Social Determinants of Health: School-Based Health Centers

Findings and Recommendations

The Community Preventive Services Task Force (CPSTF) recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities to improve educational and health outcomes.

Educational outcomes include the following:

School performance
Grade promotion
High school completion

Health outcomes include the following:

Delivery of vaccinations and other recommended preventive services
Asthma morbidity
Emergency department and hospital admissions
Contraceptive use among sexually active females
Prenatal care and birth weight
Other health risk behaviors

If targeted to low-income communities, SBHCs are likely to reduce gaps in education and improve health equity.

The full CPSTF Finding and Rationale Statement and supporting documents for Social Determinants of Health: School-Based Health Centers are available in The Community Guide Collection on CDC Stacks.

Intervention

School-based health centers must provide primary health care on-site (school-based) or off-site (school-linked). They may also provide mental health care, social services, dentistry, and health education.

Characteristics of SBHCs:

They can provide health services to students of all ages, from pre-kindergarten through high school
Students must have parental consent. Individual students may not be able to get specific types of care, such as reproductive or mental health
They are often created in schools that serve predominantly low-income communities
Services may be provided to school staff, student family members, and others within the surrounding community
Use single clinician to provide primary care services, or multi-disciplinary teams to provide complex services
Medical centers or healthcare providers that are independent of the school system may provide services
Services may be available only during some school days or hours, or during non-school hours

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.

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

Summary of Results

Education-Related Outcomes:

High school non-completion: median decrease of 29.1% (5 studies)
Grade Point Average: median increase 4.7% (4 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); males only: median decrease of 8.5% (2 studies); female and male students: median increase of 19.6%, unfavorable (3 studies that did not separately report outcomes)
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

Summary of 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-September 2014) from the U.S. Monetary values are presented in 2013 U.S. dollars.

Intervention Cost: Reported start-up costs ranged from $41,450 to $378,704 per SBHC (2 studies). Operation costs ranged from $16,322 to $659,684 per SBHC per year (14 studies). Operation cost per user ranged from $143 to $1,427 per year (7 studies).

Intervention Benefit: Studies from the societal perspective reported annual benefits between $15,028 and $912,878 per SBHC in averted costs (3 studies). 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).

Benefit-Cost Ratio: 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

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?

Implementation Considerations and Resources

SBHC benefits likely depend on population density. It may be necessary to develop modified models for schools in rural settings and schools with fewer students
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 magnitude of benefits. Offering services both during and outside of school hours increases effectiveness
It is expected that providing free services will increase their use and effectiveness; however, lack of information on fees prevented analysis of this expected relationship

Crosswalks

Healthy People 2030 icon Healthy People 2030 includes the following objectives related to this CPSTF recommendation.