{"id":1341,"date":"2019-05-21T23:37:52","date_gmt":"2019-05-22T03:37:52","guid":{"rendered":"https:\/\/ctlsites.uga.edu\/hprb7010may2019\/?page_id=1341"},"modified":"2019-06-06T00:51:45","modified_gmt":"2019-06-06T04:51:45","slug":"school-based-health-centers-2","status":"publish","type":"page","link":"https:\/\/ctlsites.uga.edu\/hprb7010may2019\/school-based-health-centers-2\/","title":{"rendered":"School-Based Health Centers"},"content":{"rendered":"\n\n\n\n\n\t\n\n\t\n\t\n\t\n\t
Author & Year<\/th>Intervention Setting, Description, and Comparison Group<\/th>Study Population Description and Sample Size<\/th>Effect Measure
\n(Variables)
\n<\/th>		Results, Including Test Statistics and Significance<\/th>Follow-Up Time <\/th>\n<\/tr>\n<\/thead>\n
Rilie, Margaret, Laurie, Anna, Plegue, Melissa, & Richardson, Carlene; 2016<\/td>The setting is the University of Michigan Hospital Health Systems Regional Alliance for Healthy Schools, which runs six school-based health centers in low income neighborhoods <\/td>The study population consists of adolescent patients from the Ypsilanti Health Center; participants were chosen because they were patients at the health center and a medical records check showed that they were missing some kind of recommended medical service; for each service, the controls did not attend a school with a school-based health center
\n*Numbers in the control and case groups varied depending upon the variable:
\nAsthma study: 20 in the study group, 100 in the control group
\n*nutrition counseling: 103 in the study group, 508 in the control group
\n*Well-child visit group:
\n192 in the study group; 1279 in the control group
\n<\/td>		*Following a recommended asthma plan
\n*Receiving needed nutritional counseling
\n*Attending a missed well-visit
\n<\/td>		*19% increase in the percentage of teens with asthma following an asthma plan (13\/20 in the study group\u2026.65%....vs. 46\/100 in the control group\u2026.46%....p-value .19.
\n*33.7% increase in the number of teens in need of nutrition counseling receiving it (50\/103\u2026.48.5%...in the study group vs. 75\/508\u2026.14.8% in the control group)
\n*Well-child visit 5.8% increase (137\/192\u2026.71.4% in the study group vs. 839\/1279\u202665.6% in the control group)
\n<\/td>		Baseline 12 months and intervention period 10 months <\/td>\n<\/tr>\n
Cornwell, Macey; 2018<\/td>The intervention setting is a rural community in Kentucky; the participants served as their own controls<\/td>*450 clinic patients invited; 129 accepted the invitation to participate
\n
\n*62% (n=80) were female
\n*27% (n-34) were 9th-12th graders
\n *36% (n=45) were full-time school employees
\n
\n<\/td>		*Number of emergency room visits for non-emergency situations
\n*Patients\u2019 perceived access to healthcare
\n*patient satisfaction
\n<\/td>		1) Patients experienced statistically significant reductions in needing to go to the emergency room for non-emergency care (Based on the Wilcoxon Signed Rank Test (t=4.2; p=<0.0001
\n2)
\n* 60% of participants strongly agree that the clinic has increased their access to healthcare; 37% agree; 3% were neutral (p=<0.001)
\n<\/td>		January 1st, 2018-September 31, 2018<\/td>\n<\/tr>\n
Paschall,
\nMallie &
\nBersamin,
\nMelina,
\n2018
\n<\/td>		The authors studied the large dataset cross-sectional survey of the Oregon Healthy Teens data, which is part of the Youth Risk Behavior Survey administered once per year in all public schools willing to participate<\/td>*168 public schools in Oregon participated, 25 had SBHCs, 14 of these drastically increased their availability of mental health services (both acute care and long-term care) <\/td>*School-wide prevalence of student-reported depressive episodes, suicide ideation, and suicidal attempts <\/td>*Multilevel regression was completed, controlling for age, race, gender, ethnicity, and SES (as measured by school free and reduced lunch)
\n*Schools whose health centers increased their mental health services saw a statistically significant decline in self-reported depressive episodes among students than those which did not add mental health access (OR=0.82, 95% CI .72, .93); Schools with increased access to mental health services saw statistically significant reductions in suicide ideation (OR =.81, 95% CI: .69, 0.94, p <0.01
\n*Reduced suicide attempts (OR=0.92, 95% CI=0.73, 1.17)
\n<\/td>		3 years <\/td>\n<\/tr>\n
Bersamin, Melina; Coulter, Robert; Gaarde, Jenna; Garbers, Samantha; Mair, Christina & Santelli, John, 2018<\/td>The study examined the relationship between SBHCs and school connectedness. Cross-sectional data from 503 California public high schools in were examined using multiple regression analysis. <\/td>*The study group (students in schools with a SBHC ) was 36, 892 students. The control group (students without a SBHC in their school) was 263, 108 students.
\n
\nStudy Group:
\nBlack: 2,632
\nWhite: 3,369
\nHispanic: 17,103
\nAsian: 10, 610
\n
\nControl Group:
\n
\nBlack: 8,927
\nWhite: 63,431
\nHispanic: 131, 706
\nAsian: 32, 721
\n<\/td>		The researchers examined the interaction between availability of health centers, students\u2019 SES and parents\u2019 level of education and their perceptions concerning adult caring, adult expectations that they did their best everyday, and meaningful participation in school activities <\/td>Among students whose parents had an education equal to or less than a high school diploma scores for perceptions of adult caring were up 0.06 points (p=0.01), scores for adult expectations increased 0.04 (p=0.01) , and scores for meaningful participation in school activities increased 0.03 (p=0.01). <\/td>1 year<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n\n\n

Part 1: Community Guide Update and Rationale for Intervention<\/strong><\/p>\n\n\n\n

The Community Preventive Services Task Force (CPSTF) currently recommends the implementation and maintenance of school-based health centers for the purpose of improving educational and health outcomes. This recommendation is based upon a systematic literature review of 46 studies completed before 2014. We reviewed four studies since the Task Force\u2019s recommendations and found that the more recent studies have found similar results to previous studies, and so there is sufficient evidence to continue with the task force\u2019s evaluation of, \u201cRecommended,\u201d<\/strong> for school-based health centers. <\/p>\n\n\n\n

Impact on Adolescents\u2019 Mental Health<\/p>\n\n\n\n

One of the areas the Task Force\nconsidered in its systematic Review was the effect of school-based health\ncenters on adolescents\u2019 mental health. Paschall, M. & Bersamin, M. (2018)\nused the Oregon Healthy Teens Survey, part of the national Youth Risk Behavior\nStudy, to compare self-reported reductions in depressive episodes, suicide\nideation, and suicide attempts. The results showed that school-based health\ncenters which provide a range of both acute and long-term mental health care\ncan be very effective in improving students\u2019 mental health. Specifically,\nstudents attending the schools in the study population had a protective OR of\n0.82 (95% Confidence Interval .72, .93), a protective OR of .81 for suicidal\nideation (95% Confidence Interval .69, 0.94) and a reduction in suicide\nattempts that was not statistically significant (protective OR of 0.92,\nConfidence Interval 0.73, 1.17). Though the measures are a little different\nthan in the previous studies, it appears these results are at least as\nfavorable as those the Task Force used.<\/p>\n\n\n\n

Impact on Preventive Healthcare Access <\/p>\n\n\n\n

Additionally, the original Task Force evaluated\nsix studies regarding the access to preventive healthcare. We considered two\nrelevant new studies in this area: Cornwell, M. (2018) and Rilie, M., Laurie,\nA., Plegue, M. & Richardson, C. (2016). The former evaluated the variable\nof access to care at a rural clinic in Kentucky. All 450 staff and student\npatients received invitations, and 129 participated. The study didn\u2019t provide\npercentages, but reduction in patients needing to visit the emergency room for\nnon-emergency care was significant based on a t-value of 4.2 on the Wilcoxon\nSigned Rank Test with a very persuasive p-value of < 0.0001. Similarly, 97%\nof clinic users reported statistically significant increased access to\nhealthcare (60% strongly agreed, nobody disagreed, and just 3% of patients were\nneutral (Cornwell, M., 2018). The latter study examined six school-based\nclinics in rural Michigan. The researchers saw a 19% increase in the percentage\nof teens with asthma following an asthma plan (which matched the median\ndecrease of asthma morbidity of 19.3% across two studies evaluated by the Task\nForce precisely). Previous studies showed an average increase of 12% in use of\npreventive services, but this study demonstrated a 33.7% rise in students\nreceiving nutrition counseling, which is significantly higher. Similarly,\nattendance at well-child visits in this study increased by 5.8%, over twice the\n2.2% found by the Task Force. <\/p>\n\n\n\n

 New Consideration: Impact on School Connectedness<\/p>\n\n\n\n

Finally, over the past few years, a new\nfocus area in school-based health center research has emerged: school\nconnectedness evaluation. Bersamin, M., Coulter, R., Gaarde, J., Garbers, S.,\nMair, C. & Santelli, J. (2018). The researchers examined cross-sectional\nhealth survey data from 36,892 study group participants and 263, 108 control\ngroup students. Students were asked to rate from 1 (not at all) to 4 (very much\nso) questions about their school connectedness. The variable of caring\nrelationships was measured by the survey item, \u201cAt my school there is a teacher\nor other adult who really cares about me.\u201d The variable of teacher expectations\nwas measured by the item, \u201cAt my school there\u2019s a teacher or some other adult\nwho always wants me to do my best.\u201d Finally, meaningful involvement was\nmeasured with the item, \u201cAt my school I do things that make a difference.\u201d To\nmake policy recommendations about areas where school-based health centers would\nbe most effective, the authors used multiple logistic regression to examine the\npossible interaction between students\u2019 access to health centers, their parents\u2019\nlevel of education, and their feeling of connectedness to the school. A\nrelevant finding is that for the overall student population as a whole, no\nstatistically significant relationship was found between the presence of a\nschool-based health center and students\u2019 feelings of connectedness to school.\nHowever, by examining students by groups, the researchers found that among\nstudents whose parents had less than or equal to a high school diploma, the\noutcomes changed. These students reported an increase in 0.06 points on\nfeelings adults cared about them, a rise of 0.04 for the question about adult\nexpectations, and 0.03 rise on the question about meaningful participation\n(Bersamin, Coulter, Gaarde, Garbers, Mair & Santelli, 2018). In conclusion,\nthe new studies show results that demonstrate similarly positive (and sometimes\nhigher) positive effects than the previous studies examined by the Task Force.\nImprovement in the additional variable of school connectedness has also been\nproposed in recent research. That\u2019s why we elect to keep the evaluation at,\n\u201cRecommended.\u201d  <\/p>\n\n\n\n

Part 2: Theoretical Framework and Model: <\/strong><\/p>\n\n\n\n

Social Cognitive Theory is a conceptual model concerning how individuals\nlearn. It was created by Albert Bandura, who taught psychology at Stanford\nUniversity (Vinney, 2019). It addresses how individuals affect and in turn get\nformed by their interactions with their environment. In 1977, Bandura conceived\nSocial Learning Theory, in which he posited that learning is an interactive\nprocess, whereby people learn positive and negative behaviors through watching\nothers and imitating their actions. He later revised the model into Social\nCognitive Theory to stress the importance of the thought processes that exist\nduring the process (Vinney, 2019). Many theories address only an initial\nbehavioral change; however, SCT is unique in its consideration of how individuals\nself-monitor continual actions in order to maintain goal-setting behaviors\n(Lamorte, 2018). Self-efficacy is the newest component of the concept, built on\nwhen the Social Learning Theory was revised into Social Cognitive Theory\n(Lamorte, 2018). This theory will explain how children who may have had limited\nencounters with medical services learn to use School-Based Health Centers to\nimprove their health and well-being. <\/p>\n\n\n\n

  1. Reciprocal Determinism: this is the background of the model. It is the three-way interaction between an individual and his or her personal history, the environment, and emerging behaviors (defined as when an individual engages in actions that achieve some kind of desired goal) (Lamorte, 2018). The implementation of a school-based health center provides a change of environment for the children of Decatur, GA. The goal is that they themselves will impact the environment through having the chance to share their wishes for a health center. (For example, they may perceive their most essential health need as acute care: a doctor\u2019s visit or medications when they are sick or they may realize that they have untreated asthma and desire services.) In turn, the goal is that the students will be impacted by the change of environment of the health center and will learn to attend the health center for acute as well as long-term health needs, such as treatment for depression or vaccinations. <\/li>
  2. Behavioral Capability: This part of the model posits that an individual can perform a desired behavior because he or she has the needed information and skills (Lamorte, 2018). Students will work in their homerooms during advisement and during their Health and Physical Fitness classes to monitor their own vaccine history, medical records, and mental health (through self-administered mental health assessments). They will receive information through videos and presentations from local nurses and health professionals regarding how to use the services of a health center to manage and prevent chronic diseases. They will practice role-playing asking their parents if it\u2019s okay if they can use the health center and practice asking their teachers when would be an appropriate time to visit. They will complete practice appointment request cards to ensure they have the skills to seek care. <\/li>
  3. Observational Learning: This part of the theory explains that learning is a social process. People watch others perform actions and then repeat what they see (Lamorte, 2018). Student leaders, such as cheerleaders, football players, members of the dance team, student council, and homecoming court, will be selected to be some of the first students to visit the new school health center. They will then visit homerooms and health classes as well as create posters and maybe short videos for morning announcements explaining how the school health center helped them and encouraging other students to attend. (Students\u2019 privacy will of course be honored; no student will be encouraged to share personal health information if he\/she is reluctant or if it is confidential.) <\/li>
  4. Reinforcements: The individual will change internally as a response to the environment and the environment will give feedback regarding the changes an individual makes (Lamorte, 2018). Children who received their recommended vaccines will feel proud they are taking care of themselves. Children who develop an asthma action plan will breathe more easily. Children who receive nutritional counseling as needed will have the knowledge to lose weight and will gain confidence about their appearance. <\/li>
  5. Expectations: This section of the theory explains that an individual expects some kind of outcome to occur in response to his or her behaviors. Individuals who place value on said effect are more likely to exert effort to achieve it (Lamorte, 2018). In health class children will watch videos showing the difference in quality of life between individuals who manage their asthma as compared to those who do not. Children will research the Measles vaccination crisis occurring around the world to learn the importance of staying up-to-date with all recommended vaccines. <\/li>
  6. Self-Efficacy: This describes an individual\u2019s confidence that he or she is capable of performing a behavior due to one\u2019s own skills or knowledge. It also can be based upon one\u2019s knowledge of related barriers and supports (Lamorte, 2018). Children have little say over their own access to healthcare. They are not the purchasers or holders of health insurance, and they lack transportation to visit a doctor and are unlikely to have their own money to pay for services. Further, most of the time they cannot consent to their own treatment without their parents\u2019 or guardians\u2019 permission. Historically, these factors all cause significant hurdles to children seeking and receiving healthcare. School-based health centers have the potential to significantly increase children\u2019s feelings of self-confidence. If their parents sign permission at the beginning of each school year, they can independently walk to treatment any time they choose. If children without health insurance receive grant funding to receive care any fears that their health needs will cause hardship to their families will be eased. These factors will increase competency in seeking care. <\/li><\/ol>\n\n\n\n
    \"\"<\/figure>\n\n\n\n

    Part 3: Logic Model, Causal and Intervention Hypothesis, and Intervention Strategies<\/strong><\/p>\n\n\n\n

    Target Population:<\/strong><\/p>\n\n\n\n

    The intervention will be targeted for adolescents from low income households, in between the ages of 11 to 14 years (middle school) in the Decatur, Georgia area. Decatur is located five miles northeast of downtown Atlanta. During the 1960s and 1970s property values fell dramatically, causing economic distress in the area. Though the city of an estimated population of 20, 000 has seen some progress, huge racial discrepancies now remain (http:\/\/www.city-data.com\/city\/Decatur-Georgia.html). Specifically, it is one of the cities in Georgia that received a grade of F for Minority Social and Economic Indicators from the Georgia Health Equity Initiative (Georgia Health Equity Initiative, 2008). A grade of F means that racial minorities in a given county have disturbingly poor wellness and that racial inequity is severe (Georgia Health Equity Initiative, 2008). Another indicator that received failing marks was in Primary Care Access. This means that the location would be a perfect location for a school-based health center because it could reduce disparity by serving as the Primary Care facility for children who lacked healthcare. Reproductive Health Outcomes were rated at B-, meaning that moderately high racial differences in access exist (Georgia Health Equity Initiative, 2008). Therefore, adding reproductive health services to the school-based health center would provide access to young females in need. Further, mental health indicators received a grade of C-, which shows that a combination of below expected outcomes are worsened by severe racial inequality, so the plan to add mental health services to the school would be justified (Georgia Health Equity Initiative, 2008). Finally, 21.3% of individuals have no insurance, and 4.7% speak no English at home (Georgia Health Equity Initiative, 2008).<\/p>\n\n\n\n

    Intervention Mapping<\/strong><\/p>\n\n\n\n
    \n  <\/strong>\n  <\/strong>\n  <\/strong>\n Intervention Method<\/strong>\n <\/td>\n  <\/strong>\n  <\/strong>\n  <\/strong>\n Alignment with Theory<\/strong><\/strong>\n <\/td>\n  <\/strong>\n  <\/strong>\n  <\/strong>\n Intervention Strategy <\/strong><\/strong>\n <\/td><\/tr>
    \n Build\n self-efficacy  \n <\/td>\n Social Cognitive\n Theory explains that individuals will be more likely to perform an activity\n that they feel they can perform successfully. Based on this theory, if\n students know they can successfully go through the steps required to gain\n treatment at the health center, they will be more likely to take control of\n their health needs by utilizingk the services of the health center. \n  \n <\/td>\n  \n During advisement\n time groups of students will take a tour of the health center. They will meet\n the employees and have a chance to see all the rooms and equipment available.\n They will participate in a mock registration activity by completing practice\n paperwork.    \n <\/td><\/tr>
    \n  \n Increase knowledge\n of the services available at the school-based health center.  \n <\/td>\n  \n Social Cognitive\n Theory explains that when children have knowledge, they build behavioral capacity.\n By understanding the services that are available at the school-based health\n center, such as acute medical assistance, long-term disease management, and\n reproductive health services, \n children gain the\n capacity to seek treatment. \n <\/td>\n  \n Staff from the\n school-based health center will visit to teach students which services are\n available at the health center and how and when to get treatment. They will\n run through a Powerpoint, hold a class discussion, and then play an\n educational game using the classroom Smartboard.  \n <\/td><\/tr>
    \n  \n Build Social Support \n  \n <\/td>\n  \n Social Cognitive\n Theory says that individuals practice new behaviors when they have Social Support.<\/strong> Visiting the health\n center to create an action plan for chronic disease control, possible\n vaccinations (if afraid of needles or side effects) or especially to seek\n reproductive services could be intimidating the first time. Students are\n encouraged to bring a friend with them for social support when they attend\n their visits.  \n  \n  \n <\/td>\n  \n Students will write\n a short journal paragraph in their health class as a class opener regarding\n who they would bring with them to a doctor\u2019s visit and why and then be\n encouraged to share their responses with a classmate or the whole group. For\n closure, the teacher will encourage students to follow up on their plan by\n bringing a friend to their appointment for social support. \n <\/td><\/tr>
    \n Increase Commitment<\/strong> to follow any wellness\n plans that were created at wellness visits.   \n \n <\/td>\n Based on Social\n Cognitive Theory, Outcome Expectations<\/strong>\n demonstrate that when students value the outcome of a behavior, they are more\n likely to exert effort to achieve it. \n <\/td>\n Students will watch\n videos about chronic disease management. The main characters in the videos\n will be other teenagers or young adults who have successfully controlled\n their chronic diseases such as asthma and how collaborating with a health\n professional made it possible. The videos will also feature health\n professionals explaining the improvement in overall quality in life that is a\n result of managing one\u2019s health conditions effectively.  \n Students will be\n given write about a chronic health condition they have and to create a\n commitment to seek medical treatment for it. If they do not have a chronic\n disease themselves, they can journal about a loved one with a chronic\n condition and some steps he or she could take to stay healthy. \n  \n <\/td><\/tr><\/tbody><\/table>\n\n\n\n

    School Based Health Center Logic Model<\/strong><\/p>\n\n\n\n

    \"\"<\/figure>\n\n\n\n

    Intervention Hypothesis <\/strong>  <\/p>\n\n\n\n

    1.The tour will build self-efficacy because the children will practice completing needed paperwork and scheduling an appointment.<\/p>\n\n\n\n

    2. The Powerpoint, class discussion, and game will build behavioral capacity by giving students the knowledge of services available in the school-based health center. <\/p>\n\n\n\n

    3. Bringing a friend to wait in the waiting room of the health center will build social support. <\/p>\n\n\n\n

    4. The journal entries will increase participants\u2019 commitment to follow a wellness plan if prescribed by their doctor. <\/p>\n\n\n\n

    Causal Hypothesis<\/strong><\/p>\n\n\n\n

    1. Building social support will decrease spread of\ntransmissible diseases because students will encourage their friends to attend\nthe health center for acute care visits. <\/li>
    2. Increasing self-efficacy will increase the percentage of\nstudents attending annual wellness visits and following up with recommended\ncare. <\/li>
    3. Building knowledge of the services available will result in\nimproved lung and heart health, fewer diabetes-related emergencies, and reduced\nincidence of suicidal thoughts and self-harm episodes.  <\/li>
    4. Commitment to follow a wellness plan recommended by a physician will\nresult in improved lung and heart health, fewer diabetes-related emergencies, and\nreduced incidence of suicidal thoughts and self-harm episodes.  <\/li><\/ol>\n\n\n\n

      SMART\nOUTCOME OBJECTIVES<\/strong><\/p>\n\n\n\n

      Goal 1:<\/strong> Increase knowledge of services available\nat the school-based health center and when they are needed. <\/p>\n\n\n\n