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Table 1 Characteristics of studies

From: A systematic review of the role of school-based healthcare in adolescent sexual, reproductive, and mental health

School-based healthcare (SBHC) and sexual, reproductive, and mental health outcomes
First author, year, country Study design Participants/Sample Sexual and reproductive health (SRH), mental health (MH), and other outcomes
Evhthier, 2011, USA Controlled before and after study 5,930 (1374 girls, 1,226 boys) students from 12 high schools in Los Angeles Sexually experienced girls with access to SBHC had increased hormonal contraceptive use (18.1% vs. 12.4%), were tested for a STD (33.8% vs. 22.7%), received STI/pregnancy prevention care (61.4% vs. 53.1%) and used emergency contraception at last intercourse (3.8% vs. 1.8%). There were no significant differences in condom use at last intercourse. None of outcomes were significantly different between boys without access to a SBHC
Kirby, 1991, USA Controlled before and after study Six SBHCs from different parts of the USA and four comparison schools Although three schools reported more contraceptive use by students, overall there was no evidence SBHC reduced pregnancy rate. One school reported significantly increased use of contraceptives at last sex for boys and girls compared to the comparison school. Schools with increased usage of contraceptives and condoms emphasized pregnancy and HIV prevention throughout the school
Kisker, 1996, USA Cohort study 3,050 young people from 19 schools with SBHCs and a nationally representative sample of 859 urban youth Reduction in age of sexual debut in students with SBHC compared to students from nationally representative sample. No difference in rate of pregnancy or contraceptive use between the students. Knowledge of effective contraceptives was 64% vs. 53% for those with SBHC vs. nationally representative sample. There was a reduction in number of students who had ever considered suicide (21% vs. 22%) in those with SBHC. No difference in those who had attempted suicide. However there was no difference in health status, no difference in alcohol, cigarette, and marijuana use. No difference in educational outcomes between those with SBHC compared to the comparison students
Utilization of school-based healthcare (SBHC)
First author, year, country Study design Participants/Sample Findings on utilization
Adelman, 1993 USA Cross-sectional study 471 (220 boys, 251 girls) students in one Los Angeles school 44% of potential users used SBHC. Majority were girls (57%). Over 1-year period 5% had not used SBHC; 39% made 2 to 5 visits and 8% made 6 to 8 visits. 49% of all students accessed medical services; 28% MH services and 18% birth-control supplies. No differences between users and non-users in terms of demographics or school grades. Majority of non-users perceived themselves as healthy (36%). Ease of access most commonly cited reason for utilization (45%)
Allison, 2007, USA Cohort study 3,599 adolescents (790 SBHC users and 925 other users) from nine SBHCs, nine Community Clinics, and two urgent care centers in Denver SBHC users less likely than other users to be insured (37% vs. 73%), more likely to have made three or more primary care visits (52% vs. 34%), less likely to have used emergency care (17% vs. 34%), more likely to have received a health maintenance visit (47% vs. 33%), influenza vaccine (45% vs. 18%), a tetanus booster (33% vs. 21%), and a hepatitis B vaccine (46% vs. 20%). Compared to traditional outpatient sites, SBHCs improve access to care for underserved adolescents
Amaral, 2011, USA Cross-sectional study 4,640 students from four schools in California 85% of sample were SBHC users and majority were girls (60%). 15% of users had accessed mental health services. Students who considered suicide in past year were 52% more likely than peers to have sought SBHC services (OR = 1.52; 95% CI:1.30, 1.78) and 112% more likely to have utilized SBHC MH services (OR = 2.12, 95% CI: 1.68 to 2.66). Users more likely to report substance abuse. Students without public medical insurance more likely to access SBHC MH services (63%; OR = 1.63, 95% CI: 1.24, 2.14). Users reported significantly lower grades than their peers
Anglin, 1996, USA Cohort study 6080 students attending three SBHCs in Denver 63% of students enrolled in the SBHC used it during the 4-year period, representing 42% of the total student population. Service users were more likely to be girls and Hispanic. The most common reasons for use were mental health problems (25%). Reproductive health advice was sought by only 11% of users. SBHC users had higher visit rates for mental health than adolescents using traditional healthcare services. SBHCs that provide a variety of medical and mental health services seem to increase utilization rates. These rates do not represent over-use, but rather appear to signify utilization patterns that occur when students have free access to needed services
Ballasone, 1991, USA Croos-sectional study 614 (313 boys, 301 girls) students in one school in Washington state 43% of all students enrolled in school used the SBHC, majority of whom were girls (53%); 58% of users accessed medical services; 20% mental health services; 6% birth control advice (clinic did not prescribe or dispense contraceptives); and 4% pregnancy test. Users were significantly more likely than non-users to exhibit high risk behaviors, for example, drug use (17% vs. 8%) and alcohol usage (50% vs. 35%). Users were consistently more likely to know where to access services, for example, birth control assistance (82% vs. 72%). 80% of users found services to be needed, accessible, and helpful. 70% of non-users reported not requiring services; 6% reported parental objections; and 12% were too embarrassed
Britto, 2001, USA 2,832 students in six intervention schools and 2,036 students in six matched comparison schools in Ohio In the first year 51.2% of the intervention vs. 45% of comparison students did not seek care they needed. In the second year the proportion was 50.4% vs. 50.9%, respectively; 18.4% intervention students vs. 17.7% of comparison students had mental health visits in year 1 and 17.7% vs. 18.1% in year 2
Coyne-Beasely, 2003, USA Cross-sectional study 949 sexually experienced students (455 boys, 494 girls) in a convenience sample of seven schools with SBHC in North Carolina Girls were more likely than boys to report needing reproductive health/STI services. 80% of girls reported they would use SBHC for reproductive/STI care, compared with 47% of boys. None-use was associated with not needing the services; confidentiality and continuing with usual healthcare providers. It is worthwhile placing reproductive and STI services in SBHCs where many adolescents have unmet health needs related to pregnancy prevention and STIs
Guo, 2008, USA Controlled before and after study 109 students with mental health problems in four schools with a SBHC and two matched comparison in Ohio Those with a depressive disorder were more likely to use services (20% vs. 10.3%) compared to those without access to a SBHC. For students generally, the proportion of students accessing mental healthcare services increased (5.6% vs. 2.6% in urban schools and 5.9% vs. 0.2% in rural schools) compared to those without a SBHC. Students with mental health problems and who had a SBHC had significantly lower healthcare costs than those students without a SBHC
Harold, 1993, USA Cross-sectional study 225 (72 boys, 443 girls) students in four schools in a large Mid-Western city More girls than boys utilized the SBHCs (92% vs. 8%). 59% of the sample were Caucasian; 23% African American; 10% Hispanic; 6% Asian; 4% Native American. Majority of students sought services related to pregnancy and sexual activity. 11% were pregnant at time they requested services; 58% attended for ‘family planning’ services. However, SBHC staff felt that students often used stated reasons for using clinic as means with which to start discussion about other concerns. Because students were less likely to seek services in unfamiliar settings, it is essential for SBHC staff to assess and meet the health and mental health needs of students
Ingram, 2010, UK Cross-sectional study 515 SBHC service users (72 boys, 443 women) from 16 schools in South West England More girls than boys accessed reproductive health services (83% vs. 17%). Each student made an average of 2.6 visits per year. 61% said they attended SBHC because it was easily accessible. Barriers included embarrassment, cultural issues, and concerns about confidentiality. SBHCs attracted normally underserved adolescents
Jepson, 1998, USA Cohort study 2000 SBHC users from one school in New York Mental health services represented 17% of all visits made to SBHC during a 1-year period. These students attended an average of four mental health visits per year. The majority of visits were made by girls (79%). Issues relating to pregnancy were the most common reason for seeking mental health services, whilst ongoing depression and suicidal ideation represented 22% of visits. For high-risk youth in particular, the convenience and accessibility of SBHCs can improve timely medical and mental health assistance
Juszczak, 2003, USA Cohort study 451 (176 boys, 275 girls) students from three high schools in New York Over half (56%) of the sample used SBHC. Visits were primarily for medical (66%) and mental health (34%) services. Urgent and emergency care use was four times more likely for adolescents who had never used SBHC. SBHC can complement other health services and improve utilization of mental health services by underserved groups
Kaplan, 1998, USA Cohort study 342 students (148 boys, 194 girls) from three schools in Denver The majority of SBHC visits were made by girls (63%). Those with access to SBHC were more than 10 times likely to make a mental health visit or substance abuse visit compared to those without access to SBHC and 98% of these visits were made to SBHC). Students with access to SBHC had 38% to 55% fewer visits per year to after-hours care (for example, emergency visits) than those without access. SBHCs are particularly effective at improving access to and treatment for mental health and substance abuse problems
Langille, 2008, Canada Cross-sectional survey 1,629 students (831 boys, 798 girls) from three schools with SBHC in Nova Scotia More girls than boys used SBHC services (49% vs. 10%). Of those who used services girls were significantly more likely to use reproductive health services than boys (81% vs. 32%). Although sexual activity and alcohol abuse were identified among many non-users, all high-risk behaviors were significantly more likely to be exhibited by SBHC users. In this group of SBHC users, boys were seen to be more frequent binge drinkers (61% vs. 52%) and marijuana users (19% vs. 8%) compared to girls, whilst girls were seen to be more sexually active (63% vs. 57%), and have more frequent thoughts of suicide (18% vs. 13%) compared to boys. SBHC needs to find better ways to engage with boys and for reaching high-risk students
Pastore, 1998, USA Cross-sectional survey 630 students (284 boys, 347 girl) in one school with SBHC in New York Frequent users were more likely to be girls (68% vs. 32%). The SBHC was used for mental health services (34%) and sexuality-related care (15%). No significant differences were found among average, frequent users, and non-users in their rates of depression, suicidal ideation and attempt, alcohol involvement, or exposure to violence. Of users and non-users with mental health problems 50% knew someone who had been murdered. Non-use was related to reporting already having a physician (60%), being healthy and not needing services (50%), and parental objection (20%). Users reported high overall satisfaction with services (92%), and felt that it was confidential (74%)
Pastore, 2004, USA Cohort study 2,090 students using SBHC in two schools in New York In both schools girls made most visits to SBHC (72% and 63%). In both schools visits made were for mental health issues (11% and 19%) and reproductive health issues (12% and 20%). SBHC serves students’ reproductive and mental healthcare needs and they should provide comprehensive medical and mental health services to improve access for adolescents
Soleimanpur, 2010, USA Cross-sectional survey Focus groups 7410 students using 12 SBHCs in California SBHCs were the most commonly reported source of medical (30%), family planning (63%), and counseling (31%). Significant improvements were reported in mental health outcomes and reproductive health. Students liked SBHCs because of perceived confidentiality of services, because they were free and convenient and because they found the staff friendly. SBHCs increased access to care and improved mental health, resilience, and contraceptive use
Szumilas, 2010, Canada Secondary analysis of cross-sectional survey 1, 629 students (831 boys, 798 girls) from three schools with SBHC in Nova Scotia More girls than boys used the SBHC for mental health support in the preceding school year (20.4% vs. 5.3%) with girls most often asking for relationship support and boys for support with substance use. Students who used SBHC significantly more likely to report lower school performance, more sexual health risk-taking, suicidal behavior, and risk for depression. Boys reported confidentiality concerns. There was substantial need for mental health support and significant unmet need, particularly for boys
Walter, 1996, USA Cross-sectional survey 3,738 (1,992 boys, 1,746 girls) students in four schools with SBHC in New York Just over one-third (36%) of the study sample had utilized SBHC services during the academic year.Except grade differences, no other demographic differences were observed between users and non-users. Higher number of users compared to non-users reported sexual intercourse (22% vs. 18%), failure to use birth control (22% vs. 13%), suicide intentions or attempts (16% vs. 12%). SBHC can attract and provide a range of primary and preventative health services for underserved adolescents who may be most in need of such services
Weist, 1995, USA Cross-sectional survey 164 (77 boys, 87 girls) students in one inner city school in Baltimore 34% of the sample were clinic users, of whom 52% were girls. Frequent users were significantly more likely to be girls (12/14 students). In general frequent users were more depressed and anxious than other groups. No significant differences were observed between users and non-users on psychosocial measures
Wolk, 1993, USA Cohort study 1,413 students in one Denver school Girls were significantly more likely to be frequent users than average users. Frequent users were significantly more likely to be diagnosed with mental health conditions (23%) compared to average users (3.7%); 61% of all SBHC visits were for mental health purposes. The high prevalence of risky behaviors by users of SBHC emphasized the importance of SBHC within high schools
Contextual issues in the provision of school-based healthcare
First author, year, country sample Study design Contextual issues
Billy, 2000, USA Secondary analysis of cohort study 104 high schools (91 public, 13 private) Schools with students experiencing more health risks were more likely to provide school-based health services. State policies were important and community provision of health services influenced provision in schools. More affluent communities were more likely to provide SBHC. Contextual factors appear to create a demand for services
Santelli, 2003, USA Cross-sectional survey 551 SBHCs in 313 schools in the US SBHC was more common in urban (55%) and rural (33%) than suburban (12%) areas. Most (76%) were open full-time and 48% were open during school holidays. Counseling, pregnancy testing, STD/HIV services were often provided on site (range 55% to 82%), whilst on-site availability of contraception ranged from 3% to 28% and was often provided by referral externally. Most schools (76%) reported prohibitions about providing contraceptive services on site. More established SBHCs were more likely to allow independent adolescent access without parental permission
Peak, 1996, USA Cross-sectional survey 180 school health services (109 SBHCs and 16 school-linked) Established centers in urban and suburban areas provided the broadest range of services. Thirty-three per cent made at least one contraceptive method available. Restrictions on these services came mainly from school district policy. Although such services offer a promising solution to delivering sexual and reproductive health care external and internal policies restrict their availability and scope