The Journal of School Nursing2024, Vol. 40(1) 58–73© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221096802journals.sagepub.com/home/jsn
School connectedness is an important factor in the lives of youth and are a leverage point for optimizing youth’s social, emotional, and physical health. This study presents a meta-analysis examining the relationship between school connectedness and four health domains that are prevalent in adolescence, have implications for adult health, and often co-occur: mental health, sexual health, violence, and high-risk substance use. Ninety articles published between 2009 and 2019 were included in the analysis. The study found that school connectedness had a protective average effect size across all health domains (Hedges’ g = −0.345, p-value<0.001). When examined separately, school connectedness had a significant protective relationship with substance use (g = −0.379, p < 0.001), mental health (Hedges’ g = −0.358, p < 0.001), violence (Hedges’ g = −0.318, p < 0.001), sexual health (Hedges’ g = −0.145, p < 0.001), and with co-occurring risks (Hedges’ g = −0.331, p < 0.001). These results provide strong evidence that school connectedness has the potential to prevent and mitigate multiple health risks during adolescence.
school connectedness, school nurse, co-occurrence, health risks, meta-analysis, students
Students’ levels of school connectedness, or the extent to which students believe that adults and peers in their school care about them and their learning (Centers for Disease Control and Prevention [CDC], 2009), has been linked to behavioral, emotional, and academic outcomes in adolescence (Areba et al., 2021; Liu et al., 2020; McCabe et al., 2022; Resnick et al., 1997; Weatherson et al., 2018) and even into adulthood (Steiner et al., 2019; Viner, 2005). In general, scholars tend to view school connectedness on a continuum with higher levels of school connectedness associated with positive outcomes and lower school connectedness associated with poorer outcomes (Steiner et al., 2019). Elementary, middle, and high school students who report high levels of school connectedness have better grades and are less likely to repeat a grade or drop out of high school (Catalano et al., 2004). Previous studies suggest variabilities of school connectedness by grade level (Liu et al., 2020; Whitlock, 2006), revealing contextual differences related to students’ developmental stages. Research shows that students in lower grade levels tend to have higher levels of connectedness in comparison to their older peers (Whitlock, 2006).
Researchers define school connectedness in a myriad of ways. School connectedness is a broad concept, encompassing the relationship between the student, teachers and school staff, peers, and the greater school environment (CDC, 2009; Garcia-Moya et al., 2019; Gowing & Jackson, 2016). Thus, school connectedness is described in the literature using various terminology reflecting a variety of different but related subconstructs including school belonging, bonding, attachment, and engagement (Allen et al., 2022; Barber & Schluterman, 2008; Brown & Evans, 2002; Garcia-Moya et al., 2019; McNeely et al., 2002; O’Brennan & Furlong, 2010). Given the breadth of school connectedness as a construct and the evolving conversation about its parameters, there is a need for thoughtful consideration of boundaries of this construct within scientific work. Within this particular meta-analysis, we consider school connectedness at the level of students’ relationship to the school and maintain an inclusive definition of the construct, examining literature that uses terminology of school connectedness explicitly, as well as three relevant subconstructs: social affiliation, school belonging, and attitudes about school importance. These subconstructs are operationalized in ways that are consistent with our focus on relationships and perceptions of relationships at the school-level: (1) social affiliations: positive school relationships, feeling cared about and/or respected by adults at school, perceiving availability to interact with adults at school; (2) school belonging: feeling part of the school, feeling safe in school, feeling happy at school; and (3) attitudes about school importance: caring about school, trying to do one’s best at school (Marraccini & Brier, 2017).
School connectedness is of increasing interest to adolescent health researchers because of its relationship to educational and health outcomes. Evidence suggests that young people who feel connected to school have better health outcomes during adolescence and adulthood than those who report low levels of school connectedness (Bond et al., 2007; Steiner et al., 2019). Steiner et al. (2019) found that youth who feel connected to school were 48% to 66% less likely to have mental health issues (i.e., suicidality, anxiety, or depression), experience violence victimization, engage in risky sexual behaviors, or use substances in adulthood. Other research studies focused on individual health outcomes during adolescence also demonstrate that school connectedness is protective for mental health (Bond et al., 2007), substance use (Weatherson et al., 2018), sexual and reproductive health (Markham et al., 2010), and violence and risk-taking behaviors (Chapman et al., 2011; Chung-Do et al., 2017). Given these associations, efforts to increase school connectedness may be beneficial in supporting students at high risk; reducing the likelihood for negative health and academic outcomes; and enhancing the long-term social, emotional, and physical health of young people.
This evidence is particularly compelling given the ongoing burden of health risk behaviors among adolescents in the US. For example, in the 2019 Youth Risk Behavior Survey, 45.7% of high school students reported condomless sex, 29.2% reported being current alcohol drinkers, and 18.8% seriously considered attempting suicide (CDC, 2020). Additionally, health disparities exist by sex, race/ethnicity, and sexual/gender identity. For example, YRBS data indicates that a greater percentage of male high school students (28.3%) reported being in a physical fight in comparison to female students (15.3%), and approximately 29.9% of Black and Hispanic high school students reported being bullied on school property during the past 12 months in comparison to 23.1% of White students (CDC, 2020). Sexual and gender minority students routinely report higher rates of suicide risk behaviors, experiences of violence, and substance use, such as the 44.8% of sexual minority students that reported seriously considering attempting suicide in the past year compared to 14.5% of their heterosexual peers (CDC, 2020). Set against this backdrop, programs focused on developing school connectedness, particularly among high-risk or vulnerable populations of students, may assist in mitigating health disparities among school-age youth.
Furthermore, health risk behaviors often cluster or co-occur among adolescents (Hale & Viner, 2016), meaning that youth who report one risk behavior are more likely to report multiple risk behaviors. Theoretical approaches help to contextualize why this co-occurrence may occur. Syndemics theory postulates that health risk behaviors are inextricably reinforced and bound to one another due to shared upstream causes like poverty and stigma (Singer & Clair, 2003). This binding of health risk behaviors creates an additive and synergistic effect that is greater than any one of the factors would be in isolation (Singer et al., 2006). Youth health behavior data support the validity of these theories of co-occurring risk. Students who report suicide risk behaviors (i.e., ideation or attempt) are more likely to misuse prescription drugs (Burke & Alloy, 2016); adolescents involved in violent dating relationships, as victims or perpetrators, report poorer mental health outcomes (Choi et al., 2017); and youth who report physical or sexual abuse are more likely to report substance use (Heneghan et al., 2015).
In this context of co-occurring risk behaviors, there is a need to understand mechanisms that might both lessen co-occurring risk behaviors among youth and remedy associated health disparities. School connectedness is well-suited to serve as such a mechanism; however, a synthesis of the literature to evaluate this possibility has yet to be adequately explored. To date, only four related meta-analyses focused on school connectedness exist: one focused on school connectedness and suicidal thoughts and behaviors (Marraccini & Brier, 2017), two focused on school belonging (Allen et al., 2018; Korpershoek et al., 2020), and one focused on the efficacy of interventions that target school connectedness (Chapman et al., 2013). A comprehensive examination of how school connectedness and its relationship to co-occurring student health outcomes has yet to be explored. Thus, to fill this gap, we present a meta-analysis of literature containing data on the relationship of school connectedness to four health domains: mental health, high-risk substance use, sexual health, and violence. These domains were selected because they are prevalent in adolescence, have implications for adult health and well-being, and often co-occur. The following four research questions guided this meta-analysis:
(1) What relationship does school connectedness have on domains of health risks prevalent in adolescence—poor mental health (e.g., anxiety, depression), high-risk substance use (e.g., non-medical use of prescription medications and illegal substances excluding cannabis), sexual health (e.g., number of sexual partners, use of contraception), and violence (e.g., victimization or perpetration of physical violence, bullying, sexual violence, or dating violence)—and their co-occurrence?
(2) Does the relationship of school connectedness to health behaviors vary by subpopulations of vulnerable youth?
(3) Does the relationship of school connectedness to health behaviors vary by subconstruct of school connectedness (i.e., social affiliation, school belonging, and attitudes about school importance)?
(4) Are there grade levels (elementary, middle, or high school) when school connectedness has a stronger relationship to health behaviors?
To address the research questions, a systematic search was conducted of peer-reviewed publications published from 2009 to October 2019 in the United States. This metaanalysis focused explicitly on observational and intervention research that included a quantitative assessment of the relationship between school connectedness and at least one health outcome in the four domains of interest. Articles were systematically retrieved using seven medical/health and social science databases: PubMed/MEDLINE, Web of Science, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO, ERIC (Education Resources Information Center), and ProQuest. To find relevant research, the authors worked with a research librarian to identify critical keywords from the three domains structured the search strategy: (1) school-aged, (2) school connectedness, and (3) at least one of our health outcomes of interest (Table 1).
Prior to reviewing the full article, a title review was conducted with all articles in the sample. After the title review, 3,970 abstracts were removed from the sample for not meeting one of the following criteria: focus on school-aged youth; US-based study; include terms school connectedness or a subconstruct of school connectedness in the title; or include at least one of the four health domains of interest. To meet inclusion criteria for full-text review, articles had to present all of the following: (1) contain the identified search terms in the title, abstract, or keywords; (2) a scale or single item that was used to measure school connectedness (i.e., either the full construct or one of the subconstructs, such as school belonging, school engagement, etc.) at the individual level, meaning individual perceptions of school connectedness, rather than aggregated measures of connectedness of a school); (3) peer reviewed journal; (4) published in English; (5) published between 2009 and 2019; (6) analysis of data collected from a sample of school-aged youth (K-12th grade) at baseline; (7) at least one outcome of interest—behaviors, experiences, and health outcomes related to sexual health, mental health, highrisk substance use, and violence—measured at the individual level; (8) empirical findings from observational or intervention research; (9) research conducted in the U.S.; and (10) statistics allowing calculation of an effect size describing the relationship between school connectedness and an outcome in at least one of the four domains of interest. Non-peer-reviewed articles, qualitative research, reviews, and non-empirical publications were excluded from the review.
A team of five coders screened the abstracts of included articles identified in the literature search using a standardized form. To establish intercoder reliability, an initial subset of 20% of the articles were screened by all coders and discrepancy in coding was discussed. Once intercoder agreement was achieved (92%), the remaining abstracts were divided among the coding team for screening. After abstract review, a team of seven coders independently reviewed and summarized the full text articles that met the inclusion criteria. The coding team normed with 10% of the identified articles to ensure consistency in the data extraction process. Intercoder reliability was measured for the article screening process and Cohen’s Kappa was calculated at 0.94. A critical assessment of the methodological quality and risk of bias of the included studies were conducted during the extraction process using the Cochrane protocol procedure and the PRISMA statement, which is a 27-item checklist used to ensure transparency when conducting systematic reviews. The team used a web-based extraction form to code the following information from each article: study aims and research questions; sample characteristics; measures and scales regarding school-connectedness constructs; study methods, location, and intervention (if applicable); and study results including statistical test used, predictors, mediators, moderators, and outcome variables. Data were extracted for articles that presented statistics regarding any association of school connectedness with the four health outcomes of interest. Summary statistics that can be used toward effect size calculations, such as sample sizes, mean and standard deviations, correlation coefficients, and odds ratios were extracted from articles and entered in a Microsoft Excel spreadsheet. To conduct the meta-analysis, data in the spreadsheet were imported into the Comprehensive Meta-Analysis (CMA) software (Borenstein et al., 2005) to compute the treatment effect sizes from various formats of summary statistics.
Effect size was calculated using statistics provided in the articles. Effect sizes are often used to measure the magnitude or practical significance of causal impact and correlation. Conceptually, effect size represents a standardized mean difference between treatment and comparison groups (Kraft, 2020). Cohen (1988) defined effect sizes as “small, d = 0.2,” “medium, d = 0.5,” and “large, d = 0.8.” However, Lipsey and Wilson (2001) concluded that psychological, educational, and behavioral treatment effects of modest values—even d = 0.1 to 0.2—should not be interpreted as trivial. Previous studies have suggested that effect sizes of 0.20 or 0.25 SD should be considered “of policy interest” (Hedges & Hedberg, 2007, p. 77), “substantively important” (What Works Clearinghouse, 2014, p. 23) or to have “educational significance” (Bloom et al., 2008, p. 295).
Effect-size estimates were calculated using CMA software. In this analysis, a standardized mean difference (g) was used, which transforms all effect sizes to a common metric across various study designs and outcome measures, and thus enabled the research team to include a diverse set of articles within in the same synthesis. In addition to producing effectsize estimates based on reported statistics (e.g., mean, correlation, odds ratio), the CMA software has a built-in weighting procedure that accounts for the sample sizes. Effect sizes from large samples are weighted more than those from small samples. Next, an article may consist of multiple studies on different outcomes from different samples. Each outcome from an independent sample within an article was treated as a separate study. Additionally, the findings were reported not only by combined effect across all estimates and articles but also by subgroups, including domains of health risks, co-occurrence, subconstructs of school connectedness, types of student populations, and educational stage. Finally, the fraction of variance that is due to heterogeneity across studies—estimated by the statistic I2—was large across all analyses (over 60% for the overall and subgroup effect sizes).
Figure 1 presents the study selection process based on the Preferred Reporting Items for Systematic and Meta-analyses (PRISMA) guidelines (Moher et al., 2009). The initial literature review search identified 7,017 articles using the described search strategy. After removing 85 duplicate records, 6,932 articles remained. After conducting a title review, 3,970 abstracts were removed for not meeting inclusion criteria, leaving 2,962 eligible abstracts for full abstract screening. An additional 2,682 records were excluded following abstract review, resulting in a sample of 280 articles for full-text review and coding. Of the remaining 280 articles, 90 were identified as meeting all inclusion criteria; they contained sufficient statistics for effect size calculation and were included in the meta-analysis.
Ninety articles presented in Table 2 were included in the analysis, representing individual 119 studies. Please note, some articles presented data for more than one study. Study location varied, with about half of the studies (48%) conducted at the local or community level, 24% conducted at the state level, and 28% conducted at the national level. Sample sizes also varied, with 40% of the articles reporting sample sizes less than 1,000 participants, 32% reporting sample sizes between 1,000 and 5,000 participants, and 28% of the articles reporting sample sizes greater than 5,000 participants. The mean sample size was 8,341, the median was 1,646 and the range was 20 participants to 337,945 participants. Of the 55 articles that explicitly specified a school setting, 38 were conducted in public schools; 12 in both public and private schools; and 5 in private, alternative, or military-connected schools. Regarding research design, 58% of the articles were observational studies (n = 51), 38% used a quasi-experimental design (n = 36), and 4% were randomized controlled trials (n = 3). The majority of the articles (87%) reported reliability statistics for school connectedness: 32% with alpha over 0.80, 7% lower than 0.70, and 48% in between.
Figure 2 summarizes the effect size estimates, using forest plot graphs generated by CMA. The graph lists each article identified by its first author. In the forest plot graph, effect size estimates from an article with multiple studies and outcomes are combined as one estimate. This approach of combining the estimate is for calculating the overall effect size regardless of subgroups. For each article, central-tendency statistics are provided along with the graphic display of the mean and confidence interval. The last row of the graph provides summary statistics from all articles. Two key statistics deserve specific attention: 1) Hedges’ g, a measure of the effect size (or the magnitude/practical significance of the effect); and 2) p-value, a measure of statistical significance of the effect. In general, Figure 2 shows that school connectedness has a statistically significant average effect size on health risks outcomes (Hedges’ g = −0.345, p-value<0.001).
Unlike the overall effect where the unit of analysis is “article,” the unit of analysis for subgroup analyses is “study.” The results that follow present school connectedness effects by subgroup, including health risk domains (i.e., mental health, sexual health, high-risk substance use, violence) presented in Table 3 and demographics (sex, race/ethnicity, sexual and gender minority) presented in Table 4. The results also present the effect of school connectedness subconstructs (i.e., social affiliation, school belonging, attitude about school importance) on individual health risk domains in Table 6 as well as the educational stage (i.e., elementary, middle, high school) in which school connectedness may have the greatest impact, presented in Table 7.
Effect by Health Risk Domains. Table 3 presents the effect for each individual health risk domain and co-occurrence. Mental health risk was the outcome domain studied most frequently, accounting for 52 studies; sexual health risk was the domain studied least frequently with only nine studies. Meta-analysis shows that school connectedness has a statistically significant protective effect, reducing risks for all four health domains. School connectedness had the strongest protective effect on high-risk substance use (Hedges’ g = −0.379, p-value<0.001), followed by mental health (Hedges’ g = −0.358, p-value<0.001) and violence (Hedges’ g = −0.318, p-value<0.001). School connectedness had the smallest effect on sexual health (Hedges’ g = −0.145, p-value<0.001). Twenty-one studies examined the effects of school connectedness on co-occurring health risks defined as engagement in two or more health risk domains. Table 3 shows that the average effect size of school connectedness on co-occurring health risks was medium and statistically significant (Hedges’ g = −0.331, p-value<0.001), indicating school connectedness has a protective effect on co-occurrence.
Effect by Demographics. Thirty-three studies examined how school connectedness influences health risks by race/ethnicity, sex, and sexual and gender minority status (Table 4). In addition to having a protective effect for all students, school connectedness had a greater protective effect on health risk behaviors for students of color, which included three studies examining African American youth, three studies examining Asian American youth, and three studies examining Hispanic/Latino youth (Hedges’ g = −0.484). School connectedness had the strongest protective effect on male students’ health risks (Hedges’ g = −0.400, p-value<0.001), more so than female students’ health risks (Hedges’ g = −0.363, p-value<0.001). Meta-analysis also revealed a statistically significant average effect size for school connectedness on health risk outcomes in samples comprised exclusively of sexual and gender minority students (Hedges’ g = −0.296, p-value<0.001). While selected studies examined differential effects for males and females separately, as well as effect for students of color and sexual and gender minority students, none of the studies specifically examined the effect for racial/ethnic majority (i.e., exclusively White) or non-sexual or gender minority students.
This meta-analysis also examined how the effects of school connectedness varied by outcome within different subgroups. Subgroups that were included in more than two studies were included in this analysis. Several conclusions can be drawn according to results reported in Table 5. For example, the effect of school connectedness for female students is largest for violence (Hedges’ g = −0.351, p-value<0.001), followed by mental health risks (Hedges’ g = −0.293, p-value<0.001). For male students, the opposite is true, the effect size of school connectedness is largest for mental health (Hedges’ g = −0.614, p-value<0.001), followed by violence (Hedges’ g = −0.218, p-value<0.001). For students of color, school connectedness has the strongest protective effect on mental health risks (Hedges’ g = −0.593, p-value<0.05). Among sexual and gender minority students, school connectedness has a strong protective effect on highrisk substance use (Hedges’ g = −.313, p-value<0.001) and mental health (Hedges’ g = −.301, p-value<0.001).
Effect by Subconstructs of School Connectedness. Forty-seven studies were included in analyses of the effect of subconstructs of school connectedness on health risk across domains. Results in Table 6 show that the three subconstructs of school connectedness—social affiliation, school belonging, and attitudes about school importance—have a statistically significant, medium sized, protective effect on student health risks (Hedges’ g = −0.368, −0.316, −0.337, respectively). Subconstructs of school belonging and attitudes about school importance have greater effects on reducing risks related to violence (Hedges’ g = −0.355 and Hedges’ g = −0.423, respectively) than social affiliation (Hedges’ g = −0.276, p-value<0.001). Social affiliation has a medium protective effect for high-risk substance use (Hedges’ g = −0.455, p-value<0.001). We did not see a strong protective effect exerted by school belonging on highrisk substance use (Hedges’ g = −0.092, p-value<0.001). This analysis excluded 43 studies that reported mixed subconstructs.
Effect by Educational Stage. Forty-five studies examined the effect of school connectedness on health risks by educational stage (i.e., elementary, middle, or high school). Results in Table 7 show that effects were statistically significant and with a similar magnitude for middle (Hedges’ g = −0.351, p-value<0.001) and high schools (Hedges’ g = −0.383, p-value<0.001). Although the effect size was the largest for students in elementary schools, it was not statistically significant, likely due to small sample size (includes only two studies). This sub-analysis excluded the 55 studies where student populations were across timeframes.
Additional analyses by educational stage and specific outcomes (see Table 5) found that school connectedness is most protective against high-risk substance use at both the middle (Hedges’ g = −0.454, p-value<0.001) and high school (Hedges’ g = −0.424, p-value<0.001) levels. School connectedness has a stronger protective effect on reducing violence risks among students in high school (Hedges’ g = −0.374, p-value<0.001) than middle school (Hedges’ g = −0.278, p-value<0.001). School connectedness also appears to have a slightly stronger protective effect on reducing mental health risks in high school (Hedges’ g = −.382, p-value<0.001) in comparison to middle school (Hedges’ g = −.369, p-value<0.001). Sensitivity analysis in Table 8 shows that effect-size estimates are similar between observational studies and those using experimental or quasiexperimental designs, which demonstrates the robustness and consistency of the effect size estimate across studies.
School connectedness is an important factor contributing to adolescent health. Our findings confirm that the preponderance of extant research suggests a significant, protective relationship between school connectedness and the health outcomes of violence, high-risk substance use, mental health, sexual health, as well as their co-occurrence. Our analysis used a detailed definition of school connectedness that explicitly included examination of three subconstructs of school connectedness (i.e., social affiliation, school belonging, and attitudes about school importance), whereas past analyses have focused on one construct (Allen et al., 2018; Korpershoek et al., 2020).
The relationship between school connectedness and the outcomes of interest, while generally similar in effect size, varied in strength by individual health risk, student demographics, and educational stage. School connectedness had protective relationships with outcomes across all four domains of interest (i.e., mental health, high risk substance use, sexual health, violence); and had the largest protective relationship with mental health outcomes. This finding is especially important given that 2019 YRBS data indicated that 36.7% of high school students reported feelings of sadness or hopelessness and 18.8% seriously considered attempting suicide (CDC, 2020). These indicators and several others (e.g., seriously considered attempting suicide; made a plan to attempt suicide) have been trending in the wrong direction in the past 10 years (CDC, 2020) and may be further exacerbated by the COVID-19 pandemic (Clemens et al., 2020). School connectedness has a strong protective relationship with mental health outcomes and given increasing challenges to the mental health of adolescents, promoting school connectedness may yield reductions in negative mental health outcomes (Marraccini & Brier, 2017). Combined, our findings and these statistics suggest that schools are well situated to improve child and adolescent mental health by supporting district and school policies and practices that improve students’ sense of school connectedness.
School connectedness had the smallest but still significant relationship to sexual health risks such as condom use and having multiple sexual partners. While the magnitude of the effect on sexual risks was relatively smaller than that on other health risk domains, the fact that the relationship was still significant is consistent with previous research showing school connectedness significantly protected students against engagement in risky sexual behaviors (Resnick et al., 1997; Steiner et al., 2019). Research shows that predictors of sexual health risks are complex (Caminis et al., 2007), so it is noteworthy that our analysis found any significant relationship with school connectedness. It is possible that the relationship between school connectedness and sexual health risks may be mediated through protective factors that influence young people’s engagement in sexual health risk behaviors (e.g., self-efficacy, communication). Future research into these possible pathways is warranted, as they may inform the foci of sexual health interventions. Although the magnitude of the effect of school connectedness on sexual health outcomes was modest, this finding remains notable and could benefit from further exploration.
The relationship of school connectedness to health risk outcomes also varied by student demographic characteristics, including sex, race/ethnicity, and sexual/gender minority status. Regarding sex, previous research has demonstrated that school connectedness is a strong protective factor for both male and female students to prevent substance use and early initiation of sexual activity (Resnick et al., 1997). Similarly, this study found that school connectedness was particularly important for both male and female students as it relates to mental health and violence outcomes. Our analysis found that school connectedness had a significant effect size for female students for violence outcomes, and a medium effect size for male students for mental health outcomes. These results suggest that the influence of school connectedness may vary for male and female students by type of health risks, but remain important for all students, regardless of sex. These findings are consistent with previous research that examined sex differences in associations of school connectedness with adolescent risk-taking (Langille et al., 2014). Violence and mental health risks are often predicted and are exhibited differently by sex (Breslau et al., 2017; Krahé & Berger, 2017). Given that our findings reflect these larger trends, prevention efforts may benefit from acknowledging sex differences in adolescent risk-taking behaviors and tailoring intervention strategies accordingly.
In relationship to race/ethnicity, previous studies have shown that students of color are less likely to feel connected to school, have less favorable experiences of safety, and have fewer relationships with supportive adults (Anyon et al., 2016; Voight et al., 2015), a pattern that is concerning given the relationship between school connectedness and health outcomes. This meta-analysis found that for students of color, school connectedness had the strongest protective effect on mental health risks, suggesting that interventions focused on fostering school connectedness among students of color may significantly benefit these youth.
School connectedness is particularly important for youth from marginalized groups. This study found that school connectedness demonstrated a protective effect for sexual and gender minority students. Sexual and gender minority youth report more substance use, suicide risk, and victimization in comparison to their heterosexual peers (Kann et al., 2018). Research reflects that the school environment can be particularly challenging for sexual and gender minority students (Lesesne et al., 2015; Rose et al., 2018). Our analysis provides evidence that school connectedness has a protective relationship with high-risk substance use and mental health outcomes among sexual and gender minority students, suggesting an opportunity for increased prevention efforts aimed at increasing school connectedness among sexual and gender minority youth help combat these health risks.
This meta-analysis found that all three subconstructs of school connectedness (i.e., social affiliation, school belonging, and attitudes about school importance) had a protective relationship with student health risks in all domains of interest (i.e., mental health, violence, substance use, and sexual risk behavior), albeit to different degrees. The consistency of the relationship of school connectedness with these health outcomes, regardless of subconstruct, underscores the importance of implementing interventions that encompass multiple subconstructs of school connectedness. While little is known about wide-scale practices to increase school connectedness in the US, there is some evidence suggesting that school practices, such as supportive rather than punitive discipline (Payton et al., 2008), are associated with less homophobic bullying and higher school connectedness (Day et al., 2016), and that programs such as the Seattle Social Development Program can impact student connection to school (Catalano et al., 2004).
Findings from this meta-analysis suggest that there may be educational stages in which school connectedness is most influential for young people, particularly during middle and high school. Although the effect size for school connectedness was largest for youth in elementary school, it was not statistically significant; however, this is likely due to small sample size (n = 2). This finding highlights the need to further explore the impact of school connectedness at the elementary level for violence and mental health, as substance use and sexual risk may not be particularly relevant for this developmental stage. However, there is considerable evidence that supports the efficacy of building connectedness at the elementary school level for child health, which predate the educational stage for this review and/or did not measure our outcomes of interest (e.g., Bradshaw et al., 2010; Durlak et al., 2011; Hawkins et al., 1999; Horner et al., 2009). These studies indicate the benefits of establishing school connectedness early in the lives of children. Still, we did find that school connectedness had a protective effect in both middle and high school and was particularly protective for violence and mental health outcomes at the high school level. Given what we know about declining rates of school connectedness in middle and high school (Monahan et al., 2010), these findings may indicate that to curb violence and improve mental health among middle and high school students it may be worthwhile to investigate how best to bolster school connectedness during these years.
This study is not without limitations. First, this study includes a limited sample size; specifically, the sample sizes for elementary school studies and for some subgroup analyses were small. Future research should consider expanding the search/inclusion/exclusion parameters to identify a larger sample of elementary school studies. The health risks we examined in this analysis are not commonly investigated in elementary age youth (e.g., substance use, sexual health); thus, future research on the effect of school connectedness on health outcomes may need to reconceptualize developmentally appropriate health outcomes within these domains for a better assessment of the effect of school connectedness in elementary school. Second, this study only focused on three subconstructs of school connectedness, which may somewhat limit the breadth of the investigated phenomena. Future studies could build upon this study’s search strategy to include additional concepts and constructs related to school connectedness. Third, this metaanalysis focused only on literature published within peerreviewed journals, which cannot account for unpublished findings or findings published within the gray literature.
Overall, our finding that school connectedness was protective across all four health domains has important implications for school nurses seeking to optimize the health and well-being of students. School nurses are well positioned to establish and maintain school connectedness due to their overall knowledge of health risks, accessibility to students, and knowledge of the school environment (Mazyck, 2021; McCabe et al., 2022). This meta-analysis highlights the importance of identifying universal interventions for school connectedness. While limited data exists, reviews of schoolbased interventions intended to promote school connectedness have demonstrated some success in both increasing connection and reducing health risk engagement (Chapman et al., 2013). Models such as School-wide Positive Behavior Support (Horner et al., 2009) and Seattle Social Development Project (Catalano et al., 2004; Hawkins et al., 2001), all offer evidence-based, holistic efforts that contribute to students’ feelings of connection to school across primary and secondary school settings and families.
The findings from this meta-analysis also demonstrate the importance of targeted interventions for youth at disproportionate risk. This analysis found that school connectedness is important for all students but may be particularly important for students of color and sexual and gender minority youth. Feeling connected to school involves positive and prosocial connections to peers, teachers, school nurses, and other staff at school. Positive student-teacher relationships enhance school connectedness among students of color (Daly et al., 2010) and sexual and gender minority students (Joyce, 2015). Additionally, appealing to the interests of students and connecting them with peers sharing similar interests can be a powerful tool for forming social connections and engendering positive regard for school and peers. Sponsoring groups that directly promote inclusive and safe environments, such as Gay Straight Alliances or Genders and Sexualities Alliances (GSAs), may help to engage and safeguard sexual and gender minority students more directly while also establishing school norms of inclusion and respect for all persons.
There are a number of actions that school nurses can take to improve school connectedness among students. First, school nurses can advocate and support students, especially marginalized students, resulting in students feeling both valued and accepted. Second, school nurses can help students develop the skills needed to engage in school activities by implementing programs or practices that encourage students to engage with their peers, teachers, and other school staff. Third, given the connection between school connectedness and participation in extracurricular activities, school nurses can assist students with exploring and planning for new interests, which in turn will help students foster close relationships and reach their personal goals (CDC, 2009). As a consistent health advocate in a student’s life, school nurses are in a prime position to create a sense of connectedness to school, which has the potential to impact students’ overall health and well-being.
Research continually demonstrates the benefits for youth of having strong connections to their schools, and our findings further solidify the importance of this aspect of the school ecology in the lives of young people. More intervention research is needed to show how to successfully increase youth’s feelings of connection and positive regard for school. Specifically, additional attention to optimizing youths’ sense of connection, belonging, affiliation to, and importance of school stands out as a clear first step in the direction of leveraging this important protective factor to preventing youth engagement in multiple health risk behaviors. Public health and school health leaders are challenged to critically examine existing strategies and identify opportunities to increase students’ connectedness to school. In summary, school connectedness has the potential to mitigate multiple poor health outcomes during adolescence and offers an effective strategy for reducing youth health risks nationally. This study gives school nurses and public health leaders strong, current evidence of the importance of school connectedness in the lives of young people and points to opportunities for school-based prevention strategies focused on enhancing school connectedness among youth.
The authors would like to thank Jennifer Duffy, Michelle Segall, Linda Baffo, Jennifer Mezzo, Zach Timpe, Bianka Michalski, Sanjana Pampati, and Riley Steiner for their contributions to this work.
All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by India Rose, Jing Sun, Xiaodong Zhang, Michelle Johns, and Marci Hertz. The first draft of the manuscript was written by India Rose, Catherine Lesesne, and Jing Sun. All authors reviewed and commented on the first and subsequent versions of the manuscript and read and approved the final manuscript.
Available upon request.
Not applicable.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The findings and conclusions in the manuscript are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
This project was supported by funding from the Division of Adolescent and School Health (DASH) in the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) at the Centers for Disease Control and Prevention (CDC), Contract # HHSD2002013M53944B, Task Order #75D30118F03441.
India D. Rose https://orcid.org/0000-0002-7476-2898
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India D. Rose, PhD, MPH, CHES is a Senior Manager, Research Science at ICF, Atlanta, Georgia, USA.
Catherine A. Lesesne, MPH, PhD is a Specialist Executive at Deloitte Consulting, Atlanta, Georgia, USA.
Jing Sun, MA, is a Senior Manager, Child Welfare and Education at ICF, Fairfax, Virginia, USA.
Michelle M. Johns, MPH, PhD, is a Senior Research Scientist in the Academic Research Centers at NORC, Atlanta, Georgia, USA.
Xiaodong Zhang, MPP, PhD, is a Senior Director, Child Welfare and Education at ICF, Richmond, Virginia, USA.
Marci Hertz, MS, is a Lead Health Scientist in the Centers for Disease Control and Prevention’s Division of Adolescent and School Health, Atlanta, Georgia, USA.
1 ICF, Atlanta, GA, USA
2 Deloitte Consulting, Atlanta, GA, USA
3 NORC, Atlanta, GA, USA
4 Centers for Disease Control and Prevention, Division of Adolescent and School Health, Atlanta, GA, USA
Corresponding Author:India D. Rose, ICF, 2635 Century Center Parkway NE, Suite 1000, Atlanta, GA 30345.Email: India.Rose@icf.com
