Characteristics of Children Seeking Care at School-Based Health Centers

Introduction

School-based health centers (SBHCs) are a unique safety-net healthcare setting that can increase access to healthcare for underserved populations by providing healthcare at school.^1–3 According to the American Academy of Pediatrics (AAP) 2021 Policy Statement on SBHCs and Pediatric Practice, SBHCs have the potential to overcome critical healthcare barriers for children in the United States due to this co-location.^2,4 Since their emergence in the 1960s, the number of SBHCs has grown significantly⁵ and they are described by experts as an important method of healthcare delivery for our nations’ youth, with a strong potential to advance health equity.^6,7

SBHCs provide primary care, preventive services, immunizations, and management of chronic conditions, helping children access healthcare that might otherwise be difficult to obtain. They also offer confidential reproductive and mental health services, which are particularly important for adolescents and improve outcomes in these domains.^4,8,9

While SBHCs were specifically implemented to serve children from low-income and underrepresented backgrounds, there has yet to be a comprehensive, multi-state study describing which children use SBHCs. Prior studies indicate that SBHCs are located in schools serving a high proportion of low-income and minoritized children and that children accessing SBHC care utilize more appropriate preventive care, particularly for children with asthma.^10–12 However, the current literature lacks a comprehensive characterization of the pediatric population utilizing these school-based healthcare services nationwide. Prior studies describing this population have limited generalizability due to data being drawn from only one to two states, are subject to recall bias due to survey-based design, and/or do not characterize the type of care that children receive within a SBHC.^5,10–14

In addition, little is known regarding children who exclusively use SBHCs and those who use SBHCs as well as community health centers (CHCs) which is critical in understanding who is using SBHCs, for what purpose (e.g., preventive or emergent care), and what care gaps SBHCs may be filling for our children’s most vulnerable youth along with the potential synergy of receiving care from two distinct safety net settings.

In this study, using data from a large, multi-state data network, we aimed to address these research and healthcare delivery questions. Our three objectives were to 1) analyze the sociodemographics of children using SBHCs, both exclusively and in conjunction with traditional CHCs across participating states, 2) assess the prevalence of asthma and overweight, two of the most common chronic diseases in school-aged children in our target population and 3) evaluate healthcare utilization, including well-child visits and rates of influenza and pneumococcal vaccinations. Due to SBHCs unique school location and the specific challenges that children may face when exclusively seeking care at SBHCs (e.g., geographic, transportation, financial, educational or cultural barriers), we hypothesized that children seeking care exclusively at SBHCs may represent a different group of children than those who seek care at both SBHCs and more traditional CHC settings.

Methods

This retrospective cross-sectional study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Results

Discussion

This is the largest observational study characterizing the sociodemographics and health care utilization of children who use SBHCsacross a multi-state U.S. sample. Notably, our results demonstrate that children actively seeking SBHC care are predominantly from minoritized groups, including a large population of low-income, uninsured, and Hispanic children. Our findings build on prior work that was limited to small sample size, single-state cohorts or survey-based designs,^1,5,11,18,19 and uniquely offers a more generalizable and detailed analysis with a comparison between children using SBHCs exclusively and those also accessing community-based health centers (CHCs).

Overweight and asthma rates among SBHC-users were comparable to the general pediatric population. By school-age subgroups, rates of overweight were lowest in the pre-school age group, compared to older school-age groups, which is also consistent with the national averages by school-age subgroups.²⁰ Interestingly, across all school-age groups, the prevalence of asthma in the SBHC + group was considerably higher than national averages¹⁷ at 10-15% as compared to 6-8% in the SBHC-only group for all age groups. Since nearly 1 in 6 children in the SBHC+ group had asthma, SBHCs may be an ideal setting to provide adjunctive and optimized asthma care for children seen at CHCs suffering from this common chronic illness. It is important to note that we observed a lower-than-expected asthma prevalence in the SBHC-only group, particularly given the large representation of racial and ethnic minority children and a high degree of urbanicity in this population. This may indicate a high burden of asthma symptoms yet lack of an asthma diagnosis in this study group. Moreover, the higher care utilization observed in the SBHC+ group may be due to more medical complexity and needs in this group, potentially affording more opportunity to identify and document an asthma diagnosis.

Overall, our study shows that children are receiving preventive care at SBHCs with well-child visits and influenza vaccines, and there is potential for implementing more preventive pediatric care into this setting. Children in the SBHC+ group had more well-child visits and influenza vaccinations compared to children in the SBHC-only group, highlighting a potential synergy between the SBHC and CHC settings to provide optimal preventive pediatric care. Access to both settings may allow low-income children to receive more comprehensive care and mitigate the chance of being lost in either healthcare system. It is worth highlighting that while the number of well-child visits and vaccinations were lower in the SBHC-only group as compared to the SBHC+ group, the rates of uninsured children were much higher in the SBHC-only group as compared to the SBHC + group (13.4% versus 2.6% respectively), highlighting the potential importance of SBHCs in providing preventive care to a uniquely vulnerable group of children that may not otherwise receive preventive services. Our findings build on results from prior studies indicating that SBHCs seem to improve healthcare access for uninsured and low-income populations¹ and are perceived to be more accessible than traditional primary care settings.²¹

Interestingly, in subgroup analyses by age groups, preschoolers received the most well-childcare and influenza vaccinations, indicating the possibility that younger siblings of school-aged children may particularly be benefitting from SBHC care, perhaps by receiving preventive services where their older sibling is dropped off or picked up on a daily basis, or that schools with co-located preschool programs may be associated with SBHC use. This may underscore the value of SBHCs to families with children across a broad age range.

Most importantly, this study demonstrates that SBHCs are providing substantial preventive care services to many vulnerable children, highlighting their role in improving equitable access to care, particularly among minoritized and low-income populations. Since the children receiving care at both SBHC plus CHCs seem to be receiving more well-childcare and influenza vaccination than those receiving SBHC exclusive care, it is possible that there is powerful synergy occurring between these care settings, which has direct implications for policy, funding, and integration of SBHCs into broader health systems. As we consider whether and how to expand the funding, availability and locations of SBHC services, this study indicates that SBHCs and CHCs may work best in conjunction rather than in siloes to provide optimal pediatric preventive care. Policies supporting SBHC expansion and integration with CHCs could enhance preventative service delivery and reduce disparities among high-need pediatric populations. Future research should include the examination of a third cohort of children who exclusively seek care at non-school based CHCs and compare their sociodemographics and care utilization with the two cohorts of children examined in this study. Making data exchange possible in real-time between SBHCs and CHCs will only likely enhance communication and improve the care quality of children.

The strengths of this study are the use of a large, multi-state data network of CHCs allowing the most comprehensive examination of SBHC users to date. We utilized EHR data as opposed to survey-based design like prior national studies on SBHCs, mitigating recall bias. Moreover, to our knowledge, this is the only study examining the differences between the sociodemographics and healthcare utilization of children seeking care exclusively in SBHCs and in SBHCs plus more traditional CHCs.

It is important to note limitations of our study which include selection bias as we did not have access to EHR data outside of our data network. This analysis included data from 14 geographically and demographically diverse states, but differences in regional distribution, health policy context, and SBHC availability compared with non-included states may limit generalizability to the entire U.S. Additionally, while we categorized children as “SBHC-only” users based on their lack of visits to non-SBHC clinics within the OCHIN network, we were unable to account for care received outside of this network. Because EHRs are not universally linked across healthcare systems in the U.S., it is possible that some children classified as SBHC-only may have received care at unaffiliated facilities not captured in our dataset. This limitation is inherent to EHR-based studies and may affect the interpretation of exclusive SBHC utilization. Furthermore, while our study examined data available from 2018 and prior, to our knowledge, this remains the most current, comprehensive and objective assessment of health record data from a multi-state sample of SBHCs to date.

It is notable that because of wide ranging models of SBHC staffing and care delivery, the patterns of well-child utilization and vaccination may be based on the availability of certain services at given SBHCs. However, all SBHCs have the ability to provide primary care to children.⁴ Additionally, federally qualified health centers are now the largest sponsor of SBHCs in the United States; they are not the only sponsor type and there may be sociodemographic or utilization differences between SBHCs exclusive users and others based on sponsor type. We did not have access to sponsor data to perform this type of subgroup analysis, however, this is an important area for future work.

Additional future directions could include an examination of the varying models of SBHC staffing and care, ideally through mixed methods to capture nuanced differences. A deeper understanding of the current SBHC practices for preventive care across the nation through research on the varying practice patterns and capacity for preventive care in different SBHCs settings could help to inform future best practices for SBHC implementation.

Conclusion

Our findings highlight that SBHCs serve a large population of children, which is disproportionately low-income, uninsured, and Hispanic. SBHCs are providing preventive care to many minoritized children, in the form of well-child visits and influenza vaccines. Moreover, there appears to be some synergy between SBHCs and CHCs, wherein children with access to both settings receive the most preventive care. Given the population they serve, augmented access to care and services they provide, SBHCs have strong potential to address pediatric health inequities if adequately resourced, utilized, and integrated with other pediatric primary care facilities including CHCs.