School-based policy influences on preconception cardiovascular health

Project Summary Cardiovascular-related complications are a leading contributor of U.S. maternal morbidity, of which women of color bear the disproportionate burden. Current approaches to intervene on perinatal cardiovascular health emphasize prenatal lifestyle and pharmacological interventions. Given the considerable time needed to achieve optimal health, these approaches have been characterized as “too little, too late” to meaningfully reduce maternal morbidity such as gestational diabetes, pre-eclampsia, macrosomia, and preterm birth. Adolescence is a crucial period to establish optimal health trajectories to avert later life health risks. One in five adolescent girls in the U.S. is obese and nearly one in three have prediabetes, which suggests escalation of the maternal health crisis. Schools are arguably one of the most important levers available to policymakers to influence adolescent cardiovascular health. Prior research on schools has documented associations between aspects of the built, food, social and learning environments on adolescent obesity. Yet disparities in the `healthfulness' of school environments have also been documented by school-level socioeconomic and racial/ethnic composition, with lower income schools typically equipped with fewer physical activity and extracurricular resources. Rarely, has research considered the influence of school attributes on cardiovascular risk trajectories outside of obesity, examined the implications for later maternal morbidity or applied a health equity implementation framework to school policy development. We propose a mixed-method study to construct a school-based adolescent preconception cohort through innovative data linkages, engage adolescents and local stakeholders to develop acceptable school-based policy solutions to achieve health equity, and utilizes an innovative approach to capture school system dynamics using agent-based modeling. Our overall goal is to identify school policy interventions to avert excess cardiovascular and maternal health risk and to narrow racial/ethnic inequities. In Aim 1, we will assess the association between school attributes, adolescent cardiovascular risk and maternal morbidity at first birth by creating a school- based adolescent preconception cohort that leverages existing data on school environments, adolescent health and fitness records, and Medicaid birth claims data between 2008 and 2024. In Aim 2, we will engage adolescents and local stakeholders to co-design school-based solutions to improve adolescent and perinatal cardiovascular health using a participatory systems dynamic method, group model building. In Aim 3, we will test promising school-based solutions using agent-based modeling to inform later life health outcomes. Findings will inform actionable policies to transform school environments with the goal of disrupting lifecourse trajectories that lead to racial/ethnic disparities in maternal health and beyond.