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Innovation, peer teaching, and multidisciplinary collaboration: outreach from a school-based clinic.

School-based clinics (SBCs), serving the health care needs of underserved adolescents, have gained increased acceptance during the past decade. Traditionally, SBCs function as primary health care providers, with services oriented heavily toward personal care and curative services. [1], [2] Choices regarding services clinics provide usually are made based on traditional curative service models, as well as prevailing community beliefs about which ills beset their teens. Substance abuse prevention and unwanted pregnancy are popular choices of health care providers planning SBC services. Consumer attitude surveys infreqently provide a basis for program planning, yet such needs assessments are critical, both in marketing services and in identifying which services and programs will attract active participation by adolescent health care consumers. [3]

This article describes how a traditional SBC, which emphasized providing curative services, evolved with school community input into a multidisciplinary project emphasizing prevention through classroom teaching and self-esteem building activities. This model represents a framework for systematically approaching, implementing, and evaluating the classroom project intervention, while maintaining primary health care services for students.

THE SETTING

A school-based clinic in a predominantly Hispanic, inner city, neighborhood high school in Albuquerque, N.M>, with a census of approximately 1,600 students, has existed for the past six years. [4] Supervised by the University of New Mexico Dept. of Family and Community Medicine, the SBC is a multidisciplinary clinic staffed by a nurse, students, residents, fellows, and faculty from a nearby nursing and medical school. The clinic operates two half-days each week and cares for 2-25 students each half-day. Seven providers spend at least one half-day each week at the SBC.

IDENTIFYING PERCEIVED PROBLEMS

To assess the health needs of this high school community, a variety of data were collected: a break down of presenting problems seen at the SBC; an analyses of questions that students asked clinic staff during open, in-classroom question sessions; a 25-item questionnaire administered to all students concerning their own health risks and concerns; and selected interviews with administrators, teachers, and health care providers about their ranking of health and behavior problems among the high school students.

Presenting problems at the clinic showed a standard array of teen concerns at most primary care centers (Table 1) with a preponderance of visits for physical complaints or sports physical examinations. Concerns expressed by students through written questions in the classroom revealed a different pattern of concerns than those presented in the clinic, the former focusing on reproduction, sexually transmitted diseases, and chemical dependency (Table 2). Questions were frank and often a challenge for SBC staff to answer spontaneously:

"What is the quickest, most painless way of committing suicide?" "Where can you go to get birth control (condoms) without feeling embarrassed?" "Is there a diet pill that really works?" "Why does sex almost become a necessity after the first time?" "If a girl had sex with two different people and you were going to be the third, is there a greater chance of getting VD?" "What should I do when I see my parents using drugs"

To assess perceived health risks and needs of the high school students, a 25-item questionnaire was administered to a sample of the school population, grades 9-12. Survey results showed a high prevalence of feelings of depression and worry about relations with parents and friends (Table 3). Violence and drug use seem a prominent part of the social environment of about a one-thrid of students and the risk for pregnancy is high, with one-half the sexually active teens not using contraceptives.

SBC staff informally surveyed teachers, administrators, health providers, and students concerning each group's perceptions of teens' most important problems. Health providers rated unplanned pregnancy as the leading problem. Teachers and school administrators reported early school drop-out as the
                             Table 1
  Diagnoses of Consecutive Student Visits to a High Schhol SBC
              During the 1988-1989 Academic Year
     Diagnosis               Number   %
 Respiratory infection         87     20
 Sports physical examination   66     15
 Musculoskeletal               63     14
 Eye infection                 52     12
 Family planning/sexuality     51     12
 Dermatologic                  40      9
 Stress/headache/counseling    26      6
 Gastrointestinal              24      6
 Ear                           15      3
 Genitourinary                 12      3
 Other                         17      4
 Total                        453    100
                            Table 2
     Caterogies of High School Student's Questions Written
       Anonymously During Classroom Discussions With
                   Teen Clinic Providers
     Category                  Number         %
 Reproduction                    34           22
 Sexually transmitted disease    24           16
 Chemical dependency             14            9
 Acne and other skin diseases    10            6
 Nutrition                        7            5
 Depression/death/suicide         7            5
 Other                           58           38
 Total                          154    101 (rounding)
                          Table 3
            Responses to a Sample of Questions
      High School Student Questionnaire (Grades 9-12)
                                              Female    Male
                                              n=321    n=327
 Feeling
      Often feel depressed                     33%      27%
      Have tried to end my life                23%      17%
      Worry about acceptance by others         44%      35%
      Worry about not satisfying parents       58%      52%
 Violence
      Have weapons at home                     33%      45%
      Friends often become violent             36%      41%
 Drugs
      I smoke cigarettes                       17%      25%
      I drink alcohol                          39%       47%
      Family member has alcohol/drug problem   31%       22%
 Sexuality
      I am sexual active                       42%       68%
      If active, I use birth control           51%       49%


major problem. Students grouped their leading problems in the area of family relations and peer pressure and acceptance.

DESIGNING THE INTERVENTION

With limited resources and only two half-days per week available for a SBC intervention, the clinic team explored potential interventions broad enough to address the needs expressed by teens, teachers, and administrators, Interventions that raised students' self-esteem could have the greatest generalized effect, reducing a variety of risky behaviors while encouraging students to stay in school. [5], [6]

A coordinated effort was undertaken whereby each provider adopted a class which was visited weekly or biweely during the provider's half-day at the school. Teachers showing the most enthusiasm for the project were recruited at the beginning of the school year. Each teacher-provider team was encouraged to pursue activities to complement the curriculum, whether the subject was English, communication skills, or health education. To foster student ownership and control of classroom activities, the focus and selection of those activities was the students' responsibility. The following examples, taken from "field notes" written by participating health providers, represent the various classroom activities selected and pursued by the students.

Class A. Our 10th grade communications class worked for weeks on its presentation about AIDS. They conducted two teaching sessions for seventh grade students at their feeder middle school. The middle school health science teacher, delighted with the 10th grade students' presentation, invited them back to teach new subjects. She noted how much more credence many mid-school students put in advice given by high school students than in that given by their teachers. With this success under their belt, our class then offered its services on the children's ward of the county hospital. They fed infants and entertained children on the pediatric ward. They interviewed a teen mother their own age about her premature infant, his multiple corrective surgeries, and how her life had been changed by this responsibility. The students were moved by how fragile life can be.

Class B. Ours is an English class for slow learners. As a class project, each student chose a commonly abused drug to research in the libray. Each week, classroom talks focused on drug use and effects and on abuse prevention. Guest speakers were invited from Alateen, the local police, the local newspaper, and from other community groups. Students made a field trip to the university hospital and newborn nursery and learned about effects of drugs on mothers and infants during and after pregnancy. They also witnessed drug-related emergencies in the emergency room.

After collecting drug information from the research and field trips, the class developed a drug education program based on the Alcoholics Anonymous model. Each student adopted a name and persona then created a story, illustrated by a poster, about how their lives had been affected by drug abuse. For many students, the stories were about themselves, a family member, or a friend. After inclass practice, students presented their program to a local fifth grade class at a feeder elementary school.

Class C. the class was a special education health class. After a local newspaper printed a story on health-related employment opportunities, the class decided to focus on learning about health careers. During a day-long field trip to the university hospital, students spent the day with a ward clerk, nutritionist, echocardiology technician, and laboratory technician. One student, notorious for missing school on field trip days, wrote:

"I had a good time. I thought that what we did was very interesting. I learned a lot about hearts that I didn't know. Now I know what the mitral valves is. I though it was very scientific to know that much about hearts. What I am really trying to say is that I would like to become a doctor like you guys."

The teacher subsequently observed this student;s school attendance and class participation improve. Another student wrote:

"The best part that I liked was [learning about] infectious diseases, and how the bacterias grow on those plates. When I get out of high school, I might consider a job in the lab."

The students then decided they would learn CPR, which was incorporated into their class schedule. All class members were trained and later certified in Basic Life Support.

MONITORING PROGRAM IMPACT

Health care in the high school clinic was modified based on student and teacher surveys and classroom projects. First, instead of "stealing time" from the clinic to "squeeze in" classroom visits, providers blocked time away from the clinic for classroom and community projects. Second, new teen patients received a medical/social history screening form to complete before visiting the provider. The form asked about issues that had arisen in the student survey and classroom discussions but were not routine chief complaints of teens presenting to the clinic. This screening instrument successfully elicited hidden emotional and physical concerns of students presenting to the clinic with minor complaints or for sports physical examinations.

A high student turnover rate made objective changes in student attitudes and behavior difficult to measure during the academic year. As with other inner city schools, many students changed schools, some left to take the GED, some dropped out for academic or social reasons, and others returned to family in Mexico. Nonetheless, teachers and health care providers felt positive at the end of the year about the project's influence in their classes. Most teachers could identify students for whom the project made a profound impact -- a student stopping use of illicit drugs or beginning use of birth control or deciding not to drop out of school.

Most teachers felt that, compared to their usual classes, students in the intervention classes became more supportive of each other. These students were described as more open-minded and more able, over time, to talk about themselves and their feelings. The process was an esteem-builder for many students. Several teachers commented that the weekly meeting to discuss the classroom project was "the one class they don't want to ditch."

Some difficulties arose. One health provider had to decrease her classroom attendance due to another commitment. Her class resented this action and expressed feelings of abandonment and anger. Another problem arose during one class presentation on drugs at a feeder elementary school. Several teens admitted that, while they strongly opposed drug use, they still used marijuana occasionally. Two elementary school teachers were angered that the high school students revealed this information. This incident subsequently led to an important discussion between SBC providers and elementary school teachers about how honest a speaker should be about drug use.

At the end of the school year, students from the target classes, their teachers, and health care providers invited students' families to an evening presentation of the year's project. More than 200 family members attended, watching the teens put on skits, relate anecdotes, and share feelings about what they had learned. Each student received a project t-shirt. The evening held special significance for this inner city high school where few parents attend Parent-Teacher Association meetings or participate in school functions and few experience an event in which their teens are so honored. For most students struggling academically and socially, such an evening's recognition was a singular experience in their high school career.

References

[1] Black JL. School-based clinics: Filling unmet needs for teens. Contemp Pediatr. 1989;(March):117-140.

[2] Council on Scientific Affairs. Providing medical services through school-based health programs. J Sch Health. 1990;60(3):87-91.

[3] Riggs S, Cheng T. Adolescents' willingness to use a school-based clinic in view of expressed health concerns. J Adolesc Health Care. 1988;9:208-213.

[4] Gonzales C, Mulligan D, Kaufman A. Adolescent health care: Improving access by school-based service. J Fam Pract. 1985;1:263-268.

[5] Weitzman M, Klerman LK, Lamb G, Menary J, Alpert JJ. School absence: A problem for the pediatrician. Pediatrics. 1982;69:739-746.

[6] Hayes DM, Fors SW. Self-esteem and health instruction: Challenges for curriculum development. J Sch Health. 1990;60(5):208-211.

Mario Pacheco, MD, Fellow; Victor Mancha, MD, Resident; Dan Derksen, MD, Assistant Professor; Arthur Kaufman, MD, Professor; Lisa Davis, CNM, Coordinator of Adolescent Services; and Patsy Nelson, RN, Coordinator of Community Resources, Dept. of Family and Community Medicine, 2400 Tucker, NE, Albuquerque, NM 87131; and Steven Adelsheim, MD, Child Psychiatry Fellow; and Leslie Aime, RN, Psychiatric Nurse, Dept. of Psychiatry, The University of New Mexico School of Medicine, Albuquerque, NM 87131. Support for this school-based clinic project was provided by the March of Dimes Foundaton. This article was submitted January 22, 1991, and accepted for publication April 1, 1991.
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Author:Pacheco, Mario; Adelsheim, Steven; Davis, Lisa; Mancha, Victor; Aime, Leslie; Nelson, Patsy; Derksen
Publication:Journal of School Health
Date:Oct 1, 1991
Words:2250
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