Copyright 1998 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.1998
As school-based health centers (SBHCs) continue to grow, it remains important to study use of the centers. The extent to which mental health problems exist in the students with access to the centers, whether those students are using the available services, if they are satisfied with the services, and the reasons for nonuse by those students who do not enroll are all meaningful questions.
The above issues were studied in an urban high school with a 2-year-old SBHC by administering questions during physical education classes on health center use and mental health concerns. The 630 respondents were 45% male, 55% female, 61% black, 29% Hispanic, 54% in grades 9 or 10, 46% in grades 11 or 12.
Sixty percent of the students were registered in the SBHC; 40% were not registered. Seventy-five percent of registered students reported average use (≤3 visits); females were more likely than males (P=.017) to be frequent (>3 visits) users of SBHC services. Mental health problems among all participants included depression in 31%, use of alcohol 1 time or more per month in 21%, use of alcohol daily in 5%, suicidal ideation in 16%, history of a suicide attempt in 10%, knowing someone who had been murdered in 50%, and being in at least 1 fight at school in 26%. Frequent users, average users, and nonusers did not differ by age, grade, race, or any of the measured mental health problems. Among the 472 students who completed the survey section on SBHC perceptions, 305 described health center use: 92% were satisfied with health center services, 79% were comfortable being seen in the SBHC, 74% believed visits were kept confidential, 61% told their parents about each visit, and 51% considered the SBHC their regular health care source. The health center was used for mental health services by 34% and sexuality-related care by 15%. The 167 students who described reasons for not using the SBHC most frequently reported that they already had a physician (60%), did not need it (50%), prefer continuing previous health care (45%), did not get around to it (30%), parents were opposed (20%), were not comfortable (19%), did not know about the service (19%), and did not want problems known (19%).
We conclude that, in this urban high school, (1) average users, frequent users, and nonusers did not differ in the mental health problems measured in this study; (2) those who used the SBHC indicated strong satisfaction with the care received; and (3) those who did not use the SBHC chose to stay away for a variety of reasons, most commonly the availability of other care or the perception of lack of need.
A RECENT survey1 estimates that there are currently more than 900 school-based health centers (SBHCs) nationwide. As experience in SBHCs has increased in the past decade, studies of their use have aimed at determining whether students would use the centers to receive sensitive services, if they were satisfied with SBHC services and policies, and what the implications of SBHC use might be. Studies performed in the 1980s2- 6 reported that students would use the centers for sensitive services, such as reproductive health care, and that center use could influence the levels of sexual activity, pregnancy, contraception, and sexually transmitted disease. Later studies7- 9 demonstrated, in a descriptive manner, a range and depth of issues that could be seen and managed in SBHCs, with reproductive health visits constituting less than half the use of the SBHC. The high visit rates reported in these studies have implied acceptance and satisfaction by users. Surveying students regarding their attitudes toward SBHCs has also demonstrated support and satisfaction on the part of users of these services.10 Most recently, SBHC studies have begun to analyze the implications of specific use patterns. This last group of studies9,11- 19 has looked for differences between those enrolled in the clinic and the total student body, between enrolled users and nonusers, and between students who visit the clinic frequently or infrequently.
There have been a handful of reports comparing the mental health problems of students who use SBHCs with students in the same school setting who do not use the clinic. In light of data8 that indicate that up to 20% of primary diagnoses and up to 40% of visits in some programs are for mental health concerns, it is important to understand whether SBHCs serve a representative sample of students, those with the most severe psychosocial problems, or those who are the most "well-adjusted." To date, there have been reports11,13,16- 19 in the literature supporting each of these possibilities.
For example, in study by Adelman et al,18 frequent users were found more likely to report symptoms of psychological distress, such as depression, somatization, and acting out, and 28% of the students had used the SBHC for mental health and psychological services. Weist et al19 reported that nonusers of the SBHC were rated as more socially withdrawn by their peers, but users and nonusers did not differ on psychosocial measures. Wolk and Kaplan17 found that frequent clinic users (>15 visits) in an SBHC site staffed by 2 social workers and a full-time drug and alcohol counselor had a significant higher percentage of mental health visits and more high-risk behaviors, such as alcohol use, sexual activity, and poor family and peer relationships. Furthermore, Walter et al16 found that students who did use SBHC services were more likely to be involved in higher-risk behaviors and have more mental health problems.
A series of articles20- 23 has recently been published describing studies performed in the high school in which we have operated an SBHC since 1987. In 1 of these studies,21 the prevalence of several mental health problems (depression, suicidal ideation and attempts, alcohol use, and exposure to violence) among the students in the high school, 60% of whom were registered in the SBHC and 40% of whom were not was evaluated. This study gave us the opportunity to compare the demographic and mental health characteristics of SBHC users and nonusers in the school and to determine whether more-frequent SBHC users differ from less-frequent users. In addition, we surveyed SBHC users regarding their satisfaction with the services they had received, and nonusers of the SBHC were asked why they did not use the center. The data from this report add to our understanding of SBHC use patterns.
Data were collected as part of a yearly health education program conducted in a New York, NY, urban high school that has an SBHC administered by North Shore University Hospital.7 The SBHC had been in place 2 years when this study took place. The SBHC was staffed by a pediatric nurse practitioner, who also served as project director, and attending physicians and fellows from the Division of Adolescent Medicine at the North Shore University Hospital, who were present 3 to 5 hours daily on a rotating basis. Mental health services were provided by a psychologist and psychology graduate students who were collectively present approximately 50% of the time.7 The SBHC delivered health care in a comprehensive manner, providing medical and reproductive health services, as well as mental health services, both urgently and longitudinally over time—all within 1 site. The mental health and medical staff worked closely together, coming from the same institution and having the same goal of integrated service delivery.
Students attending regularly scheduled physical education classes were measured for height, weight, vision, and blood pressure during an annual health screening week conducted during February 1989.21 Students voluntarily completed an anonymous survey and were informed of medical and mental health services available at the SBHC site for additional information or assistance. The following questionnaires were used during the course of the week to survey mental health problems:
The Depression Self-rating Scale,24 an 18-item questionnaire developed by Birleson to measure depression. Each item is answered on a 3-point scale, and a score of 13 or greater is considered to represent clinically significant depression. The Depression Self-rating Scale has good concurrent validity, correlating 0.81 with the Children's Depression Inventory. It has a test-retest reliability coefficient of 0.80.24
A suicidal ideation-attempt survey,25 a 4-item series with yes or no responses to the following questions: Has there ever been a time of 2 weeks or more when you thought a lot about death? Has there ever been a time of 2 weeks of more when you felt you wanted to die? Have you ever thought of committing suicide? and Have you ever attempted suicide?
The Adolescent Alcohol Involvement Scale, revised by Robertson,26 that measures frequency of alcohol use and effects on life. Responses to the question "How often do you drink?" separated students into the categories of never, yearly, monthly, or daily.
The Violence Survey, a self-administered 9-item questionnaire developed by Bell et al,27 in which students report the type and amount of violence they have witnessed. Items include whether students have ever witnessed a stabbing, shooting, beating, or robbery.
In addition, we used an SBHC perceptions survey developed by Kirby28 as part of a multisite assessment. It contains 8 items for SBHC users and 17 items for nonusers. The items for SBHC users evaluate satisfaction with services, containing questions such as "Do you feel your visits were kept secret?" Items pertaining to nonusers explored reasons for not registering with the SBHC, for example, "I was healthy and did not need the health center" or "I do not want anyone to know about my problems."
The 630 students who participated had a mean age of 16.0 years; 55% were female and 45% male; 54% were in grades 9 or 10, 46% in grades 11 or 12; and 61% were black, 30% Hispanic, 6% white, and 3% Asian. School-based health center registration occurs at the time of a student's first visit. We defined frequent SBHC users as students who reported more than 3 visits since the beginning of the academic year in which the study took place; average health center users reported 3 visits or fewer during the same period. The study sample was representative of the approximately 1500 students enrolled in the school.
Data were analyzed as follows: (1) General distributions were determined for SBHC users and nonusers on the Depression Self-rating Scale, the suicidal ideation and attempt survey, the Adolescent Alcohol Involvement Scale, and for each item in the Violence Survey. (2) χ2 Analyses were used to determine variations by SBHC usage. (3) χ2 Analyses were also used to determine significant differences between average SBHC users and frequent users. (4) General distributions were determined for the SBHC perceptions survey.
This study was reviewed and approved by the Research, Clinical Investigation, and Publications Committee of North Shore University Hospital.
The demographics of average, frequent, and nonusers of the SBHC are outlined in Table 1. There were no significant differences by grade or race among these 3 groups. Seventy-five percent of SBHC users reported average use (≤3 visits). Frequent SBHC users were more likely to be female (68% female vs 32% male; P=.017).
Mental health problems, as have been previously reported,21 among all participants included depression in 31%, use of alcohol 1 time or more per month by 21%, use of alcohol daily by 5%, suicidal ideation by 16%, history of a suicide attempt in 10%, knowing someone who had been murdered in 50%, and involvement in at least 1 school fight by 26%.
The mental health problems of nonusers, average SBHC users, and frequent SBHC users are shown in Table 2. No significant differences were found among these 3 groups in their rates of depression, suicidal ideation and attempt, alcohol involvement, or exposure to violence.
Nearly all SBHC users reported satisfaction with the services they had received and most were comfortable going to the SBHC for their care. As outlined in Table 3, nearly three quarters of the students believed visits were kept confidential. Twenty-nine percent reported that they had found the psychological help the SBHC offered to be useful; of interest, 28% of this group of students had a Depression Self-rating Scale score of greater than 13. Most SBHC users told parents about their non–sex-related health visits, and 51% considered the SBHC their regular source of health care; 23% of students who used the SBHC for a sex-related health visit reported telling their parents of the visit.
Females were more likely than males to believe that visits were kept confidential (79% vs 67%; P=.029), to consider the SBHC their primary source of health care (56% vs 44%; P =.001), and to tell their parents about non–sex-related health visits (68% vs 54%; P =.014). No significant differences by race were noted.
As indicated in Table 4, many students who did not use the SBHC indicated that they already had a physician or thought that they were healthy and did not need care. About one fifth reported that their parents did not want them to use the SBHC and a similar number reported that they did not know about the SBHC, were not comfortable with the SBHC, or did not want their problems known. Some students (<10%) reported that they were afraid that friends, teachers, or parents would find out about their health visits.
Males were more likely than females to report reasons for not using the SBHC as being healthy and not needing care (66% vs 35%), not wanting to miss class (19% vs 8%), and being afraid that friends, teachers, or parents would find out (13% vs 3%; all P values=.013). Males were also more likely than females to report thinking that the SBHC only gave birth control (13% vs 3%; P =.015). Black students were more likely than Hispanic students to report having a physician (51% vs 31%; P =.025), while Hispanic students were more likely to report being afraid friends, teachers, or parents would find out (10% vs 3%; P=.039) as reasons for not using the SBHC. No other significant differences by race were noted.
This study demonstrates 3 major points about use of our SBHC: (1) The prevalence rates of mental health problems among the students in the school were high, and there were no differences in these rates for average users, frequent users, and nonusers of the SBHC. (2) Students who used the SBHC indicated a strong satisfaction with the care they received. (3) Those who did not use the SBHC chose to stay away for a variety of reasons, most commonly because of the availability of other care or a perceived lack of need and least commonly because of a concern about quality or confidentiality issues at the SBHC itself.
This study differs from those by Wolk and Kaplan,17 Balassone et al,11 Weist et al,19 Adelman et al,18 and Walter et al,16 each of which found greater differences than we did between users and nonusers, average and frequent users, or both of their SBHCs. Several factors may account for these differences. First, the study reported here took place early in the development of our SBHC program, at a time when there was limited availability of mental health services and no mental health group work taking place. We would speculate that if mental health groups had been in place, then frequent users would certainly have demonstrated greater mental health problems than average users, as in the studies by Adelman et al18 and Wolk and Kaplan,17 and users would probably have demonstrated greater problems than nonusers, as in the studies by Balassone et al11 and Walter et al.16 In fact, as our program grew and we added a social worker and mental health groups to the program, visits for mental health needs increased accordingly,29 demonstrating that the age of an SBHC, as well as the services offered, influence use in very specific ways. Our experience also supports the standards for SBHC staffing described in the US Department of Health and Human Services report30 that recommended that urban SBHCs need a minimum of 1.0 to 1.5 full-time social workers to address the mental health needs of each 700 enrolled students.
Our study also differed from other utilization studies in that a large percentage of all students in the school were enrolled in the SBHC. Whereas 60% of students in our study were enrolled in the SBHC, only 43% of the students in the study by Balassone et al11 and 36% in the study by Walter et al16 were enrolled students. It may well be that SBHCs that serve a smaller percentage of the school population are choosing to aim their services at those with the greatest needs. In contrast, our health service, which served a larger percentage of the students in the school, presented itself as a general, comprehensive, medical program and was perceived by students in this way.7 It has always been our goal to provide services to as many students as possible, with the understanding that access to a larger percentage of students allows us to screen for mental health concerns among as many students as we can. Clearly, as the percentage of students enrolled in an SBHC increases, the differences between users and nonusers must decrease. The number of students seen, as well as the focus of different programs, must also be taken into account in evaluating utilization studies.
The prevalence of mental health problems as previously reported21 among this urban population included depression in 13%, daily alcohol use in 5%, suicidal ideation in 16%, and suicide attempts in 10%. In addition, 50% of responding students knew someone who was murdered, one third had witnessed a stabbing or a shooting, and two thirds had witnessed a beating or a robbery. These dramatic findings underscore the importance of the mental health service delivery issues that SBHCs face.
Our study indicated that the overwhelming majority of students who used the SBHC were satisfied with the services they received. This confirms earlier work8,10,11,31 suggesting that students find SBHCs an acceptable source for health care. Half of the students reported that the SBHC was their regular source of care, underscoring the ability of such a program to increase access to care. Twenty-nine percent reported that they had used the psychological service at the SBHC and found it helpful. In addition, while females were more likely than males to be frequent SBHC users, enrollment in SBHCs by sex has generally been close to equal. This underscores the great potential SBHCs have as a resource for comprehensive medical and mental health care for adolescent males.
Last, we surveyed students for reasons for not using the SBHC. Sixty percent reported already having a physician or other source of health care. Program issues, such as confidentiality, were raised as concerns by a small percentage of students, although males were more likely to have this concern. School-based health centers aim to avoid duplication and encourage students to use their own physician if they have one, but it is less likely that such students would have access to mental health services at these sites. Barker and Adelman32 reported on the professional help–seeking behavior of minority adolescents attending an urban high school that had an SBHC and found that, despite evident need for help, respondents indicated a generally low use of mental health services and that, of those who did use professional help, school-based resources were used most often. Since SBHC users and nonusers in our study had similar demographic and mental health characteristics, one has to question the adequacy of the care being received by the nonusers and the perceived lack of need they express, especially in the area of mental health.
Despite limitations of our study caused by use of a limited number of variables and of self-report measures, the findings in this study help to more fully describe the mental health problems and SBHC use among students attending an urban high school. While the study sample was representative of those enrolled in this school, it did not include students who might be estimated to be at highest risk for mental health problems—those with long-term absences, those who skip physical education classes, or those just absent during the survey (noted to be as many as 30% daily). Additional studies are needed to review more closely the influence of staffing patterns on SBHC use, which staffing models are best suited to meet student needs, and how to better reach the nonusers in school with SBHCs.
Accepted for publication April 6, 1998.
Editor's Note: One of the most amazing findings in this study is that 50% of the participants knew someone who had been murdered! How many of you would have reported that when you were in high school?—Catherine D. DeAngelis, MD
Corresponding author: Doris R. Pastore, MD, Mount Sinai Medical Center, Adolescent Health Center, 312 E 94th St, New York, NY 10128.
Pastore DR, Juszczak L, Fisher MM, Friedman SB. School-Based Health Center UtilizationA Survey of Users and Nonusers. Arch Pediatr Adolesc Med. 1998;152(8):763-767. doi:10.1001/archpedi.152.8.763