Over the past decade, public education has been increasingly held accountable through measures of academic achievement such as standardized testing. Pressure to improve test scores has resulted in greater emphasis on traditional classroom drills at the expense of programs like health for which there is little accountability required. In such a climate, it becomes important for coordinated school health programming to be able to demonstrate its impact on academic performance. The goal of this article was to systematically review the evidence assessing the link between health programming and academic achievement and to suggest ways in which that topic might be better studied in the future.
Education is a strong predictor of lifelong health and quality of life. (1) This finding is exhibited in different populations, places, and time. (2) At least 1 investigator (3) has argued that education causes health; however, the pathways through which education leads to better health and longer life expectancy are still not clearly understood. We do know that education, health, and social outcomes are very closely interdependent. (4) Success in school and years of schooling are major factors in determining social and occupational status in adulthood and health status throughout life. (5)
Among schoolchildren, academic success, health status, and risk behaviors are related in an interdependent, cyclical fashion. Poor school performance predicts health-compromising behaviors and physical, mental, and emotional problems. (6-8) Poor nutrition, substance abuse, sedentary behavior, violence, depression, and suicidality compromise school performance. This negative cycle, established during the school years, has profound consequences for the success and productivity of our communities. (9-11) Schools are a key part of the solution to this challenge and the school is a powerful force in American society. The education community is striving to enhance academic accomplishment through activities at the federal level, such as the No Child Left Behind Act; at the state level, through allocations of state funding and state laws; and at the local level, by incorporating curriculum choices, hiring talented personnel, maintaining facilities with limited resources, and raising funds through local bond elections.
Systematic reviews of the literature are important for decision making in health and education to provide evidence-based support for health programs and policy applications in the school setting. This article describes a comprehensive literature review of the evidence that Coordinated School Health Programs (CSHP) improve academic outcomes. CSHP provide policies, activities, and services in an organized manner to promote the health of school students and staff through: comprehensive school health education; family and community involvement; physical education; school counseling, psychological, and social services; school health services; school nutrition services; and school-site health promotion for staff and faculty. (12) The purpose of this systematic review was to identify and summarize evidence about CSHP-related determinants of academic achievement.
A multidisciplinary panel was formed of 6 nonfederal, nonadvocate health researchers representing the fields of pediatrics, psychology, behavioral and social science, health promotion, and education from 3 different, collaborating Prevention Research Centers. These Prevention Research Centers are part of a national network of 33 academic centers, each with public health agency and community partners that conduct applied research and practice in chronic disease prevention and control, and are funded by the Centers for Disease Control and Prevention. Each panel member consulted experts in the fields of nutrition, physical activity, mental health, school health services, parent involvement, or school environment and policy for further information to increase the effectiveness of the search process.
For the purposes of this research review, the term evidence includes: "(1) information that is appropriate for answering questions about an intervention's effectiveness; (2) the applicability of effectiveness data; (3) the intervention's other effects (ie, side effects, intended or unintended, and health or non-health outcomes); and (4) barriers that have been observed when implementing interventions." (13) The dependent variable, academic achievement, was operationalized and measured as course grades, grade point averages (GPAs), attendance, tardiness, homework performance, study skills, classroom behavior, social skills, disciplinary action such as suspension or expulsion, dropout status, grade promotion, grade retention, educational aspirations, and/or performance on standardized tests. The independent variables were CSHP related and were operationalized and measured as physical activity/education, nutrition/food services, mental health and social services, school environment and policy, health education, health promotion, school health/clinical services, and family/parent and community involvement.
Identification of Primary Studies
The literature was searched through computerized medical, public health, and education databases containing publications from 1945 forward, with an emphasis on those from 1980 to date. The primary databases searched were The Combined Health Information Database [CHID], CINAHL, all EBM Reviews, EBSCO (All Education Databases and All Health and Wellness Databases), EconLit, ERIC, Medline, National Academy Press, PsycARTICLES, PsycInfo, PubMed, and Social Science Citations. An extensive bibliography of references was generated and provided to the panel. Research assistants located library texts and research articles, extracted information about further studies from journal and book chapter reference lists, and obtained paper copies of each document, some requiring English translation. Scientific evidence was given precedence over anecdotal experience. Randomized controlled designs were considered the "gold standard," although there were very few published in the literature, and case studies were not selected for review. Primary studies were also located from published and nonpublished reviews, and other articles were provided by expert informants. A manual search was also conducted of key journals.
Using a brief gold standard screening tool, the initial exclusion criteria applied was lack of measurement of variables related to CSHP constructs and academic achievement. The Guide standard data abstraction form (14) was used by 2 reviewers to record information about: "(1) the intervention being studied; (2) the context in which the study was done; (3) the evaluation design; (4) study quality; and (5) the results." (13) The inclusion criteria necessitated adequate description of the sampling techniques, sociodemographic characteristics of the sample and population from which it was drawn, intervention, measures, and data collection methods used, statistical analyses, results, and conclusions supported by the data. The review panel predetermined that peer-reviewed publications were highly valued because they were widely available to the health and education community in journals, many of which are now available online.
Extraction of Data from Primary Studies
Data were extracted using the standardized, pre-tested Guide developed as a systematic tool for extracting evidence by the Community Preventive Services Task Force. (13) Six reviewers were involved in the extraction process following the methods outlined in the Guide and 5 other experts were recruited to complete second reviews. Because of the paucity of research conducted in the relatively new field of CSHP and academic achievement, the data extraction form was not intended for use as a means of determining effect sizes for CSHP research interventions. At this initial stage of review of existing research literature, the intent was to identify scientifically rigorous studies of interventions and associations between CSHP components and student health and academic achievement.
Initial classification of the study design involved was based on the analytic framework provided in the Guide, for example, studies that were noncomparative, cross-sectional, case-control, or prospective or retrospective cohort, and trials that were nonrandomized or randomized. Those study designs that were ranked as highest in quality involved the use of concurrent comparison groups, for example, controls and prospective measurement of exposure to the CSHP programs and achievement outcomes. Those that were deemed moderately suitable incorporated retrospective designs or multiple pre/post-measurements but had no concurrent control group. Although still evaluated, study designs rated as least suitable involved those with single pre-/post-measurements that lacked a concurrent comparison group or those that measured exposure and outcome in a single group at the same point in time, for example, correlation studies.
Results of the systematic review are summarized in Table I according to the rigor of the research design and indicating the 8 domains of the CSHP model are as follows: health education, health services, physical education, food services, mental health services, school environment, staff health promotion, and parental involvement. Although the best programs coordinate among the 8 components and programs that coordinate more than 1 component met the standards for inclusion in the review, for clarity of presentation we elected to present programs in this format. A total of 4 research projects met the most stringent criteria of this review, a randomized controlled trial incorporating components of the CSHP model as predictors and measures of academic achievement as outcomes. An additional 13 research reports met the next most stringent criteria of a quasiexperimental study with longitudinal measurement and controls matched on relevant variables. Together, these reports provide evidence that school health programs can enhance academic outcomes.
The most rigorous studies used a randomized controlled design and evaluated the effect of health education and parental involvement or physical education on academic performance. An asthma self-management program incorporating health education and parental involvement increased academic grades for low-income minority children. (15) A subsequent study of the asthma self-management program was expanded to include health education for asthmatic children and their classmates, orientation for school principals and counselors, briefings for school custodians, school fairs including caretakers, and communication with clinicians demonstrated higher grades for science but not math or reading and fewer absences attributed to asthma as reported by parents but not fewer school-recorded absences. (16) A rigorous evaluation of Project SPARK, a physical education program, demonstrated significant gains for reading, losses for language, and no differences for math scores on a standardized test, suggesting that, even with time taken away from the academic program for physical education, overall academic functioning was not impaired. (17) In a randomized trial of physical education programs incorporating fitness or skill training for 75 minutes per day, compared with usual physical education offered 3 times a week for 30 minutes, students in the fitness and skill groups demonstrated no significant decrement in test scores compared with controls. (18) These studies suggest that implementation of physical education will not impair academic achievement on standardized tests, and implementation of asthma management programs may enhance some academic grades for low-income asthmatic children.
The Seattle Social Development Project incorporated parent involvement through parent education, health education through social skills training, and healthy school environment through teacher training in classroom management evaluated initially in a randomized controlled design for children in grades 1-4 and subsequently in a quasiexperimental design in which the panel was expanded to include additional children and schools. A substudy of the Seattle Social Development Project, including children from the original sample enrolled in first grade, randomly assigned to intervention and control condition and evaluated in fifth grade reported significant improvements in achievement test scores and grades for boys but not for girls. (19) The long-term follow-up of the original trial augmented in fifth grade with a larger panel and a late intervention in grades 5 and 6 implemented in a quasiexperimental design found 18-year-old students receiving the full intervention (grades 1-6) reported better school achievement by grade 12 as measured by a combination of self-reported GPA and number of …