Risk and Resilience Factors Associated With Frequency of School-Based Health Center Use
Original scientific journal article written by Samira Soleimanpour, Sara Geierstanger, Ruby Lucas, Sandy Ng, and Ignacio Ferrey. Published in the Journal of School Health.
The purpose of the study was: (1) to examine the risk and resilience factors associated with high-frequency SBHC use, and (2) to determine whether there were differences in reported health outcomes, including receipt of needed medical, mental health, and reproductive health care, among high-frequency SBHC users and non-users. This research can help to elucidate the role of SBHCs in adolescent health care and to possibly inform discussions about how to target services to invest in adolescent health care that may reduce long-term health care costs and disparities.
In order to do so, participants included a convenience sample of 9th and 11th grade students attending 12 public middle and high schools with SBHCs in 3 school districts in one California county during the 2018-2019 school year. The majority of students in these schools were eligible for free and reduced priced lunch (69% on average; range of 21 to 94% per school) and identified as Latino (45%), African American (18%), or Asian (22%).22 A total of 3855 youth in the target schools and grades completed the 2018-2019 California Healthy Kids Survey (CHKS), a statewide cross-sectional youth health risk and behavioral assessment questionnaire. Students were excluded from the study sample if they did not answer questions about whether they used the SBHC or if they gave conflicting answers to whether they used the SBHC and what services they received (n = 1214). The final study sample included 2641 students (69% of the original survey respondents).
Teachers sent consent forms home with students prior to the CHKS administration. CHKS is a cross- sectional survey that is administered in California’s schools.The CHKS was administered to secondary students in the 9th and 11th grades in the study schools. Passive parental consent was required for secondary students to participate, which allowed parents/guardians to inform the school only if they wanted to opt their children out of participation. Teachers administered the CHKS during 1 class period either online or on paper and were provided a script to read prior to survey administration that explained the survey’s purpose. Students could stop taking the survey at any time or skip questions they preferred not answer.
‘High-frequency SBHC users’’ were defined as students who indicated that they had ever used their school’s SBHC ‘‘ten times or more.’’ Non-users were defined as those who had never used the SBHC and ‘‘low-frequency users’’ were those who indicated they had ever used the SBHC either ‘‘1-2 times’’ or ‘‘3-9 times.’’
There were no statistically significant differences in gender or living situation of SBHC high-frequency users and non-users. However, high- frequency users were more likely to be in 11th grade (p<.0001); identify as African American and Latino race/ethnicities (p < .0001); and to report that their parent/guardians did not finish high school (p < .0001) than non-users. Low-frequency users and non-users were more likely to identify as Asian/Pacific Islander and White race/ethnicities (p < .0001), and to have parent/guardians who graduated from college (p<.0001). Non-users were more likely to report speaking English at home (p < .0001).
High-frequency users were less likely to report receiving high grades in school (eg, As and Bs) compared to low-frequency users and non-users (p<.0001). High-frequency users were also more likely to have engaged in substance use for ≥1day in the past 30days (p<.0001); experienced chronic sadness or hopelessness (p<.0001); considered suicide (p < .0001); have been victimized on school property; and had sex (p < .0001) compared to low-frequency users and non-users. There were no differences in sexual orientation between SBHC high- frequency users, low users, and non-users (p = .594). High and low-frequency users reported slightly higher scores on having caring adults at school, as compared to non-users; however, differences between non-users and high-frequency users were not significant in pair- wise comparisons.
Multivariate regression that adjusted for students’ grade, ethnicity, gender, language spoken at home, parent education, and school demonstrated that high-frequency users had a higher odds of reporting grades of mostly Cs or lower (adjusted odds ratio [AOR] = 2.55, p = .001); using substances within the past 30days, including cigarettes (AOR = 5.32, p = .001), e-cigarettes/vaping (AOR = 2.55, p = .002), 5 or more drinks of alcohol in a row within a couple of hours (AOR = 2.64, p = .003), and marijuana (AOR = 2.68, p < .001); experiencing chronic sadness or hopelessness (AOR = 2.15, p = .001); considering suicide (AOR = 3.19, p<.0001); having ever been victimized on school property (AOR = 2.22, p = .001); and being sexually active (AOR = 6.76, p<.0001) compared to non-users.
This study examined cross-sectional data to deter- mine characteristics of high-frequency users of SBHCs (10+ visits) to understand their health needs and receipt of health services. Overall, youth using the SBHCs at high frequencies were more likely to be in the 11th grade and to identify as youth of color, which is consistent with prior research. Students in higher grades may be more familiar with the availability and services offered at SBHCs. They may also have more opportunity to use the SBHC if they have attended the same school for multiple years. In addition, as students age there is an increased need for reproductive and mental health services. The finding that high- frequency users were more likely to be youth of color suggests that SBHCs may serve as a promising strategy to address health disparities, particularly in mental health care access. SBHC providers often have more experience working with teens, and bringing services to a trusted, familiar environment may help to reduce traditional barriers that create health care access disparities. Further examination of the mechanisms underlying these utilization patterns can help to strengthen health care systems to ensure equitable access to care.
Furthermore, research has shown that SBHC clients use behavioral health services more frequently but high-frequency users in this study were also more likely to visit SBHCs for more than 1 type of service, including behavioral, sexual, and medical health care, than low-frequency users. SBHCs are designed to provide integrated care under one roof, with two thirds providing medical and mental health care. The integration of mental health services and medical care is a strategy to increase access to high quality, comprehensive care, and promote health equity, further supporting the notion that SBHCs can promote equitable access to health care, and particularly mental health care.
High-frequency users were also more likely to report experiencing several risk behaviors, including being sexually active, having been harassed or victimized at school, and having considered suicide, which complements previous research.8 These youth also had nearly 7 times the odds of reporting they ‘‘always’’ received mental and reproductive health care when needed, which are the specific services needed to address their reported health behaviors, suggesting that SBHCs might be an appropriate model of care to reach higher needs youth. High-frequency users also had 3 times the odds of reporting they had talked with a health care provider in the past year about their moods or feelings or about how school is going. Given previous research suggesting that youth with higher needs often receive less health care and poorer quality care, it is promising that these youth are accessing needed services through the SBHC and reporting higher experiences of key aspects of adolescent preventive care.
There are some limitations to this study that warrant consideration. First, this study relies on cross-sectional, self-report data and some youth may be more willing to disclose this type of information on a survey than others. However, youth are told that the survey is anonymous and confidential, and they can skip any questions they do not want to answer. Another limitation is the small sample sizes for high-frequency users who reported ‘‘never’’ receiving medical care when needed. While the results are encouraging and provide evidence that high-frequency users have higher odds of receiving needed care, additional research with a larger sample could help to further explore this finding.
Another limitation is lack of data on other sources of care. While we know that the high-frequency users are getting a significant amount of care from the SBHCs, we do not know if they are also receiving care from other sources, which may contribute to their reports of getting care more often when needed. Additionally, because this study relies on a convenience sample from the schools with SBHCs and schools with high enrollment of youth of color, the results might not be generalizable to students in different communities. Finally, given the cross- sectional design of this study, it is not possible to know how the SBHCs are affecting youth’s health outcomes. While our study examined associations between high- frequency SBHC use and reported receipt of health care, it was not possible to determine causality.
Despite these limitations, the study findings con- tribute to the limited literature on youth who use SBHCs at high frequencies. Study results demonstrate that SBHCs are potentially reaching youth with many social and emotional needs who are traditionally less likely to seek health care in other settings, including youth of color. Future studies should explore a longitudinal analysis of health outcomes for high-frequency SBHC users to ascertain whether the more intensive receipt of care in adolescence leads to improved health care literacy and outcomes in adulthood. Furthermore, future research should further explore the relationship between SBHCs and adolescent social determinants of health, including whether SBHCs are reaching those with greater needs, and how this relationship impacts health care needs, access, and outcomes.
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