Social Determinants of Health: School-Based Health Centers

The CPSTF finding is based on evidence from a systematic review of 46 studies (search period through July 2014) that used diverse designs to assess multiple academic and health-related outcomes. Twenty-three studies assessed whole school effects by comparing all students in schools with SBHCs with all students in schools without SBHCs, or students in schools before and after SBHCs were set up. Seventeen studies assessed SBHC user only effects by comparing users with non-users within SBHC schools (8 studies), or SBHC users with users of other health care sources in non-SBHC settings (9 studies). Several studies included both intervention whole school and user effects.

The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to promoting health equity.

When compared with children who are not economically or socially disadvantaged, U.S. children from low-income and racial and ethnic minority populations commonly have the following:

• Worse health
• No usual place of health care
• More missed days of school because of illness
• More hunger
• More problems with their vision or hearing

Addressing these obstacles can be critical to their education and long term health.

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement [PDF – 331 kB].

Education-Related Outcomes:

• High school non-completion: median decrease of 29.1% (5 studies)
• Grade Point Average: median increase 4.7% (studies)
• Grade promotion: increases of 8.4% and 14.6% (2 studies); 1 additional study reported that SBHCs were associated with increases in students on pace to graduate

Health-Related Outcomes:

• Immunization: median increase of 15.5 percentage points (4 studies)
• Other recommended clinical preventive services: median increase of 12.0 percentage points (6 studies)
• Regular source of health care: median increase of 2.2% (7 studies)

Asthma-Specific Outcomes:

• Hospitalizations: median decrease of 70.6% (3 studies)
• Emergency department visits: median decrease of 15.8% (4 studies)
• Sickness (measured by numbers and frequencies of asthma symptoms): median decrease of 19.3% (2 studies)

Other Sickness-Related Outcomes:

• Self-reported health status (i.e., in various scales of medical, physical, chronic conditions): median decrease of 1.2%, unfavorable (4 studies); 3 additional studies reported mixed results
• Self-reported mental health problems: median decrease of 5.7% (4 studies); 4 additional studies reported generally favorable effects
• Non-asthma-related emergency department visits: median decrease of 14.5% (15 studies)
• Non-asthma-related hospitalization: mean decrease of 51.6% (2 studies)

Risk Behaviors

• Tobacco smoking: median increase of 21.0%, unfavorable (7 studies)
• Alcohol use: median decrease of 14.8% (6 studies)
• Other illicit substance use: median decrease of 27.2% (5 studies)

Sexual Risk Behaviors and Reproductive Outcomes

• Contraception use among sexually active students:
  • Both females and males: median increase of 7.8% (4 studies)
  • Females only: median increase of 17.8% (3 studies)
  • Males only: median decrease of 3.1%, unfavorable (3 studies)
• Sexual activity:
  • Females only: median decrease of 3.6% (2 studies that reported outcomes by gender)
  • Males only: median decrease of 8.5% (2 studies that reported outcomes by gender)
  • Female and male students: median increase of 19.6%, unfavorable (3 studies that did not separately report outcomes for female and male students
• Becoming pregnant or causing pregnancy:
  • Females only: median decrease of 40.0% (5 studies)
  • Males only: increase of 21.5% in causing pregnancy, unfavorable (1 study)
• Specific to pregnancy:
  • Pregnancy complications: median increase of 25%; unfavorable (3 studies)
  • Percent low birth weight: median decrease of 58.3% (3 studies)
  • Prenatal care: median 27.8% increase in the number of prenatal visits (2 studies); 2 additional studies reported increase in percent of pregnant students receiving prenatal care
  • Prenatal care initiated: pregnant students received prenatal care an average of 0.45 months earlier; 2 studies. One additional study reported 15.1 percentage point increase in the percent of pregnant students who registered for prenatal care during their 1st trimester.

Additional Analyses

• Studies that looked at schools with and without SBHCs and studies that compared students within the same school who did or didn’t receive services had similar results.
• SBHCs that were open outside of school hours were associated with lower rates of emergency department and hospital admissions than were SBHCs that were open only during school hours.
• The greater the range of services provided in an SBHC, the greater the reduction in visits to emergency departments or hospitalization.
• Findings were inconsistent on the association between the availability of contraception at on-site SBHCs (compared with off-site SBHCs) and contraception use and pregnancy or birth outcomes.
• It was not possible to determine whether providing free SBHC services affected outcomes because many of the studies did not include clear descriptions of the services provided or their costs to students.

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement [PDF – 331 kB].

Evidence shows that school-based health centers provide societal benefits that are greater than their costs. SBHCs also lead to net savings for SBHC users and the Medicaid program.

The economic review included 21 studies (search period January 1985-September 2014) from the U.S. Monetary values are presented in 2013 U.S. dollars.

Intervention Cost

• Fifteen of the included studies provided information about intervention cost, which was made of up two components: start-up cost (one-time, fixed cost) and operation cost (annually recurring medical cost).
  • Reported start-up costs ranged from $41,450 to $378,704 per SBHC (2 studies).
    • Some of the variation in cost can be explained by differences in staffing during the initial implementation phase. Also, costs were lower when SBHCs renovated space at the schools and higher when new facilities were constructed.
  • Operation costs ranged from $16,322 to $659,684 per SBHC per year (14 studies).
    • The main causes of variation were hours of work by physicians and staff, local cost of living, nationwide versus state study, and data source.
  • Operation cost per user ranged from $143 to $1,427 per year (7 studies).

Intervention Benefit

• Nine of the included studies reported on intervention benefit, which was categorized as follows:
  • Healthcare cost averted (i.e., prevented cost of hospitalization, emergency department use, medications, referrals, private clinic visits, and unintended teen pregnancies)
  • Productivity and other loss averted (i.e., prevented cost of school time and productivity losses, and travel cost and ambulance use)
  • Studies from the societal perspective reported annual benefits between $15,028 and $912,878 per SBHC in averted costs related to treatment, productivity losses, and transportation, combined with other relevant benefits (3 studies).
    • The wide range can be explained by the number of benefit components considered and whether the study included major benefit drivers (averted emergency department use, unintended pregnancy, and productivity loss).
• Studies from a healthcare payers’ perspective showed net savings to Medicaid ranging from $30 to $969 per visit (3 studies), or $46 to $1,166 per user (2 studies).
  • The variation in net savings was due mainly to the number and types of components that were included. Net savings were higher when emergency room use and care for asthma patients were included.
• Studies from the perspective of patients (or their parents) reported savings of $90 per visit (1 study) and $23,592 per user (1 study that included the averted cost of child birth from unintentional pregnancies).

Benefit-Cost Ratio

• Benefit-cost ratios were calculated from two studies that evaluated seven SBHCs.
• The societal benefit per SBHC exceeded intervention cost, with the benefit-cost ratio ranging from 1.38:1 to 3.05:1.

• Because most SBHCs are implemented in low-income or racial and ethnic minority communities, SBHCs are likely to improve health equity.
• 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, because of increased accessibility, SBHCs may be an effective way of delivering health care for any school population.
• Results apply to SBHCs that offer services on-site or provide different services on- and off-site. None of the included studies evaluated SBHCs that only provided services off-site.

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• Although SBHCs are usually located in high-need communities, the proportions of students who enroll, and those enrollees who receive SBHCs services, are often less than those in need of these services. What strategies can be used to increase use of SBHC services?
• What effect does patient cost have on overall SBHC use? Does use increase if services are free to users?
• How effective are SBHCs in schools and communities that have majorities of higher-income or non-Hispanic white students? Are there thresholds or points of diminishing returns on community income, insurance coverage, and other measures of need above which SBHCs are less effective?
• SBHCs usually offer services to school staff, student family members, and others in the community. What are the effects of SBHCs on the health of these populations?
• How effective are alternative SBHC designs used in rural areas with low population density?
• How effective are school-linked and mobile health centers?
• What is the relative impact of focused programs such as intensive asthma programs or programs focused on reproductive health when compared with general programs?
• Which components of SBHCs are being assessed, and what are characteristics of populations they serve?
• What are the long-term impacts of SBHCs in academic achievement, income, and health?
• What synergistic effects, mutual support, or redundancies might occur between SBHCs, school health polices, or classroom health education?
• What is the need for SBHCs following full implementation of the Affordable Care Act? Will fewer students need SBHCs when there is greater insurance coverage among low-income households? Or are schools an effective setting for student health care regardless of levels of insurance coverage?
• What is the cost of SBHCs per quality-adjusted life year (QALY)?
• What would the lifetime economic benefits be if studies accounted for reduced health disparity and students’ improved academic performance?
• What are the costs and benefits of mobile SBHCs?

• 91.3% of the included studies assessed school-based health centers; the remainder assessed combined school-based and school-linked health centers. No studies assessed only school-linked health centers.
• 56.5% of the studies assessed SBHCs in high schools
• 60.9% of the studies did not report hours of operation.
• 50% of the studies evaluated SBHCs that only provided primary care, without additional services.
• Most of the studies assessed primarily non-white populations, with black populations being the most common.
• Among those studies that reported socioeconomic status, most assessed low-income populations.

Knopf JA, Finnie RKC, Peng Y, et al. School-based health centers to advance health equity: a Community Guide systematic review. Am J Prev Med. 2016;51(1):114-26.

Ran T, Chattopadhyay SK, Hahn RA, Community Preventive Services Task Force. Economic evaluation of school-based health centers: a Community Guide systematic review. Am J Prev Med. 2016;51(1):129-38.

Community Preventive Services Task Force. School-based health centers to promote health equity: recommendation of the Community Preventive Services Task Force. Am J Prev Med. 2016;51(1):127-8.

Brindis CD. The “State of the State” of school-based health centers: achieving health and educational outcomes. Am J Prev Med. 2016;51(1):139-40.

Effectiveness Review

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

• Logic Model [PDF (Print Only) – 296 kB]
• Text Description [PDF – 72 kB]

Economic Review

The economic review team develops an analytic framework to align economic outcomes with each stage of the effectiveness review analytic framework. It informs the economic research questions and may be used to summarize the evidence for intervention cost, economic benefit, cost-effectiveness, and cost-benefit.

• Logic Model [PDF (Print Only) – 205 kB]
• Text Description [PDF – 88 kB]

Effectiveness Review

Summary Evidence Table – Effectiveness Review [PDF – 959 kB]

Economic Review

Summary Evidence Table – Economic Review [PDF – 275 kB]

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Allison MA, Crane LA, Beaty BL, Davidson AJ, Melinkovich P, Kempre A. School-based health centers: improving access and quality of care for low-income adolescents. Pediatrics 2007;120:e887-94.

Barnet B, Arroyo C, Devoe M, Duggan AK. Reduced school dropout rates among adolescent mothers receiving school-based prenatal care. Arch Pediatr Adolesc Med 2004;158(3):262-8.

Barnet B, Duggan AK, Devoe M. Reduced low birth weight for teenagers receiving prenatal care at a school-based health center: effect of access and comprehensive care. J Adolesc Health 2003;33:349-58.

Berg M, Taylor B, Eduwards LE, Hakanson EY. Prenatal care for pregnant adolescents in a public school. J Sch Health 1979;49(1):32-5.

Britto MT, Klosterman BK, Bonny AE, Altum SA, Hornung RW. Impact of school-based intervention on access to healthcare for underserved youth. J Adolesc Health 2001;29(2):116-24.

Denny S, Robinson E, Lawler C, et al. Association between availability and quality of health services in schools and reproductive health outcomes among students: a multilevel observational study. Am J Prev Med 2012;102(2):e14-20.

Edwards LE, Steinman ME, Hakanson EY. An experimental comprehensive high school clinic. Am J Public Health 1977;67(8):765-6.

Ethier KA, Dittus PJ, DeRosa CJ, Chung EQ, Martinez E, Kerndt PR. School-based health ceneter access, reproductive health care, and contraceptive use among sexually experienced high school students. J Adolesc Health 2011;48:562-5.

Federico SG, Abrams L, Everhart RM, Melinkovich P, Hambidge SJ. Addressing adolescent immunization disparities: a retrospective analysis of school-based health center immunization delivery. Am J Public Health 2010;100(9):1630-4.

Foy JE, Hahn K. School-based health centers: a four year experience, with a focus on reducing student exclusion rates. Osteopath Med Prim Care 2009;3:3.

Gance-Cleveland B, Yousey Y. Benefits of a school-based health center in a preschool. Clin Nurs Res 2005;14(4):327-42.

Gibson EJ, Santelli JS, Minguez M, Lord A, Schuyler AC. Measuring school health center impact on access to and quality of primary care. J Adolesc Health 2013;53(6):696-705.

Guo JJ, Wade TJ, Keller KN. Impact of school-based health centers on students with mental health problems. Public Health Rep 2008;123(6):768-80.

Guo JJ, Jang R, Keller KN, McCracken AL, Cluxton RJ. Impact of school-based health centers on children with asthma. J Adolesc Health 2005;37(4):266-74.

Hutchinson P, Carton TW, Broussard M, Brown L, Chrestman S. Improving adolescent health through school-based health centers in post-Katrina New Orleans. Child Youth Serv Rev 2012;34(2):360-8.

Juszczak L, Melinkovich P, Kaplan D. Use of health and mental health services by adolescents across multiple delivery sites. J Adolesc Health 2003;32(6):108-18.

Kaplan DW, Calonge BN, Guernsey BP, Hanrahan MB. Managed care and school-based health centers: use of health services. Arch Pediatr Adolesc Med 1998;152(1):25-33.

Kaplan DW, Brindis CD, Phibbs SL, Melinkovich P, Naylor K, Ahlstrand K. A comparison study of an elementary school-based health center: effects on health care access and use. Arch Pediatr Adolesc Med 1999;153(3):235-43.

Kerns SEU, Pullman MD, Walker SC, Lyon AR, Cosgrove TJ, Brungs EJ. Adolescent use of school-based health centers and high school dropout. Arch Pediatr Adolesc Med 2011;165(7):617-23.

Key JD, Washington EC, Hulsey TC. Reduced emergency department utilization associated with school-based clinic enrollment. J Adolesc Health 2002;30(4):273-8.

Kirby D. An assessment of six school-based clinics: services,impact and potential. Washington, DC: Center for Population Options;1989.

Kirby D, Resnick MD, Downes B, et al. The effects of school-based health clinics in St. Paul on school-wide birthrates. Fam Plann Perspect 1993;25(1):12-6.

Kirby D, Waszak C, Ziegler J. Six school-based clinics: their reproductive health services and impact on sexual behavior. Fam Plann Perspect 1991;23(1):6-16.

Kisker EE, Brown RS. Do school-based health centers improve adolescents’ access to health care, health status, and risk-taking behavior? J Adolesc Health 1996;18(5):335-43.

Klein JD, Handwerker L, Sesselberg TS, Sutter E, Flanagan E, Gawronski B. Measuring quality of adolescent preventive services of health plan enrollees and school-based health center users. J Adolesc Health 2007;41(2):153-60.

Klostermann BK, Perry CS, Britto MT. Quality improvement in a school health program. Results of a process evaluation. Eval Health Prof 2000;23(1):91-106.

Lewin Group. Healthy schools, healthy communities national evaluation: final report. Washington, DC: DHHS;1997.

Lurie N, Bauer EJ, Brady C. Asthma outcomes at an inner-city school-based health center. J Sch Health 2001;71(1):9-16.

McCord MT, Klein JD, Foy JM, Fothergill K. School-based clinic use and school performance. J Adolesc Health 1993;14(2):91-8.

McNall MA, Lichty LF, Mavis B. The impact of school-based health centers on the health outcomes of middle school and high school students. Am J Public Health 2010;100(9):1604-10.

Ricketts SA, Guernsey BP. School-based health centers and the decline in black teen fertility during the 1990s in Denver, Colorado. Am J Public Health 2006;96(9):1588-92.

Robinson WL, Harper GW, Schoeny ME. Reducing substance use among African American adolescents: effectiveness of school-based health centers. Clin Psychol Sci Pract 2003;10(4):491-504.

Sanford CC. Delivering health care to children on their turf: An elementary school-based wellness center. Journal of Pediatric Health Care 2001;15(3):132-7.

Santelli JS, Kouzis A, Newcomer S. School-based health centers and adolescent use of primary care and hospital care. J Adolesc Health 1996;19(4):267-75.

Setzer JR, Smith DP. Comprehensive school-based services for pregnant and parenting adolescents in West Dallas, Texas. J Sch Health 1992;62(3):97-102.

Silberberg M, Cantor JC. Making the case for school-based health: where do we stand? J Health Polit Policy Law 2008;33(1):3-37.

Smith P, Novello G, Chacko M. Does immediate access to birth control help prevent pregnancy? A comparison of onsite provision versus off-campus referral for contraception at two school-based clinics. J Adolesc Health 2011;2(2 Suppl):S107-8.

Strolin-Goltzman J, Sisselman A, Melekis K, Auerbach C. Understanding the relationship between school-based health center use, school connection, and academic performance. Health Soc Work 2014;39(2):83-91.

Taylor B, Berg M, Kapp L, Edwards LE. School-based prenatal services: can similar outcomes be attained in a nonschool setting? J Sch Health 1983;53(8):480-6.

Wade TJ, Line K, Huentelman T, The Health Foundation of Greater Cincinnati. Evaluation of health outcomes of students using school-based health centers. Cincinnati, OH: Cincinnati Children’s Hospital Medical Center;2005.

Walker SC, Kerns SE, Lyon AR, Bruns EJ, Cosgrove TJ. Impact of school-based health center use on academic outcomes. J Adolesc Health 2010;46(3):251-7.

Warren C, Fancsali C. New Jersey School-Based Youth Services Program: final report. New York, NY: Academy for Educational Development;2000.

Webber MP, Carpiniello KE, Oruwariye T, Lo Y, Burton WB, Appel DK. Burden of asthma in inner-city elementary schoolchildren: do school-based health centers make a difference? Arch Pediatr Adolesc Med 2003;157(2):125-9.

Weist MD, Paskewitz DA, Warner BS, Flaherty LT. Treatment outcome of school-based mental health services for urban teenagers. Community Mental Health Journal 1996;32(2):149-57.

Young TL, S.L. DA, Davis J. Impact of a school-based health center on emergency department use by elementary school students. J Sch Health. 2001;71(5):196-8.

Zimmer-Gembeck MJ, Alexander T, Nystrom RJ. Adolescents report their need for and use of health care services. J Adolesc Health 1997;21(6):388-99.

Zimmer-Gembeck MJ, Doyle LS, Daniels JA. Contraceptive dispensing and selection in school-based health centers. J Adolesc Health 2001;29(3):177-85.

Included Studies – Economic Review

Adams EK, Johnson V. An elementary school-based health clinic: can it reduce Medicaid costs? Pediatrics 2000;105:780-8.

Brindis CD. An Evaluation Study of School-Based Clinics in California: Major Findings, 1986 1991. San Francisco, CA: University of California, San Francisco; Center for Reproductive Health Policy Research: 1993.

Childeren’s Aid Society. School Based Health Centers. Author, March 2012.

Contraceptive Technology Update. School-based clinics combat teen pregnancy. Author, 1985;6(4):53-7.

21st Century School Fund. School-Based Health Care and the District of Columbia Safety Net. Medical Homes DC Report. Author, Washington (DC): 2004.

Dryfoos J. School-based health clinics: a new approach to preventing adolescent pregnancy? Fam Plann Perspect 1985;17:70-5.

Dryfoos JG. School-based health clinics: three years of experience. Fam Plann Perspect 1988;20:193-200.

Foch BJ. School-based health centers: a review. International Pediatrics 1995;10:286-91.

Fothergill K, Ballard E. The school-linked health center: a promising model of community-based care for adolescents. J Adolesc Health 1998;23:29-38.

Guo JJ, Jang R, Keller KN, McCracken AL, Pan W, Cluxton RJ. Impact of school-based health centers on children with asthma. Journal of Adolescent Health 2005;37:266-74.

Guo JJ, Wade TJ, Pan W, Keller KN. School-based health centers: cost-benefit analysis and impact on health care disparities. American Journal of Public Health 2010;100:1617-23.

Horton JM, Lima-Negron J. School-Based Health Centers: Expanding the Knowledge and Vision. New York State Coalition for School-Based Health Centers, New York: 2009.

Keeton V, Soleimanpour S, Brindis CD. School-based health centers in an era of health care reform: building on history. Current Problems in Pediatric and Adolescent Health Care 2012;42(6):132-58.

Massachusetts Association for School-Based Health Care. Making the Cost-Savings Case for School-Based Health Centers SBHCs Avoid Unnecessary Emergency Department Visits: Contribute to Reduction in State Health Care Spending. Author, Boston (MA): 2012.

McKinney DH, Peak GL. School-Based and School-Linked Health Centers, Update 1993. Advocates for Youth, Washington (DC): 1993.

Moore JD, Jr. Healthcare goes to school with kids in Denver County. Mod Health 1998;28: 52-4.

Nystrom RJ, Prata A. Planning and sustaining a school-based health center: cost and revenue findings from Oregon. Public Health Rep 2008;123:751-60.

Schlitt JJ, Juszczak LJ, Eichner NH. Current status of state policies that support school-based health centers. Public Health Reports 2008;123:731-8.

Siegel LP, Krieble TA. Evaluation of school-based, high school health services. J Sch Health 1987;57:323-5.

Silberberg M, Cantor JC. Making the case for school-based health: where do we stand? Journal of Health Politics, Policy and Law 2008;33:3-37.

Tereszkiewicz L, Brindis. School-based clinics offer health care to teens. Youth Law News 1986,September-October.

Implementation Resource

Rural Health Information Hub, Social Determinants of Health in Rural Communities Toolkit
This toolkit compiles information, resources, and best practices to support development and implementation of programs to address social determinants of health in rural communities. Modules include program models, implementation and evaluation resources, and funding and dissemination strategies.

• School and Workplace-based Healthcare

This literature search was performed to provide a systematic review of the evidence to the Guide to Community Preventive Services.

Eight databases (PubMed, Embase, CINAHL, ERIC, Google, NTIS, Web of Science (WOS), and WorldCat) were searched in March 2013 and July 2014, using the search terms listed below. The databases searched covered publications in biomedical sciences, education, and behavioral sciences. The types of documents searched in the databases included journal articles, books, book chapters, reports, websites, and conference papers.

Search terms and search strategies were adjusted to each database, based on controlled and uncontrolled vocabularies and search software. Plurals, hyphenated, non-hyphenated, and British spellings were searched for each term. Once the literature search was completed, Community Guide staff reviewed the citations using the following inclusion and exclusion criteria.

Inclusion English language publication, countries with high-income economies

Exclusion Non-English language publication, countries lacking high-income economies

Search Results

Search results table

Database Searched	# Results	After Deduping	Date Searched	# Duplicates
CINAHL	21	11	7/9/2014	10
EMBASE	46	36	7/9/2014	10
ERIC	54	54	7/10/2014	0
NTIS	0	0	7/10/2014	0
PubMed	1578	1576	7/9/2014	2
WorldCat	3	3	7/10/2014	0
WOS	209	160	7/10/2014	49
Google	5	3	7/10/2014	2
Total	1916	1843		73

Search Terms Used in Alphabetic Order

* = truncation

• Africa
• analys*
• analyz*
• assess*
• Asia
• assessment
• attendance
• benefi*
• Central America
• clinical trial
• clinical trials as topic
• council on school health
• decreas*
• developing countries
• efficac*
• evaluat*
• impact
• improv*
• increas*
• interven*
• Latin America
• lessen
• Mexico
• outcome
• pilot
• predict*
• program
• progress
• promis*
• protect
• random*
• reduc*
• result
• SBHC
• school based adolescent health
• school based adolescent hepatitis
• school based care
• school based caries prevent*
• school based centers
• school based cervical cancer education
• school based cessation program
• school based chemotherapy
• school based child sexual abuse prevention
• school based childhood obesity
• school based chlamydia control program
• school based chlamydia screening
• school based clinic
• school based clinical practice
• school based clinicians
• school based community intervention
• school based condom availability
• school based condom distribution
• school based condom education
• school based control program
• school based dental
• school based depression prevention program
• school based depression screening
• school based deworming
• school based diabetes care
• school based diabetes mellitus prevention program
• school based dietary intervention
• school based health
• school based health care
• school based health care staff
• school based health center
• school based health clinic
• school based health intervention
• school based health screening
• school based healthcare staff
• school based immunization assessment
• school based influenza immunization
• school based nurs*
• school based physician
• school based primary care
• school based primary health care
• school based substance abuse services
• school based telehealth
• school clinic*
• school dental service
• school dental care
• school dental clinic
• school dental health
• school dental hygiene
• school dental inspection
• school dental medicine
• school dental nurse
• school dental personnel
• school dental program
• school dental scheme
• school dental screen*
• school dental service
• school dental sealant program
• school dental therapist
• school dental treatment
• school dentist*
• school based dietary intervention
• school health care
• school health services
• school located
• school located health center
• school located health clinic
• school located immunization
• school located influenza vaccination
• school located mass influenza
• school located vaccination
• school mental
• school nurse
• school physician
• school wellness
• school wellness policies
• solve
• solving
• South America
• trial
• United States
• utility

Descriptions of Databases Searched

CINAHL (EBSCOHOST) provides indexing for more than 3,000 journals from the fields of nursing and allied health. The database contains more than 2.3 million records. Years covered: 1981 current.

Embase (OVID) – indexing more than 3,500 international journals in the following fields: drug research, pharmacology, pharmaceutics, toxicology, clinical and experimental human medicine, health policy and management, public health, occupational health, environmental health, drug dependence and abuse, psychiatry, forensic medicine, and biomedical engineering/instrumentation. There is selective coverage for nursing, dentistry, veterinary medicine, psychology, and alternative medicine. Years covered: 1974 current.

ERIC (ProQuest) – The ERIC (Education Resources Information Center) database is sponsored by the U.S. Department of Education to provide extensive access to educational-related literature. ERIC provides ready access to education literature to augment American education by increasing and facilitating the use of educational research and information to improve practice in learning, teaching, educational decision-making, and research. ERIC provides coverage of journal articles, conferences, meetings, government documents, theses, dissertations, reports, audiovisual media, bibliographies, directories, books and monographs. Years covered: 1966 current.

Google web search engine (includes Google Scholar, which covers journal articles)

NTIS (ntis.gov) serves our nation as the largest central resource for government-funded scientific, technical, engineering, and business related information available today. Years covered: 1964 current.

PubMed (pubmed.gov) comprises more than 22 million citations for biomedical literature from MEDLINE, life science journals, and online books. Citations may include links to full-text content from PubMed Central and publisher web sites. Years covered: 1946 current.

Web of Science (Web of Knowledge Thomson Reuters) – the world’s leading scholarly literature in the sciences, social sciences, arts, and humanities and examine proceedings of international conferences, symposia, seminars, colloquia, workshops, and conventions. Years covered: 1980 current.

WorldCat (worldcat.org) – the world’s largest library catalog, WorldCat contains millions of books, reports, conferences, dissertations, theses, audiovisuals, electronic publications, and articles from the past few centuries.

Search Strategies Used in Each Database Database: PubMed

Searched on 7/9/2014
Results: 1578

(((“2013/03/12″[Date – Entrez] : “3000”[Date – Entrez]) AND ( “2013/01/01″[PDat] : “2015/12/31″[PDat] ))) AND ((((((((“School Health Services”[Mesh] AND (English[lang]))) AND “united states”[mesh] AND (English[lang]))) OR ((((((((((((((((((((((“school located immunization programs” OR “school located influenza vaccination” OR “school located mass influenza” OR “school located mass vaccination”)) AND (English[lang]))) OR (“school located vaccination” AND (English[lang]))) OR (((“school dental care” OR “school dental clinic” OR “school dental clinics” OR “school dental health” OR “school dental hygiene” OR “school dental inspection” OR “school dental inspections” OR “school dental medicine” OR “school dental nurse” OR “school dental nurses” OR “school dental personnel” OR “school dental program” OR “school dental programme” OR “school dental programmes” OR “school dental programs” OR “school dental scheme” OR “school dental screening” OR “school dental screenings” OR “school dental sealant program” OR “school dental service” OR “school dental services” OR “school dental therapist” OR “school dental therapists” OR “school dental treatment” OR “school dentist” OR “school dentistry” OR “school dentists”)) AND (English[lang]))) OR (((“school dentist” OR “school dentistry”)) AND (English[lang]))) OR (“council on school health” AND (English[lang]))) OR (“sbhcs” AND (English[lang]))) OR (“sbhcs” AND (English[lang]))) OR (((“school clinic” OR “school clinics”)) AND (English[lang]))) AND (((“school health based” OR “school health based parasite control” OR “school health care”)) AND (English[lang]))) AND (“school mental” AND (English[lang]))) AND (((“school nurse” OR “school nurses”)) AND (English[lang]))) OR (((“school physician” OR “school physicians”)) AND (English[lang]))) OR (((“school wellness” OR “school wellness policies” OR “school wellness policy” OR “school wellness policy implementation”)) AND (English[lang]))) OR (((“school based adolescent health” OR “school based adolescent health care” OR “school based adolescent health care program” OR “school based adolescent hepatitis” OR “school based adolescent hepatitis b” OR “school based adolescent hepatitis b vaccination”)) AND (English[lang]))) OR (“school based health” AND (English[lang]))) OR (((“school based adolescent health” OR “school based adolescent health care” OR “school based adolescent health care program” OR “school based adolescent hepatitis” OR “school based care” OR “school based caries prevention” OR “school based caries preventive” OR “school based centers” OR “school based cervical cancer education” OR “school based cessation program” OR “school based chemotherapy” OR “school based child sexual abuse prevention” OR “school based childhood obesity” OR “school based chlamydia control program” OR “school based chlamydia screening” OR “school based clinic” OR “school based clinical practice” OR “school based clinicians” OR “school based clinics” OR “school based community intervention” OR “school based condom availability” OR “school based condom distribution” OR “school based condom education” OR “school based control program*” OR “school based dental care” OR “school based dental clinic” OR “school based dental clinics” OR “school based dental health” OR “school based dental program” OR “school based dental screening” OR “school based dental sealant” OR “school based dental services” OR “school based depression prevention program” OR “school based depression screening” OR “school based deworming” OR “school based diabetes care” OR “school based diabetes mellitus prevention program” OR “school based dietary intervention”)) AND (English[lang]))) OR (“school-based asthma” AND (English[lang]))) OR (“school-based care” AND (English[lang]))) AND (English[lang])) AND (English[lang]))) NOT (((((((“Developing Countries”[Mesh]) OR “Latin America”[Mesh]) OR “Asia”[Mesh]) OR “Mexico”[Mesh]) OR “Central America”[Mesh]) OR “South America”[Mesh]) OR “Africa”[Mesh] AND (English[lang])) AND (English[lang]))) NOT (brazil OR brasil AND (English[lang]))

Database: ERIC

Searched on 7/10/2014
Results: 54

2013-2014

“school based health center*” OR SBHC or SBHCs OR “school based health clinic*” OR “school clinic” OR “school clinics” OR “school health clinic*” OR “school health centre*” OR “school health center*”

Database: Embase (OVID)

Searched on 7/9/2014
Results: 46

(school-based-health-center* or school-based-health-centre* or school-based-health-clinic* or sbhc or sbhcs or school-health-service*).ti,kw,tw.
AND

(“201312” or “201313” or “201314” or “201315” or “201316” or “201317” or “201318” or “201319” or “201320” or “201321” or “201322” or “201323” or “201324” or “201325” or “201326” or “201327” or “201328” or “201329” or “201330” or “201331” or “201332” or “201333” or “201334” or “201335” or “201336” or “201337” or “201338” or “201339” or “201340” or “201341” or “201342” or “201343” or “201344” or “201345” or “201346” or “201347” or “201348” or “201349” or “201350” or “201351” or “201352” or “201401”).em.

Database: CINAHL

Searched on 7/9/2014
Results: 21

S9 S7 AND S8

S8 Limiters – Published Date: 20130401-20151231

S7 S1 OR S2 OR S3 OR S4 OR S5 OR S6

S6 (TX “school located”)

S5 TX (sbhc or sbhcs)

S4 TX (“school based health centre” or “school based health centres” or “school health centre” or “school health centres” )

S3 TX ( “school based health clinic” or “school based health clinics” or “school based clinic” or “school based clinics” or “school based clinical” or “school health clinic” or “school health clinics”)

S2 (TX ‘”school based primary care”)

S1 TX (“school based health center” or “school based health centers”)

Database: Google

Searched on: 7/10/2013
Results: 5

“school based health centers” +2014

Database: NTIS

Searched on 7/10/2014
Results: 0

[Advanced Search – exact phrase searches each run separately]

Since 2013

school based health center

school based health centers

SBHC

SBHCs

school based health clinic

school based health clinics

school clinic

school clinics

school health clinic

school health clinics

school health centre

school health centres

school health center

school health centers

school health service

school health services

Database: WoS (Web of Science)

Searched on 7/10/2014
Results: 209

Indexes=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH Timespan=2013-2014

# 33 #32 OR #31 OR #27 OR #26 OR #23 OR #21 OR #17 OR #16 OR #15 OR #14 OR #13 OR #9 OR #8 OR #1

# 32 #31 OR #27 OR #26

# 31 #28 AND #11

# 30 #29 AND #28

# 29 #28 OR #11

# 28 TI=(strateg*)

# 27 #25 AND #24

# 26 TS=(“school based health service*”)

# 25 #19 OR #11

# 24 TS=(study or studies)

# 23 #22 AND #19

# 22 TS=(eval* or success* or assess* or improv* or efficac* or combat* or recommend* or prevent* or interven* or trial or trials or program* or utility or progress* or solve or solving or result* or outcome* or predict* or benefi* or analys* or analyz* or pilot or random* or protect* or impact* or reduc* or lessen* or increas* or decreas* or amerliorat* or promis*)

# 21 #20 AND #19

# 20 TI=(eval* or success* or assess* or improv* or efficac* or combat* or recommend* or prevent* or interven* or trial or trials or program* or utility or progress* or solve or solving or result* or outcome* or predict* or benefi* or analys* or analyz* or pilot or random* or protect* or impact* or reduc* or lessen* or increas* or decreas* or amerliorat*)

# 19 Topic=(“school health service*”)

# 18 Topic=(“school health service*”) AND Title=(truant* or truancy or attendance or absent* or “missed school” or “missing school” or “miss school”)

# 17 Topic=(“school nurse*” or “school physician*” or “school based doctor*” or “school based primary care” or “school based primary health care” or “school doctor*”) AND Title=(truant* or truancy or attendance or absent* or “missed school” or “missing school” or “miss school”)

# 16 #15 OR #14

# 15 TS=(“school dental care”)

# 14 TS=(“school dental clinic*” or “school dental health” or “school dentist*” or “school based dental” or “school based dentist*”)

# 13 Topic=(“school nurse*” or “school physician*” or “school based doctor*” or “school based primary care” or “school based primary health care” or “school doctor*”) AND Title=(eval* or success* or assess* or improv* or efficac* or combat* or recommend* or prevent* or interven* or trial or trials or program* or utility or progress* or solve or solving or result* or outcome* or predict* or benefi* or analys* or analyz* or pilot or random* or protect* or impact* or reduc* or lessen* or increas* or decreas* or amerliorat*)

# 12 Topic=(“school nurse*” or “school physician*” or “school based doctor*” or “school based primary care” or “school based primary health care” or “school doctor*”) AND Topic=(eval* or success* or improv* or efficac* or combat* or recommend* or prevent* or interven* or trial or trials or program* or utility or progress* or solve or solving or result* or outcome* or predict* or benefi* or analys* or analyz* or pilot or random* or protect* or impact* or reduc* or lessen* or increas* or decreas* or amerliorat*)

# 11 Topic=(“school nurse*” or “school physician*” or “school based doctor*” or “school based primary care” or “school based primary health care” or “school doctor*”)

# 10 Topic=(“school located nurs*” or “school located physician*” or “school located health care” or “school located healthcare”)

# 9 Topic=(“school based nurs*” or “school based physician*” or “school based health care” or “school based healthcare”)

# 8 #7 OR #6 OR #5 OR #4 OR #3 OR #2

# 7 Topic=(“school clinic”)

# 6 Topic=(“school located health centre*”) OR Topic=(“school located health center*”) OR Topic=(“school health clinic*” or “school health centre*” or “school health center*”)

# 5 Topic=(“school located health clinic*”)

# 4 Topic=(“school based health clinic*”)

# 3 Topic=(“school-based health clinic*”)

# 2 Topic=(“school-based health centre*”)

# 1 Topic=(“school-based health center*”)

Database: WorldCat

Date Searched: 7/10/2014
Results: 3

Since 2013

“school based health center*” or “school based health clinic*” or sbhc or sbhcs or “school based dental clinic*” or “school dental clinic*” or “school based dental care”

Search Strategy – Economic Review

The following databases were used for the systematic search: PubMed, EconLit, ERIC, JSTOR, Social Sciences Citation Index (SSCI), databases at the Centre for Reviews & Dissemination at the University of York, and Google Scholar. The search period was January 1985 to September 2014.

To identify relevant studies, the economic keywords below were used in the search strategy along with subject keywords and terms searched in the effectiveness review. Studies with economic information that were identified by the effectiveness review team were also considered.

Studies were included in the review if they met the intervention definition, provided cost or benefit information, were primary studies, were conducted in high-income countries, and were written in English.

Economic Search Terms

economic, cost, benefit, cost-benefit, benefit-cost, utility, cost-utility, expenditure, cost effectiveness, cost of illness, cost saving, cost averted, $, dollar, WTP, willingness to pay, net cost, increment, opportunity cost, travel cost, treatment cost, lost productivity, fixed cost, operation cost, variable cost, sensitivity analysis, breakeven, discount rate, value, QALY, DALY, capital cost, life time cost, medical cost, time cost, treatment saving, funding, money

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• SBHC benefits likely depend on population density. It may be necessary to develop modified models for schools in rural settings and schools with fewer students.
• While SBHCs are particularly relevant to low-income communities, financing can be challenging. Medicaid and the State Children’s Health Insurance Program (SCHIP) have been common sources of financing for SBHCs.
• Included studies indicated that the greater the range of services offered by an SBHC, the greater the magnitude of benefits. Offering services both during and outside of school hours increases effectiveness.
• It is expected that providing free services will increase their use and effectiveness; however, lack of information on fees prevented analysis of this expected relationship.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Increase the proportion of adolescents who had a preventive health care visit in the past year — AH-01
• Increase the proportion of adolescents who speak privately with a provider at a preventive medical visit — AH-02
• Increase the proportion of 4th-graders with reading skills at or above the proficient level — AH-05
• Increase the proportion of 4th-graders with math skills at or above the proficient level — AH-06
• Reduce chronic school absence among early adolescents — AH-07
• Increase the proportion of high school students who graduate in 4 years — AH-08
• Increase the proportion of 8th-graders with reading skills at or above the proficient level — AH-R04
• Increase the proportion of 8th-graders with math skills at or above the proficient level — AH-R05
• Increase the proportion of secondary schools with a full-time registered nurse — AH-R08
• Increase the proportion of children and adolescents who get preventive mental health care in school — EMC-D06
• Increase the proportion of schools with policies and practices that promote health and safety — EH-D01
• Reduce pregnancies in adolescents — FP-03
• Increase the proportion of adolescent females who used effective birth control the last time they had sex — FP-05
• Increase the proportion of adolescent males who used a condom the last time they had sex — FP-06
• Increase the proportion of adolescent females at risk for unintended pregnancy who use effective birth control — FP-11
• Reduce hospitalizations for asthma in people aged 5 to 64 years — RD-D02
• Reduce emergency department visits for people aged 5 years and over with asthma — RD-03
• Increase the proportion of adolescents who get recommended doses of the HPV vaccine — IID-08
• Increase the proportion of people who get the flu vaccine every year — IID-09