School-based clinic use and school performance

Effect of a Comprehensive School-Based Health Center on Academic Growth in K-8th Grade Students

OBJECTIVE

School-based health centers (SBHCs) improve health care access, but associations with educational outcomes are mixed and limited for elementary and middle school students. We investigated whether students enrolled in a comprehensive SBHC demonstrated more growth in standardized math and reading assessments over 4 school years versus nonenrolled students. We also explored changes in absenteeism.

METHODS

Participants were students enrolled in 2 co-located Title I schools from 2015-19 (1 elementary, 1 middle, n = 2480). Analysis of math and reading was limited to students with baseline and postbaseline scores (math n = 1622; reading n = 1607). Longitudinal regression models accounting for within-subject clustering were used to estimate the association of SBHC enrollment with academic scores and daily absenteeism, adjusting for grade, sex, body mass index category, health conditions, baseline outcomes (scores or absenteeism), and outcome pretrends.

RESULTS

More than 70% of SBHC-enrolled students had math (1194 [73.6%]) and reading 1186 [73.8%]) scores. Enrollees were more likely than nonenrollees to have asthma (39.7% vs 19.6%) and overweight/obesity (42.4% vs 33.6%). Adjusted baseline scores were significantly lower in math and reading for enrollees. Mean change from baseline for enrollees exceeded nonenrollees by 3.5 points (95% confidence interval [CI]: 2.2, 4.8) in math and 2.1 points (95% CI: 0.9, 3.3) in reading. The adjusted rate of decrease in daily absenteeism was 10.8% greater for enrollees (incident rate ratio 0.772 [95% CI: 0.623, 0.956]) than nonenrollees (incident rate ratio 0.865 [95% CI: 0.696, 1.076]).

CONCLUSIONS

SBHC enrollees had greater health and educational risk but demonstrated more growth in math and reading and less absenteeism than nonenrollees.

Improving Health Equity and Outcomes for Children and Adolescents: The Role of School-Based Health Centers (SBHCs)

School-based health centers (SBHCs) provide a critical point of access to youth in low-resource communities. By providing a combination of primary care, reproductive health, mental health, vision, dental, and nutrition services, SBHCs improve the health, wellbeing, and academic achievement of the students they serve. SBHCs operate in collaboration with schools and community primary care providers to optimize the management of chronic health conditions and other health concerns that may result in suboptimal scholastic achievement and other quality of life measures. Conveniently located in or near school buildings and providing affordable, child- and adolescent-focused care, SBHCs reduce barriers to youth accessing high quality health care. SBHCs provide essential preventive care services such as comprehensive physical examinations and immunizations to students without a primary care provider, assist in the management of chronic health conditions such as asthma, and provide reproductive and sexual health services such as the provision of contraceptives, screening and treatment for sexually transmitted infections (STIs), and management of pregnancy. Additionally, some SBHCs provide vision screenings, dental care, and nutrition counseling to students who may not otherwise access these services. SBHCs have been demonstrated to be a cost-effective model of health care delivery, reducing both health care and societal costs related to illness, disability, and lost productivity.

Advancing health equity by addressing social determinants of health: Using health data to improve educational outcomes

Data from two social determinants of health-access to health care and access to a quality education-are combined to examine the impact of health on student achievement. Data from a high poverty, high performing K-8 school revealed a significant negative correlation between the number of visits to a school-based nurse and standardized academic assessments. Fixed effect regression confirmed the effect of total number of visits to the school-based nurse on performance on standardized assessments, and also revealed that two types of visits, neurological and gastrointestinal, were predictive of student performance. Taken together, these results suggest that when students are suffering from ill health their academic performance is negatively impacted. Implications for improving health equity through data-driven educational interventions are discussed.

The Link Between School Attendance and Good Health

More than 6.5 million children in the United States, approximately 13% of all students, miss 15 or more days of school each year. The rates of chronic absenteeism vary between states, communities, and schools, with significant disparities based on income, race, and ethnicity. Chronic school absenteeism, starting as early as preschool and kindergarten, puts students at risk for poor school performance and school dropout, which in turn, put them at risk for unhealthy behaviors as adolescents and young adults as well as poor long-term health outcomes. Pediatricians and their colleagues caring for children in the medical setting have opportunities at the individual patient and/or family, practice, and population levels to promote school attendance and reduce chronic absenteeism and resulting health disparities. Although this policy statement is primarily focused on absenteeism related to students' physical and mental health, pediatricians may play a role in addressing absenteeism attributable to a wide range of factors through individual interactions with patients and their parents and through community-, state-, and federal-level advocacy.

Application of the Human Well-Being Index to Sensitive Population Divisions: A Children's Well-Being Index Development

The assessment of community well-being is critical as an end-point measure that will facilitate decision support and assist in the identification of sustainable solutions to address persistent problems. While the overall measure is important, it is equally vital to distinguish variations among groups within the population who may be impacted in a different manner. The U.S. Environmental Protection Agency (US EPA) developed the Human Well-Being Index (HWBI), as a way of measuring these outcomes and assessing community characteristics. The HWBI approach produces a suite of indicators, domains and a final composite index appropriate for characterizing well-being of a population. While generalized approaches are needed, it is important to also recognize variations in well-being across community enclaves. This paper presents an adaption of the HWBI for child populations to test the applicability of the index framework to specific community enclaves. First, an extensive literature review was completed to ensure the theoretical integrity of metric and indicator substitutions from the original HWBI framework. Metric data were then collected, refined, imputed where necessary and evaluated to confirm temporal and spatial availability. A Children's Well-Being Index (CWBI) value, representing the same indicators and domains of well-being as the original HWBI, was calculated for the population under age 18 across all US counties for 2011. Implications of this research point to an effective, holistic end-point measure that can be tracked over time. Similarly, there is great potential for the application of the original HWBI method to other statistical population segments within the greater US population. These adaptations could help identify and close gaps in equity of resource distribution among these groups.

School-based interventions for reducing disciplinary school exclusion: a systematic review

This Campbell systematic review examines the impact of interventions to reduce exclusion from school. School exclusion, also known as suspension in some countries, is a disciplinary sanction imposed by a responsible school authority, in reaction to students' misbehaviour. Exclusion entails the removal of pupils from regular teaching for a period during which they are not allowed to be present in the classroom (in-school) or on school premises (out-of-school). In some extreme cases the student is not allowed to come back to the same school (expulsion). The review summarises findings from 37 reports covering nine different types of intervention. Most studies were from the USA, and the remainder from the UK. Included studies evaluated school-based interventions or school-supported interventions to reduce the rates of exclusion. Interventions were implemented in mainstream schools and targeted school-aged children from four to 18, irrespective of nationality or social background. Only randomised controlled trials are included. The evidence base covers 37 studies. Thirty-three studies were from the USA, three from the UK, and for one study the country was not clear. School-based interventions cause a small and significant drop in exclusion rates during the first six months after intervention (on average), but this effect is not sustained. Interventions seemed to be more effective at reducing some types of exclusion such as expulsion and in-school exclusion. Four intervention types - enhancement of academic skills, counselling, mentoring/monitoring, and skills training for teachers - had significant desirable effects on exclusion. However, the number of studies in each case is low, so this result needs to be treated with caution. There is no impact of the interventions on antisocial behaviour. Variations in effect sizes are not explained by participants' characteristics, the theoretical basis of the interventions, or the quality of the intervention. Independent evaluator teams reported lower effect sizes than research teams who were also involved in the design and/or delivery of the intervention.

Plain language summary

Interventions can reduce school exclusion but the effect is temporary: Some interventions - enhancement of academic skills, counselling, mentoring/monitoring, and skills training for teachers - appear to have significant effects on exclusion.The review in brief: Interventions to reduce school exclusion are intended to mitigate the adverse effects of this school sanction. Some approaches, namely those involving enhancement of academic skills, counselling, mentoring/monitoring and those targeting skills training for teachers, have a temporary effect in reducing exclusion. More evaluations are needed to identify the most effective types of intervention; and whether similar effects are also found in different countries.What is this review about?: School exclusion is associated with undesirable effects on developmental outcomes. It increases the likelihood of poor academic performance, antisocial behavior, and poor employment prospects. This school sanction disproportionally affects males, ethnic minorities, those who come from disadvantaged economic backgrounds, and those with special educational needs.This review assesses the effectiveness of programmes to reduce the prevalence of exclusion.What are the main findings of this review?: What studies are included? Included studies evaluated school-based interventions or school-supported interventions to reduce the rates of exclusion. Interventions were implemented in mainstream schools and targeted school-aged children from four to 18, irrespective of nationality or social background. Only randomised controlled trials are included.The evidence base covers 37 studies. Thirty-three studies were from the USA, three from the UK, and for one study the country was not clear.School-based interventions cause a small and significant drop in exclusion rates during the first six months after intervention (on average), but this effect is not sustained. Interventions seemed to be more effective at reducing some types of exclusion such as expulsion and in-school exclusion.Four intervention types - enhancement of academic skills, counselling, mentoring/ monitoring, and skills training for teachers - had significant desirable effects on exclusion. However, the number of studies in each case is low, so this result needs to be treated with caution.There is no impact of the interventions on antisocial behaviour.Variations in effect sizes are not explained by participants' characteristics, the theoretical basis of the interventions, or the quality of the intervention. Independent evaluator teams reported lower effect sizes than research teams who were also involved in the design and/or delivery of the intervention.What do the findings of this review mean?: School-based interventions are effective at reducing school exclusion immediately after, and for a few months after, the intervention (6 months on average). Four interventions presented promising and significant results in reducing exclusion, that is, enhancement of academic skills, counselling, mentoring/monitoring, skills training for teachers. However, since the number of studies for each sub-type of intervention was low, we suggest these results should be treated with caution.Most of the studies come from the USA. Evaluations are needed from other countries in which exclusion is common. Further research should take advantage of the possibility of conducting cluster-randomised controlled trials, whilst ensuring that the sample size is sufficiently large.How up-to-date is this review?: The review authors searched for studies published up to December 2015. This Campbell systematic review was published in January 2018.

Executive Summary/Abstract

BACKGROUND: Schools are important institutions of formal social control (Maimon, Antonaccio, & French, 2012). They are, apart from families, the primary social system in which individuals are socialised to follow specific codes of conduct. Violating these codes of conduct may result in some form of punishment. School punishment is normally accepted by families and students as a consequence of transgression, and in that sense school isoften the place where children are first introduced to discipline, justice, or injustice (Whitford & Levine-Donnerstein, 2014).A wide range of punishments may be used in schools, from verbal reprimands to more serious actions such as detention, fixed term exclusion or even permanent exclusion from the mainstream education system. It must be said that in some way, these school sanctions resemble the penal system and its array of alternatives to punish those that break the law.School exclusion, also known as suspension in some countries, is defined as a disciplinary sanction imposed by a responsible school authority, in reaction to students' misbehaviour. Exclusion entails the removal of pupils from regular teaching for a period during which they are not allowed to be present in the classroom or, in more serious cases, on school premises.Based on the previous definition, this review uses school exclusion and school suspension as synonyms, unless the contrary is explicitly stated. Most of the available research has found that exclusion correlates with subsequent negative sequels on developmental outcomes. Exclusion or suspension of students is associated with failure within the academic curriculum, aggravated antisocial behaviour, and an increased likelihood of involvement with punitive social control institutions (i.e., the Juvenile Justice System). In the long-term, opportunities for training and employment seem to be considerably reduced for those who have repeatedly been excluded. In addition to these negative correlated outcomes, previous evidence suggest that the exclusion of students involves a high economic cost for taxpayers and society.Research from the last 20 years has concluded quite consistently that this disciplinary measure disproportionally targets males, ethnic minorities, those who come from disadvantaged economic backgrounds, and those presenting special educational needs. In other words, suspension affects the most vulnerable children in schools.Different programmes have attempted to reduce the prevalence of exclusion. Although some of them have shown promising results, so far, no comprehensive systematic review has examined these programmes' overall effectiveness.OBJECTIVES: The main goal of the present research is to systematically examine the available evidence for the effectiveness of different types of school-based interventions aimed at reducing disciplinary school exclusion. Secondary goals include comparing different approaches and identifying those that could potentially demonstrate larger and more significant effects.The research questions underlying this project are as follows: Do school-based programmes reduce the use of exclusionary sanctions in schools?Are some school-based approaches more effective than others in reducing exclusionary sanctions?Do participants' characteristics (e.g., age, gender, ethnicity) affect the impact of school-based programmes on exclusionary sanctions in schools?Do characteristics of the interventions, implementation, and methodology affect the impact of school-based programmes on exclusionary sanctions in schools? SEARCH METHODS: The authors conducted a comprehensive search to locate relevant studies reporting on the impact of school-based interventions on exclusion from 1980 onwards. Twenty-seven different databases were consulted, including databases that contained both published and unpublished literature. In addition, we contacted researchers in the field of school-exclusion for further recommendations of relevant studies; we also assessed citation lists from previous systematic and narrative reviews and research reports. Searches were conducted from September 1 to December 1, 2015.SELECTION CRITERIA: The inclusion and exclusion criteria for manuscripts were defined before we started our searches. To be eligible, studies needed to have: evaluated school-based interventions or school-supported interventions intended to reduce the rates of suspension; seen the interventions as an alternative to exclusion; targeted school-aged children from four to 18 in mainstream schools irrespective of nationality or social background; and reported results of interventions delivered from 1980 onwards. In terms of methodological design, we included randomised controlled trialsonly, with at least one experimental group and onecontrol or placebo group.DATA COLLECTION AND ANALYSIS: Initial searches produced a total of 42,749 references from 27 different electronic databases. After screening the title, abstract and key words, we kept 1,474 relevant hits. 22 additional manuscripts were identified through other sources (e.g., assessment of citation lists, contribution of authors). After removing duplicates, we ended up with a total of 517 manuscripts. Two independent coders evaluated each report, to determine inclusion or exclusion.The second round of evaluation excluded 472 papers, with eight papers awaiting classification, and 37 studies kept for inclusion in meta-analysis. Two independent evaluators assessed all the included manuscripts for risk of quality bias by using EPOC tool.Due to the broad scope of our targeted programmes, meta-analysis was conducted under a random-effect model. We report the impact of the intervention using standardised differences of means, 95% confidence intervals along with the respective forest plots. Sub-group analysis and meta-regression were used for examining the impact of the programme. Funnel plots and Duval and Tweedie's trim-and-fill analysis were used to explore the effect of publication bias.RESULTS: Based on our findings, interventions settled in school can produce a small and significant drop in exclusion rates (SMD=.30; 95% CI .20 to .41; p<.001). This means that those participating in interventions are less likely to be suspended than those allocated to control/placebo groups. These results are based on measures of impact collected immediately during the first six months after treatment (on average). When the impact was tested in the long-term (i.e., 12 or more months after treatment), the effects of the interventions were not sustained. In fact, there was a substantive reduction in the impact of school-based programmes (SMD=.15; 95%CI -.06 to .35), and it was no longer statistically significant.We ran analysis testing the impact of school-based interventions on different types of exclusion. Evidence suggests that interventions are more effective at reducing expulsion and in-school exclusion than out-of-school exclusion. In fact, the impact of intervention in out-of-school exclusion was close to zero and not statistically significant.Nine different types of school-based interventions were identified across the 37 studies included in the review. Four of them presented favourable and significant results in reducing exclusion (i.e., enhancement of academic skills, counselling, mentoring/monitoring, skills training for teachers). Since the number of studies for each sub-type of intervention was low, we suggest that results should be treated with caution.A priori defined moderators (i.e., participants' characteristics, the theoretical basis of the interventions, and quality of the intervention)showed not to be effective at explaining the heterogeneity present in our results. Among three post-hoc moderators, the role of the evaluator was found to be significant: independent evaluator teams reported lower effect sizes than research teams who were also involved in the design and/or delivery of the intervention.Two researchers independently evaluated the quality of the evidence involved in this review by using the EPOC tool. Most of the studies did not present enough information for the judgement of quality bias.AUTHORS' CONCLUSIONS: The evidence suggests that school-based interventions are effective at reducing school exclusion immediately after, and for a few months after, the intervention. Some specific types of interventions show more promising and stable results than others, namely those involving mentoring/monitoring and those targeting skills training for teachers. However, based on the number of studies involved in our calculations, we suggest that results must be cautiously interpreted. Implications for policy and practice arising from our results are discussed.

School-Based Health Centers to Advance Health Equity: A Community Guide Systematic Review

CONTEXT

Children from low-income and racial or ethnic minority populations in the U.S. are less likely to have a conventional source of medical care and more likely to develop chronic health problems than are more-affluent and non-Hispanic white children. They are more often chronically stressed, tired, and hungry, and more likely to have impaired vision and hearing-obstacles to lifetime educational achievement and predictors of adult morbidity and premature mortality. If school-based health centers (SBHCs) can overcome educational obstacles and increase receipt of needed medical services in disadvantaged populations, they can advance health equity.

EVIDENCE ACQUISITION

A systematic literature search was conducted for papers published through July 2014. Using Community Guide systematic review methods, reviewers identified, abstracted, and summarized available evidence of the effectiveness of SBHCs on educational and health-related outcomes. Analyses were conducted in 2014-2015.

EVIDENCE SYNTHESIS

Most of the 46 studies included in the review evaluated onsite clinics serving urban, low-income, and racial or ethnic minority high school students. The presence and use of SBHCs were associated with improved educational (i.e., grade point average, grade promotion, suspension, and non-completion rates) and health-related outcomes (i.e., vaccination and other preventive services, asthma morbidity, emergency department use and hospital admissions, contraceptive use among females, prenatal care, birth weight, illegal substance use, and alcohol consumption). More services and more hours of availability were associated with greater reductions in emergency department overuse.

CONCLUSIONS

Because SBHCs improve educational and health-related outcomes in disadvantaged students, they can be effective in advancing health equity.

School-based health centers and pediatric practice

School-based health centers (SBHCs) have become an important method of health care delivery for the youth of our nation. Although they only represent 1 aspect of a coordinated school health program approach, SBHCs have provided access to health care services for youth confronted with age, financial, cultural, and geographic barriers. A fundamental principle of SBHCs is to create an environment of service coordination and collaboration that addresses the health needs and well-being of youth with health disparities or poor access to health care services. Some pediatricians have concerns that these centers are in conflict with the primary care provider's medical home. This policy provides an overview of SBHCs and some of their documented benefits, addresses the issue of potential conflict with the medical home, and provides recommendations that support the integration and coordination of SBHCs and the pediatric medical home practice.

The relationship between school-based health centers, rates of early dismissal from school, and loss of seat time

BACKGROUND

This study sought to understand the relationship between school-based health centers (SBHCs) and academic outcomes such as early dismissal and loss of seat time (the time students are available in school to learn or to access support services).

METHODS

A quasi-experimental research design was used to compare rates of early dismissal and loss of seat time between students who received SBHC and traditional school nursing services and students who received only traditional school nursing services. This study was a secondary data analysis of 764 "walk-in" visits during a 3-week period in 2 urban high schools in western New York state. Both schools provided school nursing services, and 1 of the 2 offered the option to enroll in an SBHC.

RESULTS

SBHCs significantly reduced the number of early dismissals from school (p = .013) in a comparison with students who received school nursing services alone. Students not enrolled in an SBHC lost 3 times as much seat time as students enrolled in an SBHC. Race, gender, age, poverty status, and presence of a preexisting illness did not influence these findings.

CONCLUSIONS

These findings suggest that SBHCs have a direct impact on educational outcomes such as attendance. Recommendations for further research include replication of this study to increase confidence in its findings and using early dismissal and loss of seat time as indicators of attendance to measure other health outcomes related to SBHCs and school nursing.

Toward a healthy high schools movement: strategies for mobilizing public health for educational reform

Although research shows that education and health are closely intertwined, health professionals have difficulty using this evidence to improve health and educational outcomes and reduce inequities. We call for a social movement for healthy high schools in the United States that would improve school achievement and graduation rates; create school environments that promote lifelong individual, family, and community health and prevent chronic illness, violence, and problems of sexual health; and engage youths in creating health-promoting environments. Achieving these goals will require strengthening and better linking often uncoordinated efforts to improve child health and education. Only a broad social movement has the power and vision to mobilize the forces that can transform educational and health systems to better achieve health and educational equity.

Linking improvements in health-related quality of life to reductions in Medicaid costs among students who use school-based health centers

OBJECTIVES

We examined whether improvements in pediatric health-related quality of life (HRQOL) stemming from use of school-based health centers (SBHCs) resulted in lower Medicaid costs.

METHODS

We analyzed data on 290 students from a 3-year, longitudinal SBHC evaluation conducted in Cincinnati, Ohio, in 2000 to 2003, including 71 with a mental health diagnosis and 31 with asthma, who had linked Ohio Medicaid records. HRQOL was measured using the Pediatric Quality of Life Inventory. Panel regression examined whether changes in parent-reported and student self-reported HRQOL predicted changes in Medicaid costs.

RESULTS

After adjustment for gender, age, SBHC status, and Medicaid type, we found cost reductions for every 1-point increase of parent-reported total ($36.39; P<.01), physical ($35.36; P<.05), and psychosocial ($25.94; P<.01) HRQOL. Significant cost reductions were also associated with student-reported total ($8.94; P<.05) and psychosocial ($7.79; P<.05) HRQOL increases. These effects were significant among the asthma subgroup but not the mental health subgroup. Physical HRQOL ($6.12; P=.27) effects were not significant.

CONCLUSIONS

Improvements in pediatric HRQOL translate into lower Medicaid costs, supporting the use of HRQOL as an outcome for evaluating SBHCs.

The relationship between school-based health centers and the learning environment

BACKGROUND

School-based health centers (SBHCs) have improved access to primary and preventive health care for underserved children and youth by bringing comprehensive health services into the schools while addressing critical health problems that make it difficult for students to learn. Despite the findings on the positive effects of SBHCs on health outcomes, the literature investigating the relationship between SBHCs and the learning environment is scant. This purpose of this study is to add to the literature by investigating the correlation between SBHCs and perceptions of the overall school learning environment.

METHODS

This study investigates the relationship between SBHCs and the learning environment utilizing a retrospective quasi-experimental design. Researchers used secondary data from the 2007 Board of Education Learning Environment Survey (LES) of a large northeastern city to compare schools with SBHCs and schools without SBHCs.

RESULTS

The findings demonstrate that the presence of a SBHC is associated with greater satisfaction in 3 out of 4 learning environment domains.

CONCLUSIONS

Perhaps by helping to eliminate the barriers that affect lower-performing students' readiness to learn, while improving student and parent engagement, SBHCs can partner with schools to reach their performance and accountability goals.

Impact of School-Based Health Center use on academic outcomes

PURPOSE

The purpose of this study was twofold: (1) to examine the effects of School-Based Health Center (SBHC) use on academic outcomes for high school students, using a well-controlled, longitudinal model, and (2) to examine whether SBHC medical and mental health service use differentially impacts academic outcomes.

METHODS

Analyses used a latent variable growth curve modeling approach to examine longitudinal outcomes over five school semesters for ninth grade SBHC users and nonusers from Fall 2005 to Fall 2007 (n = 2,306). Propensity score analysis was used to control for self-selection factors in the SBHC user and nonuser groups.

RESULTS

Results indicated a significant increase in attendance for SBHC medical users compared to nonusers. Grade point average increases over time were observed for mental health users compared to nonusers. Discipline incidents were not found to be associated with SBHC use.

CONCLUSIONS

SBHC use was associated with academic improvements over time for a high-risk group of users. The moderating effect of type of use (medical and mental health) reinforces the importance of looking at subgroups when determining the impact of SBHC use on outcomes.

Is the health and wellbeing of university students associated with their academic performance? Cross sectional findings from the United Kingdom

This study explored the associations between health awareness, health behaviour, subjective health status, and satisfaction of students with their educational experience as independent variables and three outcomes of educational achievement as dependent variables. We undertook two simultaneous cross-sectional surveys among students from one University in the UK during 2008-2009. The first survey was a general health survey; the second survey measured students' satisfaction with different aspects of their learning and teaching experience. Students' registration numbers linked the responses of both questionnaires together, and subsequently linked the questionnaires to the university database to import the grades that students actually achieved in their studies. Generally, on average, students (N = 380) exhibited medium to high satisfaction with their educational experiences. In the multivariate regression analyses, students' satisfaction with their educational experiences was not associated with any of the three indicators of educational achievement (actual module mark; perceived own performance; importance of achieving good grades). The associations of educational satisfaction, health, health behaviours, heath complaints and financial parameters with the three outcomes of educational achievement did not differ between male and female students. Each of the health, health behaviours, health complaints and financial parameters were selectively associated with only some but not all three indicators of student educational achievement. We conclude that the findings support a conceptual framework suggesting reciprocal relationships between health, health behaviour and educational achievement. Comprehensive health promotion programmes may have the potential to influence relevant predictors of educational achievement in university students.

Access and utilization patterns of school-based health centers at urban and rural elementary and middle schools

OBJECTIVE

We examined patterns of enrollment, use, and frequency of use in school-based health centers (SBHCs), as well as the referral, diagnosis, and disposition of SBHC visits among newly implemented SBHCs.

METHODS

Four rural and four urban school districts implementing SBHCs were examined from 2000 to 2003. Total school enrollment for students was 13,046. SBHC enrollment and medical encounter data were tracked using a Web-based medical database. Descriptive analyses were conducted to evaluate primary care access and utilization patterns.

RESULTS

A total of 7,460 (57.2%) students were enrolled in their SBHCs, of which 4,426 used the SBHC at least once for a total of 14,050 visits. SBHC enrollment was greater in urban districts but rate of utilization was higher in rural districts. Black students, students with public or no health insurance, and students with asthma or attention deficit disorder had higher enrollment and utilization. Rural parents referred more children to SBHCs than urban parents. Teachers referred more students who were black, had asthma, had no public or health insurance, or had acute-type health issues. Total visits increased during the three years, with the largest increase in mental health services. Students who were younger, white, attended rural schools, had public or health insurance, or had infections were more likely to be sent home. Those with chronic conditions and visits for mental health were more likely to be returned to class.

CONCLUSION

Utilization patterns suggest improved access to needed health care for disadvantaged children. SBHCs are an important part of the safety net for the populations they are intended to serve.

Health risk behavior of youth in foster care

PROBLEM

Many adolescent health problems are predominantly caused by risk behavior. Foster adolescents have disproportionately poor health; therefore, identification of risk behavior is critical.

METHOD

Data from a larger study were analyzed to investigate the health risk behavior of 56 youth in foster care using the Child Health and Illness Profile-Adolescent Edition.

FINDINGS

Data indicated that youth in foster care had some increased risk behavior when compared with a normative adolescent population. Younger adolescents and those in relative placement had less risky behavior. Risk behavior was increased for youth in foster care when they were in group homes, had experienced a parental death, or had a history of physical or emotional abuse or attempted suicide.

CONCLUSIONS

These results point to areas of strength and vulnerability for youth in foster care and suggest areas for clinicians and caregivers of these adolescents to focus interventions towards harm reduction and enhancement of resiliency.

Coordinated school health programs and academic achievement: a systematic review of the literature

BACKGROUND

Few evaluations of school health programs measure academic outcomes. K-12 education needs evidence for academic achievement to implement school programs. This article presents a systematic review of the literature to examine evidence that school health programs aligned with the Coordinated School Health Program (CSHP) model improve academic success.

METHODS

A multidisciplinary panel of health researchers searched the literature related to academic achievement and elements of the CSHP model (health services, counseling/social services, nutrition services, health promotion for staff, parent/family/community involvement, healthy school environment, physical education, and health education) to identify scientifically rigorous studies of interventions. Study designs were classified according to the analytic framework provided in the Guide developed by the Community Preventive Services Task Force.

RESULTS

The strongest evidence from scientifically rigorous evaluations exists for a positive effect on some academic outcomes from school health programs for asthmatic children that incorporate health education and parental involvement. Strong evidence also exists for a lack of negative effects of physical education programs on academic outcomes. Limited evidence from scientifically rigorous evaluations support the effect of nutrition services, health services, and mental health programs, but no such evidence is found in the literature to support the effect of staff health promotion programs or school environment interventions on academic outcomes.

CONCLUSIONS

Scientifically rigorous evaluation of school health programs is challenging to conduct due to issues related to sample size, recruitment, random assignment to condition, implementation fidelity, costs, and adequate follow-up time. However, school health programs hold promise for improving academic outcomes for children.

School-based health centers and the primary care physician: an opportunity for collaborative care

Located throughout the country, SBHCs are an important resource for primary care physicians caring for children and adolescents. It is beneficial for primary care physicians to become familiar with school-based resources in their community. Information about SBHCs nationwide is available from the NASBHC [4,16] and The Center for Health and Health Care in Schools [3,7,12,15]. Partnering with SBHCs can have important benefits for your practice, including improved continuity of care, management of chronic dis-eases like asthma, opportunities for group and multidisciplinary interventions for overweight children, and access to SBHC mental health services. Specializing in adolescent issues, with the advantage of proximity, SBHC providers can be an invaluable asset in managing and helping to monitor your patients, especially when other community resources are limited or services are difficult to access. In our own centers, we are currently exploring ways to simplify ongoing routine communication with primary care providers. Consider discussing this opportunity for collaborative services with your patients and contacting your local SBHC to discuss how you would like to communicate and work together.

School-based health centers and academic performance: research, challenges, and recommendations

School-based health centers (SBHCs) provide physical and mental health services on school campuses to improve student health status, and thereby potentially facilitate student academic success. With a growing emphasis on school accountability and the simultaneous dwindling of resources at the federal, state, and local levels, SBHCs face increasing pressures from school administrators and funders to document their impact on student academic achievement. This article reviews the methods, findings, and limitations of studies that have examined the relationship between SBHCs and academic performance. It also describes methodological challenges of conducting and interpreting such research, and discusses factors and intermediate variables that influence student academic performance. Recommendations are offered for SBHC researchers, evaluators, and service providers in response to the pressure they are facing to document the effect of SBHC services on academic outcomes.

Understanding adolescents' sleep patterns and school performance: a critical appraisal

The present paper reviews and critiques studies assessing the relation between sleep patterns, sleep quality, and school performance of adolescents attending middle school, high school, and/or college. The majority of studies relied on self-report, yet the researchers approached the question with different designs and measures. Specifically, studies looked at (1) sleep/wake patterns and usual grades, (2) school start time and phase preference in relation to sleep habits and quality and academic performance, and (3) sleep patterns and classroom performance (e.g., examination grades). The findings strongly indicate that self-reported shortened total sleep time, erratic sleep/wake schedules, late bed and rise times, and poor sleep quality are negatively associated with academic performance for adolescents from middle school through the college years. Limitations of the current published studies are also discussed in detail in this review.

Reducing Substance Use Among African American Adolescents: Effectiveness of School-Based Health Centers

This paper explores the impact of school-based heath centers (SBHCs) on the substance use behaviors of low-income, inner-city African American adolescents. Researchers surveyed 2,114 9th- and 11th-grade students from seven inner-city public high schools (three with SBHCs and four without SBHCs). Of the initial 2,114 students, 598 SBHC students and 598 non-SBHC students were successfully matched using ethnicity, grade, gender, and propensity scores. The results of separate grade × gender × SBHC ANOVAs indicated significant grade × SBHC interactions (i.e., such that substance use decreased in SBHC schools while increasing in non-SBHC schools) for cigarettes (p = .05) and marijuana (p< .001), but not for alcohol. These findings show that the SBHC intervention model is promising toward the prevention and reduction of substance use among high-risk African American adolescents and highlight the importance of accessible, holistic, and culturally appropriate health care.

Telehealth in a rural school-based health center

Telehealth is a new technology for the delivery of health care that allows a provider to deliver health care to a client at a remote setting via full, real-time video and audio interaction (American Nurses' Association, 1996). Telehealth does not change traditional health care standards or practice. School-based health centers are designed specifically for children and offer a continuum of preventive and acute care interventions that few other health care entities can provide (School-Based Adolescent Health Care Program, 1993). Telehealth and a school-based health center were joined together in a pilot project to demonstrate the efficacy of primary care via telehealth and to determine the value of this technology to the school and community. The telehealth capability enhanced the role of the school nurse and increased access to primary care for the students. The students were quick to adapt to the technology. The role of the school nurse was essential to the success of this project.

Assessment of school-based health centers in a rural state: the West Virginia experience

PURPOSE

To assess the capability of school-based health centers (SBHCs) to provide access to health care for rural youth.

METHODS

Review of annual patient records from SBHCs in West Virginia. Ten of 24 SBHCs in West Virginia in operation from July 1994 to June 1997 were selected for the study. Enrollment and utilization rates were generated for each site. A comparison was made between rates of enrollment, utilization, and annual visits among youth with private insurance, those covered by Medicaid, and youth without insurance. Rural and urban SBHCs within West Virginia were compared based on enrollment, utilization, and visit rates. The diagnostic categories were analyzed. Finally, enrollment rates, utilization rates, and insurance status for the West Virginia SBHCs were compared with national norms.

RESULTS

Enrollment rates rose steadily during the study period from 27% in Year 1 to 64% by the end of Year 3. The utilization rate was 67% in Year 3. The youth with either Medicaid or no insurance comprised 52% of enrollees, but they accounted for 63% of all visits. West Virginia SBHCs have a higher rate of Medicaid users than the national average for SBHCs, and the annual visit rate for West Virginia youth is higher than the national average for nonmetropolitan adolescents. The enrollment rate of 64% is slightly higher than the national average for SBHCs. Within West Virginia, the enrollment rate in rural schools was significantly higher, 86% compared to 46% (p < .001), and the utilization rate was 70% in rural centers compared to 63% in the urban centers (p < .001).

CONCLUSION

When SBHCs are available in rural areas, students use them. In West Virginia, SBHCs have contributed to providing access to health care for rural youth.

Principles for developing interdisciplinary school-based primary care centers

A 50% increase has occurred in the number of school-based primary care centers (SBPCCs) in the United States since 1993-94. Public schools offer a well-established and respected community-based infrastructure within which health centers may feasibly be developed. SBPCCs have documented improved access to care for underserved children and some initial success in addressing the complex morbidities and associated behavioral risk factors of children and adolescents. This paper presents five working principles to help communities establish SBPCCs that link community health and social services with their educational system. The principles encompass community participation, early assessment of community needs, integration of health and human services with educational services through an interdisciplinary and interagency team approach, development of a business plan, and program evaluation. These principles reflect the experiences of 22 Texas communities which operate 76 SBPCCs. They should prove helpful to many other communities and states that propose to develop, finance, and evaluate school-based, interdisciplinary health care and prevention services.

Development of a nurse-managed, school-based health center

As the healthcare environment continues to change, nurses are developing models for interdisciplinary care in a variety of community settings. The high school is an ideal treatment setting for the delivery of health services to adolescents. This article describes the development of a nurse-managed, school-based health center. The steps in planning and implementing this interdisciplinary service and training site are outlined to provide a guide for nurses wishing to develop autonomous community practice settings.