School-Based Health Centers and School Connectedness

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.

Inequitable Changes in School Connectedness During the Ongoing COVID-19 Pandemic in a Cohort of Canadian Adolescents

BACKGROUND

We examined whether subgroups of adolescents experienced disparate changes in school connectedness-a robust predictor of multiple health outcomes-from before the COVID-19 pandemic to the first full school year following pandemic onset.

METHODS

We used 2 waves of prospective survey data from 7178 students attending 41 Canadian secondary schools that participated during the 2019-2020 (T1; pre-COVID-19 onset) and 2020-2021 (T2; ongoing pandemic) school years. Fixed effects analyses tested differences in school connectedness changes by gender, race, bullying victimization, socioeconomic position, and school learning mode.

RESULTS

Relatively greater declines in school connectedness were reported by students that identified as females, were bullied, perceived their family to be less financially comfortable than their classmates, and attended schools in lower income areas. Marginally greater school connectedness declines resulted among students attending schools that were fully online at T2 than those at schools using a blended model.

CONCLUSION

Results point to disparate school connectedness declines during the pandemic, which may exacerbate pre-existing health inequities by gender and socioeconomic position, and among bullied youth.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

Effective strategies to improve school climates for equity denied groups are critical for pandemic recovery and preparedness for future related events.

Chronic Health Condition Management and School-Based Health Centers in New York: Findings From the 2020 School Health Profiles Survey

School-based health centers (SBHCs) are associated with numerous positive aspects of student health services. Many schools in the United States (US) do not have transparent policies on chronic health condition (CHC) management. Of particular concern is the underreporting of the delivery of health services in U.S. schools concerning CHC management and its relationship with the presence or absence of a SBHC. Data from the 2020 School Health Profiles (SHP) Survey were examined in New York public secondary schools. Specific health services were reviewed, together with the presence or absence of a SBHC, including daily medication administration, stock rescue medication, case management services, community partners, chronic disease-specific education, and assurance that students with CHCs were enrolled in an insurance program. A significantly greater proportion of schools with a SBHC compared with schools without a SBHC provided: (1) daily medication administration (92.9% vs. 86.5%; p < .001), (2) stock or rescue medication (84.9% vs. 77.4%; p < .001), (3) case management services (83.1% vs. 67.2%; p < .001), (4) disease-specific education for families (63.1% vs. 57.2%; p = .022), (5) student and family connection to community health services (84.2% vs. 76.5%; p < .001), and (6) ensured that a protocol existed whereby students with a CHC were enrolled in an insurance plan if eligible (79.6% vs. 66.8%; p < .001). Findings suggest that data on a national scale include essential facts for states to consider concerning school health policies and practices. Additional research should examine the intricacy of elements connected with school-based health care to understand better the care provided to children with CHCs.

Mixed-methods Exploration of Telehealth-supported Long-acting Reversible Contraceptive Services in School-based Health Centers: How Much Added Value?

INTRODUCTION

This study explored adolescent and young adult preferences and experiences with telehealth-supported long-acting reversible contraceptive (LARC) services in New York City school-based health centers (SBHCs) during COVID-19.

METHOD

Sequential mixed methods included post-LARC insertion surveys and in-depth interviews.

RESULTS

Survey respondents (n = 45) were aged 14-21 years and predominantly Hispanic (53.3%). Only four respondents completed a postinsertion visit via telehealth. Most (82.2%) preferred in-person for future LARC visits; none preferred telehealth. Four themes emerged in interviews (n = 15): LARC self-efficacy and autonomy; SBHC convenience and accessibility; comfort with SBHC providers; and preference for in-person visits despite telehealth benefits.

DISCUSSION

Although telehealth theoretically adds value to LARC service delivery, uptake and preference for telehealth in the SBHC context were low. Despite the perceived acceptability of telehealth, adolescents and young adults prefer in-person SBHC visits, suggesting SBHC access may eliminate barriers to care that telehealth seeks to overcome.

Rates, Patterns, and Predictors of Follow-up Care for Adolescents at Risk for Substance Use Disorder in a School-Based Health Center SBIRT Program

PURPOSE

To examine rates, patterns, and predictors of follow-up care for adolescents screened as being at risk for substance use disorder (SUD) in a school-based health center (SBHC) Screening, Brief Intervention and Referral to Treatment (SBIRT) program.

METHODS

Electronic health records were extracted of adolescents who received health care services from one of three high school-based health centers implementing SBIRT. Patterns and predictors of engagement in follow-up care within 8 weeks following the week of a positive SUD risk screen were analyzed using item response theory (IRT) modeling.

RESULTS

Out of 1,327 adolescents receiving SBHC services, 81.2% completed a health screening questionnaire. Of screened adolescents, 17.7% were positive for SUD risk. Across the 8-week follow-up period, 65.4% of adolescents at risk for SUD received at least one follow-up visit. IRT modeling indicated that high levels of engagement in follow-up care were characterized by contact with a behavioral health care (BHC) provider. The percentage of adolescents having follow-up contact with a BHC provider increased significantly after the onset of the COVID-19 pandemic. Engagement in follow-up care was predicted by risk for depression, history of suicidal behavior, being female, and previous sexual activity.

DISCUSSION

SBHCs provide a favorable setting for screening and detecting adolescents at risk for SUD. Adolescents at risk for SUD should receive follow-up contact with a BHC provider. Enhanced follow-up engagement efforts may be warranted for adolescents at risk for SUD without risk for depression or suicidal history, as well as for females and those with previous sexual activity.

Effectively Supporting Youth with Chronic Illness in Schools: External Partnerships and Training Recommendations

Across Western countries, approximately 15% to 20% of school-aged children and adolescents have a health-related disorder, with incidence rates of childhood chronic health conditions (CHCs) increasing. This contribution comprehensively reviews disease-level, school-level, and systems-level issues related to effectively supporting children with CHCs succeed from both psychosocial and educational perspectives. This article also delineates training needs as they pertain to graduate preparation and/or professional development to equip school personnel to appropriately address students' needs. The article concludes with recommendations for evidence-based prevention and intervention strategies and potential avenues for interdisciplinary collaboration and models of coordinated care for these medically compromised youth.

Depression and sleep disorders among AIDS orphans in an HIV/AIDS high-epidemic area in China

BACKGROUND

The Liangshan Yi Autonomous Prefecture is home to the largest population of Yi ethnic minority within mainland China. Due to the high HIV/AIDS epidemic, many Yi children become AIDS orphans who lost one or both parents to AIDS-related causes. This study explored the prevalence and correlates of AIDS orphans' depressive symptom, sleep disorders and their comorbidity.

METHODS

A cross-sectional survey was conducted to collect pertinent information from 467 AIDS orphans and 856 non-orphans of Yi ethnic minority. Depressive symptoms were screened by a two-item Patient Health Questionnaire (PHQ-2). The symptoms of insomnia were assessed by the Insomnia Severity Index (ISI), which was complemented by one item from the Pittsburgh Quality Sleep Index (PSQI) to measure the frequency of nightmare.

RESULTS

The prevalence of depression (26.8% vs. 20.4%, P = 0.009) and comorbidity of depression, insomnia and nightmare (7.5% vs. 4.3%, P = 0.046) was significantly higher for AIDS orphans than for non-orphans. Risk factors such as ostracization and self-reported poor physical health had stronger effects on depressive symptoms and sleep disorders for AIDS orphans than for non-orphans. On the other hand, peer support, as an important protective factor, was significantly and negatively associated with depressive symptoms and sleep disorders for AIDS orphans.

CONCLUSIONS

AIDS orphans of Yi ethnic minority reported higher levels of depressive symptoms and comorbidity of depression and sleep disorders than their non-orphan counterparts. These symptoms were exacerbated by ostracization and self-rated poor physical health but lowered by peer support.

Adolescent Connectedness: A Scoping Review of Available Measures and Their Psychometric Properties

Introduction

Adolescent connectedness, a key component of positive youth development, is associated with various positive health outcomes. Several measures have been developed to assess this construct. However, no study has summarized data on the existing measures of adolescent connectedness. We conducted this scoping review to fill this gap. We specifically aimed to: (i) identify the existing measures of adolescent connectedness, (ii) determine the most frequently used measures among the identified measures, and (iii) summarize the psychometric properties of these measures with a keen interest in highlighting their cross-cultural utility and validity.

Methods

We searched CINAHL, Embase, PsycInfo, PubMed, and Web of Science databases for relevant articles published since database inception to 7th February 2021. Our search structure contained the key words "Adolescents", "Connectedness", and "Measures". We also searched Open Gray for potentially relevant gray literature.

Results

We identified 335 measures from 960 eligible studies assessing various domains of adolescent connectedness, including school, family, community, peer, ethnic, racial, cultural, religious/spiritual, and self-connectedness. Most of the included studies (72.1%) were from North America and Europe. Most of the measures (n = 132, 39.4%) were measures of school connectedness among adolescents. Of the identified measures, 60 of them met our criteria of frequently used measures (i.e., the top five most used measures per domain of connectedness). These frequently used measures were used across 481 of the included studies with 400 of them reporting their psychometric properties. The reported reliability of these measures was adequate (Cronbach's alpha ≥ 0.70) in 89.8% of these studies. These measures also appeared to be valid in terms of their face, content, construct, criterion, convergent, discriminant, concurrent, predictive, measurement invariance, and cross-cultural validity.

Conclusions

There exists a wide array of measures of adolescent connectedness. Sixty of these measures have been frequently used across studies and appear to be reliable and/or valid. However, this evidence is mostly from North America and Europe. This is a reflection of the limitation of this review where only studies published in English were considered. It might also reflect the paucity of research in other regions of the world. More research is needed for clearer insights.

Subjective well-being among AIDS orphans in southwest China: the role of school connectedness, peer support, and resilience

BACKGROUND

Few studies have explored the health and development of AIDS orphans using the positive youth development (PYD) framework. Grounded in this framework, the main objective of this study is to examine how internal assets (i.e., resilience) and external assets (i.e., school connectedness, peer support) affect subjective well-being among Yi AIDS orphans in the Liangshan Yi Autonomous Prefecture, Sichuan province, China.

METHODS

A cross-sectional survey was conducted by interviewing 571 AIDS orphans and 979 non-orphans of Yi ethnic minority from 5th-10th grades. Structural equation models (SEM) were utilized to identify and estimate the direct and indirect effects of internal and external assets on subjective well-being.

RESULTS

The average score of subjective well-being was significantly lower for AIDS orphans than for in non-orphans (P < 0.05). Resilience, school connectedness, peer support (number of friends, caring friends), and self-rated physical health had significant and positive direct effects on subjective well-being. In addition, the effects of school connectedness, and peer support on subjective well-being were mediated by resilience.

CONCLUSIONS

Positive individual and school-related contextual assets can bolster subjective well-being among AIDS orphans. The design of health intervention programs for AIDS orphans should incorporate these positive development assets.

Implementation of Telehealth Services in Rural Schools: A Qualitative Assessment

BACKGROUND

In rural areas with health professional workforce shortages, telehealth offers an opportunity to address service gaps and meet the health needs of students. Few studies have examined telehealth implementation in rural schools. This study explores facilitators and barriers to the implementation of telehealth programs in rural schools and identifies strategies for successful implementation to inform future school-based telehealth initiatives.

METHODS

We conducted semi-structured qualitative interviews with 50 key informants involved in the implementation of telehealth programs funded through the School-Based Telehealth Network Grant Program. Researchers completed a thematic analysis of interview transcripts.

RESULTS

The most commonly cited barriers were technology, reimbursement for services, and facilitating acceptance of the telehealth among school staff, clinicians, parents, and students. Key informants identified strategies for facilitating program implementation, including technology training and support, marketing efforts, and integration into existing school processes.

CONCLUSIONS

School-based telehealth can augment clinical capacity in areas with clinician shortages. Entities interested in such an approach to care must engage with their school community to ensure successful implementation. For rural, school-based telehealth to gain greater adoption and be sustained, these services must be reimbursable by Medicaid and private insurers.

The Role of School Connectedness in Supporting the Health and Well-Being of Youth: Recommendations for School Nurses

The importance of students feeling connected in school cannot be overstated, as this perception is crucial to support their health and well-being. A lack of school connectedness can lead to adverse physical and mental health outcomes, including bully victimization. Numerous factors, including individual, social, and environmental, influence students' perceived sense of school connectedness. School nurses are well positioned to establish and maintain school connectedness due to their knowledge, accessibility to students, and familiarity with the school environment. This article details the importance of school connectedness and describes the associations between school connectedness, bullying, and mental health. In addition, we offer recommendations geared toward school nurses regarding strengthening school connectedness and promoting a culture of care and inclusivity within school environments, especially salient in the context of the COVID-19 pandemic.

Contextualizing the Association Between School Climate and Student Well-Being: The Moderating Role of Rurality

BACKGROUND

In rural communities, understanding and improving school climate may benefit youth facing unique contextual challenges to well-being. As education research rarely focuses on rural schools, we aimed to examine school climate and student well-being with a particular focus on rural schools, compared to suburban schools.

METHODS

Cross-sectional survey data were collected from 62,265 students in 22 rural and 78 suburban Maryland middle and high schools. Student self-report data were collected on school climate (safety, engagement, and environment) as well as internalizing problems, behavior problems, stress, substance abuse, and future orientation. Multiple-group, multilevel models were fit to compare between rural and suburban schools.

RESULTS

On average, rural students reported significantly lower perceptions of safety and engagement than suburban students. Safety and engagement were generally associated with higher youth well-being. A number of moderated effects were observed, which generally suggested stronger associations between school-level climate-particularly engagement-and more positive outcomes for rural compared to suburban students.

CONCLUSIONS

Students' perceptions of safety and engagement were associated with student well-being, in some cases with stronger associations for rural students. These findings suggest that efforts to improve school climate may be particularly impactful for rural students.

Intersectional Differences in Protective School Assets by Sexuality, Gender, Race/Ethnicity, and Socioeconomic Status

BACKGROUND

School assets-such as connectedness, caring relationships with adults, high behavioral expectations from adults, and meaningful participation-are associated with positive outcomes for adolescents. However, little is known about how school assets differ among adolescents with intersecting marginalized identities.

METHODS

We used the 2013-2014 California Healthy Kids Survey (N = 320,462 students) to examine differences in school assets with respect to sexuality, gender, race/ethnicity, and socioeconomic status using adjusted multilevel linear regression models.

RESULTS

Sexual minority, gender minority, racial/ethnic minority, and low socioeconomic status adolescents had significantly lower protective school assets. For all outcomes, the differences between sexual minority and heterosexual adolescents were more pronounced among nontransgender girls than nontransgender boys; however, these differences were not consistently present among racial/ethnic minority students. For school connectedness and meaningful participation, differences for racial/ethnic minorities versus white adolescents were more pronounced among nontransgender girls than nontransgender boys. Differences between transgender adolescents and nontransgender boys were more pronounced for white adolescents compared to some other racial/ethnic minority students. Overall, adolescents with certain multiple marginalized identities had lower school assets.

CONCLUSIONS

Interventions are needed to strengthen school assets among marginalized students, thereby helping mitigate health and education inequities.

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.

Mental Health and Psychosocial Risk and Protective Factors Among Black and Latinx Transgender Youth Compared With Peers

IMPORTANCE

Black and Latinx transgender youth experience stigma that may increase their susceptibility to mental health symptoms.

OBJECTIVE

To compare past-year mental health symptoms and psychosocial factors among Black and Latinx transgender youth, White transgender youth, and Black and Latinx cisgender youth.

DESIGN, SETTING, AND PARTICIPANTS

This survey study used data from the 2015-2017 Biennial California Healthy Kids Survey with a weighted sample (N = 45 269) representative of California's secondary school population. The analytic sample (n = 19 780) included Black and Latinx transgender youth, White transgender youth, and Black and Latinx cisgender youth in the 9th and 11th grades. Data analysis was conducted from July 2020 to February 2021.

MAIN OUTCOMES AND MEASURES

Outcomes include past-year depressive symptoms and suicidality. Psychosocial risk factors include school-based victimization, gender-based harassment, sexuality-based harassment, and race-based harassment; protective factors include school connectedness and caring adult relationships.

RESULTS

The analytic sample of 19 780 participants (in 9th grade: weighted percentage, 51% [95% CI, 50% to 52%]; female participants: weighted percentage, 50% [95% CI, 49% to 51%]) included 252 Black and Latinx transgender youth (weighted percentage, 1.3% [95% CI, 1.1% to 1.5%]), 104 White transgender youth (weighted percentage, 0.7% [95% CI, 0.6% to 0.8%]), and 19 424 Black and Latinx cisgender youth (weighted percentage, 98.0% [95% CI, 97.8% to 98.2%]). For Black and Latinx transgender youth, estimated prevalence of depressive symptoms and suicidality were 50% (95% CI, 44% to 57%) and 46% (95% CI, 39% to 52%), respectively. Logistic regression models adjusted for grade, living arrangement, and reported sex indicated that compared with White transgender youth, Black and Latinx transgender youth had similar odds of depressive symptoms (adjusted odds ratio, 0.6; 95% CI, 0.4 to 1.1) and suicidality (adjusted odds ratio, 1.1; 95% CI, 0.6 to 1.8) and similar odds of all forms of harassment (eg, race-based harassment: adjusted odds ratio, 1.5; 95% CI, 0.8 to 2.6). Regression models indicated that compared with White transgender youth, Black and Latinx transgender youth had similar levels of victimization (adjusted linear regression coefficient, 0.5; 95% CI, -0.3 to 1.3) and caring adult relationships (adjusted linear regression coefficient, -0.6; 95% CI, -1.4 to 0.09) but lower levels of school connectedness (adjusted linear regression coefficient, -1.6; 95% CI, -2.9 to -0.4). With similar analyses, compared with Black and Latinx cisgender youth, Black and Latinx transgender youth had higher odds of depressive symptoms (adjusted odds ratio, 2.7; 95% CI, 2.0 to 3.7) and suicidality (adjusted odds ratio, 5.9; 95% CI, 4.3 to 8.0), higher odds and levels of all forms of harassment and victimization (eg, race-based harassment: adjusted odds ratio, 3.2; 95% CI, 2.4 to 4.5), and lower levels of school connectedness (adjusted linear regression coefficient, -2.6; 95% CI -3.3 to -1.8) and caring adult relationships (adjusted linear regression coefficient, -0.9; 95% CI -1.3 to -0.5).

CONCLUSIONS AND RELEVANCE

In this study, Black and Latinx transgender youth had high rates of mental health symptoms, with rates comparable with White transgender youth but higher than Black and Latinx cisgender youth. Their unique pattern of psychosocial risk and protective factors for these mental health symptoms should be factored in clinical preventive services and school-based interventions to support them.

Sex-Related Differences in Adolescent Cannabis Use: Influences of School Context and School Connectedness

BACKGROUND

Boys use cannabis at a younger age and more frequently than girls. It has been suggested these sex differences might vary according to students' relationship to school. We explored whether the association between sex and adolescents' cannabis use varies among schools and according to students' school connectedness.

METHODS

The study population consisted of all students from 11 secondary schools in the greater Québec City area. The sample included 6185 respondents in years 1 to 5 at the secondary level (equivalent to grades 7-11). Study outcomes were monthly cannabis use and early cannabis use.

RESULTS

The association between sex and monthly cannabis use varied significantly among schools after controlling for students' main characteristics and school socioeconomic environment. We found a statistically significant modifying effect of school connectedness on the association between sex and monthly cannabis use. For early cannabis use, we found no modifying effect of school connectedness nor any association with sex.

CONCLUSIONS

Measures to reduce adolescents' cannabis use could be better adapted to local context and more tailored to specific higher-risk groups. School connectedness is a protective factor for cannabis use, although this effect appears stronger for girls than boys.

An examination of classes of school climate perceptions among Latinx middle school students

Several studies have replicated the finding that Latinx students tend to have less favorable perceptions of school climate than their White peers. However, because most research compares Latinx students to a White standard, little is known about variation within the Latinx group and thus the opportunity to produce strength-defining counter-narratives has been missed. Using latent class analysis, this study identified meaningful classes of school climate perceptions within 20,050 Grade 7 Latinx students in California. Five climate classes were identified, lending support to the hypothesis that substantial heterogeneity of school climate perceptions exists within the Latinx student population. The results support the utility of latent class modeling for examining school climate perceptions beyond traditional variable-centered approaches. Countering the prevailing deficit narrative, the results indicate that nearly half of all Latinx respondents reported generally positive perceptions of school climate. Conversely, supporting the need for environmental supports that encourage Latinx students to voice their concerns and make decisions regarding systems that affect them, over three-quarters of the responses suggested that Latinx students perceive meaningful participation at school negatively. The results suggest the possibility of a cascade effect in the development of the psychological experience of the school, such that some dimensions of school climate perceptions may be antecedents to others. Implications for further research and intervention are discussed.

Sexual Orientation-Based Depression and Suicidality Health Disparities: The Protective Role of School-Based Health Centers

This study's purpose was to examine whether school-based health centers (SBHCs) support mental health indicators among sexual minority youth (SMY). Data came from the 2015 Oregon Healthy Teens Survey with 13,608 11th graders in 137 public high schools in Oregon. Regression results revealed significant SBHC by SMY status interactions indicating relative reductions in likelihood of depressive episodes (30%), suicidal ideation (34%), and suicide attempts (43%) among SMY in schools with SBHCs. SMY students in SBHC schools reported lower likelihood of a past-year depressive episode, suicidal ideation, and suicide attempt versus those attending non-SBHC schools. Conversely, no differences in these outcomes were observed for non-SMY by SBHC status. SBHCs may help reduce mental health disparities among SMY, a marginalized, underserved population.

The Evidence on School-Based Health Centers: A Review

Context. Pediatricians working toward health equity require health care delivery mechanisms that take on dual roles: mitigating the health effects of a maladaptive social ecosystem while simultaneously working to improve the ecosystem itself. School-based health centers (SBHCs) perform these dual roles by providing medical, mental/behavioral, dental, and vision care directly in schools where young people spend the majority of their time, maximizing their opportunity to learn and grow. Evidence Acquisition. Databases were searched extensively for research studies published between January 2000 and December 2018. Evidence Synthesis. The authors began with 3 recent high-impact reviews that covered SBHC history, health outcomes, cost-benefit, and impact on health equity. Informed by these articles, the authors organized the evidence into 4 broad categories of impact: Financial, Physical Health (including medical, vision, and dental), Mental Health, and Educational Outcomes. Using these 4 categories, the authors then performed a robust literature search using PubMed for studies that fit into these themes. Conclusions. SBHCs increase access to health services for children, families, and communities, which ultimately leads to positive short- and long-term outcomes in service of a broad range of stakeholders. Educational impact requires further attention on both outcomes and methodological approaches. Three current public health topics of importance were identified that SBHCs might be well-suited to address: Youth Gun Violence, Adverse Childhood Experiences, and the Health of American Indian/Alaskan Native communities in the United States.