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Population Health for Nurses

8.3 Educational Environment, Access, and Quality

Population Health for Nurses8.3 Educational Environment, Access, and Quality

Learning Outcomes

By the end of this section, you should be able to:

  • 8.3.1 Describe the association between health indicators and educational level.
  • 8.3.2 Explain the implications of poverty, disabilities, and discrimination on learning and access to quality education.
  • 8.3.3 Discuss the intersection between the social determinants of health and health literacy.

The evidence is clear: individuals with higher levels of educational attainment are more likely to live longer and healthier lives (ODPHP, 2020c). Higher levels of educational attainment refer to the education a person completes after receiving a high school diploma, such as earning an associate or baccalaureate degree. Education is one of the most important modifiable SDOH, as higher education is associated with increased healthy lifestyle behaviors and improved health outcomes. Those with higher educational attainment have greater economic resources and better access to health care (RHIhub, 2020a).

In contrast, a person is said to have low educational attainment if they have not completed high school. This is associated with economic insecurity and can result in overall worse health outcomes. The cycle of poverty and economic insecurity affects both educational access and the quality of education. Individuals in impoverished neighborhoods often have less access to community resources and wield less effective political influence, rendering them less able to demand higher-quality schools. Lower-quality schools lack the resources to support students, resulting in significant educational opportunity gaps based on neighborhood and school district. For example, children from low-income families are more likely to struggle with math and reading. They are less likely to graduate from high school and go to college than children from higher-income families (ODPHP, 2020c). Academically gifted children attending public schools in low-income areas are also less likely to have access to gifted and talented programs if their schools do not offer these resources or if their families cannot afford to access them elsewhere (Yaluma & Tyner, 2021). The stress of living in poverty can adversely affect a child’s brain development, making it harder for them to do well in school (ODPHP, 2020c). This can have a domino effect, as a college education is associated with safer and higher-paying jobs; individuals who do not graduate from high school or go to college are more likely to have chronic health problems (ODPHP, 2020c).

The Roots of Health Inequities

The Educational Roots of Health Inequities

The educational roots of health inequities result from institutional and systemic biases in policies that separate individuals into either resource-rich or resource-poor neighborhoods, as these neighborhoods dictate school access. This separation into resource-rich or resource-poor neighborhoods is principally based on socioeconomic position and race, resulting in wide health disparities in life expectancy and health outcomes, as education is a major factor in shaping the course of an individual’s life.

(See Weinstein et al., 2017.)

Early Childhood Development and Education

A child’s first 5 years of life are critical for cognitive, emotional, and physical growth and development. A healthy, safe, and stable early childhood helps determine if a child will have a healthy, happy life. A variety of social, environmental, and economic factors greatly affect early childhood development. Risk factors for potential developmental delays and future poor health outcomes include early life stressors, low income, and lack of access to quality early educational programs. In contrast, protective factors include higher socioeconomic status (SES), stable relationships with caregivers, and access to quality early education programs (ODPHP, 2020m).

As mentioned previously, early life stressors and ACEs impact a child’s health. Early life stressors such as physical abuse, family instability, poverty, and unsafe environments contribute to developmental delays and poor health outcomes later in life. These children may lack adequate coping skills and have difficulty regulating their emotions and behaviors, thereby struggling in early childhood education programs (ODPHP, 2020m). Inadequate social functioning skills like lack of impulse control, difficulty forming relationships, and trouble regulating behaviors can negatively impact a child’s ability to learn or connect with peers in early elementary school programs.

Poverty, by itself, negatively impacts children’s academic achievement. Research has demonstrated that children from disadvantaged backgrounds are more likely than other children to repeat grades and drop out of high school (ODPHP, 2020m). Children from communities with higher SES and more resources have been shown to experience safer and more supportive environments and better early education programs. Quality early childhood programs help foster the mental and physical development of children. They are linked to increased earning potential and higher educational attainment (ODPHP, 2020m).

Early childhood education programs can help reduce educational gaps. Head Start is a federally funded early childhood program that supports children from low-income families. It provides comprehensive services and strives to improve health, increase learning and social skills, and prepare young children for kindergarten. Studies have demonstrated that children who experience quality early education programs like Head Start that are comprehensive and include health care and nutritional components partake in less risky health behaviors such as binge drinking alcohol, smoking cigarettes, and using illegal substances and have lower risks for heart disease, obesity, hypertension, hyperglycemia, and hypercholesterolemia (ODPHP, 2020m). Quality comprehensive early childhood development and education programs reduce risky heath behaviors and prevent or delay the onset of chronic disease in adulthood.

The quality of education in elementary schools is an important determinant in the health and well-being of children. Receiving a high-quality elementary school education reduces educational disparities in children. Children attending a school with safety concerns, limited health resources, and low teacher support are more likely to experience adverse physical and mental health. Until disparities in access to quality early childhood development programs and quality school systems are addressed, children without access will suffer worse health outcomes (ODPHP, 2020m).

Theory in Action

Brain Architecture in Early Childhood

In this University of Minnesota Center for Early Education and Development video, Dr. Megan Gunnar discusses the impact of early childhood development on the future abilities and health outcomes of children.

Watch the video, and then respond to the following questions.

  1. How does early childhood development affect learning later in life?
  2. List five ways families and communities can help build a strong and proper brain foundation in early childhood.
  3. How does a strong brain foundation impact health outcomes?

High School Graduation

Most jobs require at least a high school (secondary) education. Individuals who do not complete high school have limited employment opportunities, earn lower wages, and are more likely to live in poverty. Disparities in high school completion rates exist by racial and ethnic groups with Black and American Indian/Alaska Native students having the lowest graduation rates (ODPHP, 2020o). Students’ home and school environments impact their chances of graduating from high school. High school graduation can be affected by family support, the school district, resources within the school, and the greater community.

Lack of parental involvement in school is linked to lower graduation rates. Teacher quality is also a critical factor; students who believe their teachers are of high quality and that they care are more likely to graduate, whereas students who feel their teachers are uninterested in teaching are more likely to drop out (ODPHP, 2020o). Violence and safety concerns also affect high school dropout rates. Low-income families often live in neighborhoods where schools lack resources and underperform. These factors contribute to higher dropout rates and lower academic achievement. In 2016, low-income families were almost four times more likely than high-income families to have a student not complete high school (ODPHP, 2020o). Economically insecure BIPOC communities are disproportionately represented with lower educational attainment in comparison to economically insecure White individuals. Approximately 85 percent of economically insecure White adults have at least a high school diploma, whereas only about 50 percent of economically insecure adults who identify as Latina/Latino have attained their diploma (Langston, 2018).

Reading skill level in third grade is linked to high school completion rates. One Annie E. Casey Foundation study found that almost a quarter of students with below-basic reading skill level in the third grade failed to finish high school compared with 4 percent of students with third-grade proficient reading skills who failed to finish high school (ODPHP, 2020o). Twenty-six percent of students who were not reading at the proficient level in third grade and who had lived in poverty for at least one year during their school years did not finish high school on time or at all (ODPHP, 2020o). Teen pregnancy and parenthood are also risk factors for dropping out of high school, as only half of teens who have given birth earn a high school diploma.

Many positive outcomes come with graduating from high school. Individuals with a high school diploma have a decreased risk of premature death, more employment opportunities, and a higher lifetime earning potential (ODPHP, 2020o). Lacking a high school diploma is associated with self-reported overall poor health and chronic health issues such as asthma, diabetes, heart disease, hypertension, and hepatitis. Additionally, individuals with a high school diploma who are employed full-time earn almost 25 percent more than those who are employed full-time without a high school diploma (ODPHP, 2020o). Supporting individuals to graduate high school is an important public health intervention.

Enrollment in Higher Education

Higher education refers to any education after high school, including community colleges, vocational and technical schools, colleges, and universities. Many higher-paying jobs require a college degree; less than one in five economically insecure individuals have a college degree, whereas half of economically secure individuals do (Langston, 2018). College graduates have more employment options than individuals without college degrees. On average, lifetime earnings for individuals with a bachelor’s degree are double those of individuals without a degree (ODPHP, 2020n). Higher education is associated with better-paying, less hazardous jobs. This all supports an individual’s health, as the higher their income, the greater their ability to secure material and social resources like higher-quality housing and social status (ODPHP, 2020n). Overall, higher education is associated with improved health and a decreased risk of premature death. Individuals with more education are more likely to partake in healthy behaviors, such as drinking less alcohol, exercising regularly, and seeking preventive health care when needed (ODPHP, 2020n).

How well an individual’s middle and high schools prepare them for college greatly influences their likelihood of graduating. Students who attend high schools that do not provide honors or advanced courses may be less academically prepared for college-level work than students who attend high schools that provide these courses (ODPHP, 2020n). Students without access to a consistent guidance counselor may not receive help navigating the college application and admissions process. In many low-income neighborhoods, schools lack the financial resources necessary to offer these courses and dedicated guidance counselors, potentially lowering college admissions rates for their students (ODPHP, 2020n).

While the diversity of undergraduate college students is increasing, BIPOC individuals still demonstrate lower levels of academic persistence in college compared to their White counterparts (ODPHP, 2020n). Black and Hispanic individuals also have lower college enrollment and graduation rates. These lower enrollment and graduation rates may be affected by the discrimination, social isolation, and stress of debt accumulation that these students face (ODPHP, 2020n). BIPOC students experience discrimination at rates two to four times higher than White students, and in a study up to a quarter of these students reported feeling that the discrimination they experienced adversely affected their academic outcomes (Stevens et al., 2018). Barriers to higher education exist, but strengthening the curriculum in school districts in lower-income communities and offering more teacher and guidance counselor support can help to better prepare students for the admissions process and the rigors of college (ODPHP, 2020n).

The Role of the Nurse in Addressing Educational Disparities

Community and public health nurses play an important role in early childhood, primary, and secondary education. Partnering with school nurses and administrators, community and public health nurses can use their assessment data as a foundation to influence policy development at the local level. By analyzing trends in the data and presenting this information to the local school committee and city officials, nurses can advocate for meaningful change, such as creating or expanding Head Start programs to ensure equal access to evidence-based successful early childhood education programs. Community and public health nurses can also advocate for increased funding for school districts to create high-quality primary education. Community and public health nurses can advocate for and support transition programs to support students moving from middle to high school. Additionally, nurses can advocate for advanced courses and other programs that better prepare students for the future. These types of programs can encourage students to continue with their studies.

Education Gap: The Root of Inequality

In this video, Harvard University’s Director of the Achievement Gap Initiative, Ronald Ferguson, discusses educational inequality and encouraging efforts that are being made in Boston to address these gaps. This is an example of a community-level approach to addressing educational inequalities that a community and population health nurse can spearhead and lead.

Watch the video, and then respond to the following questions.

  1. Why do you think educational gaps exist?
  2. How do you think the Boston Basics program can help address these educational gaps?
  3. What is the community health nurse’s role in addressing and responding to these educational gaps?

Language and Literacy

Literacy refers to listening and speaking skills, reading and writing skills, and cultural and conceptual knowledge. Health literacy refers to an individual’s ability to find, understand, and use health-related information (ODPHP, 2020t). Low literacy skills are linked with lower educational attainment, poorer health outcomes, and chronic diseases like diabetes and cancer (ODPHP, 2020l).

Limited English proficiency (LEP) can be a barrier to accessing health care services. Individuals with limited English proficiency tend to be immigrants to the United States who may speak another language at home. In 2019, almost 22 percent of the U.S. population ages five and above spoke a language other than English at home, and among these individuals, 39 percent reported speaking English less than very well (ODPHP, 2020l). Individuals who identify as having limited English proficiency are less likely to have a primary care provider and, therefore, less likely to have preventive health care (ODPHP, 2020l). These individuals also encounter difficulty following medication instructions and communicating with health care providers.

Many barriers impede individuals with limited English proficiency from receiving appropriate health services. A lack of trained interpreters and culturally responsive health care providers adversely affects their health. Cultural barriers, language barriers, and financial difficulties create significant obstacles for immigrants trying to access health information (ODPHP, 2020l). Language barriers create a quality-of-care issue, especially if the provider is not linguistically competent, and a lack of quality trained interpreters impedes access to mental health services for individuals with limited English proficiency (ODPHP, 2020l). See Culturally and Linguistically Responsive Nursing Care for more information on this topic.

Case Reflection

Client Education

Read the scenario, and then respond to the questions that follow.

Serena and her children attend the local community center’s biannual fair. Twice a year, the community center hosts this one-day event for the community’s residents, where they have food, games, health screenings, health promotion education events, yoga, senior center representatives, and sign-up sheets for various community groups. Serena decides to have her blood pressure (BP) taken at the screening tent. Her BP reading is 162/92. The nurse takes it manually and repeats it two times, but the readings are similar. The nurse asks Serena about any medical history of daily medications, but Serena shakes her head no. She feels lucky to be healthy overall and does not take any medications except for ibuprofen for headaches occasionally.

  1. What factors could be contributing to Serena’s elevated blood pressure?
  2. What lifestyle questions could the nurse ask Serena to develop a health teaching plan for her?
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