(Illustration by Chiara Zarmati) 

Schools have emerged as important places to address childhood health problems, such as asthma and obesity. Children spend most of their waking hours at school, where they consume up to one-half of their daily calories.1 Schools also play an important role in the life of a neighborhood, serving as local hubs where students, teachers, parents, and community members can come together.

Healthy Eating, Active Living

This collection of articles, produced for Grantmakers In Health and supported by the Colorado Health Foundation, explores the latest thinking from health funders, researchers, and advocates on healthy eating and active living (HEAL) and healthy communities.

The schools that low-income children of color attend often maintain less healthy settings for learning, with poorer air quality, less access to physical activity, higher exposure to environmental toxins, fewer health services, inadequate facilities, and less access to healthy foods and safe drinking water during the school day.2 The low-income communities in which these schools are situated are less likely to have parks, playgrounds, or green spaces for outdoor play.3 More than half of public schools do not have a full-time school nurse or counselor on staff, and less than 5 percent of the nation’s students have access to services through a school-based health center.4 Compounding matters, nearly 20 percent of students enter school with a chronic health condition, such as asthma, life-threatening allergies, diabetes, or seizure disorder. Many of these diseases have a disproportionate impact on low-income African-American and Latino students. For example, 40 percent of African-American children and 39 percent of Latino children are overweight or obese compared with 26 percent of white children.5

Since 2002, Healthy Schools Campaign (HSC) has worked at the intersection of health and education, starting as a local organization in Chicago and then expanding nationally. In its early years, the organization focused on addressing obesity and asthma by applying traditional components of the Healthy Eating Active Living (HEAL) model to the school setting. HSC advocated for healthier school meals, strong physical education policies, recess, physical activity, and other health-related issues. But in keeping with the national dialogue on student health and school wellness, HSC’s approach now includes efforts to grapple with chronic absenteeism and also build systems to fund school-based health services in order to address the full range of children’s physical, mental, and behavioral health issues.

The next few years will present important opportunities for school health advocates to address student health and wellness as states and school districts implement their new plans created under the Every Student Succeeds Act (ESSA), the education law that replaced No Child Left Behind in 2015. ESSA requires states to include a “school quality and student success” measure for the first time, which can encourage states and school districts to see student health as part of overall school success. HSC worked with states to encourage them to build accountability systems that use chronic absenteeism for this measure, and 36 states followed through. (Chronic absenteeism is commonly defined as missing 10 percent or more of a school year for any reason, including excused absences for illness.) Monitoring chronic absenteeism is a proven way to shine a light on children’s health issues, including acute illness (such as cold and flu), chronic conditions like asthma and diabetes, and mental and behavioral health issues, such as depression and anxiety.

In nearly two decades as advocates for student health and school wellness, HSC has learned the importance of combining three key strands of work: providing leadership training to prepare parents to identify and advocate for the issues that matter most; building effective policy advocacy campaigns; and creating innovative programs that support sustainable systemic changes. The lessons learned from this work provide important lessons for how student health advocates can move their efforts forward in the years to come.

Engaging and Training Parents

Parents United for Healthy Schools, HSC’s leadership program for Chicago Public Schools (CPS) parents, uses a popular education framework based on the work of educator and philosopher Paulo Freire alongside a hybrid community organizing and advocacy model. The learning process starts with participants’ own personal experiences and uses a social justice lens to help them build on their knowledge, create common understanding, and develop an action plan.

Providing parents with practical knowledge and skills that they need to become champions for change in their schools and community is central to this work. HSC helps build parents’ personal knowledge about nutrition and physical activity through experiential learning (e.g., opportunities to cook and eat healthy meals) as well as through a training and leadership development curriculum. For instance, HSC works with parents to conduct a community power analysis of the school environment and develop a common understanding of who has the authority, both formally and informally, to improve school food, for example, or make decisions about recess or health services. This analysis explores the complex interplay between school-level authority (principals and teachers) and the school district, as well as city, state, and federal policies and programs.

Parent leaders from this program have been remarkably successful. In 2006, they mobilized a rally around CPS’s first wellness policy. Only 200 parents were expected, but more than 700 parents turned out, and this impressive showing helped alter the district’s approach to parent involvement in wellness policy. Within just a few years, parent leaders had pushed the district to adopt a local school wellness policy that created a role for parent involvement in school-based wellness teams in CPS schools. Through these wellness teams, parents have promoted health at more than 50 schools, from creating after-school soccer and exercise clubs to instituting healthy snack policies and salad bars. Many parent leaders have also gone on to run for local school councils, serve on district-level committees, and speak at board meetings.

Policy Advocacy for Accountability

HSC has worked on a variety of district and national policy campaigns, many of which were built on issues and solutions identified by school stakeholders, including parents. For example, in the early years of HSC’s work, parents quickly homed in on recess as crucial in their efforts to address child obesity and asthma. CPS had not required daily recess in its schools in more than 30 years. By 2009, years of neglect had left many schools, especially those in the city’s poorest neighborhoods, without working playground equipment or green space. With leadership training and support from HSC, parents were able to bring this issue to the foreground. Parent leaders from HSC’s Parents United for Healthy Schools group submitted more than 4,000 petitions in support of recess and served on the district’s recess task force, and in 2011, the district announced that it was bringing back daily recess.

In 2017, with the support of HSC and parent leaders, CPS adopted a new wellness policy, which includes a variety of commitments around healthy food, such as specific steps toward providing healthy and less processed foods to CPS students, commitment to local and sustainable food, restrictions on food and beverage marketing during the school day, and breakfast in the classroom. Other health-promoting policies include requiring opportunities for physical activity, encouraging schools to open their facilities to the community outside of school hours, and requiring schools to provide programming that links the classroom, dining center, and school gardens. In addition, by using CPS’ massive purchasing power, some of these policies—such as those impacting the school meal program—have driven widespread local and even national changes in the marketplace.

Programs for Sustainable Implementation

Even the greatest policy wins must be implemented sustainably. In 2013, with recess reinstated and daily PE returning to many CPS schools, HSC and parent leaders identified a new problem: Playgrounds at the majority of the city’s more than 400 elementary schools were inadequate. Some had even been turned into parking lots years ago when schools moved away from recess.

In response, HSC and Openlands, a nonprofit conservation agency, launched Space to Grow to transform Chicago schoolyards into shared green spaces for outdoor learning, active play, physical education, and environmental literacy, while using green stormwater infrastructure to reduce flooding in low-income flood-prone communities. The program offers a holistic vision for a healthier school environment and supports the central role that schools play in building healthy communities. In the first phase of this program, 15 schoolyards have been transformed, five schoolyards will be built in 2019, and partners have a commitment for 14 more.

Space to Grow is a dynamic example of HSC’s model for sustainable systemic changes in practice. Parent leaders helped advocate for district-level policy and practice changes that required a new public investment in outdoor space, and HSC and other partners have layered in innovative programs to support a schoolwide focus on wellness that fully incorporates the schoolyard. Space to Grow brings together the health, education, and environmental sectors to create a comprehensive plan to sustainably support children, families, and communities. Space to Grow is regarded as a model for school districts nationally and internationally, and agreements to formally share its findings have recently been signed with the mayors of Paris and Rotterdam.

HSC is working to build programs that support sustainable policy implementation at the national level as well. For example, HSC worked with school nurses for many years, providing them with leadership training and getting their input into promoting school wellness. Through this work, HSC heard firsthand about national Medicaid guidelines that made it impossible for schools to get adequate reimbursement for health services provided to most students enrolled in Medicaid. HSC and school nurse leaders advocated for the Centers for Medicare & Medicaid Services to reverse this policy, and now HSC, in partnership with Trust for America’s Health, runs a learning collaborative that provides technical assistance and training to district and state leaders from 15 states to help them capitalize on this new source of funding for school-based health services.

Challenges and Opportunities for Children’s Health Advocates

Over the last two decades, school health advocates have become increasingly aware that student health must be broadly defined in order to be meaningfully addressed. Thus, while many school health organizations, including HSC, initially viewed this work through the lens of obesity and asthma prevention, it is increasingly clear that these conditions must be seen in the context of the entire constellation of health issues that impact school attendance and performance, including vision problems, dental pain, acute illness care, chronic health conditions, and, notably, emotional and behavioral health problems, including the impact of childhood trauma.

This focus is an essential component of children’s health. However, as funders adjust their guidelines and areas of interest, advocates in the HEAL space face the difficult challenge of linking their previous body of work to this new area of focus and finding new ways to talk about the impact of their programs, such as noting the impact of physical activity on mental health and trauma resilience. HSC has found that chronic absenteeism presents an effective framing that can help both health and education funders understand the importance of addressing a wide range of student health issues.

There are also opportunities to make this link through ESSA, the federal education law. In the coming years, HSC will be working with states across the country as they develop needs assessments and other tools that will help schools identify and address the health-related causes of chronic absenteeism. HSC is also working with national stakeholder groups, as well as directly with parents in Chicago, to help them understand the importance of the chronic absenteeism data that is included in all school report cards this year.

"One major challenge is maintaining the gains that were made during the years when children’s healthy eating and physical activity had a champion in First Lady Michelle Obama."

The inclusion of chronic absenteeism in state education policy opens up funding streams through ESSA for programs to address health issues. For instance, ESSA allows Title I funding to be used for health-related supports for low-income schools, such as school nurses or a physical education program. ESSA’s Student Support and Academic Enrichment Grants can be used to promote student health, including mental health services. And ESSA provides funding to support professional development for principals, teachers, early childhood educators, and other school personnel, which can include health and wellness topics, including trauma-informed practices.

Changes in the health sector are also presenting opportunities for school health advocates. As the health sector increasingly prioritizes prevention, population health, care coordination, and chronic disease management, health providers are realizing that school health services are a way for them to engage with populations that are otherwise hard to reach. School health services can help them meet many of the new metrics they are being held accountable for under the Affordable Care Act. In fact, the American Academy of Pediatrics released a major policy statement in February 2019 highlighting the need for health-care providers to promote school attendance in their offices, in the community, and at the state and federal policy levels.

Despite the successes that HSC has seen in Chicago and nationally over the last 16 years, the risk remains that these advances could fade. One major and immediate challenge is maintaining the gains that were made during the years when children’s health, obesity prevention, healthy eating, and physical activity had an active and visible champion in First Lady Michelle Obama, as well as momentum in legislation and funding.

School food is an example of this challenge. In May 2017, US Secretary of Agriculture Sonny Perdue announced the administration’s intentions to roll back some of the healthy school food standards. The rollbacks to sodium and whole grains requirements encompassed in the department’s new final rule, released in December 2018, would allow schools that were already meeting the requirements that went into effect in 2012 (95 percent of schools, according to the USDA’s own numbers) to weaken their school food standards.

When the proposed rollbacks were initially announced, HSC heard from several districts that they weren’t planning on rolling back the progress they had already made. Nevertheless, rolling back the standards may encourage schools to reverse any progress to date and could discourage schools that have not yet met the standards from continuing to move forward.

HSC has learned the importance of involving grassroots leaders in shaping advocacy and in educating and engaging other stakeholders. This creates a broad base of stakeholders who are engaged and can be activated to counter policy rollbacks—such as on school food—or capitalize on new opportunities—such as the inclusion of chronic absenteeism on school report cards—and makes it more likely that program and policy implementation accurately reflects the priorities and realities of schools, communities, and families. 

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Read more stories by Rochelle Davis & Sarah Weisz.