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Assessing rural community viewpoints to implement a school-based health center.

Rural areas face significant access-to-care problems due to dwindling numbers of primary care practitioners, limited office hours, hospital closings, long distances to travel for health care, and financial constraints.[1-3] School-based health centers (SBHC) offer a promising means of improving access to health care in rural areas.[4] Because school-based health centers may increase access, improve convenience, and lower costs of health services, it seems rural communities would embrace the centers. However, these communities often are closely knit, conservative, and somewhat wary of outside interventions.

Successful planning for school-based health centers in rural areas requires integrating data from diverse community sources. Undertaking a community assessment to determine the level of acceptability of a center, and the range of services to be provided is important to the community's perception and support. The information gathered helps in establishing the scope of services to be offered. More importantly, the process of bringing community members together to discuss school-based health centers promotes community participation and increases awareness about health issues facing youth in rural areas. Several community assessment methods gauged the need for school-based health centers in six schools in rural, south-central New York State in federally designated health professional shortage and medically underserved areas.

PLANNING PROCEDURES

Existing Data Review

Pertinent demographic, health, and human services data were gathered from existing sources, including the 1990 US Census (Table 1). Data were used to profile each school's relative need for a school-based health center.
Table 1
Existing Data Used to Profile the
Need for a School-Based Health Clinic

US Census:               per capita income
                         % rural residence
                         % in single-parent
                         households
                         % without telephone
                         child poverty rate

Dept, of                 # Medicaid insured
Social Services:         # of Child Protective Service
                         reports
                         # of children seen by a
                         department social worker

Dept,                    county-level adolescent
of Health:               pregnancy rate

School Records:          # of students in school per
                         grade
                         school attendance rates
                         immunization rates
                         % drop out
                         % transient families
                         % free- or reduced-lunch
                         # adolescent pregnancies


Community Organizational Activities

Initial interest in school-based health centers was identified by telephone conversations with school district superintendents who received information about potential grant funds and the state guidelines for school-based health centers. The authors visited superintendents, school nurses, and other administrators. Three schools decided to form a joint advisory council at this initial stage. Three other schools formed separate advisory councils. Councils were comprised of school staff and board members, parents, community, business, and religious leaders (eg, local companies, store owners, day care provider), local legislators, and student body leaders. Councils were convened to consult on the design, content, and scope of the community assessment, and to form subcommittees. Many advisory council members had children or grandchildren in school, and were already involved in health and safety projects. Board members from county agencies, the local vocational school, and local Planned Parenthood, groups already providing limited services to schools, were interested in the integration and nonduplication of services. The advisory board's interest and momentum were motivated by winning the planning grant initially and subsequently maintained by the prospects of having school-based health centers in their schools.

Focus Groups

Focus groups were conducted separately with community members, school staff, and students in grades 6-12 in each district. A school administrator and the advisory council selected key informants who were aware of the potential for bias in such groups and therefore attempted to select a diverse cross-section of individuals, including skeptics. Focus groups were conducted by the authors and assistants (not school staff) experienced in conducting such groups. When possible, same-gender professionals conducted male and female student focus groups. Participants were encouraged to be candid about their views about school-based health centers and were assured anonymity. Twenty-four focus groups were held, four in each school district, with six to nine participants per group. Results reporting community views, school staff views, and student views follow.

Community Views. Overwhelming support existed for the concept of school-based health centers. Most questions related to space, funding, billing, confidentiality, and assurance of high-quality care by the primary care providers in the centers. Parents approved of staffing by nurse practitioners and physician assistants who could write prescriptions, but they wanted assurance that these mid-level providers would be adequately supervised. Most thought school-based health centers should provide physical examinations, dental services, mental health and preventive education, but not family planning services. Most felt reproductive and substance abuse issues could be referred to other county agencies.

School Staff Views. School staffs supported the idea of school-based health centers because they could provide quick access, reduce absenteeism, and make care available for students without insurance. Absenteeism due to illness, or due to the need to leave school to see a physician, was viewed as an important problem that would be partially addressed by having access to medical care in school. Lack of space, future funding, and confidentiality issues were concerns. Proper functions of the school-based health centers were thought to include preventive health education, counseling, and screening for common diseases, but not contraception. Staff identified alcohol use as the most important substance abuse issue.

Student Views. Students were open and eager to share their views, which were frequently different from, and at odds with, views expressed by parents and school staff. Students indicated they would use the centers for physical examinations, illnesses, and as a place to talk about personal issues. Though they knew what constituted a healthy diet, they preferred to eat less healthy foods such as pizza, potato chips, and candy. Anger was reportedly dealt with more by sounds and signs of aggression than by actual fighting, though a few students described efforts by students to gather around fights to watch and encourage them.

Abuse of cigarettes, illegal substances, and especially, alcohol, was reported as heavily influenced by certain peer leaders. Many students smoke tobacco and drink alcohol, some smoke marijuana, and a few use LSD. Alcohol, as a problem, was seen as not so much the volume of alcohol consumed, but the need to drive home later. Teen-age pregnancy was perceived as a large problem, and classroom sexuality education was seen as limited by outdated methods and materials. Most students did not feel they were receiving adequate sexuality education at home. Most peers were perceived to be sexually active by graduation. Students were near unanimous in their desire for sexuality education, and about one-half would like to see condoms available in schools. Condoms are available at local drug stores (in villages that have drug stores), but students will not use these sources because "everyone knows me there." Students described finding a ride to the nearest urban area to buy contraceptives.

Telephone Survey of Parents

Twenty questions, both structured and open-ended, were carefully crafted by advisory councils to elicit community views regarding school-based health centers. Written notices about the telephone survey were sent home to parents. Using phone numbers provided by schools, a systematic random sample of student households was surveyed. Parents were assured their responses would be kept anonymous. In addition to specific questions about their child's health needs, current health care and potential use of a school-based health center, two open-ended questions queried parents about: 1) health problems they felt should not be addressed by a school-based health center, and 2) health problems that should be addressed in educational sessions for parents. At each school, 10 to 12 interviewers, authors and community volunteers, were trained to conduct the telephone questionnaire during weekday evening hours.

The telephone survey response rate was 95% (n=189 parents). Most parents (78%) felt their well child care needs were currently met, and 84% of families had health insurance. Forty percent of parents interviewed had a child eligible for the free-lunch or reduced-lunch program. Most parents (86%) favored school-based health centers and indicated they would use the center for their own child, even if they currently had a primary care provider or had health insurance. However, most parents (82%) reported their child would continue to use their current primary provider; for 52%, this provider was located more than 10 miles from home. Most parents (93%) felt well child care was important. Fifty-five percent of parents felt they could attend school-based health center visits. Seventy-two percent of parents indicated they would attend parent educational sessions.

Open-ended questions yielded a strong parental response that reproductive health issues (sexuality, STD care, and contraception) should not be addressed by the centers, but in educational sessions for parents and by family planning services off campus. Many (50%) described alcohol, illegal drug use, and teen-age pregnancy as significant problems, but only 40% felt the centers should deal with all health problems. Parents suggested that education (45%), abstinence (31%), and birth control (24%) were the primary methods for dealing with the pregnancy problem. Several respondents mentioned mental health services as an area of intense need.

School Staff Survey

Superintendents distributed a two-page, written questionnaire (14 questions) for school staff. The response rate was 34% (n =172). Rapid access to care, care for students without health insurance, and reduced absenteeism were major reasons for supporting school-based health centers. A few staff were concerned the centers were yet another way of supplanting parental responsibility. Other issues included space limitations, increased taxpayer cost in the future, and sustainability after grant funding ended.

Assurance of confidentiality for teen-agers was perceived as important. However, staff felt parents should be notified of a student's visit to the center and given the option to be present.

School staff indicated the focus of school-based health centers should be medical diagnosis and treatment, and health education to include reproductive health and substance abuse prevention. One-half the staff felt alcohol and drug use and teen-age pregnancy were problems in their schools. Abstinence and education were seen as the primary methods of dealing with an acknowledged teen-age pregnancy problem. Most staff felt that the centers should not provide sexually transmitted disease (STD) care and contraceptives.

OUTCOMES AND IMPLICATIONS

After the community assessment process was complete, five communities proceeded to support implementation of school-based health centers in their schools. One community withdrew its support. Three communities subsequently were funded to implement centers, offering comprehensive medical, mental health, and prevention services. Current enrollment is at 68% with approximately 3,000 visits in the first year.

To prevent duplication of services, children with primary care providers other than the school-based health center are faxed a one-page visit sheet that summarizes the patient's history, physical diagnosis, and management. If a complicated condition being managed by an existing primary provider arises in school and the student presents to the center, the center practitioners contact the primary care provider and inform them of the student's current problems. A joint decision then is made about how the patient should be managed. Because most children do not regularly access primary care, and limited numbers of primary care providers practice in the area, the threat to continuity of care with existing primary care providers is limited.

School-based health centers are projected to be largely self-sufficient after the five-year grant period. Local managed care companies view centers as cost-effective sources of care for children. Changes in regional managed care have altered negotiations with the school-based health centers and in some cases, a portion of the primary care capitation is being sought to support them. Centers are pursuing other funding sources to continue funding mental health services, which are not fully reimbursed by managed care plans.

Contrasting views between parents and adolescents regarding family planning services presented a significant dilemma in the development of comprehensive school-based health centers. However, these views were not static, and each community's perception and level of understanding of the centers has evolved over time. In part, this change is due to the assessment process, which promoted discussion of the issues and served as a community education tool.

Changing views also are attributable to certain circumstances. For example, in one community initially opposed to the provision of contraceptive services in the school-based health centers, four pregnancies occurred in the high school (per 100 eligible females), which led to less opposition to providing contraceptive services.

A divided view between students and parents on sensitive issues suggests a need for comprehensive health education programs for both students and adults, followed by a reassessment of the need for and appropriateness of these services. While health education for students can occur at school, parents need to be reached by home health education mailings as well as strategically scheduled educational sessions after school hours, during open houses, or parent nights. Topics parents raised during the telephone survey could be addressed in this manner as well as those raised by school and SBHC staff.

References

[1.] Rowland D, Lyons B. Triple jeopardy: rural, poor and uninsured. Health Serv Res. 1989;23(6):975-1004.

[2.] DeFriese GH, Ricketts TC. Primary health care in rural areas: an agenda for research. Health Serv Res. 1989;23(6):930-974.

[3.] Johnson L. Saving rural health care: strategies and solutions. J Health Care Poor Underserved. 1994;5(2):76-82.

[4.] Sells W, Resnick MD, Walker J. School-based and School-Linked Clinics in Rural America. A Report for the Office of Rural Health Policy, Health Resources and Services Administration. Minneapolis, Minn: University of Minnesota National Adolescent Health Resource Center; 1995.

Anne Gadomski, MD, MPH; Barbara McLaud, MSEd; Carol Lewis, MSW, ScD; and Chris Kjolhede, MD, MPH, Research Institute, Mary Imogene Bassett Hospital, One Atwell Road, Cooperstown, NY 13326. This study was funded in part by the Robert Wood Johnson Foundation through the New York State Dept. of Health "Making the Grade" initiative. This article was submitted September 29, 1997, and revised and accepted for publication April 3, 1998.
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Author:Gadomski, Anne; McLaud, Barbara; Lewis, Carol; Kjolhede, Chris
Publication:Journal of School Health
Date:Sep 1, 1998
Words:2253
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