Mental Health Needs, Barriers, and Receipt of Care Among Transgender and Nonbinary Adolescents.

PURPOSE: Transgender and nonbinary youth disproportionately experience adverse mental health outcomes compared to cisgender youth. This study examined differences in their mental health needs and supports, barriers to care, and receipt of mental health care. METHODS: This study examined cross-sectional data from 43,339 adolescents who completed the California Healthy Kids Survey, 4% (n = 1,876) of whom identified as transgender and/or nonbinary. Chi-square test and t-test were used to compare mental health needs and supports, resilience, and barriers to and receipt of care experienced by transgender and nonbinary youth compared to cisgender youth. RESULTS: Transgender and nonbinary youth were significantly more likely to experience chronic sadness/hopelessness (74% vs. 35%) and consider suicide (53% vs. 14%) and less likely to report resilience factors (school connectedness: mean score 3.12 vs. 3.52). Transgender and nonbinary youth were significantly less likely to be willing to talk to teachers/adults from school (12% vs. 18%) or parents/family members (21% vs. 43%), but more willing to talk to counselors (25% vs. 19%) regarding mental health concerns. Transgender and nonbinary youth were significantly more likely to select being afraid (48% vs. 20%), not knowing how to get help (44% vs. 30%), or concern their parents would find out (61% vs. 36%) as barriers to seeking mental health care, yet reported slightly higher odds of receiving care when needed (odds ratio: 1.2). DISCUSSION: Transgender and nonbinary youth are more likely to report mental health concerns and barriers to seeking care than cisgender youth. Increasing access to care is critical for this population.

Case Management for Social Needs of Youth and Families in School-Based Health Centers.

BACKGROUND: School-based health centers (SBHCs) are ideal settings to address social needs of youth and families. Case managers can play a vital role in social care interventions. METHODS: We piloted a program to incorporate a Case Manager into the care team of 1 SBHC serving 2 local schools with over 900 students and their surrounding communities. This project's purpose was to evaluate program feasibility, utilization, and acceptability. Our mixed-methods evaluation included analyses of data from electronic health records, client satisfaction surveys, and staff interviews. RESULTS: During the 6-month pilot, the Case Manager served 133 clients (about one third of all SBHC clients served) through 593 contacts. Most contacts included referrals to support services (90%) and 37% addressed newcomer immigrant adjustment. All 37 respondents to the satisfaction survey during the 3-month administration period (44% response rate) reported that the Case Manager made them feel comfortable asking for help; 95% reported getting the help they needed. The 7 SBHC staff interviewed shared many program benefits, including increased time for clinical services. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Inequities in children's health and educational achievement are influenced by structural factors. Results from our pilot program demonstrate that SBHCs may be well-positioned to deliver social care interventions and that case managers enhance the ability to deliver quality care. CONCLUSIONS: School-based programs to address unmet social needs are critical to supporting learning and wellness for all youth. Robust studies are needed to further test the impacts of case management in SBHCs.

Developing National Standardized Performance Measures for School-Based Health Centers: The National Quality Initiative.

BACKGROUND: Despite extensive literature on school-based health center (SBHC) characteristics and outcomes, their quality of care has not been examined nationally. Standardized quality metrics can inform health care delivery and improvement. METHODS: SBHC national performance measures (NPMs) were developed by reviewing measures from national child health quality initiatives and engaging stakeholders in a consensus-building process. NPMs were pilot-tested with 73 SBHCs and SBHCs nationally subsequently reported data. RESULTS: Five NPMs were selected including the percentage of clients annually who received at least one: (1) well-child visit, whether administered in the SBHC or elsewhere; (2) risk assessment; (3) body mass index screen with nutrition and physical activity counseling; and, if age-appropriate, (4) depression screening with follow-up treatment plan; and (5) chlamydia screening among sexually active clients. SBHCs experienced challenges with reporting during pilot-testing, particularly related to extracting data from electronic health records, and identified strategies to address challenges. Approximately 20% of SBHCs nationally voluntarily reported data during the initial year. IMPLICATIONS FOR SCHOOL HEALTH: Standardized performance measures can help SBHCs monitor and improve care delivery and demonstrate effectiveness compared to other child health delivery systems. CONCLUSION: Ongoing data collection will help examine whether measure adoption drives quality improvement for SBHCs nationwide.

Risk and Resilience Factors Associated With Frequency of School-Based Health Center Use.

BACKGROUND: School-based health centers (SBHCs) provide health care to vulnerable youth. The purpose of the study was to identify characteristics of youth who use SBHCs with the highest frequency to understand their health needs and receipt of health services. METHODS: This study examined cross-sectional survey data from adolescents in 3 urban school districts (n = 2641) to identify the characteristics of youth who use SBHCs with high frequency (10+ visits). Analyses included calculations of simple frequencies and percentages, chi-square tests of significance and multivariate regression. RESULTS: High-frequency SBHC users were more likely to have seriously considered attempting suicide (adjusted odds ratio [AOR]: 3.2), be sexually active (AOR: 6.8), and have been victimized at school (AOR: 2.2) compared to their peers who did not use the SBHC. High-frequency SBHC users were also significantly more likely than their peers to report "always" getting mental health (AOR: 7.0) and sexual health (AOR: 6.6) care when needed, and having talked with a health care provider about their moods/feelings (AOR: 3.1) and how school is going (AOR: 3.2) in the past year. CONCLUSIONS: These findings hold important relevance to demonstrating the value of SBHCs in increasing vulnerable youth's access to health care, particularly in urban settings.

Mental Health Service Provision at School-Based Health Centers During the COVID-19 Pandemic: Qualitative Findings From a National Listening Session.

INTRODUCTION: School-based health centers (SBHCs) provide health services to more than six million youth annually. When schools throughout the United States closed in spring 2020, many SBHCs were also forced to close physical operations.. METHOD: This study uses qualitative data collected from SBHC representatives nationwide to examine supports and challenges affecting mental health services provision during the COVID-19 pandemic, changes in the provision of these services, and priorities for assessing and supporting student mental health needs in the 2021-2022 school year. RESULTS: Partnerships, community and stakeholder buy-in, and student access were key supports to continuous care throughout the pandemic, whereas lack of available staff and lack of in-person access to students were key challenges. Patients demonstrated increased acuity of presenting mental health problems, more immediate and complex mental health challenges, and greater co-morbidities. DISCUSSION: SBHCs pivoted, even with limited resources, to meet students' increasing needs for mental health care.

Adverse Childhood Experiences and Resilience: Addressing the Unique Needs of Adolescents.

Adolescents exposed to adverse childhood experiences (ACEs) have unique developmental needs that must be addressed by the health, education, and social welfare systems that serve them. Nationwide, over half of adolescents have reportedly been exposed to ACEs. This exposure can have detrimental effects, including increased risk for learning and behavioral issues and suicidal ideation. In response, clinical and community systems need to carefully plan and coordinate services to support adolescents who have been exposed to ACEs, with a particular focus on special populations. We discuss how adolescents' needs can be met, including considering confidentiality concerns and emerging independence; tailoring and testing screening tools for specific use with adolescents; identifying effective multipronged and cross-system trauma-informed interventions; and advocating for improved policies.

Mental health characteristics and health-seeking behaviors of adolescent school-based health center users and nonusers.

BACKGROUND: The purpose of this study is to compare the mental health risk profile and health utilization behaviors of adolescent school-based health center (SBHC) users and nonusers and discuss the role that SBHCs can play in addressing adolescent health needs. METHODS: The sample included 4640 students in grades 9 and 11 who completed the California Healthy Kids Survey between fall 2000 and spring 2005 at 4 high schools in Alameda County, California. Chi-squared tests of significance and multivariate logistic regression were used to compare characteristics of SBHC users and nonusers and identify demographic, health status, and behavioral characteristics predictive of SBHC use. RESULTS: Controlling for demographic variables and general health status, students who reported frequent feelings of sadness, trouble sleeping, suicide ideation, alcohol or marijuana use, the recent loss of a close friend or relationship, or other difficult life event were significantly more likely to seek SBHC services than their peers. Neither health insurance status nor a student's "usual" source of health care was predictive of general SBHC use, but being on public assistance or having no insurance was predictive of a student seeking SBHC mental health services. CONCLUSIONS: These findings suggest that SBHCs are able to attract students with the most serious mental health concerns and can play an important role in meeting needs that might otherwise go unmet. The provision of SBHC mental health services in particular may fill a need among adolescents with public or no insurance.

The role of school health centers in health care access and client outcomes.

OBJECTIVES: We describe the impact of school health centers in Alameda County, California, on adolescents' access to care and their mental and physical health outcomes. METHODS: We used a multimethod evaluation of 12 school health centers to track data on clients (n=7410), services, and provider-reported outcomes; client pre-post surveys (n=286); and student focus groups (n=105 participants). RESULTS: School health centers were the most commonly reported source of medical (30%), family planning (63%), and counseling (31%) services for clients. Mental health providers reported significant improvements (P<.05) from baseline to follow-up in clients' presenting concerns and resiliency factors. Medical providers and clients also reported general improvements in reproductive health, particularly in the use of birth control other than condoms. Student focus group participants noted that school health centers helped improve access to services students might not seek out otherwise, particularly counseling and family planning services. Furthermore, students noted that they liked school health centers because of their confidentiality, free services, convenience, and youth-friendly staff. CONCLUSIONS: School health centers increase access to care and improve mental health, resiliency, and contraceptive use.

Clinic consortia media advocacy capacity: partnering with the media and increasing policymaker awareness.

Media advocacy is a popular means of crafting and disseminating messages broadly and has been used by advocates to increase policymaker and public awareness of key health policy issues, such as the large number of uninsured. Some media advocacy activities are more effective than others, however, requiring increased sensitivity to the media environment and adequate resources and expertise. This article describes the results of media advocacy activities undertaken by 19 clinic consortia funded under The California Endowment's Clinic Consortia Policy and Advocacy Program from 2002 to 2006. The consortia used different media advocacy strategies and venues, including newspaper, television, radio, video, brochures, newsletters, and websites. The findings indicate that consortia may have influenced the media agenda and increased the likelihood of securing coverage of key issues, such as the role of clinics in supporting the health care safety net. There is evidence that suggests that clinic consortia media advocacy activities, such as front-page coverage in local and major daily newspapers, increased public and policymaker awareness of key clinic policy issues. Although grantees rated media advocacy overall as less effective than other advocacy activities and few reported that it had directly achieved a policy change or increased funding to clinics, nearly all thought it was effective in increasing policymaker awareness. We conclude that media advocacy is a useful tool for partnering with the media and increasing stakeholder awareness more broadly, but it should not be solely relied upon to achieve a policy change.

The role of policy advocacy in assuring comprehensive family life education in California.

As part of their 10-year $60 million Teenage Pregnancy Prevention Initiative, The California Wellness Foundation funded 18 state and local organizations to conduct policy advocacy to strengthen teen pregnancy prevention policies. This article describes how some of these grantees accomplished noteworthy goals, including the passage of the California Comprehensive Sexual Health and HIV/AIDS Prevention Education Act (SB71), the prevention of the state's pursuit of federal "abstinence-only-until-marriage" funding, and the passage of a local school district FLE policy. Grantee progress is presented through a five-stage policy change framework: Institutional Capacity and Leadership Building, Policy Issue Recognition, Policy Prioritization, Policy Adoption, and Policy Maintenance. Implications are shared for advocates, policy makers, and funders who are developing initiatives aimed at improving the health of adolescents.

Incorporating youth-led community participatory research into school health center programs and policies.

Training adolescents as student researchers is a strategy that can improve the delivery of care at school-based health centers (SBHCs) and significantly shift school health policies impacting students. From 2003 to 2006, the University of California, San Francisco, in partnership with Youth In Focus, implemented a participatory student research project to enhance the existing evaluation of the Alameda County SBHC Coalition and its participating clinic members, and to help develop and implement school health policies. Providing opportunities and training that enabled youth to identify and research the health needs of their peers, as well as advocate for improvements in SBHCs based on their research findings, represents an exciting youth development strategy. This article describes the role the youth played, how their adult partners supported their work, and the impact that their efforts had on the SBHCs and school health programming and policies in the areas of condom accessibility and mental health services.

Evaluation of a peer provider reproductive health service model for adolescents.

CONTEXT: The use of peer providers in family planning clinics has been proposed as a strategy that could better serve sexually active adolescent populations. METHODS: Baseline and follow-up survey data from 1,424 female and 166 male adolescent clients of five California community health clinics were analyzed to assess the effectiveness of a peer provider model between 1996 and 1999. Multivariable analyses examined differences in outcomes between clients' first and last clinic visits, and by whether clients received only clinical services or other components of the model (outreach and telephone follow-up) as well. RESULTS: Female clients were significantly more likely at their last visit than at their first visit to report consistent birth control use (odds ratio, 1.9), use at last intercourse (1.8) and use of effective methods (3.5), and were significantly less likely to report consistent condom use (0.7). There were no significant differences in male birth control or condom use between first and last visits. Females who received all components of the model were more likely than those who received only clinical services to return for an annual exam (2.2) and to make three or more visits during the study period (1.7). The full model was particularly effective for females who were Hispanic, had been born to adolescent mothers or had had more than one sexual partner in the six months before their first clinic visit. CONCLUSIONS: The peer provider model appears to be a promising addition to the mix of service delivery models, particularly for certain subgroups of clients. The findings underscore the importance of tailoring programs on the basis of clients' risk profiles.

School-based health centers and academic performance: research, challenges, and recommendations.

School-based health centers (SBHCs) provide physical and mental health services on school campuses to improve student health status, and thereby potentially facilitate student academic success. With a growing emphasis on school accountability and the simultaneous dwindling of resources at the federal, state, and local levels, SBHCs face increasing pressures from school administrators and funders to document their impact on student academic achievement. This article reviews the methods, findings, and limitations of studies that have examined the relationship between SBHCs and academic performance. It also describes methodological challenges of conducting and interpreting such research, and discusses factors and intermediate variables that influence student academic performance. Recommendations are offered for SBHC researchers, evaluators, and service providers in response to the pressure they are facing to document the effect of SBHC services on academic outcomes.