Journal of Community Health Nursing, 32: 89–103, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0737-0016 print / 1532-7655 online DOI: 10.1080/07370016.2015.1024543
Connecting Teens to Caring Adults in a School-Based Health Center: A Case Study Beth A. Blacksin and Patricia J. Kelly University of Missouri-Kansas City, Kansas City, Missouri
The traditional medical care system is generally unable to provide the broad health and wellness services needed by many adolescents, especially those from low-income and racial/ethnic minority communities. Using a theoretical framework adapted from Bronfenbrenner’s ecological model of multiple influencers, this case study examined how a school-based health center was able to provide a network of connections for adolescents to caring adults within the school and the local community. Contributors to this network were the creation of a student-centered community with access to adolescent-friendly services, providers acting as connectors, and care of the whole adolescent.
School-based health centers (SBHCs) in the United States enhance the use of physical and mental health care services by adolescents without concern for the ability to pay. These centers can provide a full range of age-appropriate health services, including care of minor illness and emergencies, management of chronic illnesses, mental health services, and family outreach. Located in a school or on school grounds, SBHCs are staffed by interdisciplinary teams in which nurses and nurse practitioners play critical roles, with physicians serving a more distant, supervisory function. The SBHC model is unfamiliar to many providers and researchers, and limited systematic qualitative research is available to understand the dynamics of successful centers. Understanding these dynamics can inform future development of health centers.
BACKGROUND/SIGNIFICANCE Since 1979, the Healthy People initiative has established national goals to improve the health of all Americans (U.S. Department of Health, Education and Welfare, 1979). Healthy People 2020 targets adolescents in the following areas: overall health, function and mortality, injury, violence, mental health and substance use, reproductive health, prevention of adult chronic disease and health care utilization (U.S. Department of Health and Human Services, n.d.). Utilizing 21 data sources, researchers found that US adolescents demonstrated improvement only in the categories of unintentional injury, assault, tobacco use, and reproductive health (Park, Scott, Adams, Brindis, & Irwin, 2014). Address correspondence to Beth A. Blacksin, 3440 N. Lake Shore Drive, 18 B, Chicago, IL 60657. E-mail: [email protected] Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/hchn.
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Reasons for the lack of improvement in outcomes include the fact that, collectively and as individuals, adolescents access primary care less frequently than other age groups. When they do seek services, adolescents tend to use acute or specialty care rather than finding a regular, primary care source (Natl Research Council [NRC] & Institute of Medicine [IOM], 2009), thereby reducing continuity of care and inhibiting the development of an ongoing relationship with a provider. Even if inclined to seek care, adolescents have the highest under/uninsurance rate of all population groups (Brindis & Sanghvi, 1997; NRC& IOM, 2009). This underinsurance is influenced by parental control and attitudes, cost, difficulty navigating the health care system, concerns about confidentiality, lack of comprehensive services offered at a single location, and ethnicity (Elster, Jarosik, VanGeest, & Fleming, 2003). Because both the engagement in high-risk behaviors and the formation of adult habits occur during adolescence, encouraging this population to seek regular use of physical and mental health services is important (Crosby, Santelli, & Di Clemente, 2009). However, with the implementation of the Patient Protection and Affordable Care Act (2010), improvements in both coverage and services for the adolescent population are occurring. Adolescents are benefiting from adoption of a policy of no exclusions for preexisting conditions, as well as major expansions of both private insurance and pubic coverage under Medicaid. In addition, the ACA guarantees access to services through an essential health benefit package and the lack of cost sharing for certain preventive health services like important screenings and counseling in areas such as depression, substance use, STIs/HIV, contraception and domestic violence (Park & English, 2013). The US adolescent population increased significantly in the 1960s, as did the adolescent mortality rate, with poor and marginalized adolescents experiencing worse health outcomes than higher income peers (Lear, Gleicher, St. Germaine, & Porter, 1991; Newacheck, Hung, Park, Brindis, & Irwin, 2003). During this time, school/community partnerships opened the first SBHCs in three cities: Cambridge, MA in 1967 (Porter, Avery, & Fellows, 1974); West Dallas, TX in 1970 (Lear et al., 1991); and St. Paul, MN in 1973 (Edwards, Steinman, & Hakanson, 1977). A national demonstration project funded by the Robert Wood Johnson Foundation allowed for countrywide expansion of the model, together with funding from selected states. Today, nearly 2,000 SBHCs serve approximately two million ethnically diverse youth (Lofink et al., 2013). Located in a school or on school grounds, SBHCs provide easy access and high-quality care for adolescents, especially those who are underserved, come from low-income families, or face complex social and environmental risk (Soleimanpour et al., 2010). Some SBHCs offer a variety of health promotion and health education services, and are more likely than community health centers to screen for and counsel about high-risk behaviors (Broussard, Brown, Hutchinson, & Chrestman, 2012). These centers also have a positive impact on some academic outcomes like absences and tardiness (Gall et al., 2000), grade point averages and attendance (Walker et al., 2010), and dropout (Kerns et al., 2011). An evolving concept in mitigating adolescent risk behaviors and in understanding how SBHCs work is the idea of connectedness; that is, “the belief by students that adults in the school care about their learning and about them as individuals” (Blum & Libby, 2004, p. 231). Connectedness serves as both a significant environmental protective factor for youth and a contributor to academic achievement (Centers for Disease Control [CDC], 2009). Knowledge of specifics about how SBHCs provide such services to adolescents is an area that has been minimally studied (Keeton, Soleimanpour, & Brindis, 2012). Although many of the overall outcomes of SBHCs are clear, case study methodology allows an exploration of the
CONNECTING TEENS TO CARING ADULTS
91
dynamics of how it affects the health and wellbeing of adolescents. Unraveling the connectedness process may also contribute to the development of new risk reduction strategies in SBHCs. The primary purpose of this study was to increase our understanding of the mechanism of how and why a SBHC affects the health and well-being of adolescent users.
METHODS Design This research used case study methodology to examine provider working relationships, motivations, and structure in a mature health center, as well as provider perceptions of its effect on student risk and protective factors. This methodology provided a mechanism with which to conduct a detailed examination and maintain an “intensive focus” on a selected topic (Sandelowski, 2011, p. 154). Case study methodology allowed for inquiry into the SBHC’s immediate context (the school), as well as its historical context (the process of its formation; Stake, 2005; Yin, 2009). Bronfenbrenner’s (1979) ecological approach to child health was selected because of its ability to take into account broad factors that contribute to adolescent development, from the home to distal environmental factors. Bronfenbrenner (1979) described this environment as “a set of nested structures, each inside the next, like a set of Russian dolls” (p. 3); i.e., multiple influencers affect a child’s development. Using this approach of multiple influencers, the conceptual framework for the study also incorporated Blum and Blum’s (2009) more recent resiliency model. Their model describes risk/protective factors including: (a) macro level environmental factors, such as poverty, discrimination, and structured inequality; (b) proximal level environmental factors, including family, peers, neighborhoods, and schools; and (c) individual level factors of biology, personality traits, and temperament (Blum & Blum, 2009). Their model was adapted, utilizing the portion that addresses environmental risk and protective factors, and adding detail about these factors from cited literature. The adapted framework was submitted to expert review, and became the conceptual framework that guided the study’s interview guide and data analysis (see Figure 1). Location/Sample The SBHC that was the focus of this study was created in 1996 and is nested within the high school of a suburban community near Chicago, Illinois. The school’s web site described its population as diverse, with a significant group of students experiencing poverty and minority status, thus increasing their potential for risk. As of 2012, 3,147 students were enrolled at this high school, 40.8% were low income and 2.3% were limited English learners. The ethnic breakdown of the student population included 16.3% Hispanic, 43.6% Caucasian, 31.8% African American, 3.6% Asian, 0.1% Pacific Islander, 0.3% American Indian, and 4.3% two or more races with a significant Black–White achievement gap (Illinois School Report Card, 2012). Table 1 describes the SBHC user population during academic year 2011–2012 by race, sex and insurance status. This team had 2,588 clinical encounters, representing 845 high school students. Table 2 describes visits by types of services provided.
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Environmental Risk Factors Family and community: Poverty Discrimination Inequality School: Violence and other victimization Peers: Negative peer group
Individual Risk/ Protective Factors
Environmental Protective Factors Family: Connection to at least one parent, Behavioral monitoring
Adolescent Well-being
School: Belonging to school, Liking school, Supportive caring teachers/adults, Good friends, Engagement in current and future academic progress, Perceiving discipline as fair and effective, Involvement in extracurricular activities Community: Behavioral monitoring, Youth supervision, Consistent adult values, Access to resources (health care) Peers: Positive Peer group
Biology Personality Temperament
FIGURE 1 Ecological Model of Influence of a SBHC on the Lives of Urban Adolescents (Adapted from Blum & Blum, 2009; Bronfenbrenner, 1979).
SBHC providers, staff members, and additional individuals involved in the foundation of the health center were solicited for participation and all agreed to participate. All participants were female; 8 were Caucasian, 1 African-American, 1 Hispanic, and 1 Asian; ages ranged from 36 to 58 years. Providers included a secretary/receptionist, 3 family nurse practitioners, 3 pediatricians, 1 public health nurse, 2 social workers, and an acupuncturist. The historians were individuals identified as key stakeholders in the creation of the center and included the health department director, the former district superintendent, a parent, and the city mayor; all had played central roles in the creation of the center. Data Collection Data was collected from three sources: semistructured interviews, historical documents, and epidemiologic records. Semistructured interviews were conducted with providers and historians. An interview guide was developed from the theoretical framework, literature, and personal experience with the SBHC model and included items about working at the SBHC, service provision, access to care, and the SBHC as an influence on adolescent risk and protective factors. Provider
93
CONNECTING TEENS TO CARING ADULTS
TABLE 1 School-Based Health Center (SBHC) Utilization by Sex, Race, and Insurance Status (July 1, 2011 to June 30, 2012) Enrollment∗ Sex Female Male Race Asian/Pacific Islander Black/Hispanic Black/Non-Hispanic White/Hispanic Mixed race Other White/Non-Hispanic Native American/Aleutian/Alaskan Unknown Insurance status Private Uninsured Medicaid/All kids Unknown
971 (52%) 897 (48%) 42 (2%) 21 (1%) 754 (42%) 240 (13%) 33 (2%) 0 776 (42%) 1 (
Connecting Teens to Caring Adults in a School-Based Health Center: A Case Study Beth A. Blacksin and Patricia J. Kelly University of Missouri-Kansas City, Kansas City, Missouri
The traditional medical care system is generally unable to provide the broad health and wellness services needed by many adolescents, especially those from low-income and racial/ethnic minority communities. Using a theoretical framework adapted from Bronfenbrenner’s ecological model of multiple influencers, this case study examined how a school-based health center was able to provide a network of connections for adolescents to caring adults within the school and the local community. Contributors to this network were the creation of a student-centered community with access to adolescent-friendly services, providers acting as connectors, and care of the whole adolescent.
School-based health centers (SBHCs) in the United States enhance the use of physical and mental health care services by adolescents without concern for the ability to pay. These centers can provide a full range of age-appropriate health services, including care of minor illness and emergencies, management of chronic illnesses, mental health services, and family outreach. Located in a school or on school grounds, SBHCs are staffed by interdisciplinary teams in which nurses and nurse practitioners play critical roles, with physicians serving a more distant, supervisory function. The SBHC model is unfamiliar to many providers and researchers, and limited systematic qualitative research is available to understand the dynamics of successful centers. Understanding these dynamics can inform future development of health centers.
BACKGROUND/SIGNIFICANCE Since 1979, the Healthy People initiative has established national goals to improve the health of all Americans (U.S. Department of Health, Education and Welfare, 1979). Healthy People 2020 targets adolescents in the following areas: overall health, function and mortality, injury, violence, mental health and substance use, reproductive health, prevention of adult chronic disease and health care utilization (U.S. Department of Health and Human Services, n.d.). Utilizing 21 data sources, researchers found that US adolescents demonstrated improvement only in the categories of unintentional injury, assault, tobacco use, and reproductive health (Park, Scott, Adams, Brindis, & Irwin, 2014). Address correspondence to Beth A. Blacksin, 3440 N. Lake Shore Drive, 18 B, Chicago, IL 60657. E-mail: [email protected] Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/hchn.
90
BLACKSIN AND KELLY
Reasons for the lack of improvement in outcomes include the fact that, collectively and as individuals, adolescents access primary care less frequently than other age groups. When they do seek services, adolescents tend to use acute or specialty care rather than finding a regular, primary care source (Natl Research Council [NRC] & Institute of Medicine [IOM], 2009), thereby reducing continuity of care and inhibiting the development of an ongoing relationship with a provider. Even if inclined to seek care, adolescents have the highest under/uninsurance rate of all population groups (Brindis & Sanghvi, 1997; NRC& IOM, 2009). This underinsurance is influenced by parental control and attitudes, cost, difficulty navigating the health care system, concerns about confidentiality, lack of comprehensive services offered at a single location, and ethnicity (Elster, Jarosik, VanGeest, & Fleming, 2003). Because both the engagement in high-risk behaviors and the formation of adult habits occur during adolescence, encouraging this population to seek regular use of physical and mental health services is important (Crosby, Santelli, & Di Clemente, 2009). However, with the implementation of the Patient Protection and Affordable Care Act (2010), improvements in both coverage and services for the adolescent population are occurring. Adolescents are benefiting from adoption of a policy of no exclusions for preexisting conditions, as well as major expansions of both private insurance and pubic coverage under Medicaid. In addition, the ACA guarantees access to services through an essential health benefit package and the lack of cost sharing for certain preventive health services like important screenings and counseling in areas such as depression, substance use, STIs/HIV, contraception and domestic violence (Park & English, 2013). The US adolescent population increased significantly in the 1960s, as did the adolescent mortality rate, with poor and marginalized adolescents experiencing worse health outcomes than higher income peers (Lear, Gleicher, St. Germaine, & Porter, 1991; Newacheck, Hung, Park, Brindis, & Irwin, 2003). During this time, school/community partnerships opened the first SBHCs in three cities: Cambridge, MA in 1967 (Porter, Avery, & Fellows, 1974); West Dallas, TX in 1970 (Lear et al., 1991); and St. Paul, MN in 1973 (Edwards, Steinman, & Hakanson, 1977). A national demonstration project funded by the Robert Wood Johnson Foundation allowed for countrywide expansion of the model, together with funding from selected states. Today, nearly 2,000 SBHCs serve approximately two million ethnically diverse youth (Lofink et al., 2013). Located in a school or on school grounds, SBHCs provide easy access and high-quality care for adolescents, especially those who are underserved, come from low-income families, or face complex social and environmental risk (Soleimanpour et al., 2010). Some SBHCs offer a variety of health promotion and health education services, and are more likely than community health centers to screen for and counsel about high-risk behaviors (Broussard, Brown, Hutchinson, & Chrestman, 2012). These centers also have a positive impact on some academic outcomes like absences and tardiness (Gall et al., 2000), grade point averages and attendance (Walker et al., 2010), and dropout (Kerns et al., 2011). An evolving concept in mitigating adolescent risk behaviors and in understanding how SBHCs work is the idea of connectedness; that is, “the belief by students that adults in the school care about their learning and about them as individuals” (Blum & Libby, 2004, p. 231). Connectedness serves as both a significant environmental protective factor for youth and a contributor to academic achievement (Centers for Disease Control [CDC], 2009). Knowledge of specifics about how SBHCs provide such services to adolescents is an area that has been minimally studied (Keeton, Soleimanpour, & Brindis, 2012). Although many of the overall outcomes of SBHCs are clear, case study methodology allows an exploration of the
CONNECTING TEENS TO CARING ADULTS
91
dynamics of how it affects the health and wellbeing of adolescents. Unraveling the connectedness process may also contribute to the development of new risk reduction strategies in SBHCs. The primary purpose of this study was to increase our understanding of the mechanism of how and why a SBHC affects the health and well-being of adolescent users.
METHODS Design This research used case study methodology to examine provider working relationships, motivations, and structure in a mature health center, as well as provider perceptions of its effect on student risk and protective factors. This methodology provided a mechanism with which to conduct a detailed examination and maintain an “intensive focus” on a selected topic (Sandelowski, 2011, p. 154). Case study methodology allowed for inquiry into the SBHC’s immediate context (the school), as well as its historical context (the process of its formation; Stake, 2005; Yin, 2009). Bronfenbrenner’s (1979) ecological approach to child health was selected because of its ability to take into account broad factors that contribute to adolescent development, from the home to distal environmental factors. Bronfenbrenner (1979) described this environment as “a set of nested structures, each inside the next, like a set of Russian dolls” (p. 3); i.e., multiple influencers affect a child’s development. Using this approach of multiple influencers, the conceptual framework for the study also incorporated Blum and Blum’s (2009) more recent resiliency model. Their model describes risk/protective factors including: (a) macro level environmental factors, such as poverty, discrimination, and structured inequality; (b) proximal level environmental factors, including family, peers, neighborhoods, and schools; and (c) individual level factors of biology, personality traits, and temperament (Blum & Blum, 2009). Their model was adapted, utilizing the portion that addresses environmental risk and protective factors, and adding detail about these factors from cited literature. The adapted framework was submitted to expert review, and became the conceptual framework that guided the study’s interview guide and data analysis (see Figure 1). Location/Sample The SBHC that was the focus of this study was created in 1996 and is nested within the high school of a suburban community near Chicago, Illinois. The school’s web site described its population as diverse, with a significant group of students experiencing poverty and minority status, thus increasing their potential for risk. As of 2012, 3,147 students were enrolled at this high school, 40.8% were low income and 2.3% were limited English learners. The ethnic breakdown of the student population included 16.3% Hispanic, 43.6% Caucasian, 31.8% African American, 3.6% Asian, 0.1% Pacific Islander, 0.3% American Indian, and 4.3% two or more races with a significant Black–White achievement gap (Illinois School Report Card, 2012). Table 1 describes the SBHC user population during academic year 2011–2012 by race, sex and insurance status. This team had 2,588 clinical encounters, representing 845 high school students. Table 2 describes visits by types of services provided.
92
BLACKSIN AND KELLY
Environmental Risk Factors Family and community: Poverty Discrimination Inequality School: Violence and other victimization Peers: Negative peer group
Individual Risk/ Protective Factors
Environmental Protective Factors Family: Connection to at least one parent, Behavioral monitoring
Adolescent Well-being
School: Belonging to school, Liking school, Supportive caring teachers/adults, Good friends, Engagement in current and future academic progress, Perceiving discipline as fair and effective, Involvement in extracurricular activities Community: Behavioral monitoring, Youth supervision, Consistent adult values, Access to resources (health care) Peers: Positive Peer group
Biology Personality Temperament
FIGURE 1 Ecological Model of Influence of a SBHC on the Lives of Urban Adolescents (Adapted from Blum & Blum, 2009; Bronfenbrenner, 1979).
SBHC providers, staff members, and additional individuals involved in the foundation of the health center were solicited for participation and all agreed to participate. All participants were female; 8 were Caucasian, 1 African-American, 1 Hispanic, and 1 Asian; ages ranged from 36 to 58 years. Providers included a secretary/receptionist, 3 family nurse practitioners, 3 pediatricians, 1 public health nurse, 2 social workers, and an acupuncturist. The historians were individuals identified as key stakeholders in the creation of the center and included the health department director, the former district superintendent, a parent, and the city mayor; all had played central roles in the creation of the center. Data Collection Data was collected from three sources: semistructured interviews, historical documents, and epidemiologic records. Semistructured interviews were conducted with providers and historians. An interview guide was developed from the theoretical framework, literature, and personal experience with the SBHC model and included items about working at the SBHC, service provision, access to care, and the SBHC as an influence on adolescent risk and protective factors. Provider
93
CONNECTING TEENS TO CARING ADULTS
TABLE 1 School-Based Health Center (SBHC) Utilization by Sex, Race, and Insurance Status (July 1, 2011 to June 30, 2012) Enrollment∗ Sex Female Male Race Asian/Pacific Islander Black/Hispanic Black/Non-Hispanic White/Hispanic Mixed race Other White/Non-Hispanic Native American/Aleutian/Alaskan Unknown Insurance status Private Uninsured Medicaid/All kids Unknown
971 (52%) 897 (48%) 42 (2%) 21 (1%) 754 (42%) 240 (13%) 33 (2%) 0 776 (42%) 1 (
