The Journal for Nurse Practitioners
Volume 3, Issue 10 , Pages 713-720, November 2007

School-Based Health Centers: A Model for Improving the Health of the Nation's Children

  • Laurie Scudder, MS, NP

      Affiliations

    • Laurie Scudder, MS, NP, is a nurse practitioner for Baltimore City School-Based Health Centers and assistant editor of JNP.
    • ,
  • Patricia Papa, MSN, CRNP

      Affiliations

    • Patricia Papa, MSN, CRNP, is an administrative nurse practitioner at Prince George's County School System and the founding president of the Maryland Assembly on School-Based Health Care.
    • ,
  • Laura C. Brey, MS

      Affiliations

    • Laura C. Brey, MS, is the training director of the National Assembly on School-Based Health Care.

Article Outline

Adolescence is often a challenging time, and these challenges become more daunting for children who live in poverty. Access to health care is an issue for these teens, and limited funds as well as the ability to get to health centers create further barriers, especially for preventive health care services. Adolescents today face many health care issues that will have a profound effect on their lives. The increased incidence of obesity and the subsequent morbidities such as type 2 diabetes will have lifelong effects on their health. The rising incidence of significant mental health disorders affects not only their ability to be successful in school but also their capability to function as independent adults. School-based health centers (SBHCs) are an innovative health delivery model that is ideally situated to address these morbidities. This article summarizes the health problems teens are facing in 2007 and the creative ways some SBHCs have addressed these problems.

Keywords:  School-based health care

 

Healthy People 2010, the third generation of health initiatives intended to address the health problems of the nation, represented a shift away from simple mortality measures toward the overarching goal of increasing the quality and years of healthy life. Although an evaluation of progress toward achieving the objectives outlined in that document revealed that positive changes had been achieved for infants, children, and adults, the analysis concluded that the goals for adolescents and the elderly had not been met.1

The Healthy People documents, although noting the effect of poverty on health, did not include abolition of poverty and its negative health effect as a leading health indicator but urged consideration of socioeconomic status in assessment of all indicators, attempting to ensure that health disparities attributable to poverty would be identified and, in a perfect world, corrected.

The effects of inequity are felt perhaps most profoundly in our nation's schools. The collision of poverty, poor nutrition, violence, and risk-taking behavior combine to create an environment, particularly on the high school level, that can make learning all but impossible.

Numerous studies over the years have documented the litany of concerns that face poor teens, including risky sexual behavior with the resultant increase in pregnancy and sexually transmitted infections, substance use, higher rates of chronic diseases such as asthma, and poorer use of preventive services such as immunizations, dental prophylaxis, and effective well-child care. Layered on these serious health risks are the cluster of problems labeled “new morbidities” such as obesity with its paradoxically higher incidence of nutritional deficiencies, such as osteopenia and anemia, and an ever-risking prevalence of mental health disorders, particularly depression, including bipolar disorder, and anxiety.

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The New Morbidities 

Obesity 

The rising incidence of obesity in adolescence was documented with the most recent data from the National Longitudinal Study of Adolescent Health.2 That study used definitions of obesity from the International Obesity Task Force and documented an overall obesity incidence of 12.7% in young people, aged 13 to 26 years. Obesity incidence was especially high in non-Hispanic black girls (18.4%). The prevalence of obesity increased from 10.9% in 1996 to 22.1% in 2001, with a rate of extreme obesity, defined as a body mass index (BMI; in kg/m2) greater than 40, in 4.3% in the older cohort of 19- to 26-year-olds. The increase is most rapid in Hispanic, African American, and poor children.3 In fact, obesity is becoming the most common health issue currently facing children in the United States and has been termed the “new malnutrition.”4

This rising epidemic of overweight and obesity is associated with hypertension,5 impaired glucose tolerance,3 pseudotumor cerebri,3 iron deficiency,6 sleep apnea,7 lipid abnormalities,3 left ventricular hypertrophy,8 fatty liver disease,8 and perhaps decreased bone density. Asthma, already more prevalent in urban minority youth, is exacerbated by obesity.9 Both depression and anxiety disorders have also been documented to be more prevalent in obese youth, although the link appears to be stronger in girls.10

Type 2 diabetes, a consequence of obesity, is on the rise in teens. A 2006 study that used data from two National Health and Nutrition Examination Surveys from 1999 to 2000 and 2001 to 2002 reported that almost 40,000 adolescents in the United States have type 2 diabetes. More staggering, 2.8 million were classified as prediabetic on the basis of impaired fasting glucose levels, a situation that the researchers called a “public health time bomb.”11 This condition is most prevalent in minority children.

Mental Health Disorders 

It is said that poverty isn't for sissies, and that may be particularly true for minority, poor youth in America's cities and rural communities. One study of male teens attending a Texas teen clinic noted a significant incidence of depression, anger and aggression, and relationship problems.12 Stressful life events, a staple for those living in poverty, and depression were shown to be linked, with data that suggest that stress leads to depression and depression leads to stress.13 Another study in Atlanta documented the risk-taking behavior of girls, noting the increased incidence of sexually risky behavior and substance abuse.14 Death rates for urban minority youth involved in the juvenile justice system are four to eight times that of the general population, with the overwhelming majority of these deaths the result of homicide.15 One study documented significantly lower levels of self-esteem in obese preadolescents and adolescents; these same young people were reported to demonstrate higher rates of sadness, loneliness, and nervousness and were more likely to engage in high-risk behaviors.16

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School-Based Health Care—Part of the Solution 

History of School-Based Health Care 

School-based health centers (SBHCs) provide comprehensive, confidential, culturally competent health services in settings that are integral to children. It is a sensible, appropriate, and valuable venue for the delivery of care that emphasizes prevention and early intervention.

SBHCs began in the 1960s as an initiative of the American Academy of Pediatrics. Funding from the Robert Wood Johnson Foundation in the late 1970s expanded the numbers and scope of these early centers, and the first nurse practitioner (NP) program for the development of school NPs began during that same period. Supporters of the delivery of comprehensive care in the least-restrictive setting for children included school nurses, teachers, parents, and other educators, including school boards, whose goal was to counter the inadequacy of community-based services for teens, particularly poor teens. These early efforts were controversial, facing opposition from those concerned about the delivery of reproductive health services and the potential impingement on parental rights.17

SBHCs have flourished in the past decade, and according to the National School-Based Health Care National Census School Year 2004 to 2005 there are 1708 centers in 45 states, with the majority (59%) located in urban communities. Although historically SBHCs were located in high schools, current data show that 30% are in high schools, 15% in middle schools, 20% in elementary schools, 14% in elementary-middle schools, 14% in K-12 schools, and 7% in middle-high schools. The elementary school setting has experienced the largest growth during the past 10 years.18

A 2003 survey of parents conducted by the Center for Health and Health Care in Schools, a nonpartisan policy and program resource center at The George Washington University School of Public Health and Health Services, with support from the Robert Wood Johnson Foundation, found overwhelming support for this model of care, with more than 80% of parents voicing support. This support crossed all demographic lines, with strong majorities of urban, suburban, Democratic, Republican, white, and black households all indicating support.19 A 2007 survey funded by the W.K. Kellogg Foundation noted that, when specific services were discussed, support was more varied, but even the most controversial services, such as management of sexually transmitted infections, continue to garner majority support.20

Who Uses SBHCs? 

The American Medical Association, the American Academy of Pediatrics, and the Society for Adolescent Medicine have all endorsed school-based or school-linked services for a wide range of physical and mental health conditions.20 A 1996 study conducted in Baltimore found that high school students used SBHCs most commonly for reproductive health diagnoses (28%) with psychosocial health concerns the second most common reason for care (12%). These findings were reversed for students in middle schools, where the most common reason for a child to be seen was for diagnosis or treatment of a psychosocial concern (30%) with reproductive health services the second most common reason (11%).21 In that study, the ratio of girls to boys who used SBHCs was 2:1.

A 1998 study in a New York City high school reported that the average student using an SBHC visited three or fewer times per school year. Mental health visits accounted for one third of these visits, with depression the most common diagnosis. Although boys and girls were enrolled in approximately equal numbers in this SBHC, girls were more likely to be frequent users.22

Efficacy of SBHC Care 

The focus on health promotion and disease prevention as well as the unique relationships between providers and students are assets of this model that help students develop positive behaviors to succeed. SBHCs, and the care providers in these settings, are accessible, “user-friendly,” and important sources of information. The New York City study noted that students using SBHC services reported strong satisfaction with the care received.22

A survey of Robert Wood Johnson–funded high school–based health centers completed in 1996 noted that this model resulted in improved access to health care and improved knowledge of health behaviors on the part of the students. A significantly higher number of students have visited a health care provider by their senior year in high school than that reported in other surveys of urban youth. This was particularly the case for students without access to alternative sources of health care, including uninsured teens.

Trends suggested that students enrolled in SBHCs were more likely to progress through school at the expected pace, although the difference compared with a national sample was not significant. However, an earlier study conducted in North Carolina in an alternative high school with only a 26% graduation rate found that, although clinic students were just as likely to be absent from school as nonclinic students, they were more likely to stay in school and be promoted and graduate; this was particularly true for black males enrolled in the clinic who were almost 3 times as likely to graduate.23

A study conducted in Colorado compared use of primary and subspecialty medical, mental health, and substance abuse treatment services; emergent care; and screening for high-risk behaviors by adolescents enrolled in managed care with access to an SBHC to adolescents enrolled in managed care without access to an SBHC. Adolescents with access to an SBHC were more than 10 times as likely to make a mental health or substance abuse visit.24 In addition, these teens visited an urgent care center only half as frequently as the teens without SBHC access. These teens were also more likely to receive a comprehensive health visit.

However, the effect of SBHC services, particularly on reducing risk-taking behavior, was mixed. The researchers, however, concluded that the lack of effect may have been the result of a poorly matched national sample, rather than a sample reflecting the same communities served by the SBHCs.25 In addition, the SBHCs studied had only been in existence for 2 to 3 years and may not have had sufficient time to become established in their communities.

Anecdotally, a key to the success of the SBHC model is related to access that allows health care providers the sustained, in-depth access necessary to uncover and address a whole spectrum of intractable concerns, something not offered by other models of care. Clinicians in SBHCs also have a greater opportunity to educate adolescents (their patients), and data from one study concluded that students served by an SBHC gained more knowledge about health issues by their senior year in high school and with this greater health knowledge came an increase in visits to the clinic for a wider variety of reasons.24 A survey conducted in Denver compared fertility rates during a 5-year period between black girls in areas served by SBHCs to girls in areas without clinics and concluded that, although pregnancy rates declined in both groups, the decline was more significant in areas with SBHCs. The researchers concluded that strategies used by SBHCs to identify and intervene with girls engaging in high-risk sexual behavior was the most likely cause for a dramatic decline in unintended pregnancies.26

School-Based Solutions 

Obesity. 

The intractable issue of obesity is difficult and frustrating to manage in any setting. However, SBHCs with the ability to interact frequently with students and to coordinate with other resources such as classroom teachers, physical education programs, and cafeteria staff are uniquely positioned to have a positive effect. A successful program begins with an assessment to determine what is needed by an individual school, what is already being done, and where gaps exist. This realistic review must establish practical, commonsense objectives and mechanisms for evaluation. Action for Healthy Kids, a national public-private partnership of more than 50 national organizations and government agencies formed after a 2002 call to action by former US Surgeon General David Satcher, has developed criteria for evaluation of school-based programs that is available free at their website (www.actionforhealthykids.org/pdf/exec_small.pdf).

A number of approaches have been developed with varying levels of success. Many programs are available for consideration by an individual school, and the right program should be selected based on size of school, age of students, demographic makeup of the school, resources available to students and their families, and engagement of school and community partners. The Centers for Disease Control and Prevention offers a variety of tools through the Healthy Schools, Healthy Youth program (www.cdc.gov/HealthyYouth/index.htm) to assist with this process. In addition, Action for Healthy Kids maintains a “what's working” database, a website describing and evaluating a large number of programs. Few programs specific to SBHCs have been developed, and no research compares outcomes between approaches.

The National Assembly of School-Based Health Centers website includes an anecdotal description of one of many innovative programs implemented in schools. The Nutrition Revolution is a multifaceted program developed by the SBHC at Proviso East High School in Maywood, Illinois.27 Developed in response to a chart audit conducted by the SBHC staff that confirmed the staff's observation that 70% of students were at risk for overweight, with a BMI greater than the 85th percentile, and 20% were already overweight (BMI > 95th percentile). The Nutrition Revolution includes a junk-free zone at the SBHC that combines a prohibition on consumption of junk foods such as chips, carbonated beverages, and candy at the clinic with a trade program that allows students to trade these foods with low nutritional value for healthy snacks such as fruit, pretzels, cheese, and water. Students and families also have the opportunity to participate in Cooking with Heart And Soul, which combines a one time per week cooking lesson, complete with eating the prepared foods together, and brief nutritional lectures on topics such as reading food labels, fats and sugars, serving sizes, exercise, and the Food Guide Pyramid. Prizes donated by local businesses are provided as is child care for younger siblings or the students' children. Other components of The Nutrition Revolution include a prenatal nutrition class and a walking club.

Another successful program, piloted in elementary schools across four states, is entitled Wellness, Academics & You (WAY).28 WAY was designed to reduce overweight, improve attitudes and knowledge about nutrition, and improve academic performance. This program was implemented by teachers who had applied to participate in the program, indicating a high level of commitment to this broad, standards-based program. Curriculum about wellness, nutrition, physical activity and fitness, and behavioral influences on eating was integrated across all disciplines, including language arts, mathematics, science, and health. Students participate in educational models, journaling, role play, and class discussion, with activities sequenced to build on information provided in previous lessons. In addition, physical education teachers in participating schools attended training sessions as part of the school intervention team, and a 10-minute aerobics routine was integrated into each class day. The intervention began in November 2003, and data were collected in May and June 2004. In the brief 6-month intervention period, statistically significant increases in fruit and vegetable intakes and physical activity were documented, with a corresponding positive shift in BMI and 2% reduction in the overweight population among children who participated. Anecdotally, teachers and parents reported positive changes in children's eating habits, and children self-reported increases in active play. A more complete description of the program can be found at www.wayplanet.com/wayplanet/.

As a result of a congressional mandate, schools across the United States were required to have wellness policies in place by the end of the 2006-2007 school year. Success at meeting that mandate has been varied. The National Association of State Boards of Education reports that 45 states are assisting local school districts with the development of wellness policies and that many have approved legislation or state board policies that provide direction on standards for both physical activity and nutrition.29 A Wellness Policy Tool to assist school systems and policy makers in the development of comprehensive wellness programs is available from Action for Healthy Kids at www.actionforhealthykids.org/wellnesstool/index.php.

Motivational interviewing was first developed by William Miller, PhD, and Steve Rollick, PhD, for use with clients with substance abuse problems.30 The technique also has application for the management of obesity. There are five general principles of motivational interviewing: (1) express empathy through reflective listening, (2) develop discrepancy between client's goals or values and his or her current behavior, (3) avoid arguments and direct confrontation, (4) adjust to client resistance rather than opposing it directly, and (5) support self-efficacy and optimism. The client rather than the counselor should present the arguments for change and decide when and how he or she is willing to change.

The National Assembly on School-Based Health Care website hosts a web conference that discusses the use of motivational interviewing for obesity management in schools. More information about this model can be obtained from the Substance Abuse and Mental Health Services Administration website (www.kap.samhsa.gov/products/tools/cl-guides/pdfs/QGC_35.pdf) and at www.nasbhc.org.

Depression. 

Mental health services delivered in school settings have a long and varied history, ranging from the roles of guidance counselors to school-based psychiatry. Services include preventative services to high-risk students, group interventions for behaviors such as smoking or high-risk sexual behavior, individual services, including diagnosis, therapy and medication, for students with depression, anxiety, anger management, and other definable conditions. Particular emphasis is placed on school safety, prevention initiatives, and substance abuse treatment.

SBHCs play a unique role in providing services to often hard-to-reach populations. Mental health visits in teens may occur for a variety of reasons beyond the fairly limited range of diagnosable mental health disorders; problems addressed in school settings include stress-related concerns, learning problems, situational problems, family disruptions, and a host of other concerns. In fact, a 2005 report prepared by the Center for Mental Health In Schools at the University of California, Los Angeles, reported that as many as 50% of urban youth experienced a mental health concern, defined as significant learning, behavioral, or emotional problems.31 One study that compared reasons for visits by inner-city high school students to community health centers with reasons for visits to SBHCs found that, although virtually all visits to the community centers were for medial reasons, one third of visits to SBHCs were for mental health reasons.32 In fact, that study found that teens were 21 times more likely to initiate a visit to an SBHC for a mental health concern.32 In 2006 the codirectors of the Center for Mental Health in Schools argued that this range of mental health issues, outside of diagnosable conditions that are rooted in internal pathology, requires a comprehensive management strategy that incorporates all of the professional resources of a school setting, including counseling, physical health, educational modifications, after-school programs, service learning projects, and social services.33

The New York State Department of Health School Health Program convened a School-Based Health Centers Mental Health Work Group. A report from that group issued in 2001 defined core SBHC mental health activities as the following34:

•Early identification of students likely to benefit from intervention

•Assessment and evaluation

•Individual, group, and family counseling and treatment

•Service coordination, including referral and follow-up

•Prevention and early intervention

Emphasizing that mental health activities should not be the sole purview of mental health practitioners, the work group argued that mental health care in schools is best delivered by a multidisciplinary team that allows triage of the student; fluidity between the roles of mental health professionals, school nurses, and NPs; and close coordination between team members. In addition, the work group recommended that SBHCs use a drop-in center format, frequently reassess both individual students and the SBHCs mission, and provide continuing education for all providers involved in the delivery of mental health services. Finally, the researchers of the report emphasized the need for SBHCs to collaborate with school leadership, recognizing the different and sometimes conflicting missions of school personnel, with an emphasis on delivery of education and functioning of the school institution, and health care personnel, whose primary role may be to serve as child health and mental health advocates.

Guidelines for SBHC Care 

With support from the Bureau of Primary Health Care, US Department of Health and Human Services, and the Robert Woods Johnson Foundation, Making the Grade (now the Center for Health and Health Care in Schools) developed a continuous quality improvement (CQI) tool specific to SBHCs. Because SBHCs provide care to three distinct age groups of children, the tool presents “sentinel conditions” for elementary, middle school, and high school age groups. These conditions represent typical health risks for each age group and serve as a yardstick for planning and measurement of care. The original tool recommended an annual risk assessment and biennial physical examination for students at all age levels. In addition, monitoring children's school performance is clearly important at all ages. As children grow older, the focus moves from an emphasis on immunizations, asthma, and injury, both unintentional and intentional, to mental health and behavioral concerns, including substance use, violence, sexual behaviors, including pregnancy and risk of sexually transmitted infection, and depression. The tool references a large number of tools available from professional associations, such as the Bright Futures tool from the American Academy of Pediatrics and the Diagnostic and Statistical Manual for Primary Care from the American Psychiatric Association, as well as federal and state tools such as the US Preventative Services Task Force and US Public Health Service guidelines.35

In 2003 the tool was transferred to the National Assembly on School-Based Health Care. At the assembly, the tool is housed in the Center for Evaluation and Quality where a volunteer panel of clinicians, evaluators, and administrators oversees its implementation and further development. The Bureau of Primary Health Care provided additional support to the assembly in 2002-2003 for the development of a CQI data management program that allows users to enter data from CQI tool chart audits, obtain automatic calculations, and retrieve reports based on entered data. In 2007 the tool was reviewed by an expert panel, and revisions to the existing sentinel conditions as well as additional sentinel conditions primarily related to mental health were recommended. The CQI tool with the data management application is available for download on the NASBHC website and on CD-ROM.35 The tool is available online at www.nasbhc.org/site/c.jsJPKWPFJrH/b.2743599/k.D917/CQI_Tool.htm.

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Conclusions 

Although the huge growth in SBHCs bodes well for the future of this important delivery model, funding continues to be a significant concern with the potential to derail care provided in these settings. In February 2007 Senators Dodd (D-CT) and Smith (R-OR) introduced the School-Based Health Clinic Establishment Act of 2007. The purpose of this bill is to amend the Public Service Act to establish the School-Based Health Clinic Program. The Act authorizes $50 million for fiscal year 2008 and such sums that may be necessary for fiscal years 2009 to 2012 for opening and operations of SBHCs. This bill can be read at www.nasbhc.org. In late June 2007, The Healthy Schools Act of 2007 (S 1669) was introduced by Senator Stabenow (D-MI) along with six original cosponsors and Representative Townes (D-NY). This bill would allow states to make SBHCs eligible for reimbursement under Medicaid and the State Children's Health Insurance Program (SCHIP) for covered services provided to children and adolescents who are enrolled in Medicaid and SCHIP. The bill establishes minimum criteria for “primary health services” as the core group of services offered by an SBHC, including comprehensive health and mental health assessments, intervention and treatment, oral health, social services, and health education service. The bill in its entirety can be read and tracked at http://thomas.loc.gov/. The need for stable funding is imperative for the survival of existing centers and to develop additional ones.

SBHCs are a model that has shown some success in addressing these new morbidities that affect the lives of our nation's children and adolescents. Additional studies need to be done to look at outcomes and models of care that are proven to be effective.

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References 

  1. In:  Chrvala CA ,  Bulger RJ editor. Leading Health Indicators for Healthy People 2010: Final Report. Division of Health Promotion and Disease Prevention, Institute of Medicine . Washington DC: National Academy Press; 1999;
  2. Gordon-Larsen P , Adair LS , Nelson MC , Popkin BM . Five-year obesity incidence in the transition period between adolescence and adulthood: the National Longitudinal Study of Adolescent Health . Am J Clin Nutr . 2004;80(3):569–575
  3. Baker S , Barlow S , Cochran W , et al.   Overweight children and adolescents: a clinical report of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition . J Pediatr Gastroenterol Nutr . 2005;40(5):533–543
  4. Schwarz KB , Garrett B , Hampsey J , Thompson D . High prevalence of overweight and obesity in homeless Baltimore children and their caregivers: a pilot study . MedGenMed . 2007;9(1):48
  5. Ribeiro J , Guerra S , Pinto A , Oliveira J , Duarte J , Mota J . Overweight and obesity in children and adolescents: relationship with blood pressure, and physical activity . Ann Hum Biol . 2003;30(2):203–213
  6. Nead KG , Halterman JS , Kaczorowski JM , Auniger P , Weitzman M . Overweight children and adolescents: a risk group for iron deficiency . Pediatrics . 2004;114(1):104–108
  7. Young T , Peppard PE , Gottlieb DJ . Epidemiology of obstructive sleep apnea: a population health perspective . Am J Respir Crit Care Med . 2002;165(9):1217–1239
  8. Hoppin AG . Assessment and Management of Childhood and Adolescent Obesity . Available at: www.medscape.com/viewprogram/3221 2004; Accessed May 10, 2007.
  9. Schaub B , von Mutius E . Obesity and asthma, what are the links? . Curr Opin Allergy Clin Immunol . 2005;5(2):185–193
  10. Anderson SE , Cohen P , Naumova EN , Must A . Association of depression and anxiety disorders with weight change in a prospective community-based study of children followed up into adulthood . Arch Pediatr Adolesc Med . 2006;160(3):285–291
  11. 39,000 U.S. kids have type 2 diabetes. Available at: www.medscape.com/viewarticle/531585. Accessed June 21, 2007.
  12. Smith PB , Buzi RS , Weinman ML . Mental health problems and symptoms among male adolescents attending a teen health clinic . Adolescence . 2001;36(142):323–332
  13. Waaktaara T , Helmen Borgeb AI , Fundingsrudc HP , Christiea HJ , Torgersen S . The role of stressful life events in the development of depressive symptoms in adolescence: a longitudinal community study . J Adolesc . 2004;27(2):153–163
  14. Bachanas PJ , Morris MK , Lewis-Gess JK , et al.   Predictors of risky sexual behavior in African American adolescent girls: implications for prevention interventions . J Pediatr Psychol . 2002;27(6):519–530
  15. Teplin LA , McClelland GM , Abram KM , Mileusnic D . Early violent death among delinquent youth: a prospective longitudinal study . Pediatrics . 2005;115(6):1586–1593
  16. Strauss RS . Childhood obesity and self-esteem . Pediatrics . 2000;105(1):1–5
  17. Gustafson EM . History and overview of school-based health centers in the US . Nurs Clin North Am . 2005;40(4):595–606
  18. National Assembly on School-Based Health Care  . National School-Based Health Care National Census School Year 2004-2005 . Available at: www.nasbhc.org/atf/cf/%7BCD9949F2-2761-42FB-BC7A-CEE165C701D9%7D/Census2005.pdf Accessed July 31, 2007.
  19. Center for Health and Health Care in Schools. Parents Overwhelmingly Favor Providing Health Care Services In Schools; Support Cuts Across Party Lines, Income Levels And Race, National Survey Finds. 2003. Available at: www.healthinschools.org/press/poll.asp. Accessed May 20, 2007.
  20. W.K. Kellogg Foundation. National Survey: Executive Summary. 2007. Available at: www.healthinschools.org/press/poll.asp. Accessed May 25, 2007.
  21. Borenstein PE , Harvilchuck J , Rosenthal BH , Santelli JS . Patterns of ICD-9 diagnoses among adolescents using school-based clinics: diagnostic categories by school level and gender . J Adolesc Health . 1996;18(3):203–210
  22. Pastore DR , Juszczak L , Fisher MM , Friedman SB . School-based health center utilization . Arch Pediatr Adolesc Med . 1998;152(8):763–767
  23. McCord MT , Klein JD , Joy JM , Fothergill K . School-based clinic use and school performance . J Adolesc Health . 1993;14(2):91–98
  24. Kaplan DW , Calonge NB , Guernsey BP , Hanrahan MB . Managed care and school-based health centers. Use of health services . Arch Pediatr Adolesc Med . 1998;152(1):25–33
  25. 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(5):335–343
  26. Ricketts S , Guernsey B . School-based health centers and the decline in black teen fertility during the 1990s in Denver, Colorado . Am J Public Health . 2006;96(9):1588–1592
  27. Read C . The Nutrition Revolution: a school-based health center addresses overweight and eating habits . Available at: www.nasbhc.org/TAT/Newsletter/NutritionRevolution.htm Accessed June 22, 2007.
  28. Spiegel SA , Foulk D . Reducing overweight through a multidisciplinary school-based intervention . Obesity . 2006;14(1):88–96
  29. School wellness policies and the fight on childhood obesity . Center for Health and Health Care in Schools eJournal . 2007;8(4): Available at: www.healthinschools.org/ejournal/2007/june2.htm Accessed June 24, 2007.
  30. Miller WR , Rollnick S . Motivational Interviewing: Preparing People to Change Addictive Behavior . New York, NY: Guilford Press; 1992;
  31. Center for Mental Health in Schools at UCLA  . Youngsters' Mental Health and Psychosocial Problems: What are the Data? . Los Angeles, CA: Autor; 2005; Available at: http://smhp.psych.ucla.edu/pdfdocs/prevalence/youthMH.pdf Accessed June 25, 2007.
  32. Juszcazk L , Melinkovich P , Kaplan D . Use of health and mental health services by adolescents across multiple delivery sites . J Adolesc Health . 2003;32(suppl):108–118
  33. Adelman H , Taylor L . Mental health in schools and public health . Public Health Rep . 2006;121:294–298
  34. New York State Department of Health, School Health Program  . School-Based Health Centers Mental Health Work Group Final Report, 2001 . Available at: www.healthinschools.org/sr/states/NY/nymental.asp Accessed June 25, 2007.
  35. National Assembly on School-Based Health Care  . Continuous Quality Improvement Tool for SBHCs . Available at: www.nasbhc.org/site/c.jsJPKWPFJrH/b.2743599/k.D917/CQI_Tool.htm Accessed July 31, 2007.

 In conjunction with national ethical standards, the first two authors report no relationships with business or industry that represent a conflict of interest. As noted, Brey is an employee of the National Assembly of School-Based Health Centers.

PII: S1555-4155(07)00579-X

doi:10.1016/j.nurpra.2007.08.025

The Journal for Nurse Practitioners
Volume 3, Issue 10 , Pages 713-720, November 2007

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