1. Health care utilization behaviors of school-based health center users and non-users Gorette Amaral, MHS; Sara P. Geierstanger, MPH; Samira Soleimanpour, MPH (Presenter); Claire Brindis, DrPH Institute for Health Policy Studies, University of California San Francisco American Public Health Association Annual Meeting ● November 8, 2004 ● Washington, DC

2. Learning Objectives Evaluate the extent to which school-based health centers (SBHCs) act as a primary source of health care for adolescents and recognize other sources of care used by SBHC users and non-users Describe the relationship between insurance status and the likelihood of an adolescent seeking SBHC services Discuss the role SBHCs can play in increasing access to and utilization of preventive health services among users

3. Background and Methods

4. What are School-Based Health Centers (SBHCs)? SBHCs provide an integrated health care approach with a focus on prevention and early intervention for adolescents  Screening, diagnosis, and treatment of medical and mental health problems  Referrals and linkages to community providers and resources  Health education (individual and school-wide)

5. Number of SBHCs, by State 198319901992 199 4 19961998 10 1 44 0 0 0 0 0 2 33 1 20 26 1 38 42 20 44159 31 32 17 15 34 6 41 26 40 6 43 7 3 12 32 6 80 70 30 116 102 7 1 1 3 3 56 717 27 59 2 2000 150 1,380 Source: The George Washington University, 2001.

6. Alameda County, California

7. Alameda County SBHC Coalition Formed in 1996 with 3 SBHCs Currently includes 1 middle and 10 high schools Since 1997, UCSF has been outside evaluator  Work with staff to design and implement evaluation  Provide TA to sites to implement evaluation strategies  Assist with dissemination of evaluation findings Fremont High School’s Tiger Health Clinic, Oakland, CA

8. Data Source and Analysis California Healthy Kids Survey, 1999-2002  Cross-sectional, school-wide survey  Administered to grades 9 and 11 at seven high schools with SBHCs in Alameda County, CA  N = 3,705, 39% response (Range: 21-52%) Statistical analyses  Chi squared tests of significance  Multivariate logistic regression

9. Primary research questions How do SBHC users and non-users differ on…?  “Usual” source of health care  Insurance status  Receipt of specific health care services in the past year

10. Findings

11. Sample Characteristics 28% of sample had ever used their school’s SBHC (Range: 15-47%) No significant gender difference between users and nonusers Whites and African Americans significantly more likely to be users; Asians more likely to be nonusers (p<0.05)

12. “Usual” source of health care Of users, 7% reported SBHC as primary source No other significant differences between users and non-users on “usual” source of care ** p<0.01

13. Health Care Payment Method Over half (52%) of all students had private insurance No significant differences in insurance status between SBHC users and non-users Source: California Healthy Kids Survey, 1999-2001, N=3,705

14. Insurance & SBHC Use Adjusted ‡ Odds Ratios (95% CI) Ever used SBHC, any service Ever used SBHC counseling services Private insurance (reference)1.00 Government assistance1.10 (0.88, 1.39)1.63 ** (1.24, 2.14) No insurance0.96 (0.74, 1.25)1.64 ** (1.20, 2.23) Not sure0.84 (0.69, 1.02)0.92 (0.70, 1.20) ‡ Adjusted for grade, gender, ethnicity, school attended, and self-reported health status. * p<0.05, ** p<0.01 Insurance status was not a predictor of general SBHC use (“Have you ever used the SBHC for any service?”) However, having public insurance or being uninsured significantly increased the odds of SBHC counseling service utilization

15. Receipt of specific services * p<0.05, ** p<0.01 Respondents could mark more than one answer, so totals do not necessarily add up to 100%. SBHC users and non-users had similar rates of seeking care for minor illness or injury in prior year However, users were more likely than non-users to have received important preventive services

16. Limitations Cross-sectional design Self-reported health behaviors and insurance status Response rate varied from 21-52% across sites Possible non-representativeness of sample

17. Summary of Findings Generally, users and non-users did not differ on “usual” source of care or insurance status However, having public or no insurance increased the odds of seeking SBHC counseling services Among SBHC users, 7% indicated the SBHC was their primary source of health care SBHC users and non-users had similar rates of treatment for acute services in past year, but SBHC users were more likely than non-users to have received a number of important preventive services

18. Conclusions / Implications Although few students named the SBHC as their primary source of health care, SBHCs are a significant source of secondary care. In particular, SBHCs may increase access to and utilization of essential preventive services which adolescents need to remain healthy. SBHCs are able to attract students regardless of insurance status, suggesting they possess characteristics that students may not find elsewhere (e.g., confidentiality, teen-friendly environment and staff, geographic accessibility).

19. For more information Alameda County School-Based Health Center Evaluation Institute for Health Policy Studies University of California, San Francisco Gorette Amaral, MHS Research Analyst, gorette @ itsa.ucsf.edu Sara Peterson Geierstanger, MPH Project Director, sara @ itsa.ucsf.edu Samira Soleimanpour, MPH Project Coordinator, samira @ itsa.ucsf.edu Claire Brindis, DrPH Principal Investigator, brindis @ itsa.ucsf.edu