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Systematic Review
The CPSTF recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes.
The CPSTF recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes. Improved educational outcomes include school performance, grade promotion, and high school completion. Improved health outcomes include the delivery of vaccinations and other recommended preventive services, asthma morbidity, emergency department and hospital admissions, contraceptive use among females, prenatal care and birth weight, and other health risk behaviors.
The CPSTF also finds evidence that the societal benefits of SBHCs are greater than the intervention costs. Further, SBHCs result in net savings to SBHC users and the Medicaid program.
Most evidence derives from studies of SBHCs in low-income populations. If targeted to low-income communities, SBHCs are likely to reduce educational gaps and advance health equity.
The Task Force finding is based on evidence from a systematic review of 46 studies (searched until July 2014) which used diverse designs to assess multiple academic and health-related outcomes. Twenty-three studies assessed the effects of SBHCs in overall school populations by comparing all students who had SBHCs in or linked to their schools with all students who did not (14 studies), or by assessing students before and after implementation of an SBHC (8 studies); one study included both comparisons. In these "whole school" studies the evaluation examined SBHC effects in the student population, including both users and nonusers of the SBHC. Seventeen "SBHC user" studies compared students who received services with students who did not receive services (8 studies) or received care from other sources (9 studies). Four studies included both whole-school and SBHC user study arms. Another two studies compared SBHCs; one compared a SBHC that offered onsite contraceptive services with a SBHC that did not, and the other study reported outcomes from a SBHC before and after implementation of onsite contraceptive services.
Because most SBHCs are implemented in low-income or racial and ethnic minority communities, SBHCs are likely to advance health equity. Applicability to younger grade levels is limited, as the majority evaluated high school SBHCs, whereas one study assessed middle school SBHCs, seven studies evaluated pre-K or elementary school SBHCs, and the remaining 12 studies assessed some combination of grade levels.
Most studies of SBHCs were conducted in urban communities. The adaptation of SBHC models in rural areas may be challenging because of low population density that may not be able to sustain SBHC models that are effective in higher density regions. SBHCs have not been evaluated in higher income communities. Since health care needs in these communities may be fewer and otherwise addressed, it is unclear whether SBHCs would be useful or effective. On the other hand, schools may be an effective way of delivering health care to students.
Most of the included studies assessed on-site SBHCs and several evaluated a combination of on-site and off-site SBHCs. None of the included studies evaluated off-site centers alone, thus the effectiveness of this option is not known.
This CPSTF report recommends the implementation and maintenance of school-based health centers (SBHCs) in low-income communities, based on sufficient evidence of effectiveness in improving educational and health outcomes.
In the implementation of SBHCs, the following issues should be considered:
- Billing and financing is a major challenge to SBHC implementation and sustainability
- Lack of full uptake of available SHBC services by students for whom the services are available is another challenge of SBHC implementation
- SBHC benefits likely depend on population density. It may be necessary to develop modified models for low population density and rural settings
- Included studies indicated that the greater the range of services offered, the greater the benefits. Offering services outside of in addition to within school hours also increases effectiveness
The report also identifies areas for further research.