School-based adolescent health care. Review of a clinical service

School-based health centers: cost-benefit analysis and impact on health care disparities

OBJECTIVES

We evaluated the impact of school-based health centers-which provide essential health care for students by aiming to eliminate many access barriers-on health care access disparities and conducted a cost-benefit analysis.

METHODS

We employed a longitudinal quasi-experimental repeated-measures design. Primary data sources included the Ohio Medicaid claims, enrollment file with race/ethnicity, and survey reports from parents. We used hierarchical linear modeling to control unbalanced data because of student attrition. We assessed quarterly total Medicaid reimbursement costs for 5056 students in the SBHC and non-SBHC groups from 1997 to 2003. We calculated net social benefit to compare the cost of the SBHC programs with the value that SBHCs might save or create.

RESULTS

With SBHCs, the gap of lower health care cost for African Americans was closed. The net social benefits of the SBHC program in 4 school districts were estimated as $1,352,087 over 3 years. We estimated that the SBHCs could have saved Medicaid about $35 per student per year.

CONCLUSIONS

SBHCs are cost beneficial to both the Medicaid system and society, and may close health care disparity gaps.

Impact of school-based health centers on students with mental health problems

OBJECTIVES

School-based health centers (SBHCs) play an increasingly major role in providing mental health services for students. This study evaluated the impact of SBHCs on mental health-care services and psychosocial health-related quality of life (HRQOL).

METHODS

Four SBHC intervention and two matched non-SBHC school districts were examined from 1997 to 2003. The SBHC intervention began in 2000. Data included child and parent pediatric HRQOL and Ohio Medicaid claims. A longitudinal quasi-experimental time-series repeated measures design was used for this study, involving analysis of covariance to assess health costs and regression analyses for HRQOL scores.

RESULTS

After the SBHC program, proportions of students accessing mental health-care services for urban and rural SBHC intervention schools increased 5.6% (chi2 = 39.361, p < 0.0001) and 5.9% (chi2 = 5.545, p < 0.0001), respectively, compared with increases of 2.6% (chi2 = 2.670, p = 0.1023) and 0.2% (chi2 = 0.006, p = 0.9361) for urban and rural non-SBHC schools, respectively. Using data from 109 students with mental health problems based on Medicaid claims, the study found SBHC students had significantly lower total health-care costs (F = 5.524, p = 0.005) and lower costs of mental health services (F = 4.820, p = 0.010) compared with non-SBHC students. While improvements over time in HRQOL for SBHC students compared with non-SBHC students and students from non-SBHC schools were observed, only some were statistically significant.

CONCLUSIONS

SBHC programs increase the proportion of students who receive mental health services and may improve pediatric HRQOL. SBHC students with mental health problems had lower total Medicaid reimbursements compared with non-SBHC students.

Sexually active students' willingness to use school-based health centers for reproductive health care services in North Carolina

OBJECTIVE

School-based health centers (SBHCs) in North Carolina offer limited reproductive health care services. We investigate sexually active students' willingness to seek these services at SBHCs if available and predictors of willingness to seek services.

METHODS

Cross-sectional survey of 949 sexually experienced students in 2 middle and 5 high schools in North Carolina in 1994. Bivariate and multivariate analyses tested the influence of sociodemographic characteristics, risk of pregnancy/sexually transmitted infections (STIs), and past health care utilization on willingness to use SBHCs for sexuality-related services.

RESULTS

Participants were 52% female, 52% black, and median age at first coitus was 13.0 years. Many (49%) had sex at least once a month. Most (52%) reported inconsistent contraception use. One-fifth (18%) of females had been pregnant; 10% of males reported getting a partner pregnant. Seventy-five percent had used SBHCs. Most reported they would use SBHCs for information to protect against pregnancy and STIs (58%), pregnancy testing (51%), and birth control (48%) if available. Females were more likely than males to report they would use these services (adjusted odds ratio = 3.4, 95% confidence interval = 1.9-6.7), especially those receiving free lunch (adjusted odds ratio = 2.9, 95% confidence interval = 1.2-6.8]) and those with inconsistent use of contraception. We found no association between past health care and willingness to use SBHC services.

CONCLUSIONS

Most sexually experienced students report they would use their SBHC for reproductive/STI services if they were available. Absence of these services in SBHCs represents a missed opportunity to provide health care to adolescents who are at substantial risk of pregnancy and STIs.

Use of health and mental health services by adolescents across multiple delivery sites

PURPOSE

To assess the role that school-based health centers (SBHCs) play in facilitating access to care among low-income adolescents and the extent to which SBHCs and a community health center network (CHN) provide similar or complementary care.

METHODS

A retrospective cohort design was used to compare health care service use among adolescents relying on SBHCs compared with adolescents relying on a CHN. The study sample consisted of 451 inner-city high school students who made 3469 visits between 1989 and 1993. Encounter data were abstracted from medical records. Frequency of use and reason for use are examined according to various sociodemographic and health insurance characteristics.

RESULTS

SBHC users averaged 5.3 visits per year. Minority youth who used the SBHC had the highest visit rates (Hispanic, 6.6 visits/year; African-American, 10.6 visits/year). Visits to SBHCs were primarily for medical (66%, p <.001) and mental health services (34%, p <.001). Visits at CHN sites were 97% medical (p <.001). Visits by adolescents were 1.6 times more likely to be initiated for health maintenance reasons (p =.002; confidence interval [CI], 1.17-2.06) and 21 times more likely to be initiated for mental health reasons (p = <.001; CI, 14.76-28.86) at SBHCs than at CHN facilities. Urgent and emergent care use in the CHN system was four times more likely for adolescents who never used a SBHC (p <.001; CI, 3.44-5.47).

CONCLUSIONS

This study supports the view that SBHCs provide complementary services. It also shows their unique role in improving utilization of mental health services by hard-to-reach populations. The extent to which community health centers and other health care providers, including managed care organizations, can build on the unique contributions of SBHCS may positively influence access and quality of care for adolescents in the future.

Improving the health and well-being of adolescent boys

Adolescent men are at risk of having significant unmet health care needs. Like adolescent girls, they have complex health care needs and are more likely than younger children to be to be uninsured. They are less likely than women and other age groups to seek medical attention from traditional sources of care. Because of inadequate youth-oriented services, as well as teens' developmental stage, they have a tendency to receive care that is brief and problem oriented [20]. Such care is not likely to address complex problems that may be related to risk behaviors. Adolescent boys are also more concerned with the skills of the provider offering services than with the system in which the provider functions. Opportunities for outreach to adolescent men exist within many institutions. Nurses as advocates, educators, counselors, and providers of preventive health care have a creative opportunity for enhancing services to the teenage boy. The school is a natural place to begin as adolescents spend a significant part of each day there. Family planning and STI clinics are a source of care that are not well used by adolescent males, but when they do attend it is an opportunity to identify problems, provide counseling and referrals, and offer continuity. These health care institutions are not often welcoming or comfortable for the male youth. Use of these clinics will be enhanced by providers demonstrating increased acceptance of the adolescent when he attends as well as actively requesting that he attend with his partner. The most unusual but sorely needed outreach must be made to incarcerated and delinquent adolescent male. Residential facilities for delinquent youth need to be encouraged to provide a multidisciplinary comprehensive medical, mental health, and social services model. This approach will not only benefit the adolescent but the youth's community as well. Emergency rooms represent another crucial, missed opportunity to connect with young men. With some forethought and follow-up, emergency departments must become connected to appropriate and accessible adolescent primary care resources in the community. Finally, adolescent men are an underinsured population. Nurses can be important advocates of available state insurance funds, sliding scale or free services to youth, and must be a voice in youth policy-making.

Male adolescent use of health care services: where are the boys?

PURPOSE

To describe patterns of health care use by adolescent males in the United States and clinical practice characteristics associated with their use of adolescent-specific programs.

METHODS

Secondary analysis of three national data sets to determine health care use by male adolescents: the National Ambulatory Medical Care Survey [NAMCS (1994): pediatric, family physician, internal medicine, and obstetric/gynecologic outpatient visits]; National Hospital Ambulatory Medical Care Survey [NHAMCS (1994): outpatient department (OPD) and emergency department (ED) visits]; and Comprehensive Adolescent Health Services Survey [CAHSS (1995)]. Both NAMCS and NHAMCS are representative national probability samples. Total visit estimates by adolescents in 1994 to NAMCS sites were 387,076,630, to OPD sites were 6,511,244, and to ED sites were 13,161,824. For CAHSS, 468 programs (60% of eligible) participated. Data analyses were performed using two-tailed Student's t-tests and correlation testing.

RESULTS

Older male adolescents, aged 16-20 years, account for a lower percentage of total visits to NAMCS sites combined compared to younger males, aged 11-15 years (15.8% vs. 25.1%, p <.001), mainly owing to a significant decline in visits to pediatricians (3.2% vs. 14.9%, p <.001), despite significant increases in female health care use during the same time period. Younger males were seen at similar rates compared to females at NAMCS, NHAMCS-OPD and NHAMCS-ED sites, but older males account for a significantly lower percentage of total visits than females to all NAMCS sites combined (15.8% vs. 34.7%, p <.001), the NHAMCS-ED (26.4% vs. 31.5%, p <.05), and the NHAMCS-OPD (15.0% vs. 41.2%, p =.001). Among specialized adolescent sites (CAHSS), 13-19-year-old males account for fewer visits than females to all programs types: schools (40% vs. 60%), hospitals (33% vs. 67%), and community/health departments (25% vs. 75%) (all p's < or =.001). Clinical practice characteristics correlated with having a greater proportion of male adolescent visit varied depending on the types of adolescent program examined.

CONCLUSIONS

Younger male adolescents make health care visits in relatively equal proportions to females at all NAMCS and NHAMCS locations and visits by older males are significantly reduced. Male adolescent visits are lower than females at all adolescent-specific programs; school-based clinics see the highest proportion of males. Greater understanding of male adolescents' transition between providers from adolescence to adulthood is needed to improve care to male adolescents who under-use health services.

Support for school-based reproductive health services among South Carolina voters

In 1997 a statewide random digit-dialed telephone survey of 534 South Carolina registered voters was conducted to determine level of support for school-based reproductive health services. Results indicated most voters supported services in secondary schools that would provide students with information and counseling about contraceptive methods and refer students to community-based agencies for abstinence education and counseling. Voters were less supportive of reproductive health services that would diagnose or treat sexually transmitted diseases, test for pregnancy, refer students to community-based agencies for contraceptives, or make contraceptives available to students at school. Significant associations in support for school-based reproductive health services were reported based on income, personal beliefs, intentions, and outcome expectations regarding sexuality education and contraceptive availability. These data reinforce the need for school-aged youth in South Carolina to have access to reproductive health services within their communities, outside of the school setting.

Responding to the mental health needs of Latino children and families through school-based services

This article highlights the value and utility of school-based mental health services in addressing the unmet mental health needs of Latino children and families in the United States. To better understand our nation's rapidly growing Latino population, such critical factors as demographic characteristics, cultural values, and family structure are examined. Special attention is devoted to the daunting challenges and resultant trauma experienced by many of these children and families who have recently immigrated to this country from war-torn home-lands in Central America. The mental health status of Latino children is addressed, along with various service delivery issues and psychotherapeutic modalities to facilitate their personal adjustment and social adaptation in a culturally sensitive manner. The article concludes with the presentation of an innovative school-based mental health program that offers a range of services of demonstrated effectiveness in aiding Latino children and their families. Specific strategies for replicating the program model in other culturally diverse settings are also discussed.

Elementary school-based health center use

BACKGROUND

The number of school-based health centers (SBHCs) has grown from 40 in 1985 to >900 in 1996. During the 1996-1997 school year there were 914 SBHCs, 32% of which were located in elementary schools. Despite the relatively large number of elementary SBHCs in existence, SBHCs serving elementary-aged students are not adequately represented in the literature.

OBJECTIVE

To analyze physical and mental primary health care utilization in a comprehensive elementary SBHC for an underserved Hispanic population.

DESIGN

Retrospective analyses of services used at an elementary SBHC during the 1995-1996 school year. We describe physical and mental health services utilization provided by SBHC staff who offered a range of primary medical and mental health services.

PATIENTS

The study population was predominately Hispanic, and comprised of 811 elementary school students (grades preschool through fifth) registered for SBHC use. Analyses were conducted on 591 students who used the SBHC.

RESULTS

The 591 SBHC users made 2443 visits, ranging between 1 and 54 visits/individual; mean 4 visits/student. Two thirds of visits (1638) were medical provider visits, and 33% (798) were mental health provider visits. Most students (75%) saw a medical provider exclusively, 9% saw a mental health provider exclusively, and 16% of students were seen by both. Mean duration of medical provider visits +/-SD was 15 +/- 13 minutes, mean for mental health provider visits +/-SD, 37 +/- 16 minutes. Of the 3035 diagnoses, 64% were medical and 36% were mental health diagnoses. These diagnostic frequencies are grouped as follows: acute medical (31%), health maintenance (22%), depression (10%), non-Diagnostic and Statistical Manual of Mental Disorders-IV mental health diagnoses (8%), conflict disorder/emotional disturbance (8%), chronic medical (8%), academic/learning disorder (7%), anxiety disorder (3%), and other (4%).

CONCLUSIONS

High rates of SBHC utilization by this population and the range of diagnoses recorded suggest health care delivered in a comprehensive, culturally-sensitive SBHC has the potential for impacting the health and well-being of underserved elementary-aged students.

Role of school-based health centers in referral completion

PURPOSE

This study examined referrals from School-based health centers (SBHCs) to a sponsoring hospital to determine factors influencing successful referral completion and to assess SBHCs' ability to coordinate care.

METHODS

A total of 138 referrals from eight SBHCs to Boston City Hospital between September 1993 and October 1994 were reviewed via medical records, clinic logs, and hospital registration system. A data extraction tool was used to collect information. Statistical analyses were performed to identify associations between referral completion and study variables.

RESULTS

Seventy-five percent of all referrals were completed: 55.4% on the first attempt. Forty-six percent of those referred a second time completed their referrals. Statistically significant associations between referral completion and reason for referral (p = 0.01), visit diagnosis (p = 0.005), and usual source of health care (p = 0.009) were found. Provider documentation, including referral log and patient chart, was also associated with referral completion. Neither gender, race, nor health insurance had any significant association with successful referrals.

CONCLUSIONS

This study suggests that SBHCs can significantly contribute to coordinated care for adolescents, especially for the uninsured and those without a source of health care. SBHCs were particularly effective at facilitating referral to specific services including: family planning, tuberculosis prophylaxis, and subspecialty care. Provider action, such as making appointments and documentation, was also an important factor.

Rural school-based clinics: are adolescents willing to use them and what services do they want?

Using a theoretical model of access, factors associated with rural adolescents' willingness to use primary care services through a school-based health center (SBHC) were examined. Standardized measures of health status and use were administered to 633 adolescents in grades 7-12 who resided in one rural western Maryland county. Although only 6.5% (n = 41) of the sample indicated a willingness to change their regular source of care to an SBHC, greater numbers of adolescents reported a willingness to use SBHC services, with 18%, 38%, 25%, and 16%, indicating interest in routine, acute medical, miscellaneous, and reproductive health care services, respectively. Logistic regression analysis found those adolescents who reported eligibility for free-reduced lunch and no regular source of care for illness were 3.3 and 5.4 times more likely, respectively, to use an SBHC as a primary care site than those unwilling to change their source of care. Data suggest that initially many rural adolescents appear unwilling to change their primary care site to an SBHC, but do express a willingness to use offered services.

Community reactions to reproductive health care at three school-based clinics in Louisiana

Despite the growing success of school-based health care during the past two decades, the issue of providing reproductive health care at school-based health centers remains controversial. In this article, focus group data from three school-based centers in Louisiana, each in different stages of development, demonstrates how the controversies about reproductive health may frame more general concerns about school-based care. In addition, community readiness to address directly problematic sexual behavior relates not only to the specific needs and priorities of the community but to recognition of the negative effect of the consequences of sexual behavior such as pregnancy, high drop out, and absenteeism rates on a community's educational, rather than social, goals and values.

Abnormalities in weight status, eating attitudes, and eating behaviors among urban high school students: correlations with self-esteem and anxiety

PURPOSE

The study's objective was to determine the prevalence of abnormalities in weight, eating attitudes, and eating behaviors among an urban teenage population.

METHODS

Measures of weight, height, and blood pressure were obtained from 1,001 students attending regularly scheduled physical education classes in a New York City high school the population of which was 66% black and 23% Hispanic. The mean age was 16 years old; 55% were female and 45% were male. Approximately three quarters of the students completed the Eating Attitudes Test (EAT-26), Rosenberg Self-Esteem Scale, Spielberger Trait Anxiety Inventory, and a questionnaire on eating behaviors.

RESULTS

By percent ideal body weight (%IBW), 25% of students were obese (>20% above IBW), 18% were overweight, and 5% were underweight. Abnormal EAT scores (>21), were found in 6% of males and 15% of females. Students reported that they had engaged in the following nutritional behaviors at least three times in the past week: eating candy (59%), skipping breakfast (58%), skipping lunch (42%), eating fast foods (28%), and skipping dinner (14%). Self-esteem was high in 60%, medium in 21%, and low in 19%. Mean self-esteem was significantly higher (P < .0001) than established norms. Self-esteem and anxiety were inversely correlated (r = .40, P < .001), and low self-esteem and high anxiety were both associated with high EAT scores (r = .29, P < .001). Self-esteem and anxiety of obese students did not differ from those who were of normal weight.

CONCLUSIONS

Among this population of urban high school students there were: (a) a large number of overweight adolescents; (b) a significant subgroup with eating attitudes suggestive of an eating disorder; and (c) high levels of self-esteem and normal levels of anxiety, which were independent of weight status.

Violence and mental health problems among urban high school students

PURPOSE

We sought to determine the extent of exposure to violence and its relationship to other mental health risks among an urban teenage population.

METHODS

Students attending regularly scheduled physical education classes completed a Violence Survey, a Suicidal Ideation Survey, the Depression Self-Rating Scale (DSRS), and the Adolescent Alcohol Involvement Scale. Of the 630 students who completed the anonymous assessment 45% were male, 55% female, 61% black, 30% Hispanic; 54% grades 9-10, and 46% grades 11-12.

RESULTS

Half of the students reported knowing someone who had been murdered, 61% indicated they had witnessed a robbery, 59% had witnessed a beating, 37% had witnessed a shooting, and 31% had witnessed a stabbing. Mental health problems reported by these students included: depression (DSRS score > 13) in 31%, suicidal ideation in 16%, suicide attempts in 10%, drinking > 1 x per month in 21%, and drinking daily in 5%. Univariate analysis revealed that students who witnessed a shooting or stabbing were more likely (p < .05) to be both male and black. Multivariate analysis revealed that students reporting knowing someone who was murdered were twice as likely to report suicidal ideation and four times as likely to report suicide attempts. Witnessing a stabbing was associated with twice the likelihood of reporting suicide ideation and three times the likelihood of reporting suicide attempts. Witnessing a shooting was associated with twice the likelihood of alcohol use. Witnessing a beating or robbery had no significant relationship to measured variables.

CONCLUSIONS

Among this population of urban teenagers there are many who have witnessed violence and a subgroup who have witnessed shootings and stabbings and are at increased risk for mental health problems. A comprehensive medical and psychosocial history should include a violence assessment for all urban teens.

Sports participation in an urban high school: academic and psychologic correlates

PURPOSE

To study positive and negative correlates of sports participation in inner-city youth.

METHODS

We distributed anonymous questionnaires to 838 students in gym classes of an urban New York City High School. Forty five percent of students were male and 55% female, with mean age 16.0 years; 64% in grades 9-10, and 36% in grades 11-12; 63% black, 27% Hispanic, and 10% other; and 30% A/B students, 38% C students, and 32% D/F students.

RESULTS

All students reported some involvement in sports: 37% in 1-2 sports, 29% in 3-4 sports 24% in > or = 5 sports; 20% played on local teams, and 12% on junior or senior varsity. Approximately one-third each reported no weekday sports participation (30%), 1-2 hours per day (34%), or > or = 3 hours (36%); and 34% reported no participation on weekends, 26% reported 1-2 hours per day, and 40% > or = 3 hours. Basketball, volleyball, baseball, and weight lifting were the most common sports. Enjoyment, recreation, and competition were the most commonly reported reasons for participation. While 86% of subjects considered school "extremely" or "very" important, 35% considered sports "extremely" or "very" important. However, many believed they would "definitely" or "probably" receive an athletic scholarship (52% males, 20% females). Males reported more (p < .05) weekday, weekend, and team participation, and greater expectations (p <.001) of a future in sports. Sports involvement was not statistically associated with academic performance or scores on either the Rosenberg Self-Esteem Scale or Depression Self Rating Scale. Steroid use, at least once, was reported by 11% of males and 4% of females. Thirteen percent of students (21% males, 6% females) tried to gain weight for sports and 20% of both males and females tried to lose. Sports injuries within the past year were reported by 15% of students, and approximately three-quarters could correctly answer each of five questions about basic first aid.

CONCLUSIONS

The data indicate that most of these urban youth had athletic involvement, many had unrealistic expectations for their futures, and some utilized unhealthy behaviors in an attempt to enhance performance. Among these students, no association was found between sports involvement and academic performance, self-esteem, or depression.

Patterns of ICD-9 diagnoses among adolescents using school-based clinics: diagnostic categories by school level and gender

PURPOSE

Understanding utilization patterns in school clinics is important in discerning potential health outcomes among adolescents. This study reports on high-middle school and gender differences in ICD-9 diagnostic codes for students using Baltimore school clinics in the academic year 1989-90.

METHODS

12,953 visits resulted in 17,241 individual diagnoses. Data were grouped into 17 major diagnostic categories, subcategories for reproductive health and mental health, and 20 sentinel diagnoses.

RESULTS

Reproductive health diagnoses were most common for high school clinics (28% of all diagnoses). Mental health (psychosocial) diagnoses were most common for middle school clinics (30%). Adolescent women were much more likely to use clinics for reproductive health care needs than adolescent men. Adolescent men and women used the clinics with equal frequency for mental health, although specific diagnoses varied considerably by gender.

CONCLUSIONS

This overview of diagnostic patterns among adolescents using Baltimore's school-based clinics provides a unique view of differences in health care needs between younger and older teens and between male and female teens. These data have meaningful implications for clinic staffing and enhanced outreach efforts.

A school-linked health service for adolescents in Jerusalem

This paper describes the Adolescent Health Service (AHS) and its multidisciplinary, school-linked, community-based adolescent health clinic located in a western neighborhood of Jerusalem. Files of the first 134 adolescents who completed or discontinued treatment in the clinic during the first two years of operation were reviewed for demographic data, referral source, number of visits, health concerns and clinical impressions. The clinic population included Jewish Jerusalem residents, ages 12-18, 75% of whom were female. Most referrals came from schools. The average number of visits per patient was five (range 1-20). The most frequent presenting concerns as well as the most frequent clinical impressions were in the psychosocial and nutritional domains. Concordance between presenting concern and clinical impression was 61% (k = 0.47). Health problems of Israeli high school students attending the clinic mainly were psychosocial and nutritional. The school-linked health service applied a comprehensive approach to the biopsychosocial needs of adolescents, not addressed at other health services.

Stated and unstated reasons for visiting a high school nurse's office

PURPOSE

To determine the presenting complaints of students visiting a high school nurse's office and seek associations between specific presenting complaints and psychosocial problems.

METHODS

One hundred eighty-six students visiting the school nurse in a suburban high school were surveyed with a questionnaire developed by the investigators. Categorical data were compared utilizing chi-square or Fisher's Exact Test. Associations were determined by the Kruskal-Wallis Test.

RESULTS

Headaches (25%), infections (17%), stomach aches (12%), and dizziness or tiredness (12%) were the most common presenting complaints. Students indicated that "not sleeping well" and "stress" were two factors that most frequently played a role in their visits. Most students wanted either to rest or await going home; few were interested in receiving medical care or talking to the nurse. Specific complaints of headache, dizziness or tiredness, and no specific symptom were associated (p < .05) with not sleeping well, family problems, stress, school problems and depression.

CONCLUSIONS

Complaints of headache, dizziness or tiredness, and no specific symptoms may be used as markers for exploring possible psychosocial problems underlying a visit to the school nurse. If school nurses are to address psychosocial issues, they will need to look beyond stated reasons to unstated reasons for visits. Ways to achieve this expanded level of care are discussed.

The impact of health insurance status on adolescents' utilization of school-based clinic services: implications for health care reform

PURPOSE

1) To examine variations among students with different health insurance coverage in their use of school-based clinics (SBCs), reasons for not receiving health care when needed, and reasons for using or not using SBCs, and 2) to determine if insurance status is a significant factor in predicting SBC use, after controlling for demographic variables and health status.

METHODS

Confidential questionnaires were administered to 2,860 adolescents attending 3 urban high schools with on-site SBCs. Chi-square and multiple logistic regression analyses were used to assess differences among insurance groups in patterns of SBC use and reasons for clinic use/nonuse.

RESULTS

Students with private insurance or HMO coverage had the highest rates of SBC utilization (67% & 66%) and students without health insurance and with Medicaid had the lowest (57% & 59%) (p < 0.01). While there was no difference among adolescents according to insurance group membership in their use of SBC medical services, a significantly higher proportion of students with Medicaid coverage used SBC mental health services. Students without health insurance were less likely to receive health care from any source when it was needed. After controlling for demographic variables and health status, no insurance factors remained significant.

CONCLUSIONS

SBC users represent a variety of insurance groups. Health care reform efforts need to take into account the special needs of adolescents and the challenges they face in accessing care that go beyond financial barriers to care. SBC have been shown to provide a convenient and acceptable source of care, as well as offering the opportunity to provide preventive and primary care services to at-risk youth. As the country moves to a managed care environment potential partnerships with SBCs represent a unique opportunity to improve the delivery of care to adolescents, assuring increased access to a package of health services that they need.

Frequent school-based clinic utilization: a comparative profile of problems and service needs

The purpose of this study is to compare frequent users of school-based clinic services with students who have an average rate of utilization.

SAMPLE

Of the 1413 students enrolled in a Denver school-based clinic (DSBC) during the 1989-1990 school year, frequent clinic users (n = 73) were defined as those who visited the clinic 15 times or more (range, 15-72 visits per year). Average users (n = 82) were defined as students who visited the clinic three times during the year (the mean and median number of visits per student enrolled). Average users were compared.

RESULTS

The average utilizers were found to be representative of the entire student population based on age, race, gender, and grade. The frequent users had more females (71%) and a lower grade point average (GPA) (2.11) than the average users (52% female, 2.54 GPA; p < 0.02). The frequent clinic users differed in their initial primary diagnoses as well as in the types of subsequent visits, having a significantly higher percentage of mental health-related visits than did the average users (61% versus 10%; p < 0.01). The frequent clinic users also demonstrated more high-risk behaviors such as alcohol use, sexual activity, and both family and peer relationships (p < 0.001).

CONCLUSION

These data suggest that frequent clinic users have significant health needs that may require a higher rate of utilization.

Race, ethnicity, and access to ambulatory care among US adolescents

OBJECTIVES

Improving the health of minority adolescents will require a better understanding of factors that influence their access to and use of health care. This study describes the differences in health care access and use among White, Black and Hispanic adolescents and evaluates how such differences are influenced by insurance.

METHODS

We used data on 7465 10- to 17-year-olds included in the child health supplement to the 1988 National Health Interview Survey.

RESULTS

Much higher proportions of Blacks (16%) and Hispanics (28%) than of Whites (11%) were uninsured. Despite having worse reported health status, Black and Hispanic adolescents made notably fewer doctor visits in the past year than their White peers, and were more apt to lack usual sources of routine and acute care as well as continuity between sources of care. Having health insurance was associated with greater increase in access and usage measures for minority youth than for White youth. However, racial differences persisted even after adjusting for health insurance, family income, need, and other factors.

CONCLUSIONS

Minority adolescents are particularly vulnerable to the problems of health care access that affect all youth. While health insurance is especially important for increasing appropriate health care use among minority youth, nonfinancial methods of enabling more equitable use also deserve further study.

Substance use in a school-based clinic population: use of the randomized response technique to estimate prevalence

Students attending school-based clinics acknowledge only minimal involvement with drug or alcohol use. In order to explain this unanticipated finding, we used a statistical method called randomized response to study adolescents in one school-based clinic. The sample consisted of 133 students (57% female; 75% black, 20% Hispanic, 5% other; and 58% grades 9-10, 42% grades 11-12). Using both lifetime and 30-day prevalence rates, these students revealed more cigarette smoking and alcohol use on randomized response than they had on questionnaires completed earlier the same academic year, minimal involvement with either marijuana or cocaine use by either method, and a similar amount of sexual activity by both methods. This study demonstrates that randomized response can be a useful method to generate more truthful group responses from adolescents.