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Promoting Health Equity Through Education Programs and Policies: Effectiveness of School-Based Health Centers in Improving Educational and Health Outcomes

Task Force Finding

The Community Preventive Services Task Force recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes. Improved educational outcomes include school performance, grade promotion, and high school completion. Improved health outcomes include the delivery of vaccinations and other recommended preventive services, asthma morbidity, emergency department and hospital admissions, contraceptive use among females, prenatal care and birth weight, and other health risk behaviors.

Most evidence derives from studies of SBHCs in low-income populations. If targeted to low-income communities, SBHCs are likely to reduce educational gaps and advance health equity.

Read the full Task Force Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

Intervention Definition

School-based health centers (SBHCs) provide health services to students preK-12 and may be offered on-site (i.e., school-based centers) or off-site (i.e., school-linked centers). SBHCs are often established in schools that serve predominantly low-income communities and have the following characteristics:

  • SBHCs must provide primary health care and may also include mental health care, social services, dentistry, and health education.
  • Primary care services may be provided by a single clinician, or comprehensive services may be provided by multi-disciplinary teams.
  • Services may be available only during some school days or hours, and may also be available in non-school hours.
  • Student participation requires parental consent, and services provided for individual students may be limited for specific types of care, such as reproductive or mental health.
  • Services may be provided to school staff, student family members, and others within the surrounding community.
  • Services are often provided by a medical center/provider independent of the school system.

Context

Children from low-income and racial and ethnic minority populations in the United States commonly experience worse health, are less likely to have a usual place of health care, and miss more days of school because of illness than do children from the less economically and socially disadvantaged populations. They also are more likely to be hungry and have problems with their vision or hearing. Addressing these obstacles can be critical to their education and long term health.

About the Systematic Review

The Task Force finding is based on evidence from a systematic review of 46 studies (search period through July 2014) which used diverse designs to assess multiple academic and health-related outcomes. Twenty-three studies assessed whole school effects by comparing all students in schools with SBHCs with all students in non-SBHC schools or students in schools before and after the implementation of SBHCs. Seventeen studies assessed SBHC user only effects by comparing users with non-users within SBHC schools (8 studies), or SBHC users with users of other health care sources in non-SBHC settings (9 studies). Several studies included both intervention whole school and user effects.

The systematic review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to promoting health equity.

Results

Education-Related Outcomes:
  • High school non-completion: median decrease of 29.1% (IQI:‑53.9% to ‑14.8%; 5 studies)
  • Grade Point Average (GPA): median increase 4.7% (range: 3.5% to 7.2%; 3 studies)
  • Grade promotion: increases of 8.4% and 14.6% (2 studies); 1 additional study reported that SBHCs were associated with increases in students on pace to graduate
Health-Related Outcomes:
  • Immunization: median increase of 15.5 percentage points (range: ‑22.0 to 26.1 percentage points; 4 studies)
  • Other recommended clinical preventive services: median increase of 12.0 percentage points (Interquartile Interval (IQI): 5.7 to 45.1 percentage points; 6 studies)
  • Regular source of health care: median increase of 2.2% (IQI: ‑1.8% to 12.4%; 7 studies)
Asthma-Specific Outcomes:
  • Hospitalizations: median decrease of 70.6% (range: ‑79.9% to ‑37.5%; 3 studies)
  • Emergency department visits: median decrease of 15.8% (range: ‑50.0% to ‑5.9%; 4 studies)
  • Morbidity (measured by numbers and frequencies of asthma symptoms): median decrease of 19.3% (36.4% and 2.1%; 2 studies)
Other Morbidity-Related Outcomes:
  • Self-reported health status (i.e., in various scales of medical, physical, chronic conditions): median decrease of 1.2%, unfavorable (range: ‑17.4% to 5.6%; 4 studies); 3 additional studies reported mixed results
  • Self-reported mental health problems: median decrease of 5.7% (range: ‑31.6% to 8.9%; 4 studies); 4 additional studies reported generally favorable effects
  • Non-asthma-related emergency department visits: median decrease of 14.5% (IQI: ‑33.8% to 4.6%; 15 studies)
  • Non-asthma-related hospitalization: mean decrease of 51.6% (‑86.9%, ‑16.3%; 2 studies)
Risk Behaviors
  • Tobacco smoking: median increase of 21.0%, unfavorable (IQI: ‑24.1% to 32.4%; 7 studies)
  • Alcohol use: median decrease of 14.8% (IQI: ‑19.8% to ‑9.5%; 6 studies)
  • Other illicit substance use: median decrease of 27.2% (IQI: ‑48.2% to 13.6%; 5 studies)
Sexual Risk Behaviors and Reproductive Outcomes
  • Contraception use:
    • Both females and males: median increase of 7.8% (range: ‑21.2% to 46.7%; 4 studies)
    • Females only: median increase of 17.8% (range: ‑8.5% to 54.9%; 3 studies)
    • Males only: median decrease of 3.1%, unfavorable (range: ‑6.2% to 14.5%; 3 studies)
  • Sexual activity:
    • Both females and males: median increase of 19.6%, unfavorable (range: ‑0.9% to 83.2%; 3 studies)
    • Females only: median decrease of 3.6% (‑16.0% and 8.9%; 2 studies)
    • Males only: median decrease of 8.5% (‑12.0% and ‑4.9%; 2 studies)
  • Becoming pregnant or causing pregnancy:
    • Females only: median decrease of 40.0% (IQI: ‑47.5% to 17.6%; 5 studies)
    • Males only: increase of 21.5% in causing pregnancy, unfavorable (1 study)
  • Pregnancy complications: median increase of 25%; unfavorable (range: ‑16.1% to 76.3%; 3 studies)
  • Percent low birth weight: median decrease of 58.3% (range: ‑60.4% to ‑14.4%; 3 studies)
  • Prenatal care: Median 27.8% increase in the number of prenatal visits (‑9.4% and 46.2%; 2 studies); 2 additional studies reported increase in percent of pregnant students receiving prenatal care
  • Prenatal care initiated: Pregnant students received prenatal care 0.45 months earlier; 2 studies. 1 additional study reported 15.1 percentage point increase in percent of pregnant students registered for prenatal care during 1st trimester.
Additional Analyses
  • Results did not substantially differ by whether the studies assessed whole school or user only effects.
  • There was evidence that SBHCs that remained open beyond school hours were associated with lower rates of emergency department and hospital admissions than were SBHCs that were open only during school hours.
  • The greater the range of services provided in an SBHC, the greater the reduction in visits to the emergency department or hospitalization.
  • Findings were inconsistent on the association between the availability of on-site contraception at SBHCs (compared with SBHCs that required access off-site) and reduced pregnancies or births.
  • It was not possible to examine the association between the provision of free SBHC services and outcomes because of lack of clear descriptions of service costs in many studies.

Study Characteristics

  • 91.3% of the included studies assessed school-based health centers; the remainder assessed combined school-based and school-linked health centers. No studies assessed only school-linked health centers.
  • 56.5% of the studies assessed SBHCs in high schools
  • 60.9% of the studies did not report hours of operation.
  • 50% of the studies evaluated SBHCs that only provided primary care, without additional services.
  • Most of the studies assessed primarily non-white populations, with black populations being the most common.
  • Among those studies that reported socioeconomic status, most assessed low-income populations.

Applicability and Generalizability Issues

  • Because most SBHCs are implemented in low-income or racial and ethnic minority communities, SBHCs are likely to advance health equity.
  • SBHCs have not been evaluated in higher income communities. Since health care needs in these communities may be fewer and otherwise addressed, it is unclear whether SBHCs would be useful or effective. On the other hand, because of increased accessibility, SBHCs may be an effective way of delivering health care for any school population.
  • Results are applicable to SBHCs offered on-site or both on- and off-site. None of the included studies evaluated SBHCs that were only available off-site.

Economic Evidence

Evidence shows that school-based health centers provide societal benefits that are greater than their costs. SBHCs also lead to net savings for SBHC users and the Medicaid program.

The economic review included 21 studies (search period January 1985-Septyember 2014) from the U.S. Monetary values are presented in 2013 U.S. dollars.

Intervention Cost

  • Fifteen of the included studies provided information about intervention cost, which was made of up two components: start-up cost (one-time, fixed cost) and operation cost (annually recurring medical cost).
    • Reported start-up costs ranged from $41,450 to $378,704 per SBHC (2 studies).
      • Some of the variation in cost can be explained by differences in staffing during the initial implementation phase. Also, costs were lower when SBHCs renovated space at the schools and higher when new facilities were constructed.
    • Operation costs ranged from $16,322 to $659,684 per SBHC per year (14 studies).
      • The main causes of variation were hours of work by physicians and staff, local cost of living, nationwide versus state study, and data source.
    • Operation cost per user ranged from $143 to $1,427 per year (7 studies).

Intervention Benefit

  • Nine of the included studies reported on intervention benefit, which was categorized as follows:
    • Healthcare cost averted (i.e., averted cost of hospitalization, emergency department use, medications, referrals, private clinic visits, and unintended teen pregnancies)
    • Productivity and other loss averted (i.e., averted cost of school time and productivity losses, and averted travel cost and ambulance use)
    • Studies from the societal perspective reported annual benefits between $15,028 and $912,878 per SBHC in averted costs associated with treatment, productivity losses, and transportation, combined with other relevant benefits (3 studies).
      • The wide range can be explained by the number of benefit components considered and whether the study included major benefit drivers (averted emergency department use, unintended pregnancy, and productivity loss).
  • Studies from a healthcare payers' perspective showed net savings to Medicaid ranging from $30 to $969 per visit (3 studies), or $46 to $1,166 per user (2 studies).
    • The variation in net savings was due mainly to the number and types of components that were included. Net savings were higher when emergency room use and care for asthma patients were included.
  • Studies from the perspective of patients (or their parents) reported savings of $90 per visit (1 study) and $23,592 per user (1 study that included the averted cost of child birth from unintentional pregnancies).

Benefit-Cost Ratio

  • Benefit-cost ratios were calculated from two studies that evaluated seven SBHCs.
  • The societal benefit per SBHC exceeded intervention cost, with the benefit-cost ratio ranging from 1.38:1 to 3.05:1.

Considerations for Implementation

While the Community Guide does not conduct systematic reviews of implementation, the Task Force offers the following considerations based on studies included in the evidence review, the broader literature, and expert opinion.

  • SBHC benefits likely depend on population density. It may be necessary to develop modified models for low population density and rural settings.
  • While SBHCs are particularly relevant to low-income communities, financing can be challenging. Medicaid and the State Children's Health Insurance Program (SCHIP) have been common sources of financing for SBHCs.
  • Included studies indicated that the greater the range of services offered by an SBHC, the greater the benefits. Offering services outside of, in addition to within, school hours also increases effectiveness.
  • Though it was not possible to examine the association between the provision of free SBHC services and outcomes because of lack of clear descriptions of service costs in many studies, it is expected that providing services free will increase their use and effectiveness.

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Publication Status

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Disclaimer

The findings and conclusions on this page are those of the Community Preventive Services Task Force and do not necessarily represent those of CDC. Task Force evidence-based recommendations are not mandates for compliance or spending. Instead, they provide information and options for decision makers and stakeholders to consider when determining which programs, services, and policies best meet the needs, preferences, available resources, and constraints of their constituents.

Sample Citation

The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services. Promoting health equity through education programs and policies: school-based health centers. www.thecommunityguide.org/healthequity/education/schoolbasedhealthcenters.html. Last updated: MM/DD/YYYY.

Review completed: March 2015