Running head: SCHOOL BASED HEALTH CLINICS

School Based Health Clinics

Kimberly Jaskulka, Joyce Van Hoff, Jennifer Williams, & Sharon Woodliff

Ferris State University

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Abstract

Health care disparities in America are an ever growing problem. Changes in the

economic climate have contributed to job loss and diminishing health insurance coverage.

Vulnerable populations have seen a continued growth as low income and minority

families have risen in the past two decades. School Based Health Clinics have been

developed as an innovative way to provide accessible, affordable, and consistent primary

care to children in low income schools. This paper presents an overview and the purpose

of School Based Health Clinics. Supporting and opposing points of view is substantiated

by current literature with an emphasis on health education as public policy.

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School Based Health Clinics

Health Care at School

In an effort to improve the health care to all Americans, Healthy People 2010 has

defined two main goals: to increase the quality and length of healthy life, and to eliminate

health disparities (Maurer & Smith, 2009). Inequalities in health care services exist

largely among socially disadvantaged people. Children of low income and minority

families are at a greater risk of receiving fewer health care resources and ultimately

experience poorer health outcomes. According to the World Health Organization (WHO),

creative ways to adapt primary care services to current social settings must be considered

(Gustafson, 2005). Providing health care services to children while they are at school is

an innovative approach as most children spend approximately one-third of their time at

school.

The concept of school nursing evolved in America from visiting nurses in1902

(Maurer & Smith 2009). Primary goals at that time were to oversee nutrition and injuries.

School nursing is now recognized as an essential part of the health care system. Growing

health issues demanded that services provided at school must be more specialized and

comprehensive. Out of this need, the concept of School Based Health Clinics (SBHC)

was created. The first school based health clinic was opened and organized in the late

1960’s by pediatrician Philip J. Porter in an elementary school in Massachusetts.

Presently there are more than 1500 school based health centers in the United States. The

National Assembly on School Based Health Care is an organization that promotes

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improving the health status of children by advancing and advocating for school based

health care (NASBHC 2009). Providing access to culturally competent, quality care

through school clinics is an effective way to reduce health inequalities.

Current Public Policy

Current legislation is in place to support and expand SBHC’s. Bill #HR 1338

proposes “to amend the Elementary and Secondary Education Act of 1965 to direct the

Secretary of Education to make grants to States for assistance in hiring additional school-

based mental health and student service providers” (Michigan Nurses Association).

Across the United States, there are inadequate resources for school-based counseling

professionals, and often students do not acquire any assistance for these needs. The

existing national average ratio of students to school counselors in elementary and

secondary schools is 561 to 1 (Michigan Nurses Association). This bill, sponsored by

Barbara Lee (D-CA 9th), will decrease the student-to-provider ratios, assisting school-

based clinics in providing appropriate healthcare and insurance assistance for

disadvantaged children. These changes would provide the ability to add additional help

including school counselors, school psychologists or other psychologists, child or

adolescent psychiatrists, and school social workers among such providers (Michigan

Nurses Association). The goal of this bill is to address the emotional, behavioral, and

psychosocial barriers that interfere with a student’s ability to learn and to support the

involvement of parents in their children’s health care.

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Opposing Viewpoints

“Critics of the Democratic health care proposal have been increasingly raising

concerns that the plan would provide taxpayer-subsidized abortions” (The Liberty

Council, 2009). The liberty Council (2009), a conservation group, describes its mission

as an "education and policy organization dedicated to advancing religious freedom, the

sanctity of human life and the traditional family". This view relates to the lack of control

that parents may have over their children’s health care decisions related to school based

health clinics. “With respect to sensitive services, all states allow minor consent for such

services, typical for adolescents who are 12 or older” (Fox, 2008). These services may

include: family planning, STD screening and treatment, outpatient mental health

treatment, and substance abuse treatment. In these case minors would be allowed to

consent for treatment and be able to opt for non-notification to their parents. The liberty

council argues that this places a gap in the parent-child relationship and allows children

to make decisions that may not be appropriate.

“Over the past several decades, schools have become a major battle ground over

morality-based issues as well” (Ann, 2002). Many groups believe that public education

is the root of the problem. These groups claim that public schools along with school-

based health clinics erode the relationship between parents and their children. Access to

birth control, including condoms, and provision of information or counseling related to

abortion has been opposed as “a violation of the fundamental moral code” (Ann, 2002).
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This argument focuses on maintaining an open and trusting relationship between parents

and children. Should schools be in the business of providing healthcare for our children?

This view implies that children are not cognitively able to make their own medical,

moral, and legal decisions without parental input. In a school-based health situation a

child may be put in the position of making self-motivated decisions without taking into

consideration the lifelong consequences of their actions.

The opposing views toward health-based health clinics have become a

learning curve in their continued development within the public school systems. Many

changes have been made to clinics over the years. However, most clinics continue to

follow the minor consent laws. “These laws exist to ensure that adolescents receive

services that are vital to their health”(Michigan Nurses Association). On the other hand,

opposition campaigns have been effective in preventing the opening of clinics in certain

communities. Controversy centered issues were portrayed to protect parental authority. In

this case “it is important to discuss community expectations early in the planning

process” (Schwab, 2005). This will assist in gaining a sense of what the oppositions are.

With compromise and some accepted changes, children can receive needed care while

parents maintain their sense of control over their children’s health and safety.

Supporting Viewpoints

A population based nursing concept that is directed towards health promotion

and primary prevention in the community is apparent with the utilization of school based

health clinics (SBHC). The relationship between a community nurse and the community
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in which they serve is an essential, core component of any healthcare system. The

healthcare system that attends well to our youth is found with SBHC, and the youth is an

integral part of any community. “The youth of today have the potential to be world

changers, if they are able to rise above their disadvantages and adverse situations, if they

are given the opportunity to be healthy, and if there are people along the way who are

willing to teach them how to cope with the pressures they face” (Bennett, 2008).

Community health nurses are those people that are present in the frontline of their lives.

The community health nurse delivers expert care and can support the youth in their

mental health and physical well-being by means of SBHC.

“In the 1990’s, supporters of school-based health centers included the US Public

Health Service, the American Medical Association, The American Academy of

Pediatrics, the American School Health Association, the American Nurses Association,

and other organizations that represented nurses and nurse practitioners” (Bennett, 2008).

Community nurses are able to develop interpersonal relationships with the populace of

the community’s youth. This relationship is possible due to the increase of the SBHC.

“The number of school-based health centers has increased by a factor of eight, from

about 200 in the early 1990s to more than 1,700 clinics today” (Miller-Jones, Coberly, &

Martineau, 2007). “Today, over 8.5 million American children continue to experience

overwhelming and needless suffering due to barriers that deny them comprehensive

primary health care and prevention services. School-based health care is a solution that

has proven itself time and time again. The students they serve, along with their parents
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and communities, are witnesses to improved access to comprehensive primary health care

and prevention services” (Bennett, 2008). SBHC programs serve as a positive attribute to

the overall health and well-being of the community’s youth. “SBHC provide a convenient

option for parents, result in less school time missed due to doctor appointments and

strengthen student-school, parent-school, and school-community connections” (California

School Boards Association [CSBA], 2008). If the youth within a community are well

cared for, the mothers of that same community will exhibit behaviors towards improved

health and well-being. The mothers of that community will be able to better care for the

entire family, which produces a reciprocal relationship with the rest of the community

towards wellness. This reciprocity incorporates several of the goals of a community

health nurse. “Nurses are fierce defenders of the health of individuals, families,

populations, and communities. Nurses can be the best advocates for institutional,

legislative, and regulatory change because they are one of the most trusted professionals

in society and they bring a good scientific background combined with excellent

communication skills” (Maurer, 2009). Community nurses not only have a strong

representation in the health care industry, but in the educational department of a

community by attending to the needs of the community’s health promotion.

Conclusion

School based health clinics (SBHC) are good for our children. Many of these

clinics serve in poverty areas where children are uninsured or underinsured and where

preventive health care and coverage for mental health issues are severely limited (Adams,

2000). Brindis, Klein, Schlitt, et al (2003) report that there has been a shift in the location
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of SBHS’s over the last ten years from inner cities to also include rural areas with unmet

needs. Two thirds of those served in these clinics are from minority populations.

The Student Support Act (Michigan Nurses Association) recommends that funds

of at least $1 million go to states to provide more school based health care, focusing its

allocation on disadvantaged children. The importance of providing mental and

preventative health care to this population cannot be overstated.

Many people feel as though schools should not be in the business of providing

health care, but should concentrate on providing a good education for our children. Since

their inception in 1980’s the presence of school based health clinics have shown to

improve the educational outcomes of children (Richardson, 2007). Children who are

healthy, who have accessible resources for mental health issues as well as preventive

services, are less likely to miss school days, are more able to concentrate, and are

positioned better to succeed.

To limit funding or to refuse to fund health clinics in schools in short sighted. No

Child Left Behind Act (NCLB) of 2001 came about as a way to help insure equal

education for our children (Richardson, 2007). Children who live in poverty are a

vulnerable population. Richardson (2007) reports that the stress of poverty puts these

children more at risk for health issues. Obesity, diabetes, asthma, and violence are just

some of the health risks this population faces. No matter what is taught in the classroom

or how many resources a teacher has, children who are at a disadvantage due to health

issues will have more barriers to learning than their healthy counterparts. Therefore,

funding school based health clinics is a good and wise investment. School based health
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clinics can treat acute problems on site. Health Care Professionals form long term

relationships, ensure follow up, educate, screen, and offer immunizations (Richardson,

2007). Nurses involve families in the health care decisions of their children and work

toward a healthy and safe environment in the schools in which they are located (Adams,

2000). Richardson (2007) contends that SBHC’s, in providing an environment that

promotes health and therefore better learning, actually supports compliance to NCLB.

The argument still remains that the cost of school based health clinics may be too

great for the public to bear. These clinics are resources for education and health

maintenance of children who may not have a good grasp of their diabetes or asthma, and

who may be non compliant due to any number of barriers. Adams (2000) reports that

children who use these clinics as their primary care providers avoid expensive emergency

room visits and have better overall health, avoiding hospitalizations. Not only does this

save money in the short term, but investing in the health of children will give them a

chance to grow up into adults who can contribute to society in positive ways (Richardson,

2007).

According to Brindis (2003), the “population growth in 10- to 19- year age group

is anticipated to increase to nearly 43 million by 2020” (p.105). A large majority of this

age group will be minorities who will continue to lack the ability to access health care.

Monetary support of SBHC’s will ensure their continued existence and ability to reach a

very vulnerable subset of our population; our children.

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In summary, a compelling argument can be made that providing access to

healthcare through SBHC’s answers a dual problem in our schools (Richardson, 2007).

Consistent, accessible healthcare provides for healthier children who then are in a much

better position to learn, to succeed, and to become valuable members of our society.
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Resources

Adams, K. (2000). An elementary school-based health clinic: can it reduce medicaid

costs? Pediatrics , 780-788.

Ann, B., Button, J. W., & Rienzo, P. (2002). The Politics of Youth, Sex, and Health Care

in American Schools (Haworth Health and Social Policy) (Haworth Health and

Social Policy). New York: Routledge.

Bennett, K. (2008, Spring). Changing the Future: One Child at a Time. Helping Hands,

News from the School-Community Health Alliance of Michigan, 3, 1-7.

California School Boards Association (2008). Expanding access to school health

services. Retrieved from www.csba.org

Foster, P. (1995). School-based clinics: overcoming the obstacles. Kansas Nurse , 155-

156.

Fox, H., & Limb, S. (n.d.). State Policies Affecting the Assurance of confidential Care for

Adolescents. Retrieved from www.incenterstrategies.

org/Jan07/factsheet5.pdf

Gustafson, E. (2005, December 1). History and overview of school-based health center...

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Home-NASBHC. (n.d.). Retrieved from http://www.nasbhc.org

Maurer, F. A. (2009). Community/Public Health Nursing Practice (4th ed.). St. Louis,

MO: Saunders Elsevier.

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Resources

Miller-Jones, J., Coberly, S., & Martineau, M. (2007, March 9). Implementing School

Health Programs for Better Child Health and Academic Success. The National

Health Policy Forum, 2-6.

(pdf), l. (n.d.). Michigan Nurses Association - Government Affairs - Legislative Action

Center. Retrieved October 18, 2009, from http://capwiz.com/minurses/

issues/bills/?billnum=H.R.1338&congress=111

Richardson, J. (2007). Building bridges between school-based health clinics and scholls.

Journal of School Health , 337-343.

School Health and Youth Health Promotion. (n.d.). Retrieved October 26, 2009, from

http://www.who.int/school_youth_health

Schwab, N. C. (2005). Legal Issues In School Health Services: A Resource for School

Administrators, School Attorneys, School Nurses. New York: Authors Choice

Press.

Smith, F. A., & Maurer, C. M. (2008). Community/Public Health Nursing Practice:

Health for Families and Populations [COMMUNITY/PUBLIC HEALTH NU].

Philadelphia: W.B. Saunders Company.

The Liberty Council. (n.d.). PolitiFact | School health clinics would not provide

abortions. Retrieved October 31, 2009, from http://www.politifact.com/truth-o-

meter/statements/2009/aug/07/liberty-counsel/school-health-clinics-would-not-

provide-abortions/

Weatherly, R., & Semke, J. (1991). What chance for school-based health clinics? Lessons

form the field. Social Work in Education , 151-161.

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