School Attendance Following Receipt of Care From a School-Based Health Center.

PURPOSE: School-based health centers (SBHCs) may mitigate barriers to health care access and improve students' academic outcomes, but few studies test this hypothesis. We examined whether school attendance improved after students received care at an SBHC. METHODS: We conducted a secondary analysis of data from 17 SBHCs affiliated with a single large urban school district and demographic and attendance data from SBHC users (N = 14,030) and nonusers (N = 230,046) from August 2015-February 2020. We examined the percent of full school days present each month for three years before and after students' first SBHC visit and a proxy visit date for SBHC nonusers. Propensity weighted linear regression models tested whether visiting an SBHC was associated with a change in the attendance trajectory compared to a matched sample of SBHC nonusers. RESULTS: Among SBHC users, attendance trajectories declined more steeply prior to their first SBHC visit than after the first visit (preslope -0.71%, postslope -0.05%), whereas SBHC nonusers had a similar attendance trajectory over the entire period (preslope -0.18%, postslope -0.17%), with difference-in-difference 0.65. Changes in trajectories were more pronounced for students with a mental health encounter. Prior to the first SBHC mental health visit, SBHC users displayed a marked decline in monthly attendance (preslope -1.02%). After the first mental health visit, attendance increased (postslope 1.44%), with difference-in-difference 2.33. DISCUSSION: SBHC utilization was associated with improved school attendance over time, particularly for students with a mental health diagnosis. Investing in SBHCs may reduce school absenteeism and support student health.

School-Based Health Center Utilization During COVID-19 Pandemic-Related School Closures.

BACKGROUND: Little is known regarding utilization of school-based health centers (SBHCs) during prolonged school closures, such as those that occurred during the COVID-19 pandemic. We sought to compare SBHC utilization before and after pandemic-related school closures across a network of SBHCs affiliated with a large Southern Californian urban school district. METHODS: We conducted a secondary analysis of encounter data extracted from electronic health records from 12 SBHCs that remained open despite school closures, including patient demographics and diagnostic and billing codes. We used the Clinical Classifications Software Refined to group encounters for common primary care conditions. Utilization before and during pandemic-related school closures was compared using logistic regression with cluster-robust standard errors to account for clustering within clinics, after adjusting for month of encounter. RESULTS: During the pandemic, study SBHCs conducted 52,530 encounters and maintained ∼4040 encounters/month. The frequency of encounters for annual preventative health exams increased for school-aged patients but decreased for other age groups while the frequency of encounters for mental health problems increased for all age groups. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Despite pandemic-related school closures, SBHCs appeared play a critical role in providing primary care to vulnerable communities. CONCLUSIONS: SBHCs may hold value beyond their co-location with academic instruction.

Teachers and School Health Leaders' Perspectives on Distance Learning Physical Education During the COVID-19 Pandemic.

BACKGROUND: Due to the COVID-19 pandemic, students and teachers have transitioned to online learning. The transition required changes in teaching practices to accommodate for an online learning environment. However, there are no studies characterizing physical educators' and school health experts' perspectives on physical education via distance learning or identifying best practices and their implications for student health. METHODS: Using purposive and snowball sampling, we conducted semi-structured interviews with 19 physical education teachers and school health experts across 21 California school districts on best practices for physical education via distance learning. Interviews were recorded, transcribed, and analyzed using a grounded theory approach. RESULTS: Four major themes emerged: (1) participants felt high quality physical education via distance learning was both critical and possible; (2) strategies for creating a successful distance learning environment included personalization, creativity, and inclusiveness; (3) resources necessary for success included professional development, administrative support, and equipment; and (4) lessons for the long-term. CONCLUSIONS: Participants identified effective strategies, challenges, and recommendations for the future. Participants felt optimistic about their ability to provide quality physical education via distance learning, given the necessary supports, and perceived that they played a critical role in supporting student health during the COVID-19 pandemic.

Improving contraceptive use among Latina adolescents: A cluster-randomized controlled trial evaluating an mHealth application, Health-E You/Salud iTu.

OBJECTIVE: To evaluate the effectiveness of Health-E You/Salud iTu, a mobile health application (app), on increasing knowledge, self-efficacy and contraception use among Latina adolescents, its impact on visit quality, and app satisfaction. STUDY DESIGN: This study used cluster-randomized controlled trial (CRCT) of 18 school-based health centers (SBHCs). Prior to the visit, intervention participants received the patient-centered contraceptive decision-making support app and controls answered sexual health questions on iPads. Participants completed a previsit questionnaire and 3 follow-up surveys (48 hours, 3-, and 6-months) after the recruitment visit (where intervention participants completed the app). Differences in adolescents' contraceptive knowledge, self-efficacy, and use over the 6-month follow-up were assessed by generalized mixed effects regression models. RESULTS: A total of 1,360 Latina adolescents participated; 57.2% responded to the 48-hour survey, 50.1% to the 3-month, 49.7% to the 6-month, and 42.3% to both the 3- and 6-month surveys. Health-E You users' demonstrated significant increases in pre-post knowledge (p < 0.001). Intervention participants who completed the follow-up survey reported greater increases in mean self-efficacy from baseline (23.2 intervention vs. 22.5 controls) to 6 months (26.1 vs. 23.4; b = 1.58, 95% CI 0.38-2.77, p = 0.01), and greater increases in non-barrier contraceptive use from baseline (29% intervention vs. 30% controls) to 3 months (63% vs. 45%; OR = 3.29, 95% CI 1.04-10.36, p = 0.04) and 6 months (63% vs. 44%; OR = 5.54, 95% CI 1.70-18.06, p = 0.005). Providers and adolescents reported high app satisfaction and stated it improved visit quality. CONCLUSIONS: While data suggest that Health-E You improved outcomes, findings must be interpreted cautiously. Intervention participants had higher baseline sexual activity rates, more recruitment visits for pregnancy testing, emergency contraception or birth control, and lower completion rates of follow-up surveys than controls. IMPLICATIONS: Despite declines in adolescent pregnancy in the United States, Latinas continue to have disproportionately high rates compared to white females. The Health-E You app may be an effective support tool for both adolescents and providers in SBHCs, and possibly other clinical settings, across the country to increase contraceptive use and thereby decrease unintended pregnancies. It could potentially reduce disparities in adolescent pregnancies and create more efficient visit time spent between clients and their providers.

The Association Between Nonbarrier Contraceptive Use and Condom Use Among Sexually Active Latina Adolescents.

PURPOSE: This study aimed to determine the association between use of highly effective methods of nonbarrier contraception and condom use in a sample of Latina adolescents and whether the change to a more effective method of nonbarrier contraception is associated with a change in condom use. METHODS: As part of a larger study, 442 sexually active Latina adolescents aged 14-18 years were surveyed immediately before an appointment with a medical care provider at a school-based health center and 3 months later. Ordinal logistic and linear regression were used in the analysis of cross-sectional and longitudinal data to assess the relationship between patterns of nonbarrier contraception and condom use. RESULTS: The use of all types of nonbarrier methods of contraception was significantly associated with decreased condom use. Change over time from a less effective to a more effective nonbarrier method of contraception was also associated with a decrease in condom use. Greater number of sexual encounters was associated with lower the frequency of condom use. CONCLUSIONS: The use of highly effective methods of nonbarrier contraception was associated with reduced frequency of condom use. This highlights the need to promote condom use concurrently with nonbarrier methods of contraception to improve protection against both pregnancy and STIs.

A Mobile Health Contraception Decision Support Intervention for Latina Adolescents: Implementation Evaluation for Use in School-Based Health Centers.

BACKGROUND: Health care providers are a trusted and accurate source of sexual health information for most adolescents, and clinical guidelines recommend that all youth receive comprehensive, confidential sexual health information and services. However, these guidelines are followed inconsistently. Providers often lack the time, comfort, and skills to provide patient-centered comprehensive contraceptive counseling and services. There are significant disparities in the provision of sexual health services for Latino adolescents, which contribute to disproportionately higher rates of teenage pregnancy. To address this, we developed Health-E You or Salud iTu in Spanish, an evidence-informed mobile health (mHealth) app, to provide interactive, individually tailored sexual health information and contraception decision support for English and Spanish speakers. It is designed to be used in conjunction with a clinical encounter to increase access to patient-centered contraceptive information and services for adolescents at risk of pregnancy. Based on user input, the app provides tailored contraceptive recommendations and asks the youth to indicate what methods they are most interested in. This information is shared with the provider before the in-person visit. The app is designed to prepare youth for the visit and acts as a clinician extender to support the delivery of health education and enhance the quality of patient-centered sexual health care. Despite the promise of this app, there is limited research on the integration of such interventions into clinical practice. OBJECTIVE: This study described efforts used to support the successful adoption and implementation of the Health-E You app in clinical settings and described facilitators and barriers encountered to inform future efforts aimed at integrating mHealth interventions into clinical settings. METHODS: This study was part of a larger, cluster randomized control trial to evaluate the effectiveness of Health-E You on its ability to reduce health disparities in contraceptive knowledge, access to contraceptive services, and unintended pregnancies among sexually active Latina adolescents at 18 school-based health centers (SBHCs) across Los Angeles County, California. App development and implementation were informed by the theory of diffusion of innovation, the Patient-Centered Outcomes Research Institute's principles of engagement, and iterative pilot testing with adolescents and clinicians. Implementation facilitators and barriers were identified through monthly conference calls, site visits, and quarterly in-person collaborative meetings. RESULTS: Implementation approaches enhanced the development, adoption, and integration of Health-E You into SBHCs. Implementation challenges were also identified to improve the integration of mHealth interventions into clinical settings. CONCLUSIONS: This study provides important insights that can inform and improve the implementation efforts for future mHealth interventions. In particular, an implementation approach founded in a strong theoretical framework and active engagement with patient and community partners can enhance the development, adoption, and integration of mHealth technologies into clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT02847858; https://clinicaltrials.gov/ct2/show/NCT02847858 (Archived by WebCite at http://www.webcitation.org/761yVIRTp).

Voices from Minority Youth on Help-Seeking and Barriers to Mental Health Services: Partnering with School-Based Health Centers.

Objective: Schools and school-based health centers (SBHCs) play an important role in reducing disparities in access to mental health treatment. However, there is a need to increase student engagement in school mental health services. This study sought to understand the perceptions of low-income minority youth on help-seeking and barriers to mental health services at SBHC sites. Setting: A network of SBHCs, called Wellness Centers, developed as part of a strategic plan to serve students and community members in under-resourced areas of a large urban school district. Participants and Procedures: We conducted focus groups with 76 middle and high school students at nine SBHC sites through a community-academic partnered approach from January to May 2014. The focus groups were audio-recorded, transcribed, and major themes coded with Atlas.ti.5.1. Results: Students identified teachers as a primary source of support for mental health issues, followed by peers and mental health counselors. Students felt that trust and connection were vital for help-seeking. Barriers to using SBHCs included: embarrassment; fear of judgment; concerns about confidentiality; a sense that they should keep things inside; and lack of awareness. Conclusions: Despite the resources available at SBHCs, students face barriers to help-seeking. SBHCs can help teachers and school staff gain awareness of mental health issues and services available to students. The students' recommendations-making SBHCs more comfortable, raising mental health awareness, and bolstering connections with school and SBHC staff-may improve engagement in mental health services at schools with SBHCs.

Assessing the effectiveness of a patient-centred computer-based clinic intervention, Health-E You/Salud iTu, to reduce health disparities in unintended pregnancies among Hispanic adolescents: study protocol for a cluster randomised control trial.

INTRODUCTION: Teen pregnancy rates in the USA remain higher than any other industrialised nation, and pregnancies among Hispanic adolescents are disproportionately high. Computer-based interventions represent a promising approach to address sexual health and contraceptive use disparities. Preliminary findings have demonstrated that the Health-E You/Salud iTu, computer application (app) is feasible to implement, acceptable to Latina adolescents and improves sexual health knowledge and interest in selecting an effective contraceptive method when used in conjunction with a healthcare visit. The app is now ready for efficacy testing. The purpose of this manuscript is to describe patient-centred approaches used both in developing and testing the Health-E You app and to present the research methods used to evaluate its effectiveness in improving intentions to use an effective method of contraception as well as actual contraceptive use. METHODS AND ANALYSIS: This study is designed to assess the effectiveness of a patient-centred computer-based clinic intervention, Health-E You/Salud iTu, on its ability to reduce health disparities in unintended pregnancies among Latina adolescent girls. This study uses a cluster randomised control trial design in which 18 school-based health centers from the Los Angeles Unified School District were randomly assigned, at equal chance, to either the intervention (Health-E You app) or control group. Analyses will examine differences between the control and intervention group's knowledge of and attitudes towards contraceptive use, receipt of contraception at the clinic visit and self-reported use of contraception at 3-month and 6-month follow-ups. The study began enrolling participants in August 2016, and a total of 1400 participants (700 per treatment group) are expected to be enrolled by March 2018. ETHICS AND DISSEMINATION: Ethics approval was obtained through the University of California, San Francisco Institutional Review Board. Results of this trial will be submitted for publication in peer-reviewed journals. This study is registered with the US National Institutes of Health. TRIAL REGISTRATION NUMBER: NCT02847858.

A school-based public health model to reduce oral health disparities.

OBJECTIVES: Although dental decay is preventable, it remains the most common pediatric chronic disease. We describe a public health approach to implementing a scalable and sustainable school-based oral health program for low-income urban children. METHODS: The Los Angeles Trust for Children's Health, a nonprofit affiliated with the Los Angeles Unified School District, applied a public health model and developed a broad-based community-coalition to a) establish a District Oral Health Nurse position to coordinate oral health services, and b) implement a universal school-based oral health screening and fluoride varnishing program, with referral to a dental home. Key informant interviews and focus groups informed program development. Parent surveys assessed preventative oral health behaviors and access to oral health services. Results from screening exams, program costs and rates of reimbursement were recorded. RESULTS: From 2012 to 2015, six elementary schools and three dental provider groups participated. Four hundred ninety-one parents received oral health education and 89 served as community oral health volunteers; 3,399 screenings and fluoride applications were performed on 2,776 children. Sixty-six percent of children had active dental disease, 27 percent had visible tooth decay, and 6 percent required emergent care. Of the 623 students who participated for two consecutive years, 56 percent had fewer or no visible caries at follow-up, while only 17 percent had additional disease. Annual program cost was $69.57 per child. CONCLUSIONS: Using a broad based, oral health coalition, a school-based universal screening and fluoride varnishing program can improve the oral health of children with a high burden of untreated dental diseases.

Bringing Wellness to Schools: Opportunities for and Challenges to Mental Health Integration in School-Based Health Centers.

OBJECTIVE: School-based health centers (SBHCs) reduce access barriers to mental health care and improve educational outcomes for youths. This qualitative study evaluated the innovations and challenges of a unique network of SBHCs in a large, urban school district as the centers attempted to integrate health, mental health, and educational services. METHODS: The 43 participants sampled included mental health providers, primary care providers, and care coordinators at 14 SBHCs. Semistructured interviews with each participant were audio recorded and transcribed. Themes were identified and coded by using Atlas.ti 5.1 and collapsed into three domains: operations, partnership, and engagement. RESULTS: Interviews revealed provider models ranging from single agencies offering both primary care and mental health services to colocated services. Sites where the health agency provided at least some mental health services reported more mental health screenings. Many sites used SBHC wellness coordinators and coordination team meetings to facilitate relationships between schools and health agency and community mental health clinic providers. Partnership challenges included confidentiality policies and staff turnover. Participants also highlighted student and parent engagement through culturally sensitive services, peer health advocates, and "drop-in" lunches. CONCLUSIONS: Staffing and operational models are critical in the success of integrating primary care, mental health care, and education. Among the provider models observed, the combined primary care and mental health provider model offered the most integrated services. Despite barriers, providers and schools have begun to implement novel solutions to operational problems and family engagement in mental health services.

Enhancing service delivery through title x funding: findings from California.

CONTEXT: The federal Title X grant program provides funding for family planning services for low-income women and men. In California, all clinics receiving Title X funds participate in the state's family planning program, Family PACT, along with other public and private providers. The relative extent to which Title X-funded clinics and other Family PACT providers have incorporated enhancements beyond their core medical services has never been studied. METHODS: In 2010, a survey was sent to public- and private-sector Family PACT clinicians to assess whether funding streams were associated with the availability of special services: extended clinic hours, outreach to vulnerable populations, services for clients not proficient in English and use of advanced clinic-based technologies. Bivariate and logistic regression analyses controlling for potentially confounding factors were conducted. RESULTS: Greater proportions of Title X-funded clinics than of other public and private providers had Spanish-speaking unlicensed clinical staff (89% vs. 71% and 58%, respectively) and Spanish-language signs (95% vs. 85% and 82%). Title X-funded providers were more likely than other public providers to offer extended clinic hours, provide outreach to at least three vulnerable or hard-to-reach populations, and use three or more advanced technologies (odds ratios, 2.0-2.9). CONCLUSIONS: Compared with other Family PACT providers, clinics that receive Title X funding have implemented greater infrastructure enhancements to promote access and improve the quality of service for underserved populations. This may be because Title X-funded providers have more financial opportunities to provide the array of services that best respond to their clients' needs.