While schools play an important role in this work, they can’t do it alone. Core to creating a healthy learning environment is engaging families and the community to understand the connection between health and student development and achievement. It means creating an environment where schools, parents and community partners collaborate around policies and programs that prioritize student health, well-being and safety, and ensure that students, families and staff are connected to resources focused on health and school safety. Addressing health, well-being and safety is especially crucial for student groups who already face greater health inequities.

Why does it matter for attendance?

When students are healthy and feel physically and emotionally safe, they are more likely to attend school, they are better able to focus and stay engaged and are more likely to be ready to learn. The physical and mental health and well-being of school staff is directly linked to student attendance. Prioritizing health and well-being in schools can promote healthy habits within families.

At the same time, if school is perceived as emotionally or physically unsafe, students and families may choose to avoid school altogether. A 2024 report by Panorama showed that a student’s low sense of school safety was the strongest link to chronic absence in elementary schools.

What is the evidence that improving health, well-being and safety improves attendance?

Attendance improves when schools invest in creating healthy learning environments that support the whole child and take actions to address health inequities and health-related causes of chronic absence. Research shows that attendance improves when schools:

• Prevent students from getting sick in the first place through, for example, access to immunizations, better hygiene (such as hand washing), improved indoor air quality, promoting physical activities and increasing access to school breakfast. Attendance Works, Kaiser Permanente and the National Association of School Nurses collaborated on handouts for families, educators and community partners with tips for keeping students healthy and in school.
• Meet basic nutritional needs. Multiple studies showed improved attendance from increased access and participation in school breakfast, especially when it was provided free to all students.
• Offer easy access to health screenings, including vision, hearing and dental. Multiple studies show that poor oral health can lead to a significant number of missed school days.
• Provide onsite health services such as school nurses, school-based health services, community partnerships and telehealth to support the physical and behavioral health needs of students. This can be especially important for students with disabilities and chronic health issues. For example, a study in Denver confirmed the important role that school nurses play in coordinating care for students with asthma, leading to reduced school absence and improved asthma control.
• Expand access to mental health services through onsite services and partnerships with community partners. Our blog post, The Impact of School Mental Health Services on Reducing Chronic Absence describes different models of care that have shown improvements in attendance and overall student behavioral health.
• Enlist health providers in promoting the importance of school attendance including school nurses and pediatricians.
• Invest in staff wellness. Although there is a lack of causal research showing an impact on attendance, studies show that teacher well-being is associated with teacher retention, student-teacher relationships and student outcomes.
• Reinforce positive social and behavioral skills for all students. An evaluation of Positive Action, a social, emotional character development program, shows reduced student chronic absence as one of the outcomes. Other research shows implementation of school climate initiatives such as Positive Behavior Interventions and Supports can improve attendance.
• Take steps to improve a student’s sense of safety while at school. According to the Youth Behavior Risk Survey, in 2023, 13% of high school students did not go to school because they felt unsafe either at school or on their way to or from school during the past 30 days.

Should health, well-being and safety be a priority route for reducing chronic absence in your state?

To help you decide, please consider the following:

• What does data tell you about the health, well-being and safety of students in your state? States can access a variety of health-related data to help identify unmet health needs and other trends that provide clues about the underlying reasons for absences. This information can be combined with geographic and socioeconomic factors that can inform the allocation of resources.
  • Does your state or local districts conduct student surveys about their health, well-being and safety? For example, California uses the California Healthy Kids Survey, an anonymous assessment for kids 10-years-old and above that looks at school safety, physical and mental well-being, along with multiple other areas that help guide school and student improvement.
  • Are there other measures or dashboards in your state that may serve as a resource in determining if health, well-being and safety should be a priority route? For example, the Ohio Healthy Student Profiles is a comprehensive dashboard that examines both health and education measures, including health care interactions, health conditions, student education (reading proficiency, attendance, etc.) and staff indicators (ratios of school nurse to student, etc.). The Oregon Child Integrated Dataset, developed to support policymakers and community leaders focused on child development, contains linked, cross-agency and cross-program information for children born in the state.

    National data sources such as CDC’s Youth Risk Behavior Survey which tracks specific health-related behaviors of high school students could be considered as a resource. The CDC’s Social Vulnerability Index examines demographic and socioeconomic factors (such as poverty or lack of access to transportation) and can be a resource for communities facing disasters. The National School Health Data Set: Every Student Counts provides data related to the school nursing workforce, student chronic conditions, the role of school nurses in keeping students in school and overall chronic absenteeism. State-specific data is available for those states participating. Title 5 legislation directs states to conduct a comprehensive, statewide maternal and child health (MCH) needs assessment every five years, could also be of use.

    In addition, data compilations such as the County Health Rankings & Roadmaps offer health data by location. These local community health rankings can offer insights into community health challenges and health-related causes of absence.

• What assets can your state build upon?
  • Who are the champions and cross-sector partnerships that can advance student health, well-being and safety at the state and local levels? Are there policymakers, public agencies, civic organizations, foundations, elected officials, celebrities or others who recognize the connection between health and education and are willing to advocate for specific supports? For example, the Massachusetts chapter of the American Academy of Pediatrics has become a strong advocate for addressing chronic absence among its members as well as more generally. Read about chronic absence in the MA AAP fall newsletter. In many states, the state school nurse association and state school nurse consultants can be strong champions. North Carolina has a cross-sector WSCC collaborative.
  • What funding could be leveraged to further support health, well-being and safety in schools? For example, has your state made the decision to expand school Medicaid, allowing districts to receive federal funding to support physical and behavioral health services? Medicaid also can support funding for nurses in schools? The non-profit Healthy Schools Campaign has several resources to help states expand school Medicaid, including a report that identifies states that have done so, summarizes each state’s process for expansion and provides related state documents.
  • Are there existing initiatives aimed at supporting student health, well-being and safety?
    • For example, CDC’s Whole School, Whole Community, Whole Child model is a student centered framework for addressing health in schools that emphasizes the role of the community, the connections between health and academic achievement and the importance of evidence-based school policies and practices. Are there opportunities to ensure coordination between each of the 10 components?
    • AmeriCorps Youth Mental Health Corps collaborates with state health commissioners to place trained, young people in schools to support efforts that address student mental health issues.
    • The Ohio Department of Education & Workforce developed a Supporting School Wellness Toolkit that provides educators and families with resources and recommendations for responding to challenges specific to student and staff mental health and wellness.
    • State departments have made modifications to existing student information systems to capture more detailed data around student absences, including health related absences. For example, the South Carolina Department of Education has worked with Powerschool to incorporate specific codes such as medical, flu and immunization. Access to electronic health documentation is essential for effective data collection.
    • The National Association of School Nurses developed a School Nurse-Led Surveillance of Chronic Absenteeism Manual which includes evidence-based guidance that school nurses can use to identify and address health related absences.
  • Are there bright spot schools or exemplary programs that demonstrate effective approaches to improving student health and well-being? For example, initiatives such as community schools demonstrate effective approaches to addressing social determinants of health as a means of improving student outcomes. At the state level, California is investing $4.1 billion to make one out of every three schools a community school. The non-profit Learning Policy Institute reviewed how four community schools improved absenteeism in a short report.
  • Partnerships between hospitals and schools promoting better management of chronic disease have helped to significantly improve attendance. Find examples of this from Ohio, Massachusetts and Texas described in a brief by the National Association of Chronic Disease Directors (starting page 13).
  • Data sharing partnerships can help improve coordination of student health issues. The Student Health Collaboration, a partnership with Nemours Children’s Hospital and Delaware schools allows school nurses to see a student’s health care plan and recent visits to the hospital or clinic, including medications, diagnosis and treatment. This information allows the nurse to have a clearer understanding of the student’s health issues and provide necessary support at school. The School Attendance Data Sharing and Outreach Playbook, supported by the Bloomberg American Health Initiative outlines how to plan and implement a school attendance data sharing initiative for cross-sector response.

How do your policies support student health, well-being and safety?

States can play an important role in student health, well-being and safety. The Department of Education’s Guiding Principles for Creating Safe, Inclusive, Supportive and Fair School Climates identifies five guiding principles and suggests actions for schools and districts.

As you consider whether health, well-being and safety should be a priority route to improving attendance, please consider the following:

• What are some policies or practices that improve health, well-being and safety?
  • A resource from Child Trends provides an assessment of state policies that cover each of the 10 domains of the Whole School, Whole Community, Whole Child model. How does your state compare? For example, within the health services component, every state has a law that requires vaccinations for school-age children, yet only 19 states' laws address development of onsite health centers for students.
  • Wellness policies also ensure that students receive adequate physical activity and access to supports and resources that promote health and well-being, including vision checks and other health screenings. In Michigan, the Kindergarten Oral Health Assessment law was recently enacted, ensuring that children have an oral health screening prior to starting school.
  • Addressing student mental health needs requires a multi-tiered approach that integrates mental health services and supports within schools and uses school-community collaborations to provide a continuum of mental health services. State Policy Opportunities: Advancing Comprehensive School Mental Health Systems to Support Students, developed by Mental Health America and Healthy Schools Campaign outlines policy opportunities for states.
  • Local education agencies participating in the National School Lunch Program and School Breakfast Program must develop a local school wellness policy, ensuring that students have access to healthy meals. Studies show that universal school meal policies have a positive impact on student achievement.
  • School nurses are one example of evidence-based health supports that can lead to improved attendance and overall student well-being. In Delaware and Vermont, state policy requires that every school must have a school nurse. School nurses are even more effective when supported by an electronic health record system that allows them to document health-related attendance barriers and improve health care coordination.
  • The National Association of State Chronic Disease Health Directors offers recommendations for how state health departments can strengthen partnerships between schools and hospitals in the management of chronic health conditions.
  • Restorative practices can also be used to improve student behavior and safety. Schools that implemented restorative practices saw reductions in suspension rates and risky behaviors, and an improvement in academic outcomes, especially for Black and Latino students.
• What are some counterproductive policies that should be eliminated because they diminish health, well-being and safety?
  • Many schools and districts continue to use exclusionary school discipline practices, yet there is little evidence that exclusionary school discipline practices make schools safer or deter future misbehavior. Exclusionary school discipline during preschool can impact early childhood development. High rates of suspension within a school can also negatively impact the school climate and lower academic achievement schoolwide.
  • Though many states have enacted policies to prevent schools from withholding recess as punishment, most states still allow it. A policy statement from the American Academy of Pediatrics notes that recess is a crucial and necessary component of a child’s development. Withholding it as a punishment can negatively affect a child’s relationships with teachers, feelings about school and sense of self-worth.
  • Many states and school districts have policies in place that require a doctor’s note when a student has been absent for health-related reasons. Requirements for a doctor’s clearance note should be carefully considered and limited to certain communicable diseases or cases where a student may require accommodations.