Original Research Reports

The Journal of School Nursing

1-9
Student and Teacher Perspectives © The Author(s) 2021
Article reuse guidelines:

of Service Utilization at Their sagepub.com/journals-permissions

DOI: 10.1177/10598405211025008
journals.sagepub.com/home/jsn
School-based Health Center

Jennifer A. Gruber, MA1 , Erica A. Nordquist, PhD1,

and Ignacio D. Acevedo-Polakovich, PhD1

Abstract
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 rela-
tionship. 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.

Keywords
high 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 rela-
tionships (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 repre-
sentatives (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 dif-
fering 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 varia-
tion in outcomes across centers (King & Appleton, 1999;
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
2 The Journal of School Nursing 0(0)
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 environ-
ment 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 con-
ducted a qualitative examination of student service utiliza-
tion 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 crit-
ical mechanisms that might be applicable to other cases
(Seawright & Gerring, 2008). Our goal was to understand
the factors influencing student service use.
Methods
Our work was guided by community-engaged research princi-
ples 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 teach-
ers 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 stu-
dents, 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 grad-
uation 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.
Human Subjects Approval Statement
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 administra-
tors 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 transfer-
ability of our findings to other settings. That is, on linking
our findings to other relevant research and considering
their implications for said research.
Participants
A community health worker, who was also the men’s varsity
soccer coach at the high school, recruited students and teach-
ers 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 inter-
net 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 ano-
nymity, 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.
Instrumentation
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 experi-
ences 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?”). Author
Gruber et al.
Table 1. Focus Group Protocol.
A Priori-Identified Focus Group Questions and Probes
(1) What you know about [SBHC NAME] Health Center?
(2) What are the reasons that students would use the health
services offered at the health center?
(3) What are the reasons students would not use the health
services offered at the health center?
(4) Do you feel welcome at the health center?
(5) What are your perceptions of mental health services?
(a) When I say mental health services, what do you think of?
(6) What are the reasons that students would use mental health
or counseling services offered at the health center?
(7) What are the reasons students would not use mental health
or counseling services offered at the health center?
(a) Personal choice?
(b) Time/location?
(c) Don’t want anyone to know?
(8) Who do you think would benefit most from mental health/
counseling?
(9) Are there any other things that you want to say?
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?”).
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 partic-
ipants the opportunity to clarify or add new content. Author two
did not record focus groups, per students’ requests.
Procedure
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 com-
pleted 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.
Data Analysis
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
3
(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 emerg-
ing in previous steps represented all meaning units. We
resolved discrepancies through discussion and consensus
among all authors. As a final step, we merged the subcatego-
ries into more analytical categories.
We fostered trustworthiness2 by (1) triangulating our anal-
yses 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.
Results
In Table 2, we summarize the four categories that emerged
from our analysis: (1) students’ knowledge of SBHC serv-
ices; (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
Students’ knowledge of SBHC services fell into two subca-
tegories: (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 stu-
dents 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.
4 The Journal of School Nursing 0(0)

Table 2. School-based Health Center (SBHC) Focus Groups during emergencies. This fostered mistrust and a belief that
Themes and Subthemes. the actions of the SBHC staff were unethical. One teacher
Themes Subthemes
described that—having fallen down the school stairs while
pregnant—she went to the SBHC and was told by staff to
Students’ knowledge of SBHC • Knowledge of physical health go to an urgent care center. Teachers reported frustration
services services that they themselves were not able to receive primary
• Confusion on the full range
of services
care services at the health center as receiving SBHC serv-
Teachers’ perceptions of, and • Referring students with ices could prevent taking time off work for certain health
experiences with, the SBHC mental health concerns appointments.
• Teachers’ access to SBHC
services Organizational Challenges of SBHC Implementation. Teachers
• Organizational challenges of reported that the SBHC was the only option available for
SBHC implementation mental health services for students because the school social
Accessing and utilizing SBHC • Accessing SBHC services
services • Confidentiality
worker position was eliminated when the SBHC was imple-
• Scheduling and attending mented. Teachers described feeling bitter about this change,
appointments as they had a good relationship with the previous school
• Relationships with SBHC staff social worker. Despite this, teachers described a desire to
• The physical environment work with SBHC staff to link students to supportive health
• Transgender student privacy and mental health services.
Student and teacher suggestions • Outreach activities
to improve the school–SBHC • Process improvement
relationship Accessing and Utilizing SBHC Services
Students and teachers described positive and negative expe-
Teachers’ Perceptions of, and Experiences with, riences and perceptions of accessing and utilizing SBHC
services. These fell into six subcategories. Three subcatego-
the SBHC
ries describe participants’ perspectives of the health center
Teachers reported a lack of alignment between their procedures: (1) accessing SBHC services, (2) confidentiality,
perception of the purpose of the health center and how the and (3) scheduling and attending appointments. Two sub-
SBHC operated and SBHC staff performed their roles. These categories describe participants’ perspectives of the SBHC
misperceptions fell into three subcategories: (1) referring stu- staff and environment: (4) relationships with SBHC staff
dents with mental health concerns, (2) teachers’ access to and (5) the physical environment. The sixth subcategory
SBHC services, and (3) organizational challenges of SBHC describes how the SBHC protects transgender student
implementation. Each subcategory is described below. privacy.

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 expe-
riences with referring students to the SBHC for mental health
services, where they described a lack of follow-up for stu-
dents 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 expe-
riencing 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
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 “every-
one 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 infor-
mation 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 stu-
dents. Many students reported feeling uncomfortable sharing
Gruber et al.
personal information with an unfamiliar person and worried
about experiencing stigma if peers found out they were receiv-
ing mental health services.
Scheduling and Attending Appointments. Students understood
they were responsible for keeping track of their appoint-
ments. Students and teachers were also aware that appoint-
ments 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 unwel-
coming. This includes, but is not limited to, lighting, temper-
ature, and the “clinical feel” of the environment.
Transgender Student Privacy. Teachers reported transgender
students received medical passes to access the private bath-
room inside the SBHC. Teachers described how this positive
practice protected transgender students by providing the
opportunity to maintain their privacy.
Student and Teacher Suggestions to Improve
the School–SBHC Relationship
Although we did not ask for suggestions to improve the
SBHC, participants offered multiple recommendations.
Recommendations provided by students and teachers gener-
ally 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
5
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 activ-
ities 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 health-
related 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 trans-
lator 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 appoint-
ments. 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, pro-
viding 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.
Discussion
SBHCs can facilitate access to health services among children
and youth, particularly those belonging to historically under-
served populations (Allison et al., 2007; Bains et al., 2014;
Bersamin et al., 2017). Therefore, it is important to under-
stand 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
6 The Journal of School Nursing 0(0)
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 infor-
mation about services, organizational procedures, and per-
ceptions 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 utiliza-
tion (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 rec-
ommendations 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 rela-
tionships between providers, health center staff, and patients
(Albright et al., 2016; Beem et al., 2019). Our findings illus-
trate 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 pro-
motion 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 con-
cerns 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 minor-
ity SBHC users might perceive lower-quality care than their
White counterparts (Parasuraman & Shi, 2014). Researchers
who have examined SBHC care for historically marginal-
ized populations, such as lesbian, gay, bisexual, transgen-
der, 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 recommenda-
tions to improve the SBHC. Participants thought the health
center should increase outreach activities and transparency
about procedures. Specific outreach activities included class-
room presentations, newsletters, and family outreach for stu-
dents 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.
School Nursing Implications
For schools and health departments investing in a new
SBHC, it is essential to consider the context of implementa-
tion. In our study, the SBHC implementation displaced a
valued school staff member who facilitated student access
to health services, the school social worker. This displace-
ment raised challenges for the establishment of good rela-
tions 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
Gruber et al.
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 improv-
ing student health (e.g., social workers) should play essential
roles in integrating an SBHC into the school, as their knowl-
edge of the student body’s health and well-being can inform
programming and service delivery. Further, the implementa-
tion 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 feed-
back and recommendations for the SBHC. Given the nega-
tive perceptions students and teachers reported of SBHC
staff in our study, a school nurse could support these activi-
ties. 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 pre-
sentations, providing SBHC referrals, and serving on student
health teams.
Limitations
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 set-
tings 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 prior-
itize 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
7
limitation. Although our results begin to describe the impor-
tance 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.
Conclusion
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 impor-
tance 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 impli-
cations for future directions of SBHC researchers, including
examining: (1) the implementation of new SBHCs, with
a focus on organizational climate; (2) the cultural respon-
siveness of SBHC staff and care providers; (3) the organi-
zational 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.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Jennifer A. Gruber https://orcid.org/0000-0002-4386-5122
Notes
1. Because first-person is most consistent with the epistemology
underlying qualitative methods, and with the reflexivity required
of researchers who utilize these methods (Webb, 1992), we
employ it to describe the decisions or actions that we undertook
when conducting this study.
2. Trustworthiness is an aspirational property of qualitative research
whereby the conclusions of a study can be judged by others to be
credible and useful in light of researchers’ efforts to ensure five
key components: credibility, transferability, dependability, con-
firmability, and reflexivity (Graneheim & Lundman, 2004).
8 The Journal of School Nursing 0(0)
Although this property has some parallels with the construct of
validity used in quantitative research, some methodologists
assert that these two constructs are not directly interchangeable
because of epistemological differences between qualitative and
quantitative methods (Graneheim & Lundman, 2004).
References
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 service-
level 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 inter-
disciplinary 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 anal-
ysis 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 help-
seeking 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 deliv-
ery 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
Gruber et al.
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 profes-
sional 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 sys-
tematic 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
9
health centers in a rural setting: Effects on emergency depart-
ment 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 strat-
egies 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 secon-
dary 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 dis-
parities: The protective role of school-based health centers.
Journal of Research on Adolescence, 30(1, Suppl.), S134–S142.
Author Biographies
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.