School-Based Health Centers and Academic Outcomes

1. School-Based Health Centers and Academic Outcomes Gorette Amaral, MHS University of California, San Francisco Gorette@itsa.ucsf.edu

3. First, what does the SBHC literature say?

4. Summary of Research A thorough literature review conducted in 2003 yielded 7 studies on the link between SBHCs and academic outcomes 1 6 of the 7 studies found a relationship between SBHCs with at least one of 13 academic indicators

5. Overall, 6 of the 7 quasi-experimental studies that we reviewed found a positive relationship between either the presence and/or actual use of an SBHC with at least one of 13 academic indicators The most commonly studied indicators were Absences (3 of 6 studies) Gall et al concluded that SBHC registrants decreased their absences by 50% two months after being screened and referred for mental health services, while registrants who were not referred to mental health services slightly increased their rates of absence during the same time period. McCord et al examined cross-sectional school, clinic, and health department data to find that sixth through twelfth grade SBHC users at an alternative school were slightly less likely to be absent than both non-registrants and students who registered but did not use the clinic. Webber et al surveyed parents of K-5 and found that asthmatic children enrolled in schools without an SBHC missed more days of school during a 12-month period than asthmatic children enrolled in schools with an SBHC. BUT: Kisker and Brown compared students enrolled at 19 schools that participated in the RWJ Foundation�s School-Based Adolescent Health Program to a national sample of urban youth at the beginning and end of their high school careers. Levels and trends in absences due to illness did not differ between students at SBHC schools and urban youth nationally. Warren and Fancsali found that participation in a high school-based program that included typical SBHC services � as well as family counseling and involvement, employment counseling, learning support systems, and recreational opportunities � had a non statistically significant but positive, impact on absences over the first two years of high school. An evaluation of the Dallas Youth and Family Centers, which provide school-based physical and mental health care and health education services as well as parent training and after-school programs, found that although absences decreased between the beginning and the end of the school year among students who received services, they also decreased among non-participants. Promotion to the next grade (1 of 3) McCord et al7 found that SBHC users were significantly more likely to stay in school and to graduate or be promoted than both students who registered but did not use the SBHC as well as non-registrants. As exposure to the clinic increased through more visits, the relationships between clinic use and graduation/promotion became stronger. BUT: Kisker and Brown found that the proportion of students who progressed through school at the expected pace was significantly higher for students who attended schools with SBHCs than for urban youth nationally, but the difference was small (78% versus 75%) and dose-response analyses did not provide reliable evidence that SBHCs influenced educational outcomes. The study of the Dallas Youth and Family Centers did not find a difference between the promotion rates of general users and non-users of the program. Withdrawal/drop out rates (2 of 2) The Bureau of Primary Health Care8 reported that the dropout rate measured during a particular school year at a Southern California SBHC was twice as high for SBHC non-users than for users. McCord see above. Suspension rates (0 of 2) Neither McCord nor Warren found an impact on suspension. Other indicators included: Tardiness (1 of 1) -- Gall, as described in previous slide Graduation rate (1 of 1) -- McCord, as described in previous slide Educational aspirations (1 of 1) and Credit accumulation (1 of 1) -- Warren, as described in previous slide Standardized test scores (1 of 1) -- Williams, as described in previous slide Disciplinary referrals (0 of 1), GPA (0 of 1, Educational motivation (0 of 1), Receipt of failing grade (0 of 1) Warren found no impact on these indicators..Overall, 6 of the 7 quasi-experimental studies that we reviewed found a positive relationship between either the presence and/or actual use of an SBHC with at least one of 13 academic indicators The most commonly studied indicators were Absences (3 of 6 studies) Gall et al concluded that SBHC registrants decreased their absences by 50% two months after being screened and referred for mental health services, while registrants who were not referred to mental health services slightly increased their rates of absence during the same time period. McCord et al examined cross-sectional school, clinic, and health department data to find that sixth through twelfth grade SBHC users at an alternative school were slightly less likely to be absent than both non-registrants and students who registered but did not use the clinic. Webber et al surveyed parents of K-5 and found that asthmatic children enrolled in schools without an SBHC missed more days of school during a 12-month period than asthmatic children enrolled in schools with an SBHC. BUT: Kisker and Brown compared students enrolled at 19 schools that participated in the RWJ Foundation�s School-Based Adolescent Health Program to a national sample of urban youth at the beginning and end of their high school careers. Levels and trends in absences due to illness did not differ between students at SBHC schools and urban youth nationally. Warren and Fancsali found that participation in a high school-based program that included typical SBHC services � as well as family counseling and involvement, employment counseling, learning support systems, and recreational opportunities � had a non statistically significant but positive, impact on absences over the first two years of high school. An evaluation of the Dallas Youth and Family Centers, which provide school-based physical and mental health care and health education services as well as parent training and after-school programs, found that although absences decreased between the beginning and the end of the school year among students who received services, they also decreased among non-participants. Promotion to the next grade (1 of 3) McCord et al7 found that SBHC users were significantly more likely to stay in school and to graduate or be promoted than both students who registered but did not use the SBHC as well as non-registrants. As exposure to the clinic increased through more visits, the relationships between clinic use and graduation/promotion became stronger. BUT: Kisker and Brown found that the proportion of students who progressed through school at the expected pace was significantly higher for students who attended schools with SBHCs than for urban youth nationally, but the difference was small (78% versus 75%) and dose-response analyses did not provide reliable evidence that SBHCs influenced educational outcomes. The study of the Dallas Youth and Family Centers did not find a difference between the promotion rates of general users and non-users of the program. Withdrawal/drop out rates (2 of 2) The Bureau of Primary Health Care8 reported that the dropout rate measured during a particular school year at a Southern California SBHC was twice as high for SBHC non-users than for users. McCord see above. Suspension rates (0 of 2) Neither McCord nor Warren found an impact on suspension. Other indicators included: Tardiness (1 of 1) -- Gall, as described in previous slide Graduation rate (1 of 1) -- McCord, as described in previous slide Educational aspirations (1 of 1) and Credit accumulation (1 of 1) -- Warren, as described in previous slide Standardized test scores (1 of 1) -- Williams, as described in previous slide Disciplinary referrals (0 of 1), GPA (0 of 1, Educational motivation (0 of 1), Receipt of failing grade (0 of 1) Warren found no impact on these indicators..

6. What can we confidently say about the relationship between SBHCs and academic performance?

7. We can confidently say� The current research base provides insufficient evidence to demonstrate a direct link between SBHCs and academic performance that can be widely generalized. But, the literature has demonstrated the influence of several intermediate outcomes which influence academic performance indirectly.

8. We can confidently say� Academic performance is negatively affected by: Alcohol, tobacco, and other drug use 9-13 Emotional problems 9,12,13 Poor diet 10-12 Intentional injuries 9-12 Physical illness13,14 Low self-esteem10,11 Risky sexual behavior 11 Lack of access to health care 14 Academic performance is positively affected by: High levels of resiliency, developmental assets, and school connectedness. 10,15 If SBHCs can affect these health outcomes, they can affect academic performance indirectly!

9. Why is the research on SBHCs and academic performance so limited?

10. Limitations and challenges of the current research base Lack of generalizability: Programs called �SBHCs� vary in scope and services Defining the indicators: There are no uniform definitions for outcomes being measured (i.e., what counts as an �absence�?) Study design limitations: Many studies have been cross-sectional; those that are longitudinal usually have too little follow-up time between pre and post tests Although programs that call themselves SBHCs usually have some basic characteristics in common, they can vary enormously in their scope and organization. (Academic enrichment or tutoring component, Parental training and involvement, After-school programs, Year-round versus school-year programs) The intervention studied by McCord et al required that parents have a face-to-face interview with clinic staff before their children could enroll in the clinic. It is possible that parental involvement influenced the improved outcomes. The New Jersey School Based Youth Services Program evaluated by Warren and Fancsali also extended beyond the typical scope of SBHC services, including employment counseling and learning support systems. The Dallas Youth and Family Centers provided school-based physical, mental, and health education services as well as parent training and after-school programs. Another challenge in examining the relationship between SBHCs and academic performance is that schools often differ in how they define even relatively straightforward indicators, such as absences. McCord et al counted pregnant or parenting students who received home curricula as absent. Some schools may count a student as absent after missing any period of time in a school day, whereas other schools require missing at least half a day. Kisker and Brown compared the percent of students who were absent at least 10 days in the past semester due to illness for students attending schools where an SBHC was present versus urban youth nationally. Comparisons of absence rates in these circumstances are inappropriate and can lead to inaccurate conclusions. - 3 were cross-sectional � (BPHC; McCord; Webber) Differences observed from cross-sectional comparisons of academic performance between SBHC users and non-users [BPHC; McCord; Webber] are sometimes erroneously interpreted as being a result of the intervention. In reality, studies that lack a pre- and post-test design may actually be no more than a snapshot of the performance of students who for a variety of reasons, one of which may be that student�s scholastic profile, are more predisposed to using the clinic. This says nothing about the effect of the program over time. Even studies that do measure performance longitudinally do not always measure a sufficient duration of time to determine if changes are long-lasting. [Gall compared data 2 months before and after students were referred for mental health services vs. students who were not referred. Williams looked at the second and fifth 6-week periods of the same school year. ] Although programs that call themselves SBHCs usually have some basic characteristics in common, they can vary enormously in their scope and organization. (Academic enrichment or tutoring component, Parental training and involvement, After-school programs, Year-round versus school-year programs) The intervention studied by McCord et al required that parents have a face-to-face interview with clinic staff before their children could enroll in the clinic. It is possible that parental involvement influenced the improved outcomes. The New Jersey School Based Youth Services Program evaluated by Warren and Fancsali also extended beyond the typical scope of SBHC services, including employment counseling and learning support systems. The Dallas Youth and Family Centers provided school-based physical, mental, and health education services as well as parent training and after-school programs. Another challenge in examining the relationship between SBHCs and academic performance is that schools often differ in how they define even relatively straightforward indicators, such as absences. McCord et al counted pregnant or parenting students who received home curricula as absent. Some schools may count a student as absent after missing any period of time in a school day, whereas other schools require missing at least half a day. Kisker and Brown compared the percent of students who were absent at least 10 days in the past semester due to illness for students attending schools where an SBHC was present versus urban youth nationally. Comparisons of absence rates in these circumstances are inappropriate and can lead to inaccurate conclusions. - 3 were cross-sectional � (BPHC; McCord; Webber) Differences observed from cross-sectional comparisons of academic performance between SBHC users and non-users [BPHC; McCord; Webber] are sometimes erroneously interpreted as being a result of the intervention. In reality, studies that lack a pre- and post-test design may actually be no more than a snapshot of the performance of students who for a variety of reasons, one of which may be that student�s scholastic profile, are more predisposed to using the clinic. This says nothing about the effect of the program over time. Even studies that do measure performance longitudinally do not always measure a sufficient duration of time to determine if changes are long-lasting. [Gall compared data 2 months before and after students were referred for mental health services vs. students who were not referred. Williams looked at the second and fifth 6-week periods of the same school year. ]

11. Other Research Challenges Availability of data Access to data Quality of data Method of data collection Selection of appropriate academic outcome measures Linking health and education data Consent/Confidentiality Issues HIPAA/FERPA Student mobility

12. How can SBHCs communicate their value to educators, funders, and policymakers?

13. 1. Consider the multiple influences on academic performance

14. 2. Focus on the health-academic outcomes connection Encourage educators to accept that there is a link between health and academics�and instead focus on health-related results and indicators Medical and mental health status impacts academic outcomes SBHCs impact medical and mental health status So�SBHCs can contribute, at least indirectly, to improved academic outcomes Encourage educators to accept that there is a link between health and academics�and instead focus on health-related results and indicators Medical and mental health status impacts academic outcomes SBHCs impact medical and mental health status So�SBHCs can contribute, at least indirectly, to improved academic outcomes

15. 3. Emphasize how SBHCs enhance the educational climate (Examples) SEE HANDOUT FOR FULL LISTSEE HANDOUT FOR FULL LIST

16. 3. (Continued) SEE HANDOUT FOR FULL LISTSEE HANDOUT FOR FULL LIST

17. 4. Collect health data and stories Collect health data on conditions that indirectly affect student performance Asthma Pregnancy Depression Attention Deficit with Hyperactivity Disorder (ADHD) Immunization rates Document client �success� stories Even SBHCs with limited resources can demonstrate their worth to educators�. 1. Emphasize how SBHC contribute to factors known to be associated with successful educational climates. a. Parental involvement b. Teacher/client satisfaction data 2. Document client �success� stories 3. Explore the collection of qualitative data. Present arguments that are intellectually valid but also touch peoples� hearts Even SBHCs with limited resources can demonstrate their worth to educators�. 1. Emphasize how SBHC contribute to factors known to be associated with successful educational climates. a. Parental involvement b. Teacher/client satisfaction data 2. Document client �success� stories 3. Explore the collection of qualitative data. Present arguments that are intellectually valid but also touch peoples� hearts

18. 5. Check out these resources! White Paper: Geierstanger SP, Amaral G. School-Based Health Centers and Academic Performance: What is the Intersection? April 2004 Meeting Proceedings. White Paper. Washington, DC: National Assembly on School-Based Health Care; 2005. http://www.nasbhc.org/EQ/Academic_Outcomes.pdf Journal article: Geierstanger SP, Amaral G, Mansour M, Walters SR. School-based health centers and academic performance: Research, challenges, and recommendations. Journal of School Health. 2004 Nov;74(9):347-52.

19. References Geierstanger SP, Amaral G, Mansour M, Walters SR. School-based health centers and academic performance: Research, challenges, and recommendations. Journal of School Health. 2004 Nov;74(9):347-52. Bureau of Primary Health Care. School-Based Clinics that Work. Washington, DC: US Dept of Health and Human Services, Health Resources and Services Administration; 1994. Gall G, Pagano ME, Desmond MS, Perrin JM, Murphy JM. Utility of psychosocial screening at a school-based health center. J Sch Health. 2000;70:292-298. Kisker EE, Brown RS. Do school-based health centers improve adolescents� access to health care, health status, and risk-taking behavior? J Adolesc Health. 1996;18:335-343.

20. References McCord MT, Klein JD, Foy JM, Fothergill K. School-based clinic use and school performance. J Adolesc Health. 1993;14:91-98. Warren C, Fancsali C. New Jersey School-Based Youth Services Program: Final Report. New York, NY: Academy for Educational Development; 2000. Webber MP, Carpiniello KE, Oruwariye T, Lo Y, Burton WB, Appel DK. Burden of asthma in inner-city elementary schoolchildren. Arch Pediatr Adolesc Med. 2003;157:125-129. Williams K. Final Evaluation of the 2002-2003 Youth and Family Centers Program. Dallas, TX: Dallas Independent School District, Division of Evaluation and Accountability; 2003; Also see: Pearson GT, Jennings J, Norcross J. A program of comprehensive health and mental health services in a large urban public school district. Adolesc Psychiatry. 1998;23:207-231.

21. References Blum RW, Beuhring T, Shew ML, Bearinger LH, Sieving RE, Resnick MD. The effects of race/ethnicity, income, and family structure on adolescent risk behaviors. Am J Public Health. 2000;90:1879-1884. Hanson TL, Austin G. Student Health Risks, Resilience, and Academic Performance in California: Year 2 Report, Longitudinal Analyses. Los Alamitos, Calif: WestEd; 2003. Symons CW, Cinelli B, James TC, Groff P. Bridging student health risks and academic achievement through comprehensive school health programs. J Sch Health. 1997;67:220-227. Glied S, Pine D. Consequences and correlates of adolescent depression. Arch Pediatr Adolesc Med. 2002;156:1009-1014.

22. References Klerman LV. Can school-based health services reduce absenteeism and dropping out of school? Adolesc Med. 1996;7:249-260. Bailey-Britton AM. The relationship between health and academic performance in school-age children. Issues Compr Pediatr Nurs. 1987;10:273-289. Scales PC, Roehlkepartain EC. Boosting student achievement: New research on the power of developmental assets. Search Institute Insights Evidence. 2003;1:1-10. Geierstanger SP, Amaral G. School-Based Health Centers and Academic Performance: What is the Intersection? April 2004 Meeting Proceedings. White Paper. Washington, DC: National Assembly on School-Based Health Care; 2005. Available at: http://www.nasbhc.org/EQ/Academic_Outcomes.pdf