The Relationship between Childhood Obesity, Low Socioeconomic Status, and Race/Ethnicity: Lessons from Massachusetts.

BACKGROUND: Previous studies have shown race/ethnicity, particularly African American and/or Hispanic status, to be a predictor of overweight/obese status in children. However, these studies have failed to adjust for low socioeconomic status (SES). This study assessed whether race/ethnicity remained an independent predictor of childhood obesity when accounting for variations in SES (low-income) among communities in Massachusetts. METHODS: This study was based on 2009 summarized data from 68 Massachusetts school districts with 111,799 students in grades 1, 4, 7, and 10. We studied the relationship between the rate of overweight/obese students (mean = 0.32; range = 0.10-0.46), the rate of African American and Hispanic students (mean = 0.17; range = 0.00-0.90), and the rate of low-income students (mean = 0.27; range = 0.02-0.87) in two and three dimensions. The main effect of the race/ethnicity rate, the low-income rate, and their interaction on the overweight and obese rate was investigated by multiple regression modeling. RESULTS: Low-income was highly associated with overweight/obese status (p < 0.0001), whereas the effect of race/ethnicity (p = 0.27) and its interaction (p = 0.23) with low-income were not statistically significant. For every 1% increase in low-income, there was a 1.17% increase in overweight/obese status. This pattern was observed across all African American and Hispanic rates in the communities studied. CONCLUSIONS: Overweight/obese status was highly prevalent among Massachusetts students, varying from 10% to 46% across communities. Although there were higher rates of overweight/obese status among African American and Hispanic students, the relationship disappeared when controlling for family income. Our findings suggest low SES plays a more significant role in the nation's childhood obesity epidemic than race/ethnicity.

IEP, IHP, and Section 504 Primer for New School Nurses.

Three types of documents and their frequently used acronyms play a vital role in ensuring that students with disabilities have the planning, services, and accommodations necessary to facilitate attendance and success in the school setting. Federal and state laws, as well as state nurse practice acts, govern the process and eligibility of students for these services. School nurses play a vital role in these processes, and new school nurses benefit from a comparison of the terms along with a historical explanation of the acronyms.

Cost-benefit study of school nursing services.

IMPORTANCE: In recent years, across the United States, many school districts have cut on-site delivery of health services by eliminating or reducing services provided by qualified school nurses. Providing cost-benefit information will help policy makers and decision makers better understand the value of school nursing services. OBJECTIVE: To conduct a case study of the Massachusetts Essential School Health Services (ESHS) program to demonstrate the cost-benefit of school health services delivered by full-time registered nurses. DESIGN, SETTING, AND PARTICIPANTS: Standard cost-benefit analysis methods were used to estimate the costs and benefits of the ESHS program compared with a scenario involving no school nursing service. Data from the ESHS program report and other published studies were used. A total of 477 163 students in 933 Massachusetts ESHS schools in 78 school districts received school health services during the 2009-2010 school year. INTERVENTIONS: School health services provided by full-time registered nurses. MAIN OUTCOMES AND MEASURES: Costs of nurse staffing and medical supplies incurred by 78 ESHS districts during the 2009-2010 school year were measured as program costs. Program benefits were measured as savings in medical procedure costs, teachers' productivity loss costs associated with addressing student health issues, and parents' productivity loss costs associated with student early dismissal and medication administration. Net benefits and benefit-cost ratio were calculated. All costs and benefits were in 2009 US dollars. RESULTS: During the 2009-2010 school year, at a cost of $79.0 million, the ESHS program prevented an estimated $20.0 million in medical care costs, $28.1 million in parents' productivity loss, and $129.1 million in teachers' productivity loss. As a result, the program generated a net benefit of $98.2 million to society. For every dollar invested in the program, society would gain $2.20. Eighty-nine percent of simulation trials resulted in a net benefit. CONCLUSIONS AND RELEVANCE: The results of this study demonstrated that school nursing services provided in the Massachusetts ESHS schools were a cost-beneficial investment of public money, warranting careful consideration by policy makers and decision makers when resource allocation decisions are made about school nursing positions.

The evolution of school nursing data indicators in Massachusetts: recommendations for a national data set.

The National Association of School Nurses' research priorities include the recommendation that data reliability, quality, and availability be addressed to advance research in child and school health. However, identifying a national school nursing data set has remained a challenge for school nurses, school nursing leaders, school nurse professional organizations, and state school nurse consultants. While there is much agreement that school nursing data (with associated data integrity) is an incredibly powerful tool for multiple uses, the content of a national data set must be developed. In 1993, recognizing the unique power of data, Massachusetts began addressing the need for consistent school nurse data collection. With more than 20 years' experience--and much experimentation, pilot testing, and system modification--Massachusetts is now ready to share its data collection system and certain key indicators with other states, thus offering a beginning foundation for a national school nursing data set.

What are the implications of the Institute of Medicine report "The future of nursing: leading change, advancing health" for school nursing practice?

In 2010, the Robert Wood Johnson Foundation Initiative at the Institute of Medicine issued a comprehensive report entitled, "The future of nursing: leading change, advancing health." The following is a synopsis of the report, including excerpts, recommendations, and a discussion of school nursing implications.

How may the school nurse use data effectively?

Consistent with their colleagues in other health care settings, school nurses function in a data-driven society. Collecting, analyzing, and sharing data with stakeholders are critical responsibilities for both improving school nursing practice and interpreting its importance to others. School nurses have unique opportunities to collect and use data in a variety of capacities affecting the health and education of children and adolescents. Moving into data-driven practice offers exciting surprises--and demands abilities to identify questions, understand data limitations, create and implement performance improvement programs, and use findings for evidence-based practice and advocacy.

Understanding childhood obesity in America: linkages between household income, community resources, and children's behaviors.

BACKGROUND: Understanding childhood obesity's root causes is critical to the creation of strategies to improve our children's health. We sought to define the association between childhood obesity and household income and how household income and childhood behaviors promote childhood obesity. METHODS: We assessed body mass index in 109,634 Massachusetts children, identifying the percentage of children who were overweight/obese versus the percentage of children in each community residing in low-income homes. We compared activity patterns and diet in 999 sixth graders residing in 4 Michigan communities with varying annual household income. RESULTS: In Massachusetts, percentage of overweight/obese by community varied from 9.6% to 42.8%. As household income dropped, percentage of overweight/obese children rose. In Michigan sixth graders, as household income goes down, frequency of fried food consumption per day doubles from 0.23 to 0.54 (P < .002), and daily TV/video time triples from 0.55 to 2.00 hours (P < .001), whereas vegetable consumption and moderate/vigorous exercise go down. CONCLUSIONS: The prevalence of overweight/obese children rises in communities with lower household income. Children residing in lower income communities exhibit poorer dietary and physical activity behaviors, which affect obesity.

Commercial sexual exploitation of children and the school nurse.

As trusted health professionals in the school setting, school nurses are well positioned to identify students who may be victims of commercial sexual exploitation of children (CSEC). However, until recently this issue has been clouded by lack of awareness, stigma, and/or denial. Since nationally the average age of entry for girls into the commercial sex industry (specifically prostitution) is 12-15 years old, many of these young people continue to attend school although attendance may be sporadic. Additional continuing education is needed to increase school nurses' awareness that these young victims might be in their practices, whether they are located in urban, rural, or suburban communities. As primary sources of health care for children throughout the United States, school nurses have a pivotal role in helping an exploited girl move beyond invisibility to a path of safety and support-and a new life.

Effectiveness of a school nurse-delivered smoking-cessation intervention for adolescents.

OBJECTIVE: To evaluate the effectiveness of a school nurse-delivered smoking-cessation intervention in increasing abstinence among adolescent smokers. METHODS: Thirty-five high schools were pair-matched and randomly assigned to 1 of 2 conditions, each of which consisted of 4 visits with the school nurse: (1) counseling intervention using the 5 A's model and cognitive-behavioral techniques; or (2) an information-attention control condition. Adolescents (n = 1068) who reported past 30-day smoking and interest in quitting completed surveys at baseline and at 3 and 12 months and provided saliva samples for biochemical validation of reported smoking abstinence. RESULTS: Intervention condition participants were almost twice as likely to be abstinent per self-report at 3 months (odds ratio: 1.90 [95% confidence interval: 1.12-3.24]; P = .017) compared with control participants; at 12 months there were no differences. The difference at 3 months was driven by quit rates in male students (15.0% [intervention] vs 4.9% [control]; odds ratio: 3.23 [95% confidence interval: 1.63-6.43]; P = .001); there was no intervention effect in female students at either time point (6.6% vs 7.0% at 3 months and 16.6% vs 15.5% at 12 months) and no intervention effect in male students at 12 months (13.9% vs 13.2%). Smoking amount and frequency decreased significantly in intervention compared with control schools at 3 but not at 12 months. CONCLUSIONS: A school nurse-delivered smoking-cessation intervention proved feasible and effective in improving short-term abstinence among adolescent boys and short-term reductions in smoking amount and frequency in both genders. Additional research is needed to enhance both cessation and maintained abstinence.

Life-threatening allergies revisited. What are the new opportunities to improve the care of these children in the school setting?

LTAs in children are indeed challenges, especially in busy school settings. However, for these school nurses and their leaders who assume responsibility for school preparation and management, collaborate across states, develop data systems to improve performance, and partner with allergy experts, there are opportunities for ensuring both child safety and professional growth.

Evaluating parent satisfaction of school nursing services.

The Conceptual Model of Nursing Health Policy (CMNHP) was used to guide this study of client satisfaction as one component of an ongoing assessment of the Essential School Health Service (ESHS) Programs conducted by the Massachusetts Department of Public Health. Random samples of parents/guardians of students who use the school nursing services were surveyed to determine the extent to which they were satisfied with school nursing services. The results indicate that parents/guardians have a high level of satisfaction with school nursing services. Mean rank satisfaction scores of parents of children with special health care needs were significantly higher then those parents of children without special health care needs. School nurses were encouraged to share the results of the study with various stakeholders in their school district.

A school nurse-delivered adolescent smoking cessation intervention: a randomized controlled trial.

BACKGROUND: The aim of the present study was to evaluate the efficacy of a school nurse-delivered smoking cessation intervention to improve abstinence rates among adolescents interested in quitting. METHODS: Seventy-one high schools in Massachusetts were randomized to either a four-session one-on-one school nurse-delivered smoking cessation intervention (37 schools, n = 571) or usual smoking cessation care control condition (34 schools, n = 577). Adolescents in grades 9-12 who smoked in the past 30 days completed surveys at baseline, 6 weeks and 3 months. The study was conducted during the 2002-2003 school year. RESULTS: Thirty-day self-reported abstinence rates were significantly greater in students in the intervention compared to control condition at 6 weeks (18% vs. 2%, respectively) and 3 months (24% vs. 5%, respectively). After adjusting for school and potential confounders, students in the intervention schools had odds of quitting 8 times greater than students in the control schools at 6 weeks (OR = 8.4; 95% CI 3.7, 20.6) and 6 times greater at 3 months (OR = 6.4; 95% CI 3.4, 11.4). School nurses delivered intervention with a high degree of fidelity. CONCLUSIONS: A four-session smoking cessation intervention can feasibly be delivered by school nurses and increase self-reported short-term abstinence rates among students interested in quitting smoking.

Administration of epinephrine for life-threatening allergic reactions in school settings.

OBJECTIVE: Although the potential for life-threatening allergic reactions in children is a significant health concern for schools, there is little information about the circumstances surrounding anaphylactic events that occur in schools. The objectives of this study were to determine the incidence of anaphylaxis in schools, describe the circumstances around anaphylactic events, assess practices that are used to manage students with life-threatening allergies, and identify opportunities for improvement. METHODS: A total of 109 school districts in Massachusetts completed an Epinephrine Administration Form whenever epinephrine was administered at school. Data were collected from September 2001 to August 2003. RESULTS: Forty-eight school districts reported a total of 115 administrations of epinephrine during the 2-year reporting period. In 24% of the cases, the individual was not known to have a life-threatening allergy. Almost one third (31%) of the students who received epinephrine had allergies to multiple substances, and one quarter (25%) had an allergy to peanuts or tree nuts only. Twenty-two (19%) cases occurred outside the school building on the playground, traveling to and from school, or on field trips. The administration of epinephrine most often occurred in the health office by a registered nurse. The average time from onset of symptoms to administration of epinephrine was 10 minutes. In 92% of the cases, the student was transported to a medical facility via the emergency medical system. CONCLUSIONS: Anaphylactic reactions in schools, although not frequent, are not uncommon events. A systematic review of anaphylactic events that required epinephrine administration identified opportunities for improvement in the treatment of students with life-threatening allergies.