The Journal of School Nursing2023, Vol. 39(5) 368–376© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211025008journals.sagepub.com/home/jsn
School-based health centers (SBHCs) positively influence student health. However, the extent to which these benefits are actualized varies across sites. We conducted focus groups with high school students and teachers at an underperforming SBHC to identify facilitators and barriers to student access to SBHC services. Our qualitative analysis revealed four main emergent categories: (1) students’ knowledge of SBHC services; (2) teachers’ perceptions of, and experiences with, the SBHC; (3) accessing and utilizing SBHC services; and (4) student and teacher suggestions to improve the school–SBHC relationship. Our findings suggest that the relationships between health center staff and teachers are crucial and can be damaged with poor implementation. Additionally, there was a general lack of knowledge about the procedures for accessing services at the SBHC. Participants provided recommendations, including strategies for better outreach and engagement with teachers and students, as well as operational strategies to enhance communication systems and the physical environment.
Keywordshigh school, program development/evaluation, school-based clinics, qualitative research
School-based health centers (SBHCs) provide primary care, mental health care, and health education to children and adolescents in schools, removing service barriers for students from communities experiencing health disparities (Lofink et al., 2013; Love et al., 2018). By providing a familiar environment for students to communicate with providers, SBHCs promote trusting patient–provider relationships (Albright et al., 2016; Beem et al., 2019). Most SBHCs are run by a nurse practitioner—with support from additional medical staff—and partner with mental health providers to provide these services (Love et al., 2018). To enhance service provision, some SBHCs establish student health teams with school staff, SBHC staff, and student representatives (Lai et al., 2016). Unsurprisingly, students who use SBHCs tend to be highly satisfied with their providers and the quality of care (Benkert et al., 2007; Soleimanpour et al., 2010).
Researchers have established that SBHCs successfully increase child and adolescent utilization of health care services, improving health outcomes (Arenson et al., 2019; Gibson et al., 2013). These benefits extend to mental health service utilization and outcomes (Bains & Diallo, 2016). The beneficial effects of SBHCs can be particularly impactful for students who belong to communities experiencing health service disparities, such as students who identify as racial or ethnic minorities (Bains et al., 2014; Bersamin et al., 2017), students who identify as sexual minorities (lesbian, gay, bisexual, or other; Zhang et al., 2020), and students without medical insurance (Allison et al., 2007).
SBHCs actualize their potential for benefit to varying degrees. Regulatory frameworks and local resources can limit the scope of services that SBHCs provide (Brindis et al., 2003; Lofink et al., 2013), impacting their benefits to students. Service delivery models also might vary in response to differing community health needs, as SBHCs serve a diverse array of communities (Love et al., 2018). These factors may explain why SBHC implementation tends to reduce emergency care use in urban areas (Juszczak et al., 2003; Kaplan et al., 1999; Key et al., 2002), but not in rural areas (Guo et al., 2005; Schwartz et al., 2016).
Examining the experiences of SBHC users can help researchers understand factors that account for the variation in outcomes across centers (King & Appleton, 1999; World Health Organization, 2015). Using quantitative methods, researchers consistently find high levels of satisfaction with SBHC care among student patients (Benkert et al., 2007; Klein et al., 2007; Parasuraman & Shi, 2014). There are fewer qualitative examples of research on SBHC care, but these studies can provide practical conclusions about SBHC operations. For example, Blacksin and Kelly (2015) identified SBHC staff’s positive relationships with the school as crucial to promoting school-wide benefits. Soleimanpour et al. (2010) found that students appreciated the confidentiality, convenience, and comfortable environment of SBHCs, but criticized the long waits and limited privacy. These students’ recommendations to improve the quality of care at the center included increasing outreach, offering afterschool activities, expanding hours, and ensuring privacy. Daley, Polifroni, and Sadler’s (2019) interviews with adolescent patients and SBHC nurse practitioners helped identify important components of adolescent-friendly service provision. These included privacy and confidentiality, positive relationships with providers, collaboration between school and health center staff, and accessible services.
Given the varying outcomes across SBHCs, we1 conducted a qualitative examination of student service utilization at an SBHC located in a public high school. We chose this center because its utilization rates did not meet the minimum standard set by the public health department (who ran all local SBHCs). Studying an underperforming site, or a deviant case, allows researchers to identify critical mechanisms that might be applicable to other cases (Seawright & Gerring, 2008). Our goal was to understand the factors influencing student service use.
Our work was guided by community-engaged research principles emphasizing researchers’ working collaboratively with—and being accountable to—the communities that they study (Mikesell et al., 2013). Our original data collection occurred in the context of a continuous quality improvement evaluation, and we worked closely with the administrators of local SBHCs to identify an evaluation focus and approach that was locally viable and relevant. We chose a qualitative deviant case study design focused on the perspectives of students and teachers at an underperforming SBHC.
The SBHC was located in a public high school within a medium-sized city in the Midwestern U.S. We collected data in the spring of 2017. The school served ∼1,300 students, grades 7 through 12, most of whom identified as African American (36%), Caucasian (32%), or Hispanic (23%). Additionally, school staff reported a recent influx of refugee students. Over half of the students at the high school were eligible for free or reduced lunch, and the on-time graduation rate was 56%. At the time of our study, the SBHC at this high school had been operating for ∼8 years. The SBHC was staffed by one nurse practitioner, one part-time nurse, two medical assistants (who also provide administrative support), and one social worker. The SBHC offered primary health care services, behavioral health services, and health education programs. It was open Monday through Friday, year-round, with services available for individuals between 5 and 25 years of age.
Our reanalysis of the continuous quality improvement data was reviewed and approved by Michigan State University’s Human Subjects Internal Review Board (Study No. 00004525).
During our original coding and analysis, our primary focus was providing rapid feedback to the SBHC administrators about factors that might underlie low utilization rates. That is, on linking our findings directly to the specific, single context of that SBHC. In our reanalysis for this study, our primary focus was on the relation of our findings to prior research on the utilization of SBHCs and the transferability of our findings to other settings. That is, on linking our findings to other relevant research and considering their implications for said research.
A community health worker, who was also the men’s varsity soccer coach at the high school, recruited students and teachers through text, email, and in-person inquiry. We included students in the sample if they attended the school, were in seventh through 12th grade, and spoke English. Teachers were included if they taught at the school and spoke English.
Four teachers participated in the study, all of whom were women. One teacher also brought in written information from another colleague who was not able to attend the focus group. Unanticipated problems with on-site printing and internet access prevented us from gathering additional background information from teachers and students. Thirty youth between the ages of 12 and 18 years also actively participated in the study. Although we did not store specific demographic information to protect student participants’ privacy and anonymity, most of them were male and identified as African American. Although we did not collect information about students’ utilization of the SBHC, during the focus groups students referenced personal experiences with the SBHC as well as the experiences of friends.
Our guiding concern when selecting focus group questions was to obtain insight into low utilization rates at this SBHC relative to others in the area. Presented in Table 1, the questions focused on participants’ knowledge about, perceptions of, and experiences with their SBHC (e.g., “What are reasons that students would use the health services offered at the health center?†and “Do you feel welcome at the health center?â€). Author two facilitated the focus groups and—when necessary—used probes to gather more information or details (e.g., “That sounds interesting. Can you explain how it would work?â€). Author two recorded participants’ comments using live field notes and conducted member checking at the end of each group to ensure that her notes were accurate, providing participants the opportunity to clarify or add new content. Author two did not record focus groups, per students’ requests.
We conducted one focus group with teachers (n = 4), and two focus groups with youth (n = 18 and n = 12). Each lasted ∼30 min after school time and took place in a school multipurpose room. Participants were provided with pizza or sandwiches during their participation.
Consent and Assent. We originally collected these data as part of a continuous quality improvement evaluation, designed in collaboration with the local SBHC administrators. Although we did not require written consent documentation, we completed an oral informed consent at the beginning of each group in which we described the purpose and procedures of our work, reminding youth and teachers that their participation was voluntary and that they could leave at any time without negative repercussions. To protect confidentiality, we did not record any identifiable information from participants.
For the present study, we used Graneheim and Lundman’s (2004) data analytic approach to code the information recorded in our field notes. This approach originates from nursing science and is widely used in health services research (e.g., Shin et al., 2009). As a first step, author two identified meaning units within the data. Author two then generated codes that condensed the information in these meaning units and subsequently compared the codes, grouping them into tentative subcategories. At this point, author one conducted a confirmability audit to ensure that the subcategories emerging in previous steps represented all meaning units. We resolved discrepancies through discussion and consensus among all authors. As a final step, we merged the subcategories into more analytical categories.
We fostered trustworthiness2 by (1) triangulating our analyses across sources (i.e., teachers and students); (2) reporting field notes back to participants at the end of the focus groups and amending these based on the participants’ guidance (i.e., member-checking); (3) conducting concurrent inquiry and confirmability audits; (4) engaging in individual and collective reflexivity about our biases; and (5) providing a detailed description of the context of this study.
In Table 2, we summarize the four categories that emerged from our analysis: (1) students’ knowledge of SBHC services; (2) teachers’ perceptions of, and experiences with, the SBHC; (3) accessing and utilizing SBHC services; and (4) student and teacher suggestions to improve the school–SBHC relationship. We describe each category and related subcategories in a dedicated subsection.
Students’ knowledge of SBHC services fell into two subcategories: (1) knowledge of physical health services and (2) confusion on the full range of services. Each subcategory is described below.
Knowledge of Physical Health Services. Many students were aware of, and able to list, health services provided by the SBHC. Services students identified included receiving sports physicals, annual check-ups, vaccinations, and ice packs. Among available services, students identified sports physicals as the most likely reason they and their peers use the health center.
Confusion on Full Range of Services. Many students were unaware the SBHC offered mental health services. Some students were aware a “counselor†was employed, but believed the counselor was a school guidance counselor rather than a mental health counselor. Students had mixed responses about whether contraceptive services were offered. Some students were certain they could obtain contraceptives at the SBHC. Other students noted that contraceptive services could be obtained at a nearby community health center, and not at the school. Students reported they would be more likely to utilize the health center if contraceptive services were available.
Teachers reported a lack of alignment between their perception of the purpose of the health center and how the SBHC operated and SBHC staff performed their roles. These misperceptions fell into three subcategories: (1) referring students with mental health concerns, (2) teachers’ access to SBHC services, and (3) organizational challenges of SBHC implementation. Each subcategory is described below.
Referring Students with Mental Health Concerns. One teacher was unaware that mental health services were available at the SBHC. Teachers reported concern for students’ safety and mental health but felt uncomfortable referring students to the health center. This was due to teachers’ previous experiences with referring students to the SBHC for mental health services, where they described a lack of follow-up for students and no communication on the outcomes of these referrals. For example, one teacher described how a student disclosed experiencing suicidal ideation, and the teacher acted by sending them to the SBHC to speak with the social worker. The teacher said a poster on suicide prevention was posted next to her classroom the next day. When she asked the student how they were doing, the student told her they were not seen by the social worker at the SBHC and were still experiencing suicidal ideation. Teachers described how experiences such as this left them feeling helpless, frustrated, and unsure how to support students.
Teachers’ Access to SBHC Services. Many teachers believed that the SBHC provided urgent care, but were turned away during emergencies. This fostered mistrust and a belief that the actions of the SBHC staff were unethical. One teacher described that—having fallen down the school stairs while pregnant—she went to the SBHC and was told by staff to go to an urgent care center. Teachers reported frustration that they themselves were not able to receive primary care services at the health center as receiving SBHC services could prevent taking time off work for certain health appointments.
Organizational Challenges of SBHC Implementation. Teachers reported that the SBHC was the only option available for mental health services for students because the school social worker position was eliminated when the SBHC was implemented. Teachers described feeling bitter about this change, as they had a good relationship with the previous school social worker. Despite this, teachers described a desire to work with SBHC staff to link students to supportive health and mental health services.
Students and teachers described positive and negative experiences and perceptions of accessing and utilizing SBHC services. These fell into six subcategories. Three subcategories describe participants’ perspectives of the health center procedures: (1) accessing SBHC services, (2) confidentiality, and (3) scheduling and attending appointments. Two subcategories describe participants’ perspectives of the SBHC staff and environment: (4) relationships with SBHC staff and (5) the physical environment. The sixth subcategory describes how the SBHC protects transgender student privacy.
Accessing SBHC Services. Teachers reported being unaware of the different services offered at the SBHC and were unsure how to link students to SBHC services. For example, if they were concerned about a student, they wanted to know how to make a referral to initiate mental health counseling. One teacher reported she had asked if someone from the SBHC would briefly speak to her class and was told “everyone is too busy.†Teachers described how the school had a large refugee student population and they were unsure of the procedures for non-English speakers to access the SBHC. Teachers reported they were confused whether parent permission was needed for all visits to the SBHC. They had also asked for guidelines on what to send students to the health center for, but were not given information.
Confidentiality. Both teachers and students appeared to be unsure of confidentiality. Students voiced concern that information from the SBHC would be shared with their parents. Students also expressed worry that the information they might share with the SBHC would “get out†to other students. Many students reported feeling uncomfortable sharing personal information with an unfamiliar person and worried about experiencing stigma if peers found out they were receiving mental health services.
Scheduling and Attending Appointments. Students understood they were responsible for keeping track of their appointments. Students and teachers were also aware that appointments needed to be scheduled in advance. Teachers were unsure of students’ appointment times and were unable to assist them with their appointments. Teachers also reported feeling frustrated when students who had contracted something contagious were sent back to class and had to make a future appointment. Finally, teachers believed that the SBHC should be available for students with emergent needs, whereas the teachers perceived SBHC staff believed—in most cases—it was inappropriate for them to see students without an appointment.
Relationships with SBHC Staff. Female students in one focus group reported staff in the SBHC were friendly. They reported feeling comfortable in the health center and described it as “a wonderful place.†Several other students reported a lack of rapport with health center staff, and some of their interactions with the staff left them feeling unwelcome. Students described staff as “rude,†“moody,†and that they “give weird vibes,†among other descriptors. Students described feeling as if the staff were “nice to their face†and then “had an attitude†about the students when they left the SBHC.
The Physical Environment. Students described many structural and environmental issues that made the health center unwelcoming. This includes, but is not limited to, lighting, temperature, and the “clinical feel†of the environment.
Transgender Student Privacy. Teachers reported transgender students received medical passes to access the private bathroom inside the SBHC. Teachers described how this positive practice protected transgender students by providing the opportunity to maintain their privacy.
Although we did not ask for suggestions to improve the SBHC, participants offered multiple recommendations. Recommendations provided by students and teachers generally fell into two subcategories: (1) outreach activities and (2) process improvement. Each subcategory is described below.
Outreach Activities. Teachers suggested SBHC staff could attend teacher development sessions before the academic year to give presentations on available services, required paperwork, and referral procedures. Teachers emphasized this would be important to do every year, due to the high rate of teacher turnover. Students and teachers also suggested SBHC staff could increase their presence among students by attending classes and giving 15 minute presentations on available services and paperwork requirements. This would help clarify confidentiality.
Teachers also suggested SBHC staff could organize a student health team. The purpose of the student health team would be to give presentations and facilitate fun activities on health-related behaviors. Teachers also noted it would be helpful to receive a monthly newsletter from the SBHC. They suggested content could include current events, what illnesses were going around, and other healthrelated information.
Process Improvement. Teachers identified refugee students as an increasing population in the school. They suggested SBHC staff could debrief refugee students on what to expect when they attend school. They also suggested SBHC forms could be translated, or they could offer a translator to interpret the forms to parents. Teachers noted it would be important to provide outreach efforts to help refugee parents understand how the SBHC could serve their child(ren).
Teachers reported wanting to help students keep their scheduled appointments. They suggested having the SBHC staff connect with the school’s information technology (IT) department to obtain access to the IT platform the school used. They described how receiving email alerts if students had a scheduled appointment would prevent missed appointments. They also believed it would improve overall communication.
Students described the atmosphere in the SBHC feeling uncomfortable and dark. They offered several suggestions to improve the atmosphere of the SBHC. For example, providing a water cooler with small cups for students to drink clean water. Another suggestion was to have a candy jar at the sign-in desk. A third suggestion included having more light in the waiting area. Another student recommended some plants, similar to the plants in the waiting room at a local community health center. Finally, students suggested playing culturally relevant music they could relate to.
SBHCs can facilitate access to health services among children and youth, particularly those belonging to historically underserved populations (Allison et al., 2007; Bains et al., 2014; Bersamin et al., 2017). Therefore, it is important to understand the factors associated with students’ use of these health centers. We conducted focus groups with samples of two key stakeholder groups, teachers and students, to examine factors affecting student service use at an SBHC with lower utilization than local comparisons. Teachers also discussed their perceptions of the strategic advantage of the SBHC as a point of support for underserved students, and all stakeholders provided recommendations for the improvement of the health center.
Some of the most important factors impacting children and adolescents’ access to care are the availability of information about services, organizational procedures, and perceptions of providers (Anderson et al., 2017). Results suggest that all three factors played a role in the low service utilization observed in the current site. First, students and teachers were uninformed about some of the services available at their SBHC, mental health services in particular. This lack of information prevented the utilization of mental health and other targeted services. This finding is consistent with those from prior studies of student SBHC utilization (Ijadi-Maghsoodi et al., 2018), and of extant research, which supports the assertion that providing mental health service education in school settings is key to promote utilization (Power et al., 2005).
Second, organizational procedures seemed to obstruct service utilization. Teachers and students reported that the health center did not allow drop-in or same day visits, despite best practice recommendations for SBHCs to handle emergency and acute situations on-site (Council on School Health, 2012; Daley et al., 2019). If SBHCs have the capacity to see drop-in patients, students could get recommendations from medical personnel and potentially divert costly emergency room visits.
Third, students and teachers had negative perceptions of the health center staff, viewing them as unfriendly and unable to maintain confidentiality. These negative perceptions are problematic, as positive relationships between SBHC staff and school staff have profound implications for the quality and effectiveness of a center’s services (Blacksin & Kelly, 2015; Fast, 2003). Furthermore, students who do not trust their providers tend to feel uncomfortable accessing care (Power et al., 2005). This site failed to leverage a key strategic advantage of SBHCs: favorable conditions for trusting relationships between providers, health center staff, and patients (Albright et al., 2016; Beem et al., 2019). Our findings illustrate that in SBHCs the importance of trust expands beyond relationships with patients. The poor rapport between SBHC staff and teachers adversely affected the latter’s promotion of services among their students, which aligns with findings from previous case studies of SBHCs (Fast, 2003).
Teachers highlighted the benefits of SBHC services for transgender students, promoting students’ ownership over when and how to disclose their gender identity. This aligns with the mission and potential of SBHCs to promote equity (Knopf et al., 2016). However, teachers also had concerns about the SBHC’s capacity to serve their increasing refugee student population. Although SBHCs are an accessible approach to health care delivery, there are few studies on the cultural responsiveness of these centers (Beem et al., 2019). Preliminary evidence suggests that racial and ethnic minority SBHC users might perceive lower-quality care than their White counterparts (Parasuraman & Shi, 2014). Researchers who have examined SBHC care for historically marginalized populations, such as lesbian, gay, bisexual, transgender, and queer/questioning students, have found limited staff training or procedural capacity to provide culturally responsive care (Garbers et al., 2018). If SBHCs are to fulfill their potential to promote health service equity, they must ensure that staff have the tools and training to serve populations facing disparities (Abrishami, 2018).
Without prompting, participants offered recommendations to improve the SBHC. Participants thought the health center should increase outreach activities and transparency about procedures. Specific outreach activities included classroom presentations, newsletters, and family outreach for students with specific needs. Participants also recommended that the SBHC establish a student health team, which has been demonstrated to be an effective strategy elsewhere (Lai et al., 2016). Student SBHC advisory boards can offer a deep understanding of the barriers to service utilization and identify creative solutions (Mandel & Qazilbash, 2005).
An incidental finding from our study demonstrates the detrimental effect of unfavorable implementation conditions. The school’s social worker—who was respected by school staff—was let go when the SBHC was implemented. Although school staff were assured that the SBHC would provide the same supports, they felt resentful. With time, they grew distrustful and disinvested in the health center as its scope and operations remained unclear to them. These findings converge with those of another SBHC case study (Fast, 2003), where the school nurse felt displaced by the implementation of the health center, resulting in the school staff not trusting the SBHC staff to care for students. These negative organizational climates, particularly in health care settings, impact the effectiveness of services (Glisson, 2002; Hemmelgarn et al., 2006). It is important for researchers to consider the SBHC organizational context to identify effective approaches to implementation and service delivery.
For schools and health departments investing in a new SBHC, it is essential to consider the context of implementation. In our study, the SBHC implementation displaced a valued school staff member who facilitated student access to health services, the school social worker. This displacement raised challenges for the establishment of good relations between teachers and the SBHC. As of 2015–16, 82% of public schools in the United States had a school nurse (National Center for Educational Statistics, 2020). Given the overlapping roles of school nurses and SBHC staff, the findings of our study and others (e.g., Fast, 2003) lead us to believe it would be important to (1) ensure that implementation does not displace any school staff and (2) engage with school staff—nurses in particular—to hear their thoughts and concerns about a new health center. Collecting this information will offer insight into anticipated points of tension or conflict and proactively identify solutions for how to overcome these challenges.
School nurses and other school staff dedicated to improving student health (e.g., social workers) should play essential roles in integrating an SBHC into the school, as their knowledge of the student body’s health and well-being can inform programming and service delivery. Further, the implementation of an SBHC program can both expand and refine the scope of work for a school nurse (Hacker & Wessel, 1998). There are some services that SBHCs might not be able to provide (e.g., drop-in services) due to regulatory frameworks (e.g., reimbursement processes). These gaps might be areas for school nurses to support, and the SBHC and school nurse should work together to define complementary roles.
Our study builds on the existing literature and highlights the importance of relationship building and engaging with stakeholders such as teachers and students to provide feedback and recommendations for the SBHC. Given the negative perceptions students and teachers reported of SBHC staff in our study, a school nurse could support these activities. School nurses are in a position to build meaningful, trustworthy relationships with students (Summach, 2011), and could support SBHC engagement and outreach efforts, such as by cofacilitating health and wellness classroom presentations, providing SBHC referrals, and serving on student health teams.
Our findings should be considered in the context of this study’s limitations. Our findings are from one SBHC that was selected as a deviant case due to its low utilization rates. The extent to which our findings transfer to other settings is linked to their similarity to the current setting and samples, though the mechanisms identified in a deviant case can sometimes be more broadly applied (Seawright & Gerring, 2008).
Regarding characteristics that may limit transferability, despite the school serving a diverse student body, student participants were predominantly young African American men involved in athletics. Our findings might not translate to the whole student population. Participants in our study highlighted the convenience of accessing physicals at the SBHC, but other nonathlete student populations might prioritize different services. Additionally, there is evidence that young African American men have specific health and health care needs. Previous research suggests that African American students—males in particular—are more likely to utilize SBHC services (Bains et al., 2014; Whitaker et al., 2019), and it would be inappropriate to generalize our findings to young women’s or non-African American students’ experiences with SBHCs. The small number of teachers who participated in focus groups presents another limitation. Although our results begin to describe the importance of fostering relationships between the SBHC and school staff, we are only able to describe the perspectives of the students and teachers. Future work that expands upon these findings and incorporates SBHC staff feedback is needed.
We identified four main categories from our focus groups with students and teachers: (1) students’ knowledge of SBHC services; (2) teachers’ perceptions of, and experiences with, the SBHC; (3) accessing and utilizing SBHC services; and (4) student and teacher suggestions to improve the school–SBHC relationship. Our findings highlight the importance of relationships in SBHCs actualizing their potential to provide high-quality health services to youth, both patient–provider relationships (SBHC service providers and students) and organizational relationships (the SBHC and the school). Despite our study’s limitations, these findings have important implications for practitioners and might be particularly useful for stakeholders who are in the process of, or considering, implementing an SBHC. We also believe our study has implications for future directions of SBHC researchers, including examining: (1) the implementation of new SBHCs, with a focus on organizational climate; (2) the cultural responsiveness of SBHC staff and care providers; (3) the organizational factors that promote service utilization, with a focus on communication and relationship building between SBHC staff and school staff; and (4) the importance of client and stakeholder voice in understanding and promoting health service utilization.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors received no financial support for the research, authorship, and/or publication of this article.
Jennifer A. Gruber https://orcid.org/0000-0002-4386-5122
Abrishami, D. (2018). The need for cultural competency in health care. Radiologic Technology, 89(5), 441–448. http://www.radiologictechnology.org/
Albright, K., Barnard, J., O’Leary, S., Federico, S., Saville, A., Lockhart, S., & Lee, M. (2016). School-based health centers as medical homes: Parents’ and adolescents’ perspectives. Academic Pediatrics, 16(4), 381–386. https://doi.org/10.1016/j.acap.2015.06.004
Allison, M. A., Crane, L. A., Beaty, B. L., Davidson, A. J., Melinkovich, P., & Kempe, A. (2007). School-based health centers: Improving access and quality of care for low-income adolescents. Pediatrics, 120(4), e887–e894. https://doi.org/10.1542/peds.2006-2314
Anderson, J. K., Howarth, E., Vainre, M., Jones, P. B., & Humphrey, A. (2017). A scoping literature review of servicelevel barriers for access and engagement with mental health services for children and young people. Children and Youth Services Review, 77(November 2016), 164–176. https://doi.org/10.1016/j.childyouth.2017.04.017
Arenson, M., Hudson, P. J., Lee, N., & Lai, B. (2019). The evidence on school-based health centers: A review. Global Pediatric Health, 6, 1–10. https://doi.org/10.1177/2333794X19828745
Bains, R. M., & Diallo, A. F. (2016). Mental health services in school-based health centers: Systematic review. Journal of School Nursing, 32(1), 8–19. https://doi.org/10.1177/1059840515590607
Bains, R. M., Franzen, C. W., & White-Frese’, J. (2014). Engaging African American and Latino adolescent males through school-based health centers. Journal of School Nursing, 30(6), 411–419. https://doi.org/10.1177/1059840514521241
Beem, A. A., Batlivala, C., & Norwood, A. A. (2019). School-based health centers as the pediatric expanded medical home. Journal of School Health, 89(11), 934–937. https://doi.org/10.1111/josh.12825
Benkert, R., George, N., Tanner, C., Barkauskas, V. H., Pohl, J. M., & Marszalek, A. (2007). Satisfaction with a school-based teen health center: A report card on care. Pediatric Nursing, 33(2), 103–109. http://www.pediatricnursing.net/
Bersamin, M., Paschall, M. J., & Fisher, D. A. (2017). School-based health centers and adolescent substance use: Moderating effects of race/ethnicity and socioeconomic status. Journal of School Health, 87(11), 850–857. https://doi.org/10.1111/josh.12559
Blacksin, B. A., & Kelly, P. J. (2015). Connecting teens to caring adults in a school-based health center: A case study. Journal of Community Health Nursing, 32(2), 89–103. https://doi.org/10.1080/07370016.2015.1024543
Brindis, C. D., Klein, J., Schlitt, J., Santelli, J., Juszczak, L., & Nystrom, R. J. (2003). School-based health centers: Accessibility and accountability. Journal of Adolescent Health, 32(6 Suppl.), 98–107. https://doi.org/10.1016/S1054-139X(03)00069-7
Council on School Health. (2012). School-based health centers and pediatric practice. https://doi.org/10.1542/peds.2011-3443
Daley, A. M., Polifroni, E. C., & Sadler, L. S. (2019). The essential elements of adolescent-friendly care in school-based health centers: A mixed methods study of the perspectives of nurse practitioners and adolescents. Journal of Pediatric Nursing, 47, 7–17. https://doi.org/10.1016/j.pedn.2019.03.005
Fast, J. D. (2003). An in-law comes to stay: Examination of interdisciplinary conflict in a school-based health center. Social Work, 48(1), 45–50. https://doi.org/10.1093/sw/48.1.45
Garbers, S., Heck, C. J., Gold, M. A., Santelli, J. S., & Bersamin, M. (2018). Providing culturally competent care for LGBTQ youth in school-based health centers: A needs assessment to guide quality of care improvements. Journal of School Nursing, 34(6), 424–429. https://doi.org/10.1177/1059840517727335
Gibson, E. J., Santelli, J. S., Minguez, M., Lord, A., & Schuyler, A. C. (2013). Measuring school health center impact on access to and quality of primary care. Journal of Adolescent Health, 53(6), 699–705. https://doi.org/10.1016/j.jadohealth.2013.06.021
Glisson, C. (2002). The organizational context of children’s mental health services. Clinical Child and Family Psychology Review, 5(4), 233–253. https://doi.org/10.1023/A:1020972906177
Graneheim, U. H., & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24(2), 105–112. https://doi.org/10.1016/j.nedt.2003.10.001
Guo, J. J., Jang, R., Keller, K. N., McCracken, A. L., Pan, W., & Cluxton, R. J. (2005). Impact of school-based health centers on children with asthma. Journal of Adolescent Health, 37(4), 266–274. https://doi.org/10.1016/j.jadohealth.2004.09.006
Hacker, K., & Wessel, G. L. (1998). School-based health centers and school nurses: Cementing the collaboration. Journal of School Health, 68(10), 409–414. https://doi.org/10.1111/j.1746-1561.1998.tb06318.x
Hemmelgarn, A. L., Glisson, C., & James, L. R. (2006). Organizational culture and climate: Implications for services and interventions research. Clinical Psychology: Science and Practice, 13(1), 73–89. https://doi.org/10.1111/j.1468-2850.2006.00008.x
Ijadi-Maghsoodi, R., Bonnet, K., Feller, S., Nagaran, K., Puffer, M., & Kataoka, S. (2018). Voices from minority youth on helpseeking and barriers to mental health services: Partnering with school-based health centers. Ethnicity and Disease, 28(2, Suppl.), S437–S444. https://doi.org/10.18865/ed.28.S2.437
Juszczak, L., Melinkovich, P., & Kaplan, D. (2003). Use of health and mental health services by adolescents across multiple delivery sites. Journal of Adolescent Health, 32(6 Suppl.), 108–118. https://doi.org/10.1016/S1054-139X(03)00073-9
Kaplan, D. W., Brindis, C. D., Phibbs, S. L., Melinkovich, P., Naylor, K., & Ahlstrand, K. (1999). A comparison study of an elementary school-based health center: Effects on health care access and use. Archives of Pediatrics and Adolescent Medicine, 153(3), 235–243. https://doi.org/10.1001/archpedi.153.3.235
Key, J. D., Washington, E. C., & Hulsey, T. C. (2002). Reduced emergency department utilization associated with school-based clinic enrollment. Journal of Adolescent Health, 30(4), 273–278. https://doi.org/10.1016/S1054-139X(01)00390-1
King, L., & Appleton, J. V. (1999). Pearls, pith, and provocation fourth generation evaluation of health services: Exploring a methodology that offers equal voice to consumer and professional stakeholders.
Klein, J. D., Handwerker, L., Sesselberg, T. S., Sutter, E., Flanagan, E., & Gawronski, B. (2007). Measuring quality of adolescent preventive services of health plan enrollees and school-based health center users. Journal of Adolescent Health, 41(2), 153–160. https://doi.org/10.1016/j.jadohealth.2007.03.012
Knopf, J. A., Finnie, R. K. C., Peng, Y., Hahn, R. A., Truman, B. I., Vernon-Smiley, M., … Johnson, V. C. (2016). School-based health centers to advance health equity: A community guide systematic review. American Journal of Preventive Medicine, 51(1), 114–126. https://doi.org/10.1016/j.amepre.2016.01.009
Lai, K., Guo, S., Ijadi-Maghsoodi, R., Puffer, M., & Kataoka, S. H. (2016). Bringing wellness to schools: Opportunities for and challenges to mental health integration in school-based health centers. Psychiatric Services, 67(12), 1328–1333. https://doi.org/10.1176/appi.ps.201500401
Lofink, H., Kuebler, J., Juszczak, L., Schlitt, J., Even, M., Rosenberg, J., & White, I. (2013). 2010–2011 Census Report of School-Based Health Centers.
Love, H., Soleimanpour, S., Panchal, N., Schlitt, J., Behr, C., & Even, M. (2018). 2016–17 National School-Based Health Care Census.
Mandel, L. A., & Qazilbash, J. (2005). Youth voices as change agents: Moving beyond the medical model in school-based health center practice. Journal of School Health, 75(7), 239–242. https://doi.org/10.1111/j.1746-1561.2005.tb06682.x
Mikesell, L., Bromley, E., & Khodyakov, D. (2013). Ethical community-engaged research: A literature review. American Journal of Public Health, 103(12), e7. https://doi.org/10.2105/AJPH.2013.301605
National Center for Educational Statistics. (2020). School Nurses in U.S. Public Schools. https://nces.ed.gov/surveys/ntps/
Parasuraman, S. R., & Shi, L. (2014). The role of school-based health centers in increasing universal and targeted delivery of primary and preventive care among adolescents. Journal of School Health, 84(8), 524–532. https://doi.org/10.1111/josh.12178
Power, T. J., Eiraldi, R. B., Clarke, A. T., Mazzuca, L. B., & Krain, A. L. (2005). Improving mental health service utilization for children and adolescents. School Psychology Quarterly, 20(2), 187–205. https://doi.org/10.1521/scpq.20.2.187.66510
Schwartz, K. E., Monie, D., Scribani, M. B., Krupa, N. L., Jenkins, P., Leinhart, A., & Kjolhede, C. L. (2016). Opening school-based health centers in a rural setting: Effects on emergency department use. Journal of School Health, 86(4), 242–249. https://doi.org/10.1111/josh.12375
Seawright, J., & Gerring, J. (2008). Case selection techniques in case study research: A menu of qualitative and quantitative options. Political Research Quarterly, 61(2), 294–308. https://doi.org/10.1177/1065912907313077
Shin, K. R., Kim, M. Y., & Chung, S. E. (2009). Methods and strategies utilized in published qualitative research. Qualitative Health Research, 19(6), 850–858. https://doi.org/10.1177/1049732309335857
Soleimanpour, S., Geierstanger, S. P., Kaller, S., McCarter, V., & Brindis, C. D. (2010). The role of school health centers in health care access and client outcomes. American Journal of Public Health, 100(9), 1597–1603. https://doi.org/10.2105/AJPH.2009.186833
Summach, A. H. (2011). Facilitating trust engenderment in secondary school nurse interactions with students. The Journal of School Nursing, 27(2), 129–138. https://doi.org/10.1177/1059840510392786
Webb, C. (1992). The use of the first person in academic writing: Objectivity, language and gatekeeping. Journal of Advanced Nursing, 17(6), 747–752. https://doi.org/10.1111/j.1365-2648.1992.tb01974.x
Whitaker, K., Stone, S. I., Anyon, Y., Blankenbaker, S., & Rozum, A. (2019). Academic, psychosocial, and demographic correlates of school-based health center utilization: Patterns by service type. Child and Youth Care Forum, 48(4), 545–562. https://doi.org/10.1007/s10566-019-09495-8
World Health Organization. (2015). People-centred and integrated health services: An overview of the evidence: Interim report. https://doi.org/No.WHO/HIS/SDS/2015.7
Zhang, L., Finan, L. J., Bersamin, M., & Fisher, D. A. (2020). Sexual orientation-based depression and suicidality health disparities: The protective role of school-based health centers. Journal of Research on Adolescence, 30(1, Suppl.), S134–S142.
Jennifer A. Gruber, MA, is a doctoral student at Michigan State University, East Lansing, MI, USA.
Erica A. Nordquist, PhD, is a Licensed Marriage and Family Therapist at Jenison Psychological Services, Jenison, Michigan, USA.
Ignacio D. Acevedo-Polakovich, PhD, is an associate professor at Michigan State University, East Lansing, MI, USA.
1 Michigan State University, East Lansing, MI, USA
Corresponding Author:Jennifer A. Gruber, Michigan State University, 316 Physics Road, East Lansing, MI 48824, USA.Email: gruber12@msu.edu
