Introduction

Socioeconomic status (SES) is one of the most widely used factors to predict and explain health disparities; and of all three components of SES (education, income and occupation), education is the most salient predictor of lifetime health and disease (Freudenberg & Ruglis, 2007; Deaton, 2002). In fact, when considering health-related quality of life, a 40-year-old college graduate has the same health status as a 20-year-old who did not graduate from high school (Muennig, 2007, p. 135). Education also independently predicts risk factors for cardiovascular disease (Winkelby, Jatulis, Frank, & Fortmann, 1992). In fact, not graduating high school is as strong a predictor of death from coronary heart disease as having high cholesterol or high blood pressure (Fiscella & Franks, 2004).

There exists a graded relationship between years of education and mortality (Pappas, Queen, Hadder & Fisher, 1993), and fewer years of formal education predicts both early death (Liberatos, Link, Kelsey, 1988; Molla, Madans, & Wagener, 2004) and a shorter life span (Fiscella & Franks, 2004). For example, in 2002, US residents aged 25-64 with less than 12 years of education had an age-adjusted death rate—for all health causes—17 percent higher than people who had completed high school and almost three times higher than people who had finished at least one year of college (National Center for Health Statistics, 2004). Similar differences in mortality by educational attainment were observed for chronic diseases, injuries and communicable diseases.

Compared to those with more education, people with less formal schooling have been found to suffer from higher rates of a wide range of health problems including: heart diseases, high blood pressure, diabetes, asthma, cancer, obesity, infection, injury, lung disease, having low birth weight babies, higher mortality and higher health-risk behaviors (Winkelby, Jatulis, Frank, & Fortmann, 1992; Fiscella & Franks, 2004; National Center for Health Statistics, 1998; Crimmins & Saito, 2001; Ross & Wu, 1995; Sharma, Malarcher, Giles, Myers, 2004; Link & Phelan, 1995), disability (McNeil, 2001), activity restrictions/limitations (Molla, Madans, & Wagener, 2004) and being both under and over weight (Lantz et al., 1998).

In public health literature, more formal education is causally related to health: higher education contributes to better health by increasing one’s income and occupation, thereby providing access to knowledge, skills and resources, insurance and enabling individuals to acquire more social support and networks to respond better to social stress (Muennig, 2007). It is related to a person’s ability to gain access to health information, facilities, services, technologies, resources, support, nutrition options, exercise, safe environments (home, neighborhood & work) and food security (Link & Phelan, 1995; Adler & Newman, 2002). So, too, does it “attenuate life stressors, improve social networks, reduce behavioral risk factors, and increase the likelihood of possessing health insurance” (Muennig, 2007, p. 130). For children, school design and resources are directly linked to physical activity, and therefore education affects health (Sallis et. al., 2001; World Health Organization, 2004). Thus, people with more education have a better capacity to protect and maintain their health. Finally, less education is associated with a myriad of social problems such as drug addiction, incarceration and social isolation, all of which contribute to poor health and community disruption and have significant costs to the public.

In the long run, not completing high school correlates to lower levels of civic and political participation (Baum & Payea, 2004; Junn, 2005). To this end, Rudolf Virchow said it best: “Economic stability and active political participation by the poor…were necessary for good health” (Waitzkin, 2005, p. 29).[1] By denying education, health and freedom get harmed in more than one way.

However, we can no longer conceive of the relationship between education and health as one of input and output, as sites of intervention and outcomes. If we fail to see education as a process structured by one’s opportunities to participate in its system, and whereby its experience impacts health in much the same way as living in poverty, experiencing (or perceived) racism, discrimination and environmental stressors (Hofrichter, 2003); we are gravely missing out on an opportunity to drastically re-imagine and improve two of the greatest human rights crises: educational and health inequities. So, too, do we miss out on opportunities for research, interventions and reforms for educational, health and social justice.

Measured by educational benchmarks (i.e., less than a high school education, high school diploma, some college, college degree, etc.), education becomes normed, in a system that by definition is not. I argue that if education level were indeed a definitive benchmark for health, there would not be such consistent between-group racial/ethnic differences in health status, lifespan, morbidity and mortality (Crimmins & Saito, 2001). Which is to say that schooling experiences perhaps moderate the relationship between race/ethnicity and health.

Data shows that females are more likely to graduate from high school and have longer, healthier lives. White men age 25 and over with less than a high school education had mortality rates 125 percent to 200 percent higher than white men with some college education, depending upon age (Crimmins & Saito, 2001). For Black men and women, the difference was almost 300 percent. Similar differences by educational attainment and race were found in disability rates, chronic disease, and healthy life expectancy (Crimmins & Saito, 2001; Geronimus, 2001; Geronimus & Thompson, 2004). And the connection between health and socioeconomic position is among the most vigorous findings of epidemiology and public health.

Yet racial disparities aren’t stagnant either. For young Blacks living in high-poverty urban areas, such as Harlem or Chicago’s South Side, the rates of morbidity and mortality are even more striking. In these areas, of young African Americans who reach sixteen, 33 percent of the girls and 66 percent of boys will not live to reach age sixty-five (compared to the national average where 10 percent of girls and 25 percent of boys will not reach their sixty-fifth birthday) (Geronimus & Thompson, 2004). And in some urban locales, African American young people faced a lower probability of living to age 45 than White youths, nationwide, faced for living until age 65 (Geronimus, 2000, 2001).

These health data look almost equivalent to the wide gap between the graduation rates of Whites and Blacks introduced in the beginning of this chapter. I posit that this correlation cannot be, and is not, coincidence. “Individual economic or education success does not bring the same rewards for African Americans as for Whites” (Kaufman et al, 1997 in Geronimus & Thompson, 2004, p. 256). So what is it about the process of education that is so different for students of color than for Whites? And what are its educational and health consequences?

Research on indigenous health in Australia has reported and acknowledged this phenomenon, concluding that “the role of schooling in preparing people for employment was widely acknowledged, although Western education was not generally recognized as having a positive influence on health” (Dunbar & Scrimgeour, 2007, p. 139). This may help to explain why, in the United States, a high school diploma does not confer the same outcomes across racial/ethic groups (Western, 2006). The same cultural groups who are most dispossessed by education also have the most long-standing historical relationship of colonization, exploitation and oppression at the hands of the Western worldview in the imperial United States—Native Americans, African Americans, and Mexican Americans, to name a few. So there is something very significant about the role and conflict of the histories of the groups of youth who are faring the worst in schools today; the same groups who also have deleterious health outcomes (See Carson, Dunbar, Chenhall & Baile, 2007).

Taking up these issues in the context of the graduation rate crisis that is plaguing American education (Orfield, 2004), where nationally nearly one third of all students and half of Black, Latino, and American Indian students who enter 9th grade do not graduate high school (Swanson, 2004) and where the nation’s fifty largest cities graduate, on average, graduate only 51.8% of all students, the ProjectDISH (Disparities in Schooling and Health) research collective began. The remainder of this presentation briefly explores these issues through youth participatory action research (YPAR).

Youth Participatory Action Research

Youth are experts in understanding the ways in which schools and health are intertwined. Their bodies and souls yield daily, embodied experiences at school for which no one is more expert than they are. Youth implicitly understand how the system of education and subsequent schooling operations and practices bear consequences not only to their academic achievement, but also to their mental, physical, sexual and social health and their psychological understanding of themselves and their futures. A political, epistemological and pedagogical worldview, youth participatory action research (YPAR) (Cammarota & Fine, 2008) challenges conceptions of where expertise lies and seeks to disrupt and re-imagine existing power relations. In this context of the education-health nexus, youth so clearly assert themselves as the foremost experts of marks, scars and sutures both seen and unseen that schools leave on bodies and minds.

A methodological stance, participatory action research (PAR) is grounded in challenges to ways of knowing, ways of being, expertise and power. It offers an alternative paradigm in which social and research hierarchies are dismantled through restructuring power dynamics (See: Stoudt, 2009; Payne & Hamdi, 2009). So too is PAR an alternate epistemology: uprooting beliefs in what constitutes knowledge, how and what knowledge is produced, where expertise lies and who is involved in both (See: Harding, 1998; Tuhiwai Smith, 1999, 2006). When taken as a political act, PAR is radical pedagogy—intentionally disrupting power dynamics and re-shifting the center(s) of research. Instead of researching on, PAR researchers move their positionality to a dynamic insider-outsider state and instead research with. And most importantly those traditionally researched on join the research process; researching with. That is, “PAR recognizes that those ‘studied’ harbor critical social knowledge and must be repositioned as subjects and architects of research” (Torre & Fine, 2006, p. 271. See also: Fals-Borda, 1979; Guishard, 2009; Fine, Bloom, Burns, Chajet, Guishard, Payne, Perkins-Munn & Torre, 2005; Fine & Torre, 2004; Cahill, 2004, 2007). Historically, following its South and Central American, Asian, African, European and North American roots, participatory action research aims for radical social change. It aims for fracturing and exposing deep structural violence experienced by those oppressed and on the marginal axes of society (See Reason & Bradbury, 2008). As Paulo Friere (1982) states:

To this end, Arjun Appadurai (2006) argues that research should be regarded as a right, “albeit of a special kind” (p. 167). He goes on to say, “This argument requires us to recognise that research is a specialised name for a generalised capacity, the capacity to make disciplined inquiries into those things we need to know, but do not know yet” (p. 167). This implicates specifically a component of PAR that I argue is supreme when doing youth PAR (or YPAR). That is, YPAR is a politicized pedagogical act. Research in this view is the generalized capacity to make disciplined inquires into that we all need to know, but do not know yet and that youth yearn to know. YPAR is the methodological tool for this research.

Three of the ProjectDISH youth researchers state the purpose of our research and why they joined. Their words mirror what PAR is.

Researching Schooling as a Social Determinant of Health Through YPAR

ProjectDISH (Disparities in Schooling and Health) is a youth participatory action research collective comprised of ten youth researchers ages 14-19 and myself. Located in New York City, we are diverse by gender, ethnicity and educational status. We seek to investigate how schooling affects health. Meeting weekly over the course of one year, the youth were trained as full social science researchers. Following three months of critical pedagogy work in which the youth researchers learned about and explored educational and health disparities and social science research, the youth then developed our research questions, methods, and protocols; completed human subjects certification training; were trained as focus group facilitators; collected data; analyzed data; and are now presenting at a variety of academic conferences, invited addresses, and community events to present our research. However, these are not rigid boundaries, as PAR is a cyclic process in which inquiry, questioning, research design, data collection, analysis and analysis happen in cycles, and not in a linear progression.

We employed a mixed methods design, incorporating three primary research methods: focus groups, secondary data analysis and survey. Yet within each focus group (N=6, n=22), we utilized three different qualitative methods: mapping, focus group discussions, and narrative inquiry where we asked students to write “Advice to the Mayor” telling him what schools should be doing to keep students healthy. We collected data about the relationship between school and health across several central domains, collectively addressing our research questions: information about health (i.e., health class), preventive care in school (condom distribution), health services in school (nurse or health clinic), actual bodily experiences in school, health hazards (asbestos, fights in the corridor), and psychological stress (testing, bullying, sexual harassment). The survey portion of our research came from Polling for Justice, an intergenerational, intersectoral participatory action research (PAR) project that trained forty youth researchers who (along with graduate students and faculty, affiliated community organizations and several municipal agencies) collaboratively developed a comprehensive survey of the intersecting experiences of youth with the educational, health and criminal justice systems in New York City. Polling for Justice is housed at the Graduate Center of CUNY and myself and four of the ProjectDISH youth researchers are also a part of Polling for Justice. The Polling for Justice survey seeks to survey 1,100 youth in New York City and is currently still open. However, we began preliminary analyses of Wave I of the data after we had an n of 550.

ProjectDISH data yielded findings across eight major themes: 1) Built Environment & School Design, 2) School Food and Food Policies, 3) Academic / Educational Issues, 4) Safety, Abuse & Violence, 5) Social & Mental Health Services and Resources, 6) Health & Sexuality Education, Resources and Programs, 7) Psychological Consequences of School, and 8) Physiological Consequences of School. This data would not have been possible were it not for the youth researchers, their expertise in developing innovative research methods, the focus group protocol and survey, and their expertise as students and residents of the contexts and lifeworlds which we were studying.

In addition to evidencing urban schooling conditions, through the innovative mapping prompt that the youth researchers developed, we were able to document what about school affects students’ physiological and psychological health, what specific things about school cause stress for students, and what parts of the body school affects. This is the beginning of understanding the pathways by which education is a social determinant of health and to understanding disparities in health.

In this presentation, I will describe only our mapping prompt in brief. After beginning introductions, we began the focus group with a mapping exercise. Our goal of this method was to extract data that got at ‘that which cannot be seen’ or that for which there may be no precedent for having words for. In other words, how do we examine what school is doing inside the body? We wanted to document the embodiment (Krieger 1999, 2001, 2005a, 2005b; Krieger & Smith, 2004) of schooling. How do we get at where and how school affects one’s body and health? After several brainstorming sessions and after reading two articles on mapping as a research method, we decided upon the following mapping prompt:

Participants (n=20) had twenty minutes to create their map, using poster board and a variety of crayons, colored pencils, markers and paint. After creating their maps, each participant then discussed and explained their maps to the entire focus group. This method of analysis was developed by the youth themselves. They decided that the first thing we needed to do was to figure out how many times each body part was represented across all maps. However, they thought that we should only count the number of body parts that participants “talked about”, meaning the body parts that students wrote descriptions of or drew graphic representations of on their maps, or that they talked about when describing their maps in the focus group. We then called these the “annotated body parts.” The youth felt that we should not count all body parts drawn on the map, only the annotated ones, because since we had asked participants to draw an x-ray of their body, they might have drawn some parts to illustrate the x-ray their body, and not because that part was necessarily meaningful. So, we defined an annotated body part as any body part on the map that was commented on either textually or graphically (i.e. with symbols or images). Figures represent the number of maps on which the body locations were specifically mentioned/annotated by the participants. A graphic designer then created an illustration of our data, according to Edward Tufte’s (1990, 1997, 2001, 2006) principles of data visualization, or the “visual display of quantitative information.”

This graphic provides several layers of information. First, it identifies the percentage of maps on which any given body part was drawn and specifically annotated. These percentages are depicted graphically through the relative size of circles located at each body part. In other words, the larger the sphere the more maps that body part was identified in. Second, in Figure 7.9, body parts are represented graphically and textually, where the frequency circle is located at each body part it corresponds to and additionally each body part is labeled. Of note, the penis is denoted on 100 percent of the maps that could have possibly had penises, indicating that of the two maps that could have had penises, they both drew and annotated a penis. Therefore it was represented as 100 percent of possible maps.

Quantification of Body Parts Affected by School

We see from Figure 1 that the head/brain is affected more than any other body part, primarily experienced as headaches. It is depicted on 100 percent of the maps; followed by eyes (70 percent), stomach (45 percent), mouth (40 percent), back (35 percent), hands/fingers (25 percent), whole body (20 percent), legs (20 percent), heart (15 percent), face (15 percent), lungs/chest (10 percent), butt (10 percent), nose (10 percent), shoulder/arm (10 percent), ears (10 percent), neck (5 percent), and penis (100 percent; 2 out of 2 maps). In the next section, we explore each body part in depth presenting all of the educational variables that students identified in their maps as affecting each specific appendage.

As previously we analyzed across maps, here we went deep within the maps. Following a count of each body part, the ProjectDISH collective then moved to organizing, across maps, the school “causes” for each body part being affected. After quantifying the locations in the body that school affects, the youth decide that we should first create a list of all of the words and phrases that participants used to describe what particular body parts felt like and why. For this list, we included items that were written/drawn onto to maps as well as things that were said in the participants’ verbal explanations of their map. We organized all of the annotations for each body part by body part. So, for example, we created a list of all of the things that participants identified with their head, eyes, mouth etc. When then categorized these and had the same graphic designer develop illustrations for each body part that contained both an image of the body part and the causes of what about school affected that body part.

Each figure below depicts one distinct body part and the associated features of schooling that were identified across maps as the causes for that area to be affected (I include only three out of the seventeen such figures in this presentation). This is analogous to a doctor identifying a fractured tibia in an x-ray and finding out that this student was kicked forcefully during a soccer game, an act which resulted in the break. Here we see embodied educational operations, where the data tells what and where urban public schooling experiences get taken up by students’ bodies. We see what young people are saying is also being felt.

Evidence for the Embodiment of Schooling

These analytical designs illustrate the embodiment of schooling. We see through these data visualizations that the physical, sexual and psychic body indeed takes up the social matrices of schooling and how educational possibilities, constraints and relations of power and social control affect their health. We see what causes students’ stress in schools. And survey data supports these findings. Take, for example, the finding that the stomach is affected by school, with hunger being the most significant physiological outcome. In addition to hunger and poor nutrition affecting health and cognitive functioning and development, it also has direct educational outcomes. The survey data revealed that 94.8 percent of youth had trouble paying attention in class due to hunger at least one day per week. Specifically, 29.4 percent of survey respondents were hungry one day in the past week; 24 percent, two days; 19.2 percent, three days; 5.4 percent, four days; and 16.7 percent were hungry all five days.

Or take the issue of generalized “stress” and “worry” as indicated in the above figures. Jade, a focus group participant, states “A lot of work can lead to stress or physical problems.” There was resounding agreement of this statement within her focus group. Maritza, another participant, added, “like weight loss and chest problems. How do I know? I went through it.” Lisa then chimed in, “I know, I get headaches.” Ironically, stress also affects performance (Dougall & Baum, 2001).

Of the 171 students in the Polling for Justice survey who reported that they were always worried about school, 14.6 percent “felt that life wasn’t worth living” 3-7 days per week (occasionally, moderately or all of the time), and another 15.2 percent felt life wasn’t worth living sometimes (1-2 days per week). Taken together we see that nearly one third of students who are always worried about school feel that life isn’t worth living at least once per week. And of the 157 students who are frequently worried about school, 10.8 percent felt life isn’t worth living 3-7 days per week, and 13.4 percent felt life isn’t worth living 1-2 days per week. It is shocking to see how staggering the effects of school are upon students’ mental health, depression and thoughts of suicide.

Equally, students cite that worries (i.e. stress) about school affects their overall health (self-reported health status). Of students who are always worried about school, 13.5 percent report that their overall health is either poor or fair. Of the students who are frequently worried about school, 13.9 percent say that in general their health is either poor or fair.

Yet, while these findings portray consequences of negative experiences in school, students equally report that “good grades make me happy” and that “teachers and staff who are nice” and “friends” make them happy too.

Translated into research findings, we find that the eight themes mentioned above document, implicate and affect urban schooling conditions (and associated psychological and health outcomes); sexual subjectivities of youth; health capital; the embodiment of schooling; daily schooling stressors and accumulated disadvantage on health; school non-completion; educational dispossession and violence; and education as a mediator of depression / mental health. Overall our research contributes to literature on the relationship of stress and health, documenting daily and accumulated stresses in school and their health outcomes.

Conclusion

Youth organizer Christopher Goodman said it best on February 6, 2008 speaking out against the "historic underfunding" and budget cuts to the Maryland public schools, like is happening in so many districts around the nation: “Every year, they underfund our schools, they kill us" (Kumar, 2008). Young people are literally fighting for their lives.

It is our job as critical educators, health practitioners and scholars to use all of the bones and might in our bodies, the energy and fortitude in our souls, and the relative privilege of our occupations to engage in deep, participatory action research with youth: working to reclaim their right to education and health and the humanity of our nation, and to challenge educational institutions and policies for the degrading lifetime and intergenerational costs they strap to the backs and psyches of young people.

NOTE: Graphics and content of this presentation are copyrighted and appear in full in Ruglis, J. (2009). Death of a Dropout: (Re)Theorizing School Dropout and Schooling as a Social Determinant of Health. Doctoral Dissertation, Graduate Center of the City University of New York, 2009. Dissertation Abstracts International.

related authored publications:

• Ruglis, J. (2009). Death of a Dropout: (Re)Theorizing School Dropout and Schooling as a Social Determinant of Health. Doctoral Dissertation, Graduate Center of the City University of New York, 2009. Dissertation Abstracts International.
• * Fine, M & Ruglis, J. (2009). Circuits and consequences of dispossession: The racialized realignment of the public sphere for U.S. youth. Transforming Anthropology; 17(1): 20-36. Available at: http://www3.interscience.wiley.com/cgi-bin/fulltext/122321894/PDFSTART
• * Freudenberg, N & Ruglis, J. (2007). Reframing school dropout as a public health issue. Preventing Chronic Disease; 4(4).
• Ruglis, J. (2007). Dropout. In: Mathison & Ross (Eds.) BattlegroundSchools, Volume 1, pp.Westport, CT: Greenwood Publishing. 194-203.

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1. In what ways can the health community partner with schools to help support and improve health, sexuality and social support services, programs and education?
2. In what innovative ways can health services / education / programs help keep students in school and improve graduation rates?
3. In what ways can the health community assist in improving school food, physical education and the built environment?