Available online 6 April 2024

Author links open overlay panel, , , , , , , , , , AbstractObjective

School-based health centers (SBHCs) improve healthcare access, but associations with educational outcomes are mixed and limited for elementary and middle school students. We investigated whether students enrolled in a comprehensive SBHC demonstrated more growth in standardized math and reading assessments over four school years versus non-enrolled students. We also explored changes in absenteeism.

Methods

Participants were students enrolled in two co-located Title I schools from 2015-19 (1 elementary, 1 middle, n=2,480). Analysis of math and reading was limited to students with baseline and post-baseline scores (math n=1,622; reading n=1,607). Longitudinal regression models accounting for within-subject clustering were used to estimate the association of SBHC enrollment with academic scores and daily absenteeism, adjusting for grade, sex, body mass index category, health conditions, baseline outcomes (scores or absenteeism), and outcome pre-trends.

Results

More than 70% of SBHC-enrolled students had math (1,194 [73.6%]) and reading 1,186 [73.8%]) scores. Enrollees were more likely than non-enrollees to have asthma (39.7% vs 19.6%) and overweight/obesity (42.4% vs 33.6%). Adjusted baseline scores were significantly lower in math and reading for enrollees. Mean change from baseline for enrollees exceeded non-enrollees by 3.5 points (95% CI: 2.2, 4.8) in math and 2.1 points (95% CI: 0.9, 3.3) in reading. The adjusted rate of decrease in daily absenteeism was 10.8% greater for enrollees (IRR 0.772 [95% CI: 0.623, 0.956]) than non-enrollees (IRR 0.865 [95% CI: 0.696, 1.076]).

Conclusion

SBHC enrollees had greater health and educational risk but demonstrated more growth in math and reading and less absenteeism than non-enrollees.

WHAT’S NEW

Elementary and middle school students enrolled in a comprehensive school-based health center showed greater academic growth on a commonly used standardized assessment than non-enrolled peers, despite greater health and educational risk at baseline.

Section snippetsINTRODUCTION

Lack of accessible healthcare is a threat to children’s health and educational success.1 School-based health centers (SBHCs) expand access to essential care in medically underserved communities.2, 3, 4 SBHCs are designed to support student populations experiencing health and educational disparities such as racially minoritized or geographically isolated groups and those experiencing poverty. 2, 5 The Community Preventive Services Task Force recommends the implementation and maintenance of SBHCs

Study design, setting, and participants

This was a retrospective, observational, non-randomized, comparator-controlled study using student-level data from two Title I public charter schools in an urban center. Students registered in the schools from 2015-16 through 2018-19 were eligible for inclusion. The schools served approximately 1,500 students per year in grades K-8. Ninety-nine percent of students were African American, less than 0.001% were English Language Learners, and more than 80% qualified for free or reduced-price meals.

SBHC ServicesStudy Samples

2,480 students registered in the schools between SY2015-16 and SY2018-19, of which 1,644 (66.3%) students enrolled in the SBHC with a median time from school registration to SBHC enrollment of 1.1 months (IQR: 0.0, 4.0) months. 1,192 students had ≥1 SBHC visit during the study period, with a median time from school registration to SBHC visit of 3.4 (IQR: 7.4, 17.2) months. The mean annual number of visits to the SBHC per student during the study period was 1.8 visits (IQR: 0.33, 1.5). Most

DISCUSSION

Among students in grades K-8 attending two co-located Title I public charter schools in an urban center, those enrolled in a comprehensive SBHC had higher rates of asthma and obesity, lower math and reading scores, and higher rates of absenteeism at baseline than their non-enrolled peers. Consistent with prior literature, these findings highlight the extent to which SBHCs are serving students at health and academic risk and reinforce the need to account for differential baseline risk in

Strengths and Limitations

This study addresses limitations in extant literature by including a well-defined and comprehensive SBHC and accounting for baseline differences between enrollees and non-enrollees. Nonetheless, several limitations should be considered. Data were collected during routine SBHC care and educational assessment. Lack of randomization limits the ability to assess causation and may introduce selection bias, resulting in over- or under-estimation of intervention effects. The impact of selection bias

CONCLUSION

At a time when COVID-19 has highlighted the importance of school health and the widespread impact of learning loss, there is an opportunity to leverage this increased interest to address barriers to the implementation of comprehensive SBHC programs. Despite evidence for the health and academic impacts of SBHCs, consistent sources of financial support remain limited, threatening sustainability and growth. Multi-sector investment is required to support the growth of SBHCs and improve the health

Funding/Support

Funding support for this work was provided by the Norman and Ruth Rales Foundation, the Abell Foundation, the Robert Wood Johnson Foundation Clinical Scholars Program, and the Johns Hopkins University Department of Pediatrics. Funders were not involved in the research.

Declarations of Interest

None

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

The authors have received support from the following for the production of this manuscript:

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