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

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.

The Role of School-based Interventions and Communities for Mental Health Prevention, Tiered Levels of Care, and Access to Care

This article highlights the key role of schools in addressing rising mental health disorders among youth. It champions collaboration between health and educational sectors, emphasizing child and adolescent psychiatrists' significant contribution to school-based mental health literacy and interventions. This article encourages for child and adolescent psychiatrists' involvement in policy advocacy for accessible and inclusive mental health care, championing sustainable mental health services through advocating for funding, training, and policy support.

Pediatric School Outreach: Clinical Needs of an Urban Student Population

Pediatric School Outreach (PSO) is a school-based health center (SBHC) in an urban elementary school in Toronto, Canada. PSO focuses on developmental, behavioral, mental health, and educational concerns. A retrospective chart review aimed to characterize demographics, diagnoses, and referrals of patients attending PSO. Of 137 children, ages 2 to 15 years, 73.7% were male; 58.1% had a household annual income of <$30 000 CAD. Possible or confirmed diagnoses included attention deficit hyperactivity disorder (48.5%), learning disability (35.6%), anxiety (22.0%), autism spectrum disorder (16.7%), oppositional defiant disorder (14.4%), and expressive language delay (11.4%). Involvement of community mental health and other agencies was advised in 37.9% of cases. Psychoeducational testing was recommended for 25.0% of patients. Results suggest the need for timely developmental testing, particularly for autism spectrum disorder, and accessible learning disability diagnostic support. There is potential for expansion of interprofessional care at PSO, including psychology, psychiatry, social work, and behavior therapy.

Elementary School-Based Health Centers and Access to Preventive and Asthma-Related Care Among Publicly Insured Children With Asthma in Georgia

OBJECTIVES

We assessed the effects of 3 new elementary school-based health centers (SBHCs) in disparate Georgia communities-predominantly non-Hispanic Black semi-urban, predominantly Hispanic urban, and predominantly non-Hispanic White rural-on asthma case management among children insured by Medicaid/Children's Health Insurance Program (CHIP).

METHODS

We used a quasi-experimental difference-in-differences analysis to measure changes in the treatment of children with asthma, Medicaid/CHIP, and access to an SBHC (treatment, n = 193) and children in the same county without such access (control, n = 163) in school years 2011-2013 and 2013-2018. Among children with access to an SBHC (n = 193), we tested for differences between users (34%) and nonusers of SBHCs. We used International Classification of Diseases diagnosis codes, Current Procedural Terminology codes, and National Drug Codes to measure well-child visits and influenza immunization; ≥3 asthma-related visits, asthma-relief medication, asthma-control medication, and ≥2 asthma-control medications; and emergency department visits during the child-school year.

RESULTS

We found an increase of about 19 (P = .01) to 33 (P < .001) percentage points in the probability of having ≥3 asthma-related visits per child-school year and an increase of about 22 (P = .003) to 24 (P < .001) percentage points in the receipt of asthma-relief medication, among users of the predominantly non-Hispanic Black and Hispanic SBHCs. We found a 19 (P = .01) to 29 (P < .001) percentage-point increase in receipt of asthma-control medication and a 15 (P = .03) to 30 (P < .001) percentage-point increase in receipt of ≥2 asthma-control medications among users. Increases were largest in the predominantly non-Hispanic Black SBHC.

CONCLUSION

Implementation and use of elementary SBHCs can increase case management and recommended medications among racial/ethnic minority and publicly insured children with asthma.

Behavioural, odontological and physical activity patterns of hypertense and control population

Behavioural and multifactorial factors such as odontological and physical activity habits are controlling factors in hypertension. The aim of the present study was to analyze differences in behavioral, odontological and physical activity patterns of hypertense and control population. Fifty participants with hypertension (57.5±13.6 years) and 100 participants as control group with no hypertension disease (48.9±7.9 years) were interviewed via online questionnaire. Multifactorial items in oral behavioral, health habits and physical activity profile were analyzed by a compendium of questionnaires. Result showed how control group showed significantly lower age, weight, body mass index, TV hours per day, gastritis or heartburn, dental sensibility, and sick days last year, and significantly higher level of academic education, quality of sleep and daily toothbrushing than hypertension group. In conclusion our results showed that hypertense patients presented higher levels of overweight, poor sleep quality and sedentary behaviors than control participants. In addition, hypertense patients also presented poor odontological health, showing higher indices of gastritis, dental sensibility, and sick days per year. Both groups presented a low physical activity pattern. This information allows to better understand of a multifactorial disease, as well to the creation of protocols for intervention and prevention of this disease at the behavioral level and lifestyle.

Measurement-based Data to Monitor Quality: Why Specification at the Population Level Matter?

Measurement-based care is conceptualized as a driver for quality improvement. The triple aim in the National Quality Strategy purposively muddles the population levels to provide a health policy goal that is encompassing, transactional, and will stimulate change. Specification of the population level has implications for the purpose, proposed target mechanisms that drive quality improvement, methodologic challenges, and implications for program evaluation and data interpretation. To demonstrate, population levels are conceptualized at the individual (tier 1), clinical aggregate (tier 2), and national level (tier 3).

The Influence of School-Based Health Center Access on High School Graduation: Evidence From Colorado

PURPOSE

To examine the association between the introduction of a school-based health center (SBHC) and high school graduation rates.

METHODS

We use school-level longitudinal data from Colorado that combines data on the opening of SBHCs in high schools with 4-year high school graduation rates overall and by gender between 2000 and 2018. The analytic sample consists of high schools without an SBHC in 2000 (n = 132). We compare high schools that opened SBHCs over the period to those that did not and run school-level panel fixed effects models to assess the relationship between opening an SBHC and change in high school graduation rates.

RESULTS

Schools that subsequently opened SBHCs had larger minority populations and lower average graduation rates in 2000. Opening an SBHC was associated with a 4.1 percentage point increase in the overall graduation rate (p = .077). The gender-stratified analyses indicate young men's graduation rates were most sensitive to the presence of an SBHC, increasing 4.8 percentage points (p = .051), compared to young women's graduation rates increasing 3.0 percentage points (p = .163).

CONCLUSIONS

Our findings suggest that the benefits of SBHC access may extend beyond health-specific outcomes to graduation rates.

Autonomic Profile, Physical Activity, Body Mass Index and Academic Performance of School Students

The aim of this study was to analyze the autonomic modulation, physical activity, body mass index, and academic performance of preschool and school students by grade. Extracurricular physical activity, heart rate variability, body mass index, and objective and subjective academic performance were analyzed in 180 preschool and primary school students (7.91 ± 2.29 years). Significant lower heart rate and higher parasympathetic modulation were found in 10–12-year-old primary education students. The 8–9-year-old students obtained the worst results in English and in five of the subjective academic performance items. Students aged 10–12 years old presented the highest body composition values. No significant differences were found on the extracurricular physical activity by age. No correlation between autonomic profile, physical activity, and body composition with objective academic performance was found. Nerveless subjective academic performance perception of teachers presented a negative correlation with body composition and the parasympathetic modulation. School students presented an increased body mass index and parasympathetic modulation by age. Physical activity of all students, independently of the age, were lower than the official recommendations.

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.

School-Based Health Centers and School Connectedness

BACKGROUND

Improvements in health behaviors and academic outcomes have been associated with school-based health centers (SBHCs). However, underlying mechanisms for these associations have been largely unexamined, particularly among lower-income youth. The current study examines the relationship between SBHCs and school connectedness and whether this relationship differs by youths' socioeconomic status (SES).

METHODS

Student-level cross-sectional data from 503 traditional high schools in California were analyzed using multilevel regression models. California Healthy Kids Survey 2013-2014 data included information on 3 dimensions of school connectedness and demographic characteristics including SES as measured by parental education. School-level demographic data was gathered from publicly available sources.

RESULTS

Although no significant relationship between SBHCs and any of the school connectedness dimensions emerged, there were significant cross-level interactions between SBHCs and parent education. SBHCs were more positively associated with school connectedness (adult caring, adult expectations, and meaningful participation) among lower SES students compared to students with higher SES.

CONCLUSIONS

SBHCs may be particularly effective in affecting school connectedness among lower income youth populations. This has wide ranging implications with regards to planning (eg, careful selection of where SBHCs can be most effective), and future research (eg, examining the effectiveness of specific SBHC strategies that support connectedness).

Oral health, academic performance, and school absenteeism in children and adolescents: A systematic review and meta-analysis

BACKGROUND

The authors conducted a systematic review and meta-analysis to provide a summary estimate of the association between oral health and academic performance.

TYPES OF STUDIES REVIEWED

The authors conducted a systematic search of PubMed, Embase, and Google Scholar for studies on oral health, school absence, and academic achievement published in English from January 1945 through December 2017. Exposures included subjectively or objectively measured caries, oral pain, and periodontitis. Outcomes included school absence and school achievement.

RESULTS

The authors screened a total of 2,041 studies, from which they extracted data from 14 studies of 139,989 children (12 cross-sectional studies, 1 case-control study, and 1 longitudinal study). Five studies had school absence as the primary outcome, and 7 studies had student achievement as the primary outcome. Three studies included both outcomes. The authors found no studies for periodontitis. The average modified Newcastle-Ottawa Scale score was 3.93. The authors rated 10 studies as having a low risk of bias and 4 as having a high risk of bias. Qualitative synthesis suggested that poor oral health may have negative effects on student absenteeism and achievement, but study quality was highly variable. Results from meta-analyses indicated that poor oral health was significantly associated with increased odds of poor academic performance (pooled odds ratio, 1.52; 95% confidence interval, 1.20 to 1.83) and absenteeism (pooled odds ratio, 1.43; 95% confidence interval, 1.24 to 1.63).

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Increased focus on the broader implications of improvements in oral health for children, such as educational or socioemotional development, is of further interest to practicing dentists owing to the greater connection between oral health and general health. The authors of this study found that caries or tooth pain had a negative association with academic achievement and school absenteeism. However, study quality was limited by inconsistent exposure and outcome definitions and a predominance of cross-sectional designs. Thus, causal conclusions are not supported.

Chronic Childhood Trauma, Mental Health, Academic Achievement, and School-Based Health Center Mental Health Services

BACKGROUND

Children and adolescents exposed to chronic trauma have a greater risk for mental health disorders and school failure. Children and adolescents of minority racial/ethnic groups and those living in poverty are at greater risk of exposure to trauma and less likely to have access to mental health services. School-based health centers (SBHCs) may be one strategy to decrease health disparities.

METHODS

Empirical studies between 2003 and 2013 of US pediatric populations and of US SBHCs were included if research was related to childhood trauma's effects, mental health care disparities, SBHC mental health services, or SBHC impact on academic achievement.

RESULTS

Eight studies show a significant risk of mental health disorders and poor academic achievement when exposed to childhood trauma. Seven studies found significant disparities in pediatric mental health care in the US. Nine studies reviewed SBHC mental health service access, utilization, quality, funding, and impact on school achievement.

CONCLUSION

Exposure to chronic childhood trauma negatively impacts school achievement when mediated by mental health disorders. Disparities are common in pediatric mental health care in the United States. SBHC mental health services have some showed evidence of their ability to reduce, though not eradicate, mental health care disparities.

Utilization of Mental Health Services in School-Based Health Centers

BACKGROUND

We summarize utilization patterns for mental health services in school-based health centers.

METHODS

Administrative data on school-based health center visits in New Haven, Connecticut were examined for the 2007-2009 school years. Relative frequencies of mental health visits by age were calculated as a percentage of all visits and were stratified by sex, ethnicity/race, and insurance status.

RESULTS

Mental health visits accounted for the highest proportion of visits (31.8%). The proportion of mental health visits was highest at 8 years (42.8%) and at 13 years (39.0%). The proportion of mental health visits among boys (38.4%) was higher than among girls (26.7%). Hispanic students had a lower proportion of mental health visits than black students (23.5% vs 35.8%) in all but 2 age groups. Students in the white/other ethnicity category had higher proportions of mental health visits than Hispanic and black students between ages 12 and 15. Students with no health insurance (22.5%) had lower proportions of mental health visits than students covered by Medicaid (34.3%) or private insurance (33.9%). The percentage of mental health visits by students with private insurance was highest (37.2%-49%) in the 13-15 age range.

CONCLUSIONS

Usage patterns for mental health issues show pronounced, nonrandom variation relative to age and other demographic characteristics especially with 8-year-old boys.

The Impact of Comprehensive School Nursing Services on Students' Academic Performance

Introduction: School nursing services should be evaluated through health and academic outcomes of students; however, it is observed that the number of studies in this field is limited. The aim of this study is to evaluate the impact of comprehensive school nursing services provided to 4th grade primary school students on academic performance of students.

Methods: The quasi-experimental study was conducted with 31 students attending a randomly selected school in economic disadvantaged area in Turky. Correlation analysis, repeated measures analyses of variance, multiple regression analysis were used to analyze the data with SPSS software.

Results: At the end of school nursing practices, an increase was occurred in students’ academic achievement grades whereas a decrease was occurred in absenteeism and academic procrastination behaviors. Whilst it was determined that nursing interventions including treatment/ procedure and surveillance was associated to the decrease of absenteeism, it also was discovered that the change in the health status of the student after nursing interventions was related to the increase of the academic achievement grade and the decrease of the academic procrastination behavior score.

Conclusion: In this study, the conclusion that comprehensive school nursing services contributed positively to the academic performance of students has been reached. In addition, it can be suggested that effective school nursing services should include services such as acute-chronic disease treatment, first aid, health screening, health improvement-protection, health education, guidance and counseling and case management.

A Qualitative Evaluation of Elev8 New Mexico School-Based Health Centers

There is a scarcity of qualitative studies on school-based health centers (SBHCs). We established two primary aims for this study: (a) to assess stakeholders' perceptions of Elev8 New Mexico SBHCs' functionality and (b) to provide a snapshot of the overall contribution of the program to the schools and communities they serve. We collected the data through observations and semistructured interviews. We identified issues that diminish the functionality of SBHCs, such as limited infrastructure and services, lack of cooperation between school personnel and health care providers, and lack of long-term financial sustainability. These structural, interpersonal, and logistical issues limited the contribution of the SBHCs to the health of the students and the community at large. However, Elev8 New Mexico SBHCs serve communities with considerable education and health needs and constitute a unique opportunity to provide health education, disease prevention, and quality health care to a large number of youth and adults.

Collaborative Care in Schools: Enhancing Integration and Impact in Youth Mental Health

Collaborative Care is an innovative approach to integrated mental health service delivery that focuses on reducing access barriers, improving service quality, and lowering healthcare expenditures. A large body of evidence supports the effectiveness of Collaborative Care models with adults and, increasingly, for youth. Although existing studies examining these models for youth have focused exclusively on primary care, the education sector is also an appropriate analog for the accessibility that primary care offers to adults. Collaborative Care aligns closely with the practical realities of the education sector and may represent a strategy to achieve some of the objectives of increasingly popular multi-tiered systems of supports frameworks. Unfortunately, no resources exist to guide the application of Collaborative Care models in schools. Based on the existing evidence for Collaborative Care models, the current paper (1) provides a rationale for the adaptation of Collaborative Care models to improve mental health service accessibility and effectiveness in the education sector; (2) presents a preliminary Collaborative Care model for use in schools; and (3) describes avenues for research surrounding school-based Collaborative Care, including the currently funded Accessible, Collaborative Care for Effective School-based Services (ACCESS) project.

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.

Examining the relationship between childhood health conditions and health service utilisation at school entry and subsequent academic performance in a large cohort of Australian children

AIM

Chronic health conditions are associated with poor academic outcomes. This study examines the relationship between health conditions, specialist health service utilisation and academic performance in Australian children.

METHODS

This was a quasi-longitudinal study where School Entrant Health Questionnaire (a survey tool with parent report on children's health) data for 24 678 children entering school in 2008 was matched with the 2011 National Assessment Program - Literacy and Numeracy (NAPLAN). Linear and logistic regressions were used to examine associations between health conditions, use of a specialist health service and reading and numeracy scores.

RESULTS

The study comprised 24 678 children. Children with allergies, very low birth weight, developmental delay, diabetes, spina bifida, cystic fibrosis, birth abnormality, speech problems, intellectual disability and attention-deficit/hyperactivity disorder had lower numeracy scores than those without any of these conditions (P < 0.05). The same children had higher odds (1.2-5.8) of being at or below the national minimum standard for numeracy. Children with developmental delay, epilepsy, dental problems, speech, intellectual disabilities and low birth weight had lower reading scores than those without these conditions (P < 0.05) and had higher odds of being at (odds ratio: 1.3) or below (odds ratio: 3.7) the national minimum standard for reading. Children with health conditions who had ever accessed specialist health services did not differ in their academic performance from those that had not used specialist health services.

CONCLUSIONS

Some health conditions put children at risk of poorer academic performance, and interventions to prevent this such as appropriate support services in schools should be considered.

Assessing the Impact of School-Based Health Centers on Academic Achievement and College Preparation Efforts: Using Propensity Score Matching to Assess School-Level Data in California

This study examines the association between school-based health center (SBHC) presence and school-wide measures of academic achievement and college preparation efforts. Publicly available educational and demographic data from 810 California public high schools were linked to a list of schools with an SBHC. Propensity score matching, a method to reduce bias inherent in nonrandomized control studies, was used to select comparison schools. Regression analyses, controlling for proportion of English-language learners, were conducted for each outcome including proportion of students participating in three College Board exams, graduation rates, and meeting university graduation requirements. Findings suggest that SBHC presence is positively associated with college preparation outcomes but not with academic achievement outcomes (graduation rates or meeting state graduation requirements). Future research must examine underlying mechanisms supporting this association, such as school connectedness. Additional research should explore the role that SBHC staff could have in supporting college preparation efforts.

Fostering SMART partnerships to develop an effective continuum of behavioral health services and supports in schools

The education sector offers compelling opportunities to address the shortcomings of traditional mental health delivery systems and to prevent and treat youth mental, emotional, and behavioral (MEB) problems. Recognizing that social and emotional wellness is intrinsically related to academic success, schools are moving to adopt multi-tier frameworks based on the public health model that provide a continuum of services to all children, including services to address both academic and MEB problems. In this article, we review the potential value of multi-tier frameworks in facilitating access to, and increasing the effectiveness of, mental health services in schools, and review the empirical support for school-based mental health interventions by tier. We go on to describe a community-academic partnership between the Seattle Public Schools and the University of Washington School Mental Health Assessment, Research, and Training (SMART) Center that exemplifies how multi-tier educational frameworks, research and evidence, and purposeful collaboration can combine to improve development and implementation of a range of school-based strategies focused on MEB needs of students. Finally, we present a set of 10 recommendations that may help guide other research and practice improvement efforts to address MEB problems in youth through effective school mental health programming. (PsycINFO Database Record

Measuring Success: Evaluation Designs and Approaches to Assessing the Impact of School-Based Health Centers

Since the founding of the first school-based health centers (SBHCs) >45 years ago, researchers have attempted to measure their impact on child and adolescent physical and mental health and academic outcomes. A review of the literature finds that SBHC evaluation studies have been diverse, encompassing different outcomes and varying target populations, study periods, methodological designs, and scales. A complex picture emerges of the impact of SBHCs on health outcomes, which may be a function of the specific health outcomes examined, the health needs of specific communities and schools, the characteristics of the individuals assessed, and/or the specific constellation of SBHC services. SBHC evaluations face numerous challenges that affect the interpretation of evaluation findings, including maturation, self-selection, low statistical power, and displacement effects. Using novel approaches such as implementing a multipronged approach to maximize participation, entering-class proxy-baseline design, propensity score methods, data set linkage, and multisite collaboration may mitigate documented challenges in SBHC evaluation.

Understanding the relationship between school-based health center use, school connection, and academic performance

School-based health centers (SBHCs) benefit the overall health of underserved communities. In fact, there is an abundance of evidence suggesting the positive effects that SBHCs have on physical and mental health. However, research related to understanding the relationship of SBHCs to academic outcomes such as performance and school connectedness is sparse. The purpose of the current study was to (a) compare differences between elementary, middle, and high school student SBHC users and nonusers on school connectedness and (b) test the pathways between SBHC usage and academic performance. A structural equation model was tested and found significant pathways between SBHCs, school connectedness, and academic performance.

The relationship between use of school-based health centers and student-reported school assets

PURPOSE

To examine the relationship between student-reported, school-based health center utilization and two outcomes: (1) caring relationships with program staff; and (2) school assets (presence of caring adults, high behavioral expectations, and opportunities for meaningful participation) using a school district-wide student survey. These relationships were also explored across schools.

METHODS

Using student-reported data from a customized version of the California Healthy Kids Survey from the San Francisco Unified School District (n = 7,314 students in 15 schools), propensity scoring methods were used to adjust for potential bias in the observed relationship between student utilization of services and outcomes of interest.

RESULTS

Estimates generally pointed to positive relationships between service utilization and outcome domains, particularly among students using services ≥10 times. Exploratory analyses indicate that these relationships differ across schools.

CONCLUSIONS

Use of school-based health centers appears to positively relate to student-reported caring relationships with health center staff and school assets. Future research is needed to confirm the robustness of these observed relationships.

School-based health centers in an era of health care reform: building on history

School-based health centers (SBHCs) provide a variety of health care services to youth in a convenient and accessible environment. Over the past 40 years, the growth of SBHCs evolved from various public health needs to the development of a specific collaborative model of care that is sensitive to the unique needs of children and youth, as well as to vulnerable populations facing significant barriers to access. The SBHC model of health care comprises of on-school site health care delivery by an interdisciplinary team of health professionals, which can include primary care and mental health clinicians. Research has demonstrated the SBHCs' impacts on delivering preventive care, such as immunizations; managing chronic illnesses, such as asthma, obesity, and mental health conditions; providing reproductive health services for adolescents; and even improving youths' academic performance. Although evaluation of the SBHC model of care has been complicated, results have thus far demonstrated increased access to care, improved health and education outcomes, and high levels of satisfaction. Despite their proven success, SBHCs have consistently faced challenges in securing adequate funding for operations and developing effective financial systems for billing and reimbursement. Implementation of health care reform (The Patient Protection and Affordable Care Act [P.L. 111-148]) will profoundly affect the health care access and outcomes of children and youth, particularly vulnerable populations. The inclusion of funding for SBHCs in this legislation is momentous, as there continues to be increased demand and limited funding for affordable services. To better understand how this model of care has and could further help promote the health of our nation's youth, a review is presented of the history and growth of SBHCs and the literature demonstrating their impacts. It may not be feasible for SBHCs to be established in every school campus in the country. However, the lessons learned from the synergy of the health and school settings have major implications for the delivery of care for all providers concerned with improving the health and well-being of children and adolescents.

The moderating effect of school type on the relationship between school-based health centers and the learning environment

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 study utilizes a quasi experimental study to investigate the moderating effects of school type on the relationship between school based health centers and the learning environment. Findings indicate that SBHCs in middle and elementary schools are associated with greater levels of school engagement and satisfaction with the learning environment than those in high schools.

The role of school nurses in delivering accessible health services for primary and secondary school students in Hong Kong

AIMS

To explore and describe the distinctive role of nurses in delivering school health services for primary and secondary school students in Hong Kong.

BACKGROUND

The practical responsibility of nurses in delivering school health services has not been established. There is no literature on this topic and, in particular, nothing has been written from the perspective of the practitioner in communities in Hong Kong.

DESIGN

A qualitative design using semi-structured interviews was employed.

METHODS

Thirteen school nurses were recruited and interviewed in 2006. The narratives were analysed using content analysis steps to identify categories.

RESULTS

Seven categories were formulated. School nurses described their roles as providers, counsellors, leaders, promoters, collaborators, referrers and administrators and housekeepers. The school nurses also reported that they needed to maintain a diverse range of skills and knowledge, such as effective communication skills and clinical updated knowledge, to cope with the demands and the diversity of their roles and to support the health and educational needs of the students and their local communities.

CONCLUSION

The future development of the 'one school, one nurse' policy envisaged by the current government for ordinary schools in Hong Kong will not occur unless the role of school nurses is clearly delineated and valued by society as reducing school children's and adolescents' risk-taking behaviours and promoting the health and well-being of school children and adolescents.

RELEVANCE TO CLINICAL PRACTICE

The findings provide relevant information for school nurse leaders and school nurse policy makers to understand how school nurses are practicing and promoting child and adolescent health services, which can inform regional and national policy and practice.

Is tobacco use associated with academic failure among government school students in urban India?

BACKGROUND

Not much is known about the academic correlates of tobacco use among students in developing countries. This study investigated associations between multiple forms of tobacco use, psychosocial risk factors, and academic failure among 10- to 16-year-old government school students in Delhi and Chennai, India.

METHODS

This study was a secondary analysis of data gathered from students in 7 government schools during a larger tobacco intervention trial in India. Mixed-effects regression analyses were carried out on a cross-sectional sample of 3799 students and a retrospective cohort of 2586 students. Data on tobacco use and risk factors were collected from self-reported student surveys in 2006 and 2004. Using school records, academic failure was defined as repeating the same grade level once or twice between 2004 and 2006.

RESULTS

In 2006, academic failure was significantly more prevalent among students who reported use of chewing tobacco, bidis, or cigarettes, as compared with nonusers. Students with academic failure had greater social susceptibility and intentions for future tobacco use, and poor knowledge and self-efficacy for avoiding tobacco. Cohort analyses showed that students who had reported tobacco use in 2004 were more likely to have academic failure by 2006, as compared with nonusers.

CONCLUSIONS

School health programs that incorporate tobacco control measures should be offered to government school students with poor academic outcomes in India, along with remedial education efforts. School-based longitudinal research is needed to assess effects of tobacco use in early adolescence on academic, social, and behavioral outcomes in later adolescence and young adulthood.

Position of the American Dietetic Association, School Nutrition Association, and Society for Nutrition Education: comprehensive school nutrition services

It is the position of the American Dietetic Association (ADA), School Nutrition Association (SNA), and Society for Nutrition Education (SNE) that comprehensive, integrated nutrition services in schools, kindergarten through grade 12, are an essential component of coordinated school health programs and will improve the nutritional status, health, and academic performance of our nation's children. Local school wellness policies may strengthen comprehensive nutrition services by encouraging multidisciplinary wellness teams, composed of school and community members, to work together in identifying local school needs, developing feasible strategies to address priority areas, and integrating comprehensive nutrition services with a coordinated school health program. This joint position paper affirms schools as an important partner in health promotion. To maximize the impact of school wellness policies on strengthening comprehensive, integrated nutrition services in schools nationwide, ADA, SNA, and SNE recommend specific strategies in the following key areas: nutrition education and promotion, food and nutrition programs available on the school campus, school-home-community partnerships, and nutrition-related health services.

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.

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.

A work sampling study of provider activities in school-based health centers

BACKGROUND

The purpose of this study was to describe provider activities in a convenience sample of School-Based Health Centers (SBHCs). The goal was to determine the relative proportion of time that clinic staff engaged in various patient care and non-patient care activities.

METHODS

All provider staff at 4 urban SBHCs participated in this study; 2 were in elementary schools, 1 in a middle school, and 1 in a school with kindergarten through grade 8. The study examined provider activity from 6 days sampled at random from the school year. Participants were asked to document their activities in 15-minute intervals from 8:00 a.m. to 5:00 p.m. A structured recording form was used that included 35 activity categories.

RESULTS

Overall, 1492 records were completed, accounting for 2708 coded activities. Almost half (48%) of all staff activities were coded as direct patient contact, with clinic operations the second largest category. Limited variations in activities were found across clinic sites and according to season.

CONCLUSIONS

A significant amount of provider activity was directed at the delivery of health care; direct patient care and clinic operations combined accounted for approximately 75% of clinic activity. Patient, classroom, and group education activities, as well as contacts with parents and school staff accounted for 20% of all clinic activity and represent important SBHC functions that other productivity measures such as billing data might not consistently track. Overall, the method was acceptable to professional staff as a means of tracking activity and was adaptable to meet their needs.

Integrating a school-based health intervention in times of high-stakes testing: lessons learned from full court press

Because of the growing focus on the production of favorable academic standardized test scores, schools have become increasingly resistant to sponsoring nonacademic programming, such as tobacco cessation services for students. Nevertheless, the need for such programs has not diminished. The purpose of this article is to provide descriptive information about the logistics of establishing and delivering a health intervention in schools that are resistant to nonacademic programming. The data were collected as part of a qualitative retrospective process evaluation of Full Court Press, a 5-year youth tobacco demonstration project funded by the Robert Woods Johnson Foundation and implemented in Tucson, Arizona. Lessons learned about recruiting schools, integrating programs, and managing facilitators are presented.

Making the case for school-based health: where do we stand?

School-based health centers (SBHCs) have proliferated rapidly nation-wide and remain politically popular. This article explores the disconnect between the evidence and the discourse on SBHCs, drawing upon the authors' evaluation of SBHCs in Newark, New Jersey, and a critical assessment of the evaluative literature and public discourse on school clinics to argue that a number of important issues are being overlooked by both research and advocacy. These issues include variations in the health needs and health care resources of different communities and the questions of whether and how SBHCs can best integrate with existing resources to fill unmet local needs. Furthermore, despite the cautions of experts that third-party reimbursement (via traditional fee-for-service insurance or participation in health maintenance organizations) cannot cover clinic expenses and is difficult to obtain, pursuit of reimbursement continues to be a goal of some SBHC sponsors, helping to promote a clinic model that in some communities is very likely not to be the best way to address student needs or to build on clinic strengths. Discussion around SBHCs should focus on diagnosing specific community needs, identifying the best approach to meeting those needs, and seeking funding sources that match the work that needs to be done.

From Risk to Resilience: Promoting School–Health Partnerships for Children

Across the globe, educational and health practitioners wrestle daily with the paradoxes of risk and resilience. Though the causes of risk are generally outside the control of professionals, manifestations of disadvantage directly affect service delivery and the realizing of accountability benchmarks. This article proposes a shift in attention from risk to resilience as being empowering and proactive for students and those vested in maximizing their potential. Given that resilience has been deemed an ecological phenomenon, the ecology of human development framework posited by Uri Bronfenbrenner (1979) was applied to advance the rationale for resiliency partnerships between schools and school-based health clinics.

Building bridges between school-based health clinics and schools

BACKGROUND

The 2 institutions that hold great promise in mitigating the negative cyclical relationship between poor health and educational readiness are schools and school-based health care facilities (SBHCs). In partnership with schools, SBHCs could have a profound effect on learning outcomes, which include, but are not limited to, poor concentration in school, attendance, and disturbances of normal sequential development. This article provides an overview of the role of federal, state, and local governmental agencies in the development and implementation of public educational policy and funding in an effort to provide SBHCs the foundation for building a bridge between the health and the educational lexicon.

METHODS

This article reviews literature from a wide variety of sources to develop a better understanding of the complexities associated with public K-12 education and provides suggestions for initiating meaningful interactions between SBHC supporters and educational decision makers.

RESULTS

Strategic reasoning between supporters of SBHCs and educational policy makers is critical because of the limitations of time and money for those delivering educational services. Additional projects (eg, SBHCs) no matter how well conceived will be difficult to promote unless officials can be convinced that collaboration in school-based health care actually enhances compliance with the No Child Left Behind Act.

CONCLUSIONS

Though SBHCs and schools are both committed to enhancing the lives of children, these institutions speak different languages and are accountable to very different types of public and private bodies.