Prevention - School-based Health Care

Should schools engage in health care? Or health care education? Here are two justifications: The General Accounting Office reports that Medicaid pays for the health care of 21 million children, more than one in four. Medicaid screens children for various conditions — to detect and treat conditions early. But many children are not getting these services. They lack service providers. More teens are indulging in risky behavior. Easy availability of health care services might help alleviate both of these problems.

School-based health centers (SBHCs) are on the increase. They provide medical care and education for the approximately 1 million enrolled students, particularly low-income students.

The graphic shows data from the National Assembly on School-Based Health Care (NASBHC); 806 school-based health centers completed questionnaires. The average center was located in a school with 1,004 students, with 64% of students enrolled in the center; 537 students used their center at least once. The median age of the centers was four years; the average six. SBHCs served 1.1 million students (2% of the total school enrollment), nearly two-thirds of them minorities.

SBHCs began in the 1970s as a response to poor access to health care and alarming statistics about risky behaviors and teen pregnancy. SBHCs are sponsored by health departments, community health centers, hospitals, university medical centers, and nonprofit health care agencies.

The graphic shows some of the services provided by SBHCs in the elementary, middle, and high school grades. Specifically, the centers provide basic preventive services, including vision, hearing, and dental screenings, immunizations, and so on. The centers also do mental health screening (suicide is a leading cause of death among high school students).

The chart shows that birth control information is provided by a small percentage of schools (22% of middle and 28% of high schools). Why so few? SBHCs are constrained by citizen complaints that the centers are a front for family planning activities and that the sex education offered encourages teenage pregnancy and promiscuity. President Bush's solution to the problem of unintended pregnancies and sexually transmitted diseases: "A substantial investment in abstinence education," included in his 2003 budget.

We know that teen sex is problematic; we cannot agree on what ought to be done about it. The NASBHC reports that once an SBHC has established itself and earned community trust, it is more likely to offer family planning services. Not shown on this chart is their finding that 41% of SBHCs more than 10 years old (20% of centers) offer such services.

A survey conducted by Making the Grade²¹ found that in school year 1999-2000, the number of SBHCs had grown to 1,380, operating in 45 states and the District of Columbia, up from only 120 centers in 1988. The majority (58%) are located in urban school districts; 24% are in rural districts, and 18% are in suburban districts.

SBHCs traditionally relied on private funding and grants from local, state, and federal governments. Recently, third-party payers like Medicaid have become an important source of support. The chart shows that more than 70% of SBHCs sought third party reimbursement for services in 1998-99. Medicaid contributed $9 million in 1997-98.

Where SBHCs are in place, they are accepted by the majority of students — 70% of students in elementary grades, 68% in middle grades, and 60% in high school were enrolled in the centers, and 83% of enrolled students actually used the centers.

Are kids getting the prevention message? The table below shows that greater percentages of students reported engaging in risky behaviors in 1999 than in 1991.²² These students are at risk for major killers like cardiovascular disease, cancer, and diabetes, as well as unwanted pregnancy, HIV, and sexually transmitted diseases. This is a strain on the health care system and a threat to the public health.

Do SBHCs help reduce risky behaviors? Study results reported in Journal of School Health indicate that "SBHCs have been effective in addressing health care needs but less effective in reducing risky behaviors. Focusing interventions on selected, individual high-risk behaviors such as substance use and pregnancy prevention without giving consideration to the student's social, environmental, and cultural situations resulted in minimal positive behavior change." Sounds like a tall order.

Youth Risk Behaviors That Worsened Between 1991-1999

	1991	1993	1995	1997	1999
Frequent cigarette use	12.7	13.8	16.1	16.7	16.8
Episodic heavy drinking	31.3	30.0	32.6	33.4	31.5
Lifetime marijuana use	31.3	32.8	42.4	47.1	47.2
Current cocaine use	1.7	1.9	3.1	3.3	4.0
Lifetime illegal steroid use	2.7	2.2	3.7		3.7
Used birth control pills at	20.8	18.4	17.4	16.6	16.2
last intercourse
Attended physical	41.6	34.3	25.4	27.4	29.1
education class daily

What about parental consent? In surveys, teens repeatedly mention the need for a place they can go for health information when they cannot go to their parents. The chart at the beginning of this discussion shows that 18% of young children, 10% of middle schoolers, and 8% of high school students needed parental consent to visit their SBHC. Parental consent to enroll was required in 94% of responding centers. The survey asked health centers to identify services a student could receive without parental consent. Those most frequently mentioned were emergency care, sexually transmitted disease treatment, drug and alcohol counseling, family planning, mental health counseling, and prenatal care.

Public schools must be concerned about their vulnerability to costly legal challenges when dispensing health care services. It is well known that condoms can prevent HIV/AIDS, the eighth leading cause of death for 15-24-year-olds. Yet condom availability in schools remains a controversial issue. In a recent national survey of school superintendents, 64% said they would seek legal counsel before developing condom availability programs.

Next we will look at what genetic engineering might hold in store for us relative to disease prevention.

Source: Chart: National Assembly on School-Based Health Care, "Creating Access to Care for Children and Youth: School-Based Health Center Census 1998-1999," June 2000, retrieved June 25, 2002, from http://www.nasbhc.org/. T able: National Youth Risk Behavior Surveys, 1991-1999, in "Reducing the Burden of Chronic Disease: Promoting Healthy Behaviors Among Youth," Diseases Notes and Reports, National Center for Chronic Disease Prevention and Health Promotion, Volume 14, Number 1, Winter 2001, retrieved May 31, 2002, from http://www.cdc.gov/nccdphp/cdwin2001. General Accounting Office, "Medicaid: Stronger Efforts Needed to Ensure Children's Access to Health Screening Services," GAO-01-749, July 2001; retrieved June 26, 2002, from www.gao.gov/. M.J. Friedrich, "25 Years of School-Based Health Centers," JAMA, The Journal of the American Medical Association, March 3, 1999, v281 i9 p781(1). Pamela A. Shuler, "Evaluating Student Services Provided by School-Based Health Centers: Applying the Shuler Nurse Practitioner Practice Model," Journal of School Health, October 2000, v70 i8 p348. The Alan Guttmacher Institute, "School-Based Health Centers And the Birth Control Debate," Issues in Brief, 2000 Series, No. 3, , retrieved June 25, 2002, from http://www.agi-usa.org/pubs/ib_1200.pdf. "The Untapped Power of Schools to Improve the Health of Teens," retrieved June 26, 2002, from http://www.healthinschools.org/ejournal/2002/may02_1.htm.