Re-exploring the nexus between the health and education systems in the time of COVID-19.

As devastating as the COVID-19 pandemic is, has been and will be, the uncertainty regarding the negative long-term impacts facing our children and young people are even scarier.

Though largely, and thankfully, unaffected by SARS-CoV-2 infections, children and young people have suffered in other ways that have had negative impacts on their health, whether that be through school lockdowns, or the impacts on families due to job losses or family members being infected with SARS-CoV-2. Children and young people are particularly sensitive to disruptions to their determinants of health (e.g. nutritious food, living conditions, family life, access to health and education services) and the COVID-19 pandemic and its associated lockdowns have negatively affected many of these determinants of health for children and young people globally. This paper gives an overview of the manuscripts published for a series examining the nexus between the education and healthcare systems and explores overlapping mechanisms that can help to support the health of the next generation at this crucial moment.

Global impacts of the COVID-19 pandemic

The emerging evidence on the negative impacts of the COVID-19 pandemic on children and young people is staggering. Data from UN bodies show that the COVID-19 pandemic has led to an additional ∼150 million children and young people living in multidimensional poverty (e.g. without access to education, healthcare, housing, nutrition, sanitation or water). About 370 million children may have missed nutritious school meals and ∼44 million children may have gone hungry in 2020. School closures due to the COVID-19 pandemic have affected more than 1.6 billion children and young people across 188 countries. The exact impact on their human capital and future development is difficult to predict but we know from previous crises that the negative impact will be substantial and, in many cases, irreversible.

COVID-19’s impacts closer to home

The serious concerns for the health of children and young people is not limited to resource-poor settings. Even before the pandemic, the number of children in poverty in England was predicted to increase to over 5 million by 2022, up from the 4.1 million in 2017. In 2019 there were 2.3 million children in the UK facing food insecurity. Compounded onto childhood poverty are the ∼2 million families who struggle with the ‘toxic trio’ of domestic abuse, parental substance misuse or parental mental health issues. The devastating effects of the COVID-19 pandemic are already having a negative impact in the UK that will exacerbate these already worrying trends. A survey by the Prince’s Trust found that 26% of 16–25-year-olds surveyed in the UK felt they were ‘unable to cope with life’ since the start of the pandemic; this figure increased to 40% for those not in work, education or training. Fifty per cent said their mental health worsened since the start of the pandemic and over 50% said they always or often felt anxious.

Overburdened healthcare systems

Despite the clear disruption to their determinants of health and the increase in poor health for the UK’s children and young people, care-seeking behaviour and presentation to healthcare organisations has not been commensurate with need.

The Mental Health of Children and Young People survey of 5–22-year-olds in 2020 highlighted that 21.7% of 17–22-year-olds with a probable mental disorder decided not to seek help for a mental health issue because of the pandemic, and an additional 22.9% did not seek help for both mental and physical health issues. This trend is visible in primary care, where recent data show that under-18s have rarely presented to primary care with a mental health issue during the pandemic. The same pattern can be seen in Accident and Emergency (A&E) departments, where a recent survey found that 30% of A&E paediatricians reported delayed presentations. We can expect these trends of delayed or no-presentation to continue post-pandemic because of the large backlog of cases that the NHS will have to deal with.

The essential role of schools in promoting health

‘When we close schools we close their lives, not to benefit them but to benefit the rest of society. They reap harm when we close schools.’

Good education and good health are mutually reinforcing, and schools play an essential role in children’s health. In a longitudinal study of 36,000 children, feeling connected to their school was found to be the strongest protective factor for decreasing substance use, violence, early sexual initiation and risk of injury, and was second only to feeling connected to their family in protecting against emotional distress, disordered eating and suicide. For vulnerable children, schools can mitigate the disadvantages they face in other areas of their lives. School provides a source of safety, structure and food, and positive relationships with teachers have been shown to improve children’s health outcomes into adulthood regardless of family background.

Efforts to promote health in UK schools have found support among the public and the education sector, and have improved outcomes for children and young people. The 1999 National Healthy Schools scheme and its follow-up programme for disadvantaged schools led to a 250% increase in health-promoting behaviour and several local authorities continue to offer school health award schemes. Decades of campaigning culminated in Personal, Social, Health Education (PSHE) becoming statutory in all schools in 2020, a subject which has been found to improve both health and academic attainment, with greater impact for disadvantaged students.

In addition to supporting healthy development in the long-term, schools and teachers also play a more direct role in supporting children for their acute health needs. Teachers are the most contacted professional service regarding mental health issues in 5–19-year-olds. Indeed, in 2020–21, education services were contacted for mental health support for 6–16-year-olds with a probable mental disorder at nearly double the rate of health services. Furthermore, schools and education services are a significant source of referrals for children’s social care – in 2018–19, 20% of referrals to children’s social care came from the education sector.

The prominent role schools play in children’s health is recognised by the current government through the rollout of school-based Mental Health Support Teams, with the intention to reach a fifth of schools by the end of 2022–23.

Where we fell short pre-COVID

Despite the progress that has been made, existing commitments fail to address the scale, depth and breadth of the physical and mental health crisis among children.

Childhood obesity continues to increase and has reached its highest ever rate, and the rate of childhood mental health disorders has increased by 50% in just three years, with a record one in six children currently experiencing one. British children have some of the lowest life satisfaction scores internationally, ranking 69th out of 72 countries. All of this has been compounded by the COVID-19 pandemic.

Schools are chronically under-equipped for the essential role they play in promoting health. For the nation’s children, teachers are the first responders. Yet teachers receive no routine training on child and adolescent health, and the 2015 recommendation to include such training in the new teacher training curriculum was not implemented.[9,17] Despite being a compulsory subject, PSHE education remains very much the poor relation and the schools’ inspectorate judged 40% of PSHE teaching to be ‘not yet good enough’. Over the past decade, the lesson time dedicated to PSHE has declined by a third and the government data on whether teachers have qualifications in the subjects they teach have consistently omitted PSHE altogether. Physical Education is likewise in decline, with a 14% drop in curriculum time since 2011. Schools themselves are struggling: most have experienced real-term cuts in funding and over half of teachers have considered leaving the profession due to pressures on their health and wellbeing.

Reimagining education: creating a healthier education system for all post-COVID

The lack of attention to schools’ role in health is systemic, but the potential societal benefits of reform in this area are significant. In this series, we explore the nexus between the health and education systems by highlighting four key mechanisms through which the education sector can promote health in children and young people by:

Leveraging the bi-directional links between education and health to promote resilience

Promoting health education in schools

Modifying the school determinants of children’s health

Supporting teachers as an essential health workforce

The ambitious proposals we outlined in our series would both remedy the long-standing omission of the education system’s role in supporting the health of children and young people and enable an effective and agile response to the emerging needs of the coronavirus generation.