The Journal of School Nursing2024, Vol. 40(3) 266–274© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221078989journals.sagepub.com/home/jsn
Multiple factors influence a student’s success in high school graduation. Individual factors such as disability, racial or ethnic identity, and gender may result in inequity in the school environment, interfering with learning and possibly leading to poorer educational outcomes. This secondary analysis of student educational records (N = 3,782) from 2008–2018 tested the associations among the disability, racial or ethnic identity, gender, and 5th grade attendance on high school attendance and graduation. Linear and logistic regression analysis identified students without a disability had a 40% greater chance of graduation (AOR = 1.4 [95% CI = 1.15, 1.71]) than those with a disability. Students identifying as Black, Hispanic, or Native American had half the odds of graduating compared to White students. When controlling for 9th grade attendance, these disparities decreased. Attendance in 5th grade, disability, and racial and ethnic identity influenced attendance, being on track to graduate, and high school graduation.
The World Health Organization identified that social conditions, including highest level of education, income, and employment, affect a person’s access to a healthy lifestyle, wellness and illness prevention choices, and access to health care (Commission on Social Determinants of Health, 2008). Individuals graduating from high school can further their education and attainment of greater earning potential compared to those who do not earn a diploma (McFarland et al., 2019). Not earning a high school diploma may lead to social conditions that predispose young adults to chronic illnesses in adulthood, unhealthy behaviors, high unemployment rate, and premature death (Balfanz et al., 2014; Robert Wood Johnson Foundation, 2016). Despite the importance of graduation to lifelong health, just 85% of students in the United States achieve the milestone of graduating from high school (McFarland et al., 2019). The rate of graduation for students with disabilities is 71% (McFarland et al., 2019), which is 14% less than the estimate of national averages. Ensuring that all students, those with and without disabilities, graduate from high school is an important public health issue (Freudenberg & Ruglis, 2007).
A federally recognized disability is defined as a chronic physical or mental condition that limits a student’s ability to learn or participate in other major life activities (Civil Rights Division, Department of Justice, 2016; Individuals with Disabilities Education Improvement Act of 2004, 2004). Through the Americans with Disabilities Act and the Individuals with Disabilities Education Act, the U.S. government has mandated a free and appropriate education for all children with disability, which may include an individualized education plan (IEP) or Section 504 Plan (504 Plan) (Americans with Disabilities Act Title II and Title III Regulations to Implement ADA Amendments Act of 2008, 2016; Individuals with Disabilities Education Improvement Act of 2004, 2004). When a student’s disability adversely affects their education, a collaborative plan to provide for special education services, known an IEP, is developed. For students with a disability who do not require special educational services but do require accommodations or additional professional services to participate fully in school, a 504 Plan is developed. The IEP and 504 Plan may help to assure that services needed for student success are available and thus reduce absences due to illness. In the United States, 14% of public-school students qualified for special education and have an IEP, while under 1.5% have a 504 Plan (McFarland et al., 2019; Zirkel & Weathers, 2016). For students with health conditions that limit function, the IEP and 504 Plan are academic planning strategies to ensure these students have the same opportunity to reach their full educational potential. Despite these academic plans, there are marked differences in graduation rates for those students with disabilities compared to those without (McFarland et al., 2019).
Differences in educational outcomes have also been observed in groups of different racial or ethnic identities and gender. National data demonstrate that there are differences in both attendance (percentage of school days attended per year) and graduation rates among differing racial or ethnic identity groups (McFarland et al., 2019; Office of Civil Rights, United States Department of Education Office for Civil Rights, 2019). In all racial or ethnic identity groups attendance is lowest in high school (Office of Civil Rights, United States Department of Education Office for Civil Rights, 2019). The group of students identifying as Asian has the highest attendance, while the group identifying as Native American has the lowest (Office of Civil Rights, United States Department of Education Office for Civil Rights, 2019). Students identifying as Asian or Native American are also the groups with the highest and lowest rates of graduation, respectively (McFarland et al., 2019). The disparities in graduation among minoritized students has been attributed in part to systemic racism, and can be addressed by school nurses (Aronowitz et al., 2021). Nationally, female students miss more days (22%) than male students (20%), although graduation rates are equivalent (50.5% female, 49.5% male) (National Center for Education Statistics, 2019; Office of Civil Rights, United States Department of Education Office for Civil Rights, 2019).
The relatively high numbers of students not completing high school experience more health-related risks, which create significant economic and social costs within the United States (Lansford et al., 2016; McFarland et al., 2019; Vaughn et al., 2014). For example, individuals who did not graduate from high school were more than two times as likely to report poor health and a lower quality of life than those who earned a high school diploma or a higher degree (Lansford et al., 2016; Maynard et al., 2015; Semega et al., 2017; Sum et al., 2009). In a large, nationally representative sample, dropping out of high school was associated with increased risk of diabetes, cardiovascular disease, and asthma in adulthood (Vaughn et al., 2014). This increased risk of chronic conditions can translate into mortality disparities by educational attainment. As mortality disparities widen over time, with those having less than a high school diploma living 10–14 fewer years than those with higher educational levels, education is increasingly considered an essential determinant of health (Masters et al., 2015; Olshansky et al., 2012).
Previous research examining graduation rates among students have focused mainly on whether or not a high school diploma was attained and not on intermediate educational outcomes such as attendance or a measure of being on-track to graduate in earlier grades. Research has demonstrated that school nurse interventions positively affect student attendance and academic outcomes (McKinley Yoder, 2020). In addition, past investigations have examined the outcome of high school graduation rates using crosssectional data rather than longitudinal data (Champaloux & Young, 2015; McKinley Yoder & Cantrell, 2019). Champaloux and Young (2015) as well as McKinley Yoder and Cantrell (2019) recommended stronger study designs to understand how chronic conditions, which can cause disability, among students affects educational attainment. Gee (2018) recommended that individual student predictors of attendance, such as racial or ethnic identity and disability, be examined to evaluate how they drive disparities. School nurses can use this information to promote attendance and intervene early to prevent students falling behind. This study addressed these limitations of previous studies. The aim of this study was to evaluate how disability, racial and ethnic identity, gender, and attendance in 5th grade predict disparities in educational outcomes in (a) 9th grade attendance in high school, (b) being on-track to graduate; and (c) high school graduation.
The Life Course Health Development (LCHD) framework was used to guide this study (Halfon & Hochstein, 2002) (See Figure 1). The LCHD framework proposes that an individual’s health trajectory is influenced by both individual and environmental factors (Halfon & Hochstein, 2002). In this study, the individual factors examined were whether or not the student had a disability, their attendance in 5th grade, their racial or ethnic identity which can influence their experience in the school setting, and gender. Cumulative mechanisms that are dose or exposure dependent may include frequent absences, due to disability, which result in the student missing foundational concepts, not understanding more advanced concepts in school, becoming demoralized by successive failures and eventually dropping out (Bates et al., 2017). Therefore, intermediate outcomes of attendance in 9th grade and being on track to graduate, as well as the endpoint of graduation were evaluated to understand the cumulative effect. The outcomes of this study related to environmental factors is published elsewhere (McKinley Yoder et al., 2022)
A secondary analysis of administrative longitudinal educational data was conducted using data from three time points (5th grade, 9th grade, and exit from high school). Data for this study were obtained from the Edupoint Synergy/eSIS student information system database. This administrative database contains attendance, demographic, academic, and school information from eight school districts (MESD, n.d.). The database is maintained by Multnomah Educational Services District (MESD), which provides school health services and special education, among other services, to eight school districts, and the individual district data belongs to the districts (MESD, n.d.). The study sample was drawn from a large metropolitan school district in the Pacific Northwestarea of the United States.
All eight school districts in the educational services district were invited to participate and two agreed, the largest and smallest school districts. Two districts declined and the other four did not respond to multiple invitations. The two districts that agreed to participate had quite different populations, with the smaller district having a higher graduation rate, fewer students attending schools that had high poverty rates and less racial/ethnic diversity. The study team decided not to combine the samples due to the difference in composition, and the study was completed on the largest school district only. Data was abstracted from the database by the school district and deidentified before being sent to the study authors.
Students beginning 5th grade in 2008, 2009, or 2010 were eligible to be included if they also had attendance data in 9th grade, on-track to graduate status (25% of credits to graduate by the end of 9th grade) and data about exit from school (graduation or drop out). Students who transferred to another district or did not have the on-track to graduate status in their records (this data point was phased in over the 2012–2014 school years) were excluded. In addition, the sample was stratified to ensure 20% of students had an IEP or 504 Plan through random replacement of students without disability for students with a disability until the percentage was reached. Stratification was used to ensure a sufficient sample of students with either a 504 Plan or IEP. Data were extracted from three time points (5th grade, 9th grade, and exit from school) for each of the student records for a final sample of 3,782 students.
Independent Variables. The independent student variables were 1) student IEP, 2) student 504 Plan, 3) racial or ethnic identity, 4) gender, and 5) attendance in 5th grade. Student disability was coded as a dichotomous variable: having an IEP or 504 Plan or not. Student race or ethnicity identification was a categorical variable. Student gender was coded as a dichotomous variable. Student attendance was measured as a continuous variable at 5th grade corresponding to the percentage of days attended during that year.
Dependent Variables. The dependent variables were 1) a continuous variable of the percentage of days attended in Grade 9, and two dichotomous outcome variables: 2) on-track to graduate status, and 3) high school graduation. If a student completed 25% of credits necessary to graduate by the end of the 9th grade year, they were considered to have an “on-track” to graduate status (Oregon Office of Accountability, Research and Information Services, 2018). Completing high school with a diploma within four years of starting 9th grade was considered graduation. Leaving school without records being transferred to another school or completing a GED were not considered graduation and were coded as zero (Oregon Department of Education, 2017).
Descriptive statistics were calculated for racial or ethnic identity, gender, having an IEP or 504 Plan, being on-track to graduate, and graduation for the full sample. Descriptive statistics were also calculated for three sub-samples (students with an IEP, students with a 504 Plan, and students with neither). The three samples were compared to identify if the sub-samples differed from the group of students in the sample (See Table 1). Grade 5 and Grade 9 attendance were both converted into z-scores to produce more interpretable results than the raw percentage data.
Then a series of regression analyses were conducted for the outcome variables of attendance in 9th grade, being on-track, and graduation. To examine the extent to which student variables predicted 9th grade attendance a multiple linear regression using attendance in 5th grade, racial or ethnic identity, gender, and disability status as independent variables and 9th grade attendance as the dependent variable was performed. The same independent variables were used to predict dependent variables of being on-track to graduate and graduation from high school in two separate logistic regressions. Logistic regression was used to calculate odds ratios (OR) of the dependent variable occurring. The significance of the resulting models was assessed by the omnibus chi-square test of the model coefficients. A second block of predictors, 9th grade attendance and being on-track to graduate, was added to the logistic regression analysis for graduation to evaluate how these two intermediate outcomes predicted eventual graduation. Villanova University Institutional Review Board provided an exempt approval of the study. Portland Public Schools provided approval for use of deidentified educational data.
Table 1 presents the demographics among the entire sample, as well as for those students in the sub-samples. Grade 5 attendance averaged 95% (SD = .05) in the full sample, 95% (SD = .04) in the 504 Plan sub-sample and the sub-sample with no disability, and (94%, SD = .06) in the IEP sub-sample. In 9th grade attendance decreased two percent to 93% (SD = .09) in the full sample and no disability sub-sample (SD = .08) and 92% (SD = .09) in the IEP group. Ninth grade attendance did not decrease at all in the 504 Plan group (95%, SD = .06). The majority of students were on-track to graduate by the end of their 9th grade year, and 79.8% graduated from high school. Students with a 504 Plan were much more likely to identify as White and be male compared to the entire sample and IEP subsample. Students with an IEP were more likely to be male and not be on-track at the end of 9th grade than students in the full sample.
A regression model of 9th grade attendance using individual student characteristics of grade 5 attendance, racial or ethnic identity, disability status, and gender was significant (F (10, 3781) = 71.89, p < .001). The model described 18% (Adjusted R2 = .18) of the variance in 9th grade attendance in this population. Grade 5 attendance had the most substantial impact (B = .38) on grade 9 attendance, more than three times the influence of Black (B = −.09) or Hispanic identity (B = −.11), and over seven times that of Native American identity (B = −.05) or female gender (B = −.05) (See Table 2).
The logistic regression analysis of 5th grade attendance, racial or ethnic identity, gender and disability status in predicting on-track to graduate at the end of 9th grade returned an omnibus test of model fit of (X2 (10) = 632.68, p < .001). The Nagelkerke’s R2, a pseudo R2 index to approximate the values of ordinary least squares R2 in logistic regression, was examined to identify effect size (Smith & McKenna, 2013). The Nagelkerke R2 was .21, indicating that the model explained 21% of the variance in being on-track to graduate. Students without an IEP were almost three times more likely to be on-track to graduate in 9th grade than those with an IEP. Those identifying as Black, Hispanic or Native American were about three times less likely to be on-track compared to their White counterparts (See Table 3).
In the final logistic regression analysis, two blocks were analyzed. The first was graduation regressed on the predictor variables of disability, racial or ethnic identity, gender and 5th grade attendance, and the model fit was (X2 (10) = 243.17, p < .001). The Nagelkerke R2 was.098 indicating the model explained 9.8% of the variance in graduation, although this is a pseudo- R2 statistic so should be interpreted with caution. Grade 5 attendance, identifying as Black, Hispanic, or Multiple categories, and having an IEP were all significant predictors of graduation (See Table 4).
A second block was added with the two midpoint variables, 9th grade graduation and on-track to graduate becoming predictor variables of the endpoint, graduation. In the second block, the Nagelkerke R2 increased to.31, indicating the second model tripled the predictive value of the first model, and the model (X2 (12) = 832.98, p < .001) was significant. By adding 9th grade outcomes of attendance and on-track to graduate to the model, approximately 30% of the variance in graduation rates was explained, although again this should be interpreted with caution. Attendance in Grades 5 and 9, and on-track to graduate in 9th grade significantly predicted graduation in the second block.
Using data from a large, diverse school district, this study is the first, to the authors’ knowledge, to examine the longitudinal effects of multiple student factors on educational outcomes. Three main conclusions were derived from the study’s findings. First, the likelihood of graduating from high school among students with an IEP was 30% lower than those without an IEP, supporting the findings from previous studies of students receiving special education (Schifter, 2016; Wisk & Weitzman, 2017). In the LCHD framework, receiving special education is a risk factor rather than protective factor. Notably, when attendance was controlled for, the relation between graduation rates for students with an IEP did not differ significantly from students without. Identifying the processes and factors which contribute to non-attendance in this group is integral to creating interventions that address disparities in graduation outcomes.
Second, there are significant disparities in attendance for students of racial or ethnic identities other than White or Asian. These findings suggest these disparities begin early in their education and influence later educational outcomes. For example, Black and Hispanic identifying students were three to four times less likely to be on-track at the end of 9th grade and half as likely to graduate as White students, a finding similar to national data from the Department of Education (Office of Civil Rights, United States Department of Education Office for Civil Rights, 2019). This study extends the literature, finding that these disparities exist even when disability and gender are controlled for. The LCHD framework posits that individual and environmental factors interact to determine health trajectory. For students identifying as Black, Hispanic or Native American, the environment that they experience due to systemic racism in their schools, neighborhoods, and communities limits the resources available for these students to be successful (Aronowitz et al., 2021; Bernardi & Ballarino, 2016; Dearing et al., 2016; Gottfried, 2014; Wodtke et al., 2011).
However, these analyses demonstrated that if attendance is controlled for, the racial or ethnic identity disparities in graduation are less marked, indicating that attendance is a key influence on graduation for groups at higher risk of not graduating. Examples of school nurse interventions include support of asthma medication therapy (Harrington et al., 2018; Noyes et al., 2013), case management (Bruzzese et al., 2006; Engelke et al., 2008; Levy et al., 2006; Moricca et al., 2013) and infection prevention (Wiggs-Stayner et al., 2006) have demonstrated increased attendance in student populations that identify as other than White. School nurses may also be able to identify students at risk in early years of high school and monitor attendance, along with other staff and teachers, as an early indicator of problems. Another contributor to attendance is cultural identity, or the feeling of belonging to a certain ethnic or cultural group. School nurses could capitalize on cultural identify as a strength and incorporate this aspect into plans for student success (De Witte et al., 2013). These findings can help drive policy decisions to target interventions for high-risk groups.
Although this study defined disabilities broadly as both those requiring special education (having an IEP) and those not requiring special education (504 Plan), the relatively small number of students with a 504 Plan precluded conclusions about the educational outcomes of students with disabilities not requiring special education services. The subpopulation of students with disabilities not requiring special education services (students with a chronic illness affecting their education, but not requiring an IEP) is an important area of future study. Previous research (Champaloux & Young, 2015; McKinley Yoder & Cantrell, 2019) identified this population as having poorer educational outcomes. The results of this study show that not all students with a chronic condition affecting their access to education have a 504 Plan due to lower than expected total numbers of students with a 504 Plan in this large sample.
Finally, an unintended finding of this study was disparity in students with 504 Plans was identified when comparing demographics across the entire sample and the sub-samples of students with an IEP, 504 Plan, and no disability. The prevalence of 504 plans is less (.08%) in this district than a national study of prevalence (Zirkel & Weathers, 2016) that found a prevalence of 1.02%–1.48%, but similar in that both populations in this study and the national study were disproportionately White and attended more affluent schools. The disparity in access to 504 Plans for students from low-income schools may be due to differences in parents’ access to the knowledge or skills to effectively advocate for their child needing these services (Trainor, 2010) or response of schools to accommodate the needs. This finding requires further study, as students with chronic conditions not requiring special education have poorer educational outcomes than students without chronic conditions (McKinley Yoder & Cantrell, 2019). If there were equity in access to 504 Plans for students who are female or identify as other than White, educational outcomes for these groups may be improved.
A limitation of this study is that the data were collected for educational purposes rather than research purposes. Although secondary data can provide a rich source of research information, they are limited by variables collected, method of collection, and coding compared to primary data (Thomas & Heck, 2001). For example, the type of chronic condition or severity was not available. The relatively small number of students with a 504 Plan limited conclusions about the effect of disabilities not requiring special education. The data set did not include other determinants found in the literature including parent income and occupation which affect educational outcomes (De Witte et al., 2013). The use of secondary data also introduced the risk of missing data, but an examination of missingness revealed only one data point that was missing, and this was resolved using mean imputation. Further, due to the many influences on student educational attainment, there may be additional confounding variables not included in this study. One such confounder is family poverty which was a variable not available in the data set due to district restrictions on release of that information. Because the subjects in this study were within intact groups (schools), there is also a risk of selection bias.
Education is an important determinant of health and the mechanisms leading to disparities in this determinant are an important area of ongoing study. The findings from this study suggest that if a student with a disability can maintain their 5th grade attendance level in 9th grade, the presence of the disability becomes less of a predictor of graduation. This finding necessitates further study into the drivers of nonattendance in students with disability as this affects student development. Previous studies found an association of increased student attendance as a result of school nurse interventions for student chronic conditions as well as infection prevention for entire student populations (McKinley Yoder, 2020). The influence of other school nurse interventions targeting the social determinants of health such as housing stability, racism, and community resources is an area of future study. Further, the disparities in access to 504 Plans for students who identify as female or from lowerincome schools is an area for future study. School nurses may be able to identify and advocate for 504 accommodations for students who are female, lower income, or from historically marginalized groups or support parents in gaining the knowledge and skills to effectively advocate for their child.
Further study is also needed into drivers of nonattendance in minoritized racial and ethnic identity groups, especially Black, Hispanic and Native American groups. Previous research has also demonstrated that school nurse interventions such as care coordination increase attendance in populations of students that identify as part of historically marginalized groups. Identifying and addressing the processes and factors of ableism and systemic racism which may disenfranchise these students in the educational setting may affect development and improve their likelihood of graduation and future economic and health opportunities (Aronowitz et al., 2021). School nurses, as part of the educational and healthcare systems, can address bias in these systems through advocacy. School nurses can use various tools including direct care such as care coordination for students with disabilities, and advocacy at the school and community levels to ensure that students have every opportunity to be successful.
At the time this research was completed Claire McKinley Yoder, PhD, RN, CNE was a doctoral candidate at M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship and/or publication of this article.
Claire McKinley Yoder https://orcid.org/0000-0002-8465-0048
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1 University of Portland, Portland, Oregon, USA
2 M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, Pennsylvania, USA
Corresponding Author:Claire McKinley Yoder, PhD, RN, CNE, University of Portland, 5000 N. Willamette Blvd, Portland, OR, 97203, USA.Email: mckinley@up.edu