**4. Academic achievement and health**

Academic achievement, also referred as academic performance, is the outcome of education, the extent to which a student, teacher or institution has achieved their educational goals. Academic achievement represents performance outcomes that indicate the extent to which a person has accomplished specific goals that were the focus of activities in instructional environments that include schools, colleges and universities. School systems mostly define cognitive goals that either apply across multiple subject areas such as critical thinking or include the acquisition of knowledge and understanding in a specific intellectual domain such as numeracy, literacy, science or history, among others. Academic achievement, therefore, should be considered to be a multifaceted construct covering multiple domains of learning [13].

• cultural,

• social,

• occupational,

• environmental and

148 Health and Academic Achievement

• precepts for wellness [12].

Some dimensions of health can be measurable at a specific point in time. For example, blood pressure, depression and sugar levels can be measured at specific intervals to determine someone's health. However, an unhealthy individual can achieve well-being. For example, someone with HIV, chronic cancer or diabetes can be well if they practise a healthy lifestyle. Conversely, an individual does not have to be well to be healthy. For example, an HIV-free individual can

The issue of wellness is emphasised in the definition by WHO and in the Salutogenesis theory. Therefore, it is clear that wellness is an emerging concept within the health promotion context and it is an important attribute of health. It is also clear that the concept of health has been evolving over time. Previously, there has been a medical dichotomy separating health from illness, and health was seen from a traditional pathogenic approach. This view saw health as the absence of diseases or other infirmities. The World Health Organisation attempted to change this line of thinking by proposing that health is a complete state of well-being. However, as discussed previously in this chapter, this definition was also criticised, and as a result, WHO came up with a broader definition that has been authenticated by theory. This broader view of health from the definition proposed by WHO and the Salutogenesis theory by Antonovsky and Lindstrom will be helpful in determining the various health dimensions that affect students' academic achievement. As mentioned earlier on, it seems learning institutions are using a narrow approach in promoting health among student. Most schools especially in the developed world do not have comprehensive health promotion strategies and they tend to employ the 'pathogenic' approach which is more reactive than proactive. This is characterised by the presence of student clinics for the treatment of diseases, injuries and other forms of ailments. As discussed later in this chapter, there is a need to come up with school-based interventions that address the overall health and wellness of students. Moreover, these inter-

engage in unhealthy lifestyle such as smoking or excessive alcohol intake.

ventions should be more proactive in addressing students' health needs.

Academic achievement, also referred as academic performance, is the outcome of education, the extent to which a student, teacher or institution has achieved their educational goals. Academic achievement represents performance outcomes that indicate the extent to which a person has accomplished specific goals that were the focus of activities in instructional environments that include schools, colleges and universities. School systems mostly define cognitive goals that either apply across multiple subject areas such as critical thinking or include the acquisition

**4. Academic achievement and health**

Academic achievement is commonly measured by examinations or continuous assessment. There is, however, no general agreement on how it is best tested or which aspects are most important. Some of the yardsticks that have been used to measure academic achievement include procedural knowledge such as skills or declarative knowledge such as facts. Among the many criteria that indicate academic achievement, there are very general indicators such as knowledge acquired in an educational system, more curricular-based criteria such as grades or performance on an educational achievement test, and cumulative indicators of academic achievement such as educational degrees and certificates.

Individual differences in academic performance have been linked to differences in intelligence and personality. Students with higher mental ability as demonstrated by IQ tests and those who are higher in conscientiousness (linked to effort and achievement motivation) tend to achieve highly in academic settings. Although the primary goal of educational institutions is to achieve higher standards in terms of academic performance, research shows that academic achievement is influenced by multiple factors. Factors such as learning environments, parent's academic socialisation and extra-curricular activities have a positive relationship with academic performance. Health has been seen as one of the key factors that influence academic performance. The importance of health on academic achievement was emphasised by the Centers for Disease Control and Prevention (CDC) by stating that 'CDC recognizes that the academic success of … youth is strongly linked with their health. In turn, academic success is an excellent indicator for the overall well-being of youth, and is a primary predictor and determinant of adult health outcomes' [14].

Research evidence reveals that students with poor health have a higher probability of school failure, grade retention and dropout. Previous studies found that the health services provided at school can alleviate the problem of absenteeism, late-coming and undisciplined student behaviour, and increase graduation rate. However, the relationship between student health and academic success is complex because health is a broad concept which is complex to define. Previous research has found some significant relationship between specific attributes of health and academic achievement. For example, previous research found an association between nutrition and physical activity with higher academic performance [15]. Overweight and hypertension are associated with decreased cognitive function, and overweight is associated with poorer school performance [16]. In contrast, higher levels of physical activity have been associated with better cognitive function, such as enhanced concentration and memory [17]. Results of a randomised control trial carried out in 2011 demonstrated that overweight students randomised to a 13-week exercise program exhibited dose-response benefits of exercise on executive function and mathematics achievement as well as preliminary evidence of enhanced brain activity measured via functional magnetic resonance imaging (MRI) [18].

In a longitudinal study carried out in the United States of America, the findings revealed that after accounting for family characteristics, adolescents with poorer general health were found to be less likely than healthier students to graduate from high school on time and attend college or post-secondary education [19]. The California's state education system published an extensive report linking academic achievement and health [20]. A study by researchers at the University of Washington found that Washington state schools with a lower prevalence of substance abuse also had higher scores on the Washington Assessment of Student Learning (WASL) [21].

Modern-day students who are involved in school and other extra-curricular activities experience a toll on their physical and mental health. Having a mental illness is a difficult thing to deal with, especially as a teen. Mental health disorders can affect social interactions, inability to screen out environmental stimuli (sounds, sights or smells which may be distracting to the student), inability to concentrate, lack of stamina, handling time pressures and multiple tasks, handling negative feedback and the response to change. Mental illness therefore has a great impact on academic achievement. It does not only affect emotional health but it is known to influence many domains of students' lives, including their social interactions and educational achievements. Mental illness can be linked to poor attendance, particularly frequent absences for vague, non-specific physical health problems. It has also caused difficulties with academic work such as social integration, adjustment to school, behaviour regulation, attention and concentration [23]. In a 2004 study, approximately 83% of students with emotional and behavioural disorders scored below the mean of the control group in reading, writing and math [24]. **Box 1** reveals a summary of results compiled by the National Centre for Mental Health Checkups. The results show that mental illness affects attendance, perceived competence and concentration [25].

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**Attendance**: High-school students who screen positive for psychosocial dysfunction have three times the absentee

**Perceived competence**: Students reporting high levels of psychosocial stress are more likely to perceive themselves

**Concentration**: Students with greater depression symptoms are more likely to report difficulty concentrating in

**Anxiety**: Anxiety disorders, which affect 31.9% of all adolescents and co-occur in approximately one-third of depressed youth, are associated with a reduced likelihood of attending college. People with a lifetime occurrence of social phobia are almost twice as likely to fail a grade or not finish high school as those who have never had the

**Depression**: High depression scores have been associated with low academic achievement; high scholastic anxiety; increased school suspensions; and decreased ability or desire to complete homework, concentrate and attend class. **Suicidality**: Adolescents who have attempted suicide in the previous 12 months show significantly lower levels of school performance and school connectedness than non-attempters. Students who perceive their academic performance as 'failing' are 3 times more likely to report suicidal thoughts and 10 times as likely to report suicide attempts

**Substance use disorders**: Substance abuse, including alcohol abuse in isolation, is significantly associated with

**Attention disorders**: Attention problems are the principal predictor of diminished achievement relative to expecta-

termination of primary and secondary school, failure to enter college and termination of college.

and tardy rates of students not identified with psychosocial dysfunction.

as less academically competent.

class and completing homework.

than students who feel their performance is fine.

tions on the basis of a young person's cognitive ability.

**Box 1.** Effects of mental illness on academic achievement.

condition.

A study by the Washington State Healthy Youth Survey carried out in 2006 found that the more health risks students had, the more likely it was that they also were at academic risk. The rate of increase in academic risk was very consistent; with each extra health risk added a similar difference, whether going from one to two risks or seven to eight risks (see **Figure 2**). Fewer than 10% of students with no health risk factors reported being at academic risk (having mostly Cs, Ds or Fs). About half of students with six health risk factors, and two-thirds or

more of students with at least nine health risk factors were at academic risk [26].

This association between health and academic achievement was illustrated in more detail in a study that was carried out among our own Washington youth in 2009. The study examined the relationship using data collected from Washington state students who took the Healthy Youth Survey. The survey took place in classrooms and had questions about a variety of health factors and academic indicators, such as what grades the student usually gets in school. Students were classified as being at 'academic risk' if they said they usually get Cs, Ds or Fs in school. The study identified 13 key physical and mental health risk factors that were available in the Healthy Youth Survey and somewhat common among students (see **Table 1**). The results showed that the percentage of the students at academic risk was greater for students who reported having any of the 13 health risk factors in comparison to students without the health risks (see **Figure 1**). For example, about 22% of non-smoking students were at academic risk, but more than twice as many (57%) of students who smoke were at risk. About 20% of students who ate breakfast were at academic risk, but 34% of students who did *not* eat breakfast were at risk. For each specific risk factor, the difference in academic risk by health risk factor was statistically significant, including after adjusting for gender and socio-economic status [22].


**Table 1.** Health risks that may influence student achievement.

Modern-day students who are involved in school and other extra-curricular activities experience a toll on their physical and mental health. Having a mental illness is a difficult thing to deal with, especially as a teen. Mental health disorders can affect social interactions, inability to screen out environmental stimuli (sounds, sights or smells which may be distracting to the student), inability to concentrate, lack of stamina, handling time pressures and multiple tasks, handling negative feedback and the response to change. Mental illness therefore has a great impact on academic achievement. It does not only affect emotional health but it is known to influence many domains of students' lives, including their social interactions and educational achievements. Mental illness can be linked to poor attendance, particularly frequent absences for vague, non-specific physical health problems. It has also caused difficulties with academic work such as social integration, adjustment to school, behaviour regulation, attention and concentration [23]. In a 2004 study, approximately 83% of students with emotional and behavioural disorders scored below the mean of the control group in reading, writing and math [24]. **Box 1** reveals a summary of results compiled by the National Centre for Mental Health Checkups. The results show that mental illness affects attendance, perceived competence and concentration [25].

**Attendance**: High-school students who screen positive for psychosocial dysfunction have three times the absentee and tardy rates of students not identified with psychosocial dysfunction.

**Perceived competence**: Students reporting high levels of psychosocial stress are more likely to perceive themselves as less academically competent.

**Concentration**: Students with greater depression symptoms are more likely to report difficulty concentrating in class and completing homework.

**Anxiety**: Anxiety disorders, which affect 31.9% of all adolescents and co-occur in approximately one-third of depressed youth, are associated with a reduced likelihood of attending college. People with a lifetime occurrence of social phobia are almost twice as likely to fail a grade or not finish high school as those who have never had the condition.

**Depression**: High depression scores have been associated with low academic achievement; high scholastic anxiety; increased school suspensions; and decreased ability or desire to complete homework, concentrate and attend class.

**Suicidality**: Adolescents who have attempted suicide in the previous 12 months show significantly lower levels of school performance and school connectedness than non-attempters. Students who perceive their academic performance as 'failing' are 3 times more likely to report suicidal thoughts and 10 times as likely to report suicide attempts than students who feel their performance is fine.

**Substance use disorders**: Substance abuse, including alcohol abuse in isolation, is significantly associated with termination of primary and secondary school, failure to enter college and termination of college.

**Attention disorders**: Attention problems are the principal predictor of diminished achievement relative to expectations on the basis of a young person's cognitive ability.

**Box 1.** Effects of mental illness on academic achievement.

**Table 1.** Health risks that may influence student achievement.

be less likely than healthier students to graduate from high school on time and attend college or post-secondary education [19]. The California's state education system published an extensive report linking academic achievement and health [20]. A study by researchers at the University of Washington found that Washington state schools with a lower prevalence of substance abuse also had higher scores on the Washington Assessment of Student Learning (WASL) [21].

150 Health and Academic Achievement

This association between health and academic achievement was illustrated in more detail in a study that was carried out among our own Washington youth in 2009. The study examined the relationship using data collected from Washington state students who took the Healthy Youth Survey. The survey took place in classrooms and had questions about a variety of health factors and academic indicators, such as what grades the student usually gets in school. Students were classified as being at 'academic risk' if they said they usually get Cs, Ds or Fs in school. The study identified 13 key physical and mental health risk factors that were available in the Healthy Youth Survey and somewhat common among students (see **Table 1**). The results showed that the percentage of the students at academic risk was greater for students who reported having any of the 13 health risk factors in comparison to students without the health risks (see **Figure 1**). For example, about 22% of non-smoking students were at academic risk, but more than twice as many (57%) of students who smoke were at risk. About 20% of students who ate breakfast were at academic risk, but 34% of students who did *not* eat breakfast were at risk. For each specific risk factor, the difference in academic risk by health risk factor was statistically significant, including after adjusting for gender and socio-economic status [22].

> A study by the Washington State Healthy Youth Survey carried out in 2006 found that the more health risks students had, the more likely it was that they also were at academic risk. The rate of increase in academic risk was very consistent; with each extra health risk added a similar difference, whether going from one to two risks or seven to eight risks (see **Figure 2**). Fewer than 10% of students with no health risk factors reported being at academic risk (having mostly Cs, Ds or Fs). About half of students with six health risk factors, and two-thirds or more of students with at least nine health risk factors were at academic risk [26].

**5.2. Information-based solutions**

nurses and social media.

wellness and physical exercises [28].

**5.4. Supportive health services**

small number of students [29].

**5.3. Health-promoting curriculum, instruction and training**

Prevention is better than cure. Information has played a critical role in disease prevention and the cost of information-based solutions is much less compared to the cost of treating patients. Information is a useful resource in catalysing behaviour change among school children. Disseminating health information can improve knowledge transfer from health professionals to the student population, and helps them to maintain and improve their health. Schools can introduce health intervention strategies aimed increasing awareness on a number of health issues that include food and nutrition, sexual and reproductive health, alcohol and drug abuse, depression and anxiety, physical exercise among other key health topics. Schools should use a variety of media and channels to disseminate health information, including posters, websites,

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Health education programmes can help students develop the knowledge, skills, attitudes and behaviours needed to adopt healthy behaviours. Educational interventions can also enhance knowledge and help-seeking among college students. Fitness and wellness courses have been seen as agents of change for modifying unhealthy lifestyles among college students. There is evidence that well-taught fitness and wellness classes have the potential to positively affect the attitudes and behaviours of the students that enrol in them. Educational modules are an important tool for health information dissemination and behaviour change. Conceptually based wellness courses, which are also referred to as lecture laboratories, have been designed to promote physical education and wellness among college students. The courses are an alternative to the traditional skill-based physical education courses. The courses consist of lectures and laboratory experiments. The lecture part of the course is designed to promote learning of conceptual information related to fitness and wellness and health behaviour change theory as well as learning of self-management skills that result in real-world application. The laboratory sessions are designed to provide students with hands on skills on matters related to

Supportive health services are targeted interventions or support for selected students, as well as provision of a broad range of services that can influence health. For example, school nurses and counsellors refer students who currently smoke to cessation classes or other help for quitting. The Centers for Disease Control and Prevention observes that supportive services can have a high impact on individual students, but only for the selected students who would have been identified as students at risk. These services usually require relatively more staff resources to sustain. For example, individual counselling programmes for students at risk for substance abuse may effectively impact the behaviour of individual students, but may not impact the prevalence of substance abuse at the school as a whole, because they only reach a

**Figure 2.** Number of risk factors and academic achievement.
