is highly correlated with income and occupation, evidence suggests that education exerts the strongest influence on health (1-4). More formal education is consistently associated with lower death rates (4), while less education
predicts earlier death. The less schooling people have, the higher their levels of risky health behaviors such as smoking, being overweight, or having a low level of physical activity (5). High school completion is a useful measure of educational attainment because its influence on health is well studied, and it is widely recognized as the minimum entry requirement for higher education and
well-paid employment.
Although the beneficial effect of education varies by sex, age, and race/ethnicity, with blacks benefiting more than whites from more education (6), current policies exacerbate education-related health disparities,
with women, whites, young adults, and United States–born residents having higher graduation rates than their respective counterparts (7). Moreover, the gap in
health status between people who are well educated and those who are not has grown in recent decades (6).
Pathways by Which Graduation Contributes to Improved Health
A good education leads to good health in several ways. First, the more
schooling people have the more money they earn, enabling them to purchase better housing in safer neighborhoods, healthier food, better medical care and health insurance, and more education; each of these
factors is associated with improved health (3,8,9). Each one allows individuals to move up the occupational and
income ladder, giving them more prestige and power, both of which are associated
with better health. High school completion is also the gateway into college,
which offers even greater benefits than high school alone. Second, education
facilitates healthier behavior choices by offering learners access to health
information and tools to acquire help and resources such as smoking cessation
programs. Third, education helps people to acquire social support, strengthen
social networks, and mitigate social stressors (3,9,10). The more education
people have the more social support they have (10). Education helps people to gain a sense of control over their lives (9), an outcome associated with better health.
According to a recent review by Cutler and Lleras-Muney (3), policies that increase educational attainment could have a large effect on population health. Moreover, estimates suggest that investments to improve educational achievement can save more lives than
can medical advances (11). To realize these possibilities, public health researchers need to develop new conceptual and
analytic approaches to studying the reciprocal relationships between health and education and consider education as an arena for intervention as well as a marker or moderator for social position (3,12).
In recent decades, educational attainment in the United States has improved significantly.
From 1975 through 2000, the proportion of adults aged 25 years or older who completed high school increased from 63% to 84% (7). However, high dropout
rates are increasingly concentrated among low-income and black and Latino students, and the rate at which students leave school
between grades 9 and 10 has tripled (13). These trends indicate that more young adolescents are
in jeopardy.
The Cumulative Promotion Index (CPI) (13) uses enrollment data to estimate the probability that a student entering 9th grade will graduate with a regular diploma in the traditional
4 years. Although many students finish high school in 5 or more years, the more narrowly defined CPI offers several advantages as a measure: it is commonly used,
data are systematically collected, and it triggers the funding mandates set in the federal No Child Left Behind Act. The CPI method of calculating graduation shows that nearly one-third of students in the United States and half of black, Hispanic, and American Indian students who enter 9th grade do not graduate with a diploma in
4 years
(Table 1).
Graduation rates in the nation’s largest cities are lower still. In 2001,
6 of the 10 largest cities in the United States had overall graduation rates of less than 50%
(Table 2). In 2002, 18% of
the nation’s 11,129 high schools promoted fewer than 60% of their students (15).
Most of these schools with low promotion rates were concentrated in cities
with low average incomes and with high proportions of blacks and Hispanics (15).
Understanding why young people leave school can inform the design of polices that
will increase school graduation rates. Although a comprehensive analysis of multidisciplinary
studies of factors associated with school completion is beyond the scope of this
article, Table 3 summarizes findings from social science and educational research on dropout
rates, assessing the impact of factors from different levels of society (e.g., individual, community, school). The multiple factors associated with dropout
rates suggest that no single type of intervention can end our nation’s dropout crisis.
Although much of the research on school completion focuses on the psychological
traits of students and the organizational characteristics of teachers, schools, and
school systems, some researchers have examined the impact of health. Health has
direct and indirect effects on school dropout rates. Student health problems associated with dropping
out are substance use; pregnancy; and psychological, emotional, and behavioral problems (27-30). Teenage pregnancy is the leading cause of dropping
out of school for adolescent women; an estimated 30%–40% of female teenaged dropouts are mothers (29). Early parenting also affects young men who drop out to support a child.
Mental illness and emotional disturbance also account for a significant percentage of dropouts (31). Health problems also affect dropout
rates indirectly by forcing young people, especially young women, to cope with family physical or mental illness, often imposing on teenagers
responsibilities that can lead to their leaving school (32). The few researchers who examined the
impact of addiction, mental illness, chronic diseases, or mortality among parents on students’ school achievement suggest
it has a substantial effect (33,34).
Interventions to reduce school dropout rates seek to change individuals, families, schools, school systems, or public policies
related to poverty, welfare, or employment. Most educational research has focused on evaluating interventions designed to alter
the school curriculum, improve support for teachers, or change the institutional
mindset in schools, as summarized in Table 4.
Interventions that have the potential to improve school achievement and
reduce school dropout rates by improving the health of students are of particular
interest to health professionals. These school-based interventions include
coordinated school health programs; health clinics; mental health programs;
substance abuse prevention and treatment programs; comprehensive sex education, human immunodeficiency virus infection prevention, and pregnancy
prevention programs; special services for pregnant and parenting teens; violence prevention programs; and interventions to change the schools’ social climate (29,31,43-49). Table 5 lists the approaches that have the potential to reduce dropout
rates.
Although the focus here is on adolescents, these approaches are also used in
elementary and middle schools. In addition, community-based programs can also
promote adolescent health but are beyond the scope of this article.
Many schools offer several different types of health programs shown in Table 5. However, these activities are seldom coordinated,
and they do not target reducing school dropout rates as an outcome. Few innovative or effective programs have
gone beyond pilot studies or have been provided funding that assured sustainability. Evaluation studies that assess the impact of health programs
on school dropout rates are rare, a disturbing gap given the importance of school dropout as a health, social
justice, and economic issue. As a result, a comprehensive framework explaining the mechanisms by which various types of health programs reduce dropout
rates is not available, making it difficult for school or health officials to select the most effective interventions for their
setting.
Although evidence shows that education is an important determinant of health and that changes in school policy can improve educational outcomes, public health professionals have seldom made improving school completion rates a health priority.
In addition, poor health interferes with children’s capacity for education, and a variety of school-based health interventions have the potential to improve school
achievement. With a few important exceptions, health providers have not developed lasting partnerships with schools, nor have researchers provided the evidence needed to improve or replicate health programs that can reduce school dropout
rates.
Improving graduation rates is a specific objective that can bring health professionals and educators together for research, intervention, and advocacy to improve the lives and well-being of young people. We suggest five priorities for action. Local implementation will, of course, depend on which constituencies are mobilized, but every community can take some action to make the
link between health and school completion a priority for action.
Target schools and cities with the most serious dropout problems for intensive intervention. In the United States, about 1000 high schools fail to graduate half their students, and in more than 20 cities at least three-quarters of high school students attend schools where fewer than 60% of students graduate (14). These appalling statistics
undermine health, economic development, and social justice, and they serve as powerful generators of disparities in health. To reduce school dropout
rates, the National Research Council Panel on High-Risk Youth recommended in 1993 that “the primary institutions that serve youth — health, schools, employment, training — are
crucial and we must begin with helping them respond more effectively to
contemporary adolescent needs. Effective responses will involve pushing the boundaries of these systems, encouraging collaborations between them and reducing the number of adolescents whose specialized problems cannot be met through primary institutions” (59, p. 193). A good
first step would be to create state or municipal intersectoral dropout prevention
councils in places where there is a disproportionate number of dropouts. Such councils could design, seek funding
for, implement, and evaluate the educational, vocational, antipoverty, and health interventions at the intensity and scale needed to improve school completion rates
in their areas.
Develop, implement, and evaluate health interventions to improve school completion rates. The paucity of research that explores the reciprocal connections between health and school achievement makes the development of a coordinated research agenda that will better identify health-related determinants of
children dropping out of school an urgent priority. Such an agenda
could guide the selection and evaluation of interventions to reduce dropout
rates. Two promising avenues for research are studies of health interventions that better engage young people in their schools and that connect young people to caring adults. Schools that foster student engagement
in their studies are more likely to graduate their students (35,60), and young people who feel connected to at least one adult in
their school are much more likely to graduate (35). Some intervention research suggests that changes in school climate can increase
students’ connection to adults and their level of engagement in their
studies (58). Health interventions, including those targeted at sexual and reproductive health, healthy relationships, family health, violence
prevention,
substance use, and
mental health, have the potential to engage young people in schooling and connect them to caring adults.
Strengthen support for health education teachers.
Developing and implementing new approaches to school-based health education and health services that can reduce dropout
rates will require well-trained school health education teachers, nurses, and mental health professionals, each currently in short supply. Better integration between health
education and services in the school and community, consistent funding for school health education, partnerships
between schools and universities, and strong professional preparation programs
for health education teachers can
help to reduce dropout rates by addressing student, family, and community health.
Advocate for evidence-based interventions that can improve health and reduce dropout
rates. Health professionals can play a positive role in the contentious debates about
providing services in schools addressing sex education; substance abuse; birth control, pregnancy, and parenting services; violence prevention; and mental health. By bringing evidence of effectiveness and public
support into public deliberations on these issues, offering science-based arguments in support of interventions
addressing these issues, joining coalitions that can compete effectively in the political arena, and explaining the links between health and education, health professionals can contribute to more informed public participation.
Put reducing high school dropout rates on the public health agenda. The
public health community can bring its expertise in advocacy to the
campaign to make improving graduation rates a high national priority. Simply reframing school dropout as a health issue has the potential to bring new players into the effort — parents, health
institutions, young people, civil rights groups — and to encourage public officials to
think of the dropout problem as central to community health and as a long-term solution beneficial to population health. Educating the public and policy makers about the long-term benefits of improved school completion (e.g., reductions in socioeconomic and racial/ethnic health disparities,
lifetime health care costs, unhealthy behavior) can provide additional incentives for action. More specifically, public health professionals can advocate for
good school health programs and can encourage administrators of these programs to make improving school completion a key objective. As citizens, taxpayers, parents, and advocates for social justice, public health professionals can join the
fight for equitable funding and staffing of schools as well as advocating for school systems to be rated on their success in improving school completion through fair and equitable means.
Seldom have health and education professionals been in a better position to work together to achieve common goals. Rarely has a single problem —
high school dropout rates — contributed to so many adverse social, economic, and health conditions. Our nation’s young people deserve no less than a concerted effort to improve school completion
rates and thus give young people a gateway to lifetime
health and success.
It is not possible to eliminate health disparities without simultaneously reducing disparities in educational achievement.
The populations that are most severely affected by the epidemics that have
threatened this nation’s health in the last several decades are the populations most at risk of dropping out of school. By bringing together
programs to improve
health and school achievement and by making reducing school dropout rates a public health, educational, and human rights priority, public health professionals have the opportunity to make a lasting contribution to promoting population health and social justice.
Corresponding Author: Nicholas Freudenberg, DrPH, Distinguished Professor of Urban Public Health, Hunter College School of Health Sciences, City University of New York, 425 E 25th St, New York, NY 10010. Telephone: (212) 481-4363. E-mail: nfreuden@hunter.cuny.edu.
Author Affiliation: Jessica Ruglis, Graduate Center, City University of New
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Table 1. National Graduation Rates, by Race
or Ethnicity and Sex, United States, 2001
Race or Ethnicity
Female %
Male %
Total %
American Indian/Alaska Native
51.4a
47.0a
51.1
Asian/Pacific Islander
80.0a
72.6a
76.8
Black
56.2
42.8
50.2
Hispanic
58.5
48.0
53.2
White
77.0
70.8
74.9
All students
72.0
64.1
68.0
Source: Swanson CB (14). a Rate based on estimates that cover between 50% and 75% of the student population.
Table 2. Graduation Rates for the 10 Largest Public School Districts in the United States, 2001
District (Enroll-
ment)
Characteristic
Cumulative Promotion
Index Graduation Rates, %
Largest Racial or Ethnic Group
% Min-
oritya
% Free or Re-
duced Lunchb
Total
American Indian
Asian
Hispanic
Black
White
New York City, NY (1,066,516)
Hispanic
84.7
71.9
38.2
41.2
60.9
30.1
32.2
57.9
Los Angeles Unified School District, CA (721,346)
Hispanic
90.1
73.5
46.4
50.8
76.6
40.2
48.1
68.1
City of Chicago, IL (435,261)
Black
90.4
—
48.4
—
80.6
50.8
42.1
65.3
Dade County, FL (368,625)
Hispanic
88.7
59.3
52.1
—
84.7
52.8
46.8
60.7
Broward County, FL (251,129)
White
58.8
37.1
47.2
49.5
79.5
—
35.2
55.7
Clark County, NV (231,655)
White
50.1
26.3
51.9
51.5
79.1
37.3
40.1
58.7
Houston Indepen-
dent School District, TX (208,462)
Hispanic
90.0
70.7
40.2
—
78.1
34.7
39.5
62.3
Philadelphia City, PA (201,190)
Black
83.3
66.7
41.9
27.1
59.5
31.5
41.1
45.6
Hawaii Depart-
ment of Education, HI (184,360)
Asian
79.6
43.7
66.0
70.9
66.8
59.9
60.7
64.7
Hills-
borough County, FL (164,311)
White
48.2
47.4
55.0
—
86.3
51.0
41.5
60.2
Dashes (—) indicate that district provided no data for this group. Source:
Swanson CB (14). a Indicates percentage of nonwhite students enrolled in the district. b Indicates
percentage of students in the district eligible for federal free or reduced-cost lunch programs,
a proxy for poverty and socioeconomic status.
Table
3. Summary of Factors Associated With Dropping Out of School
Individual or Family
Neighborhood or Community
School or School System
Low family socioeconomic status
Racial or ethnic group
Male
Special education status
Low family support for education, less opportunity for nonschool learning, few study aids and resources in the home
Low parental educational attainment
Residential mobility
Low social conformity
Low acceptance of adult authority
High levels of social isolation
Behaviors such as disruptive conduct, truancy, absenteeism, and lateness
Being held back in school
Poor academic achievement, low grades or test scores
Academic problems in early grades
Not liking school
Feelings of “not fitting in” and of not belonging
Perceptions of unfair or harsh disciplines
Feeling unsafe in school
Not engaged in school
Being suspended or expelled
Conflicts between work and school
Having to work or support family
Substance use
Pregnancy
Living in a low-income neighborhood
Having peers with low educational aspirations
Having friends or siblings who are dropouts
Low socioeconomic status of school population
High level of racial or ethnic segregation of students between schools in a
district or within tracks or classes in a building
High proportion of students of color in school
High proportion of students enrolled in special education
Location in central city
Large school district
School safety and disciplinary policies
High-stakes testing
High student-to-teacher ratios
Academic tracking
Discrepancy between the racial or ethnic composition of students and
faculty
Lack of programs and support for transition into high school for 9th and 10th graders
References: 16-20
References: 21-23
References: 16, 24-26
Table 4. Summary of Educational Interventions for Improving Student Engagement in School and Academic Success
Structural, Institutional, and Organizational Changes
Changes to Curriculum and Instruction
Changes in Teacher Support
Safe, nonthreatening learning environment
Small class size
Small school size
Systemic, comprehensive school reform
Culturally proficient leadership
Community, business, and university collaboration
Student involvement in school policies
Reducing retention and suspension
Efforts focused on 9th grade transition
Small learning communities
Parent and family training and involvement
Violence prevention and conflict resolution programs
Culturally competent school and classroom culture
Alternative school safety and fair discipline strategies
Alternative school models: school-to-work programs, apprenticeship, vocational, service learning
Extend class periods or increase instructional time
Opportunities for “catch up” courses and for out-of-school programs
Academic content that is of interest and relevance to the students
Academic and social supports for students
Advisory periods
Elimination of academic tracking
Student-centered, culturally relevant, and diverse pedagogy and practice
Opportunities for extra schooling: after school, summer, Saturday, or extended-day school
Fair, clear, rigorous, and high expectations and standards for all students
Tutoring
Mentoring programs
Behavioral and psychosocial support
Efforts to build relationships, foster school engagement and social support, and reduce alienation
Diverse and individualized instruction and use of instructional technologies
Early intervention and academic supports
Interdisciplinary instruction
Common planning times
Integrated interdisciplinary planning processes
Professional development
Coaching and mentoring
Comprehensive teacher training
Support for staff risk-taking, self-governance, and collaboration
Collective responsibility and increased autonomy from central control
Highly qualified, certified, and well-prepared teachers
Teachers teaching only in their field of certification
Education programs to help teachers promote social justice
Teacher training for effective instruction of and care for culturally and linguistically diverse learners
Sources: 19, 35–42
Sources: 19, 35–38, 40
Sources: 19, 38, 40, 41
Table 5. Health Interventions
That May Contribute to Improved School Completion Rates
Type of Intervention (Selected References)
Program Activities
How the Intervention Reduces Dropout
Rates
Coordinated school health program (43,50)
Health education; physical education; health services; nutrition services; counseling, psychological, and social services; healthy school environment; health promotion for the staff, family, and community; partnerships
Teaches decision-making skills for better life choices; reduces absenteeism; offers early intervention and referrals for learning, psychological, substance abuse, and mental health problems; makes school more engaging; connects students to caring adults; engages families and communities in lives of young people
School-based health clinic (51,52)
Primary and preventive health care, referrals, assistance in finding health insurance and health care for family, reproductive health services, mental health counseling
Reduces family health problems; offers early intervention and treatment for psychological and physical health problems that can interrupt schooling; reduces teen pregnancy
Mental health programs (31,53)
Assessment and early intervention for young people with psychological, learning, or behavioral problems; referrals for children and families; counseling; staff training
Prevents problems that can interfere with school from becoming more serious; connects young people to caring adults; makes school more engaging; provides counseling or referrals for family mental health problems
Substance abuse prevention and treatment programs (45,54)
Alcohol, tobacco, and drug use prevention education; peer education; early intervention for drug users; support for young people with substance-abusing parents; referrals for drug treatment or counseling
Reduces or delays onset of heavy alcohol or marijuana use; offers young people with a drug-using parent a source of support; makes school more engaging
Sex, HIV infection, and pregnancy prevention programs (46,47,55)
Sex education; HIV infection prevention services; referrals for
reproductive and sex health services; birth control; peer education; sexually transmitted infection prevention
Reduces or delays teen pregnancy; connects young people to caring adults or peers
who encourage healthy behavior
Services for pregnant and parenting teens (29,56)
Child care; parenting education; reproductive health services; continued participation in high school academics/courses
Encourages and supports teen mothers to continue schooling;
delays second pregnancy
Violence prevention programs (47,57)
Peer education/mediation; anger management; conflict resolution; violence prevention education; psychosocial services; individual and group counseling
Makes young people feel safer in school; makes school more engaging; connects young people to caring adults or
peers who encourage healthy behavior
School climate (49,58)
Policy changes to reduce stigmatization, bullying, aggressive policing, or punitive disciplinary measures; peer education; increased opportunities for close adult-student interactions
Improves student engagement in school activities; connects young people to caring adults; reduces bullying, stigmatization, and distrust of authority
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Prevention, or the authors’ affiliated institutions. Use of trade names is for
identification only and does not imply endorsement by any of the groups named
above.
