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Health Equity: School-Based Health Centers

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What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on evidence from a systematic review of 46 studies (search period through July 2014) that 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 schools without SBHCs, or students in schools before and after SBHCs were set up. 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 CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to promoting health equity.

Context

When compared with children who are not economically or socially disadvantaged, U.S. children from low-income and racial and ethnic minority populations commonly have the following:

  • Worse health
  • No usual place of health care
  • More missed days of school because of illness
  • More hunger
  • More problems with their vision or hearing

Addressing these obstacles can be critical to their education and long term health.

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 616 kB].

Education-Related Outcomes:

  • High school non-completion: median decrease of 29.1% (5 studies)
  • Grade Point Average: median increase 4.7% (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 (4 studies)
  • Other recommended clinical preventive services: median increase of 12.0 percentage points (6 studies)
  • Regular source of health care: median increase of 2.2% (7 studies)

Asthma-Specific Outcomes:

  • Hospitalizations: median decrease of 70.6% (3 studies)
  • Emergency department visits: median decrease of 15.8% (4 studies)
  • Sickness (measured by numbers and frequencies of asthma symptoms): median decrease of 19.3% (2 studies)

Other Sickness-Related Outcomes:

  • Self-reported health status (i.e., in various scales of medical, physical, chronic conditions): median decrease of 1.2%, unfavorable (4 studies); 3 additional studies reported mixed results
  • Self-reported mental health problems: median decrease of 5.7% (4 studies); 4 additional studies reported generally favorable effects
  • Non-asthma-related emergency department visits: median decrease of 14.5% (15 studies)
  • Non-asthma-related hospitalization: mean decrease of 51.6% (2 studies)

Risk Behaviors

  • Tobacco smoking: median increase of 21.0%, unfavorable (7 studies)
  • Alcohol use: median decrease of 14.8% (6 studies)
  • Other illicit substance use: median decrease of 27.2% (5 studies)

Sexual Risk Behaviors and Reproductive Outcomes

  • Contraception use among sexually active students:
    • Both females and males: median increase of 7.8% (4 studies)
    • Females only: median increase of 17.8% (3 studies)
    • Males only: median decrease of 3.1%, unfavorable (3 studies)
  • Sexual activity:
    • Females only: median decrease of 3.6% (2 studies that reported outcomes by gender)
    • Males only: median decrease of 8.5% (2 studies that reported outcomes by gender)
    • Female and male students: median increase of 19.6%, unfavorable (3 studies that did not separately report outcomes for female and male students
  • Becoming pregnant or causing pregnancy:
    • Females only: median decrease of 40.0% (5 studies)
    • Males only: increase of 21.5% in causing pregnancy, unfavorable (1 study)
  • Specific to pregnancy:
    • Pregnancy complications: median increase of 25%; unfavorable (3 studies)
    • Percent low birth weight: median decrease of 58.3% (3 studies)
    • Prenatal care: median 27.8% increase in the number of prenatal visits (2 studies); 2 additional studies reported increase in percent of pregnant students receiving prenatal care
    • Prenatal care initiated: pregnant students received prenatal care an average of 0.45 months earlier; 2 studies. One additional study reported 15.1 percentage point increase in the percent of pregnant students who registered for prenatal care during their 1st trimester.

Additional Analyses

  • Studies that looked at schools with and without SBHCs and studies that compared students within the same school who did or didn’t receive services had similar results.
  • SBHCs that were open outside of 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 emergency departments or hospitalization.
  • Findings were inconsistent on the association between the availability of contraception at on-site SBHCs (compared with off-site SBHCs) and contraception use and pregnancy or birth outcomes.
  • It was not possible to determine whether providing free SBHC services affected outcomes because many of the studies did not include clear descriptions of the services provided or their costs to students.

Summary of Economic Evidence

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 616 kB].

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-September 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., prevented cost of hospitalization, emergency department use, medications, referrals, private clinic visits, and unintended teen pregnancies)
    • Productivity and other loss averted (i.e., prevented cost of school time and productivity losses, and travel cost and ambulance use)
    • Studies from the societal perspective reported annual benefits between $15,028 and $912,878 per SBHC in averted costs related to 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.

Applicability

  • Because most SBHCs are implemented in low-income or racial and ethnic minority communities, SBHCs are likely to improve 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 apply to SBHCs that offer services on-site or provide different services on- and off-site. None of the included studies evaluated SBHCs that only provided services off-site.

Evidence Gaps

Additional research and evaluation are needed in these areas, to fill existing gaps in the evidence base.

  • Although SBHCs are usually located in high-need communities, the proportions of students who enroll, and those enrollees who receive SBHCs services, are often less than those in need of these services. What strategies can be used to increase use of SBHC services?
  • What effect does patient cost have on overall SBHC use? Does use increase if services are free to users?
  • How effective are SBHCs in schools and communities that have majorities of higher-income or non-Hispanic white students? Are there thresholds or points of diminishing returns on community income, insurance coverage, and other measures of need above which SBHCs are less effective?
  • SBHCs usually offer services to school staff, student family members, and others in the community. What are the effects of SBHCs on the health of these populations?
  • How effective are alternative SBHC designs used in rural areas with low population density?
  • How effective are school-linked and mobile health centers?
  • What is the relative impact of focused programs—such as intensive asthma programs or programs focused on reproductive health—when compared with general programs?
  • Which components of SBHCs are being assessed, and what are characteristics of populations they serve?
  • What are the long-term impacts of SBHCs in academic achievement, income, and health?
  • What synergistic effects, mutual support, or redundancies might occur between SBHCs, school health polices, or classroom health education?
  • What is the need for SBHCs following full implementation of the Affordable Care Act? Will fewer students need SBHCs when there is greater insurance coverage among low-income households? Or are schools an effective setting for student health care regardless of levels of insurance coverage?
  • What is the cost of SBHCs per quality-adjusted life year (QALY)?
  • What would the lifetime economic benefits be if studies accounted for reduced health disparity and students' improved academic performance?
  • What are the costs and benefits of mobile SBHCs?

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.

Publications

Knopf JA, Finnie RKC, Peng Y, et al. School-based health centers to advance health equity: a Community Guide systematic review. Am J Prev Med. 2016;51(1):114-26.
Ran T, Chattopadhyay SK, Hahn RA, Community Preventive Services Task Force. Economic evaluation of school-based health centers: a Community Guide systematic review. Am J Prev Med. 2016;51(1):129-38.
Community Preventive Services Task Force. School-based health centers to promote health equity: recommendation of the Community Preventive Services Task Force. Am J Prev Med. 2016;51(1):127-8.
Brindis CD. The "State of the State" of school-based health centers: achieving health and educational outcomes. Am J Prev Med. 2016;51(1):139-40.

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