Reframing School Dropout as a Public Health Issue
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].
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.
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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.
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Impact of High School Graduation on Health
Education is one of the
strongest predictors of health: the more schooling people have the better their
health is likely to be. Although education is highly correlated with income and
occupation, evidence suggests that education exerts the strongest influence on
health (1-4). More formal education is consistently associated with lower death
rates (4), while less education predicts earlier death. The less schooling
people have, the higher their levels of risky health behaviors such as smoking,
being overweight, or having a low level of physical activity (5). High school
completion is a useful measure of educational attainment because its influence
on health is well studied, and it is widely recognized as the minimum entry
requirement for higher education and well-paid employment.
Although the beneficial
effect of education varies by sex, age, and race/ethnicity, with blacks
benefiting more than whites from more education (6), current policies exacerbate
education-related health disparities, with women, whites, young adults, and
United States–born residents having higher graduation rates than their
respective counterparts (7). Moreover, the gap in health status between people
who are well educated and those who are not has grown in recent decades (6).
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Pathways by Which Graduation Contributes to
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
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
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High School Graduation in the United States
In recent decades,
educational attainment in the United States has improved significantly. From
1975 through 2000, the proportion of adults aged 25 years or older who completed
high school increased from 63% to 84% (7). However, high dropout rates are
increasingly concentrated among low-income and black and Latino students, and
the rate at which students leave school between grades 9 and 10 has tripled
(13). These trends indicate that more young adolescents are in jeopardy.
The Cumulative Promotion
Index (CPI) (13) uses enrollment data to estimate the probability that a student
entering 9th grade will graduate with a regular diploma in the traditional 4
years. Although many students finish high school in 5 or more years, the more
narrowly defined CPI offers several advantages as a measure: it is commonly
used, data are systematically collected, and it triggers the funding mandates
set in the federal No Child Left Behind Act. The CPI method of calculating
graduation shows that nearly one-third of students in the United States and half
of black, Hispanic, and American Indian students who enter 9th grade do not
graduate with a diploma in 4 years (Table
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).
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Causes for School Dropout
Understanding why young
people leave school can inform the design of polices that will increase school
graduation rates. Although a comprehensive analysis of multidisciplinary studies
of factors associated with school completion is beyond the scope of this
article, Table 3 summarizes
findings from social science and educational research on dropout rates,
assessing the impact of factors from different levels of society (e.g.,
individual, community, school). The multiple factors associated with dropout
rates suggest that no single type of intervention can end our nation’s dropout
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).
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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
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.
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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
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
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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
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.
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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: firstname.lastname@example.org.
Author Affiliation: Jessica
Ruglis, Graduate Center, City University of New York, New York, New York.
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