Thesis Nurs. 1997 B795a c. 2 Brabender, Janice. Adolescents' preferences for high school-based 1997. Adolescents’ Preferences for High School-Based Health Services by Janice Brabender Submitted in Partial Fulfillment of the Requirements for the Master of Science in Nursing Degree Approved by: /I jdcfith Schilling, CRNP, PhD V Committee Chairperson of Edinboro University of Pennsylvania Date PhD, RN Committee Member Edinboro University of Pennsylvania Date Mary Lou$Celler, CRNP, PhD Committee Member Edinboro University of Pennsylvania Date 0 Acknowledgments First, I would like to thank Dr. Judith Schilling for her support, assistance, and editing as chairperson during this project. I would like to thank Dr. Geisel and Dr. Keller for their assistance as members of my committee. I thank my husband and family for their enduring patience and support throughout this project. Finally, a special thanks goes to my sons, Colin and Kyle, and future son-in-law, Chris, without their computer expertise and assistance, this project would not have come to fruition. ii Adolescent Preferences for School-Based Health Service Abstract This study investigated high school students’ preferences for school-based health services. This non-experimental, quantitative design used a researchermodified questionnaire. The survey addressed accessibility of services, availability of comprehensive medical services and health education/counseling at school, and identified students’ preferences in those services offered at school. The survey was completed by 117 students at a high school in northwestern, Pennsylvania. Thirty­ eight percent stated they should have received health care and did not. Reasons included inconvenient office hours, lack of resources to pay fees, not wanting to see the family doctor, or miss school. These agreed with what is reported in the literature. Students were most interested (60% to 88%) in treatment for minor injuries, illnesses, and having routine physical examinations for sports and working papers. Interest was also high in education on health and nutrition, smoking, drug and alcohol abuse, and weight reduction. Overall, the results of this study agreed with findings in the literature. With the information generated from this study, an initial proposal for a school-based clinic was developed. It included a brief statement of the problem, the results of the needs assessment, statistics showing an increased pattern of usage of health room services, program plan and goals, expected costs, and possible funding sources. Table of Contents Content Page Acknowledgments ii Abstract iii List of Tables vii Chapter I: Introduction 1 Statement of the Problem 3 Theoretical Framework 3 Statement of the Research Purpose 4 Assumptions 5 Definition of Terms 5 Limitations 6 Summary 6 Chapter II: Review of the Literature 7 Health Problems of Today’s Youth 7 Barriers to Access 11 Historical Background 12 Importance of School-Based Clinics 13 Opposition to School-Based Clinics 16 Services Provided and Costs 17 iv Staffing and Clinic Hours 18 Funding Options 18 Summary 21 Chapter III: Research Methodology 22 Research Design 22 Sample 22 Informed Consent 22 Instrumentation 23 Analysis of Data 24 Proposal Development 24 Summary 24 25 Chapter IV: Results Demographics 25 Accessibility 28 Results on General Health Care and Counseling/Health Education 28 Summary 33 Chapter V: Discussion 34 Summary 34 Conclusions 35 Recommendations 37 39 References v 47 Appendixes A: Letter of Permission 48 B: Introduction Script 49 C: Student Survey 50 D: Initial Proposal 53 vi List of Tables Page Table Table 1. Demographic Data 26 Table 2. Sources of Care 27 Table 3. How health care is paid 27 Table 4. Accessibility Data 29 Table 5. Accessibility at School 30 Table 6. General Health Care 31 Table 7. Counseling and Education 32 vii 1 • Chapter I Introduction School can play a key role in helping children begin a lifetime of good health (Passarelli, 1994). However, America’s children face problems today that differ from previous generations (Blum, 1987). These problems are complex and rooted in the social and economic inequities of our times. Fuchs and Reklis (1992) report on the effects of these inequities. Although birth rates to teenagers overall have decreased, teenage pregnancy is still a problem. Violent deaths due to suicide and homicide have increased at alarming rates. Crimes, misdemeanors, drug and alcohol offenses have led to an overall increase of 41% in the rate of juvenile incarceration. Although approximately 66% to 93% of children under the age of 7 with health insurance visit their family doctors for regular care, only 49% to 53% over the age of 7 have regular care (Schmittroth, 1994). Schmittroth also writes that sexually transmitted disease incidence has risen and reports that cases of child abuse and neglect have risen 12.7% in the early 1990s. Adolescence, the transitional time between childhood and adulthood, is plagued with risk-taking behaviors that impact on the morbidity and mortality of youth (Blum, 1987; Council on Scientific Affairs, 1989; Fuchs & Reklis, 1992). There is a need to know and understand why these behaviors are continually increasing and how they can be addressed. Schools have always promoted health education (Baker, 1994). Health 2 programs in schools have evolved from simply educating to actually providing health care (DeAngelis, 1981). Health care provided at schools fills the gap in services for adolescents between the pediatric and adult populations (Gonzales et al., 1985). Several studies concluded that school-based clinics are effective in filling this need (Blum, Pfaffinger, & Donald, 1982; Gonzales et al., 1985; Pacheco et al., 1991; Weathersby, Lobo, & Williamson, 1995). School-based clinics can provide some answers for these problems of adolescents today (DeAngelis, 1985; Hyche-Williams & Waszak, 1990; Pacheco et al., 1991; Velsor-Friedrich, 1995). Health services provided in these clinics are available, confidential, community-based, and affordable to adolescents (Terwilliger, 1994). This type of environment encourages students to take responsibility for their own health care and provides them with the means to do so (Igoe, 1991). By 1990, 33 states had school-based clinics in operation (Waszak & Neidell, 1991). These clinics have provided a successful answer to accessibility problems to health care for adolescents (Council on Scientific Affairs, 1990; Gonzales et al., 1985; Terwillinger, 1994). The Council on Scientific Affairs (1990) wrote that “adolescents have the lowest rate of physician office visits of any age group” (p.87). And approximately 20% of U. S. adolescents have serious health problems such as asthma, heart disease, or depression (Velsor-Friedrich, 1995). Accessibility is an important issue in health care delivery because, as Uphold and Graham (1993) describe, nearly 14% of all Americans are without health 3 insurance, increasing numbers of women are in the work force, and one in five children under the age of 17 lives in poverty. School-based clinics may not provide all the answers to these problems, but they can assist in impacting on the morbidities and mortalities of adolescents today (Blum, 1987; Council of Scientific Affairs, 1989; Nudel, 1992; Rienzo, 1994). Statement of the Problem Adolescents face many obstacles when seeking health care. They are the only age group to have an increase in mortality rates (Uphold & Graham, 1993). Despite their potential health hazards, adolescents access health care less frequently than any other age group (Council on Scientific Affairs, 1990). Theoretical Framework Dorothea Orem’s (1995) self-care theory of nursing provides the framework for this study. Orem defines self-care agency as “the complex acquired ability to meet one’s continuing requirements for care that regulates life processes, maintains or promotes integrity of human structure and functioning and human development, and promotes well-being”(p. 145). Orem expands her theory by identifying self-care requisites as the reason for engaging in self-care. They can be of several types. Adolescents frequently exhibit health deviation self-care requisites. They become injured during participation in competitive athletic programs, suffer from emotional or social problems, or simply become ill and require interventions to restore normalcy. Adolescents need to seek 4 care when this demand arises because they may no longer be capable of caring for themselves. Adolescence is the transitional period from childhood to adulthood (Kazden, 199j). It is during this period that children develop independence from their parents. While developing this independence adolescents make decisions regarding their own lives, health, and general well-being. According to Orem, adolescents would then have the right and responsibility to care for themselves because it has been a learned activity. Igoe (1991) believes that adolescents possession of Orem’s self-care abilities will empower them to become wise consumers of future health care. Nurse practitioners found in school-based clinics are trained professionals who can compensate for adolescent health-deviation self-care requisites and assist them in their ability to preserve their health and well-being, or restore it. School­ based services would then have the potential to greatly impact adolescent health hazards, mortality rates, and accessibility problems. By identifying the specific health needs of adolescents, school-based services can be successfully developed to meet their perceived needs and preferences for services. Statement of the Research Purpose The purpose of this study was to assess adolescents’ preferences for high school-based health care services. 5 Assumptions The study was based on the following assumptions: 1. Research subjects responded honestly to the questions. 2. Research subjects who responded understood the explanations and instructions as written on the questionnaire. Definition of Terms Special terms were defined as follows: 1. Adolescents are children ages 10 through 18 who are in a period of rapid physical, emotional, intellectual and social change that is often turbulent (Rew, 1995). 2. School-based clinics (SBCs) are sites where primary care is delivered at schools (Rienzo, 1994). 3. Primary care is integrated, accessible health care services by clinicians who address a large majority of personal health care needs, develop a partnership with patients, and practice in the context of family and community (Institute of Medicine, 1996). 4. Nurse practitioner is a primary care provider who performs assessments, analyzes health data, initiates and implements an appropriate plan of care, follows-up on findings, and refers as needed (Sinclair, 1997). 5. Accesssibility is health care that is available, community-based, and affordable (Terwilliger, 1994). 6 Limitations Limitations of this study were as follows: 1. This study was limited to a convenience sample of a small group of adolescents in one small town in northwest Pennsylvania. 2. The research tool used in this study was researcher-modified. .Summary The status of adolescent health is a critical issue today (Fuchs & Reklis, 1992; Nudel, 1992). Adolescents are the future of the world but rising social, economic, and health problems have impacted their health status and well-being. The purpose of this study was to complete a needs assessment of high school students to determine the kinds of school-based health services that they need and prefer. This would provide insight into whether a nurse practitioner-managed school­ based clinic would be welcomed as a feasible way to address the unmet health care needs of these adolescents. Definitions, assumptions, and limitations of this study were identified. 7 Chapter II Review of the Literature The purpose of this study was to determine the perceived health needs of high school students and what kinds of health services are necessary to meet those needs. This review of literature provides an historical overview of the development and rationale of school-based clinics. Included in this review are services provided at the clinics, and their funding sources. Health Problems of Today’s Youth The United States Department of Health and Human Services ([DHHS], 1990) issued a report entitled Healthy People 2000: National health promotion and disease prevention objectives which listed access to preventive care as one of its primary objectives for children. Sources of its data indicated that school-aged students lacked sufficient health care (Dougherty et al., 1992). Studies from the early 1980s indicated that 33% of children aged 6 through 16 years had not visited a doctor in the preceding year and 15% were without a regular source of medical care (Hadley, Levick, & Kirby, 1986). Adolescents aged 11 through 20 years visited clinicians’ offices even less often than any other age group. They were also the group who had occurrences of acute conditions such as sore thioats and otitis media that went untreated. This suggests numerous unmet health needs of school-aged children were great. Adolescents in particular are the only age group in the United States to experience falling rather than improving health status (Blum, 1987). This 8 deterioiation has been accompanied by substantial morbidity and social problems (Kann et al., 1996). Fuchs and Reklis (1992) offered several explanations for this phenomenon. First, religion does not play an important part in most American lives anymore. Second, the widespread acceptance of divorce and unwed motherhood has fragmented the traditional family unit. And third, the powerful influence of television has had detrimental effects on the physical activity and intellectual development of children. The U. S. Office of Technology Assessment ([OTA], 1991a) made the following statement on the status of adolescent health: “Adolescents are generally perceived as healthy, but this perception may be deceptive”(p. 3). Immunization rates have dropped in the United States (DHHS, 1993b). In 1991 less than 60% of two- year olds had been fully immunized. Adolescents suffer from the vaccine-preventable diseases of varicella, hepatitis B, measles, and rubella (Centers for Disease Control and Prevention [CDC], 1997a). This partly results from previous vaccination programs’ lack of emphasis on improving coverage among adolescents. The incidence of asthma has risen dramatically over the years (DHHS, 1993b). In the last two decades a 60% increase in occurrence has been seen. These are just a few of the health conditions that lead to absenteeism, learning difficulties, and eventual school failure. In 1987, Blum compiled information regarding the mortality and morbidity rates of adolescents. The results indicated that deaths due to communicable diseases 9 had been replaced with rising violent death rates from homicide, suicide, and accidents. Poor grades in school, absenteeism, probation issues, and family problems were found to be indicators for this trend. Fuchs & Reklis (1992) discovered similar results. The CDC (1996) surveillance survey on health-risk behaviors among adolescents found 72% of all deaths in adolescents were from violence-related causes. Although death due to communicable diseases, unintentional injuries, cancer, and congenital anomalies had decreased considerably for children under the age of 15, no reduction in overall death rate had occurred (CDC, 1997b). Mortality from violence continues to rise for adolescents (CDC, 1996). Teenagers, although they appear to be physically healthy, are known to engage in risky behaviors. During this age of experimentation, adolescents develop health habits that can have long-term consequences (Adams, Gullotta, & Markstrom, 1994). Poor decision-making skills result in the use of harmful drugs and alcohol, or tobacco products. The DHHS (1993 a) reported that in 1991, 20% of youth ages 12 to 17 had used alcohol in the previous month, 10% had smoked cigarettes, and 4% had used marijuana. Nationwide, the incidence of these risky behaviors increased by 1995 (Kann et al., 1996). More than 50% of youth the same ages had consumed alcohol in the prior month, 16% had smoked cigarettes, and over 25% had used marijuana. Sexual experimentation begins during adolescence. Youth become exposed to unplanned pregnancies and their social implications (Adams et al., 1994, DHHS, 1993b). Blum (1987), citing data from the National Longitudinal Survey of Work 10 Experience, noted that only 53% of pregnant teenagers who dropped out of school ever finished high school. Drop-out rates and resultant poverty have a high correlation since the job market is limited for those without a diploma. Birth rates for teenagers actually have declined this decade in all teenage subgroups (CDC, 1997e). This decline may partly result from increased contraception usage due to widespread health education strategies (CDC, 1997d). Sexually transmitted diseases (STDs) pose still another risk from sexual experimentation in adolescents. The report entitled Summary of Notifiable Diseases for 1995 (CDC, 1996) listed primarily STDs in their top 10 list of reportable diseases among all age groups. Gonorrhea, chlamydia, acquired immunodeficiency syndrome (AIDS), syphilis, and hepatitis B were among the most reported diseases. Although AIDS is on this top 10 list, AIDS deaths have recently decreased substantially (CDC, 1997c). Violence is still another morbidity for adolescents. It is also identified as a national health objective in the government document Healthy People 2000 (DHHS, 1990). Several studies have been done to document exposure, prevalence, and effects of violence (Fry-Bowers, 1997; Jones, 1997). The CDC (1997b) reported that until 1994 U. S. children under the age of 15 experienced a decrease in overall death rate. Homicide and suicide rates by firearms increased substantially for this same age group. The adolescent age group of 15 to 19 experienced the greatest increase in death rates due to homicides (Children’s Defense Fund, 1996). This rate showed an 11 increase of 154% by the early 1990s. The Youth Risk Behavior Surveillance (Kann et al., 1996) studied trends among U. S. high school students finding that 20% carried weapons ( a gun, knife, or club); 38% had beenini a physical fight in the prior 12 --------- months; and 24% had seriously considered attempting suicide, and 8% had made an actual attempt. The effects of violence are not only physical. Fry-Bowers (1997) found that behavioral, psychosocial, and legal consequences can result and greatly impact our children. Finally, obesity predisposes children and adolescents to many acute and chronic medical conditions (CDC, 1997f). Findings from a nutrition examination survey (CDC, 1997f) indicated that the trend towards obesity continues in all age groups including children and adolescents. The same survey suggested that this trend resulted from the intake of high caloric foods exceeding the physical activity expenditure of children. Barriers to Access Adolescents face various barriers when accessing health care. Gonzales (1985) commented that health care was poorly accessible and underutilized by teenagers. This possibly was due to the distance the health care provider was from the teen when services were needed, and/or delays in scheduling appointments. Teens are also intensely private and may be hesitant to share their concerns. The Council on Scientific Affairs (1990) listed other obstacles: parental consent requirements, perceived or actual lack of confidentiality, payment issues, the 12 constraints that have resulted from changing family and work patterns, locations and office hours of health care facilities, and adolescent compliance with treatment issues or the ability to follow-up on the clinician’s recommendations. The OTA (1991b) agreed with these findings. In addition, the lack of trained providers who specialize in adolescent problems posed another barrier for this age group. And, private physicians may have some difficulties identifying and treating the behavioral, emotional, and substance abuse problems adolescents experience. Historical Background The concept of school-based clinics (SBCs) was developed in response to the need for better health services for school-age students (Waszak & Neidell, 1990; Pacheco et al., 1991; Nudel, 1992; Uphold & Graham, 1993; Terwilliger, 1994). The idea for SBCs originated in Cambridge, Massachusetts when the health department began caring for children in their neighborhood elementary school (Nudel, 1992). Shortly afterwards in the early 1970's , the first two adolescent SBCs opened in West Dallas, Texas and St. Paul, Minnesota Both were located in high schools but for different reasons. The St. Paul clinic was developed to address the community s concern about the rising incidence of teenage pregnancies. The Dallas clinic was the community’s and the school’s solution to the lack of available health care for disadvantaged youth. What started out as an experiment in these two locations has now been transformed into a model to improve young people’s access to health care ( DHHS, 1993b). 13 obert Wood Johnson Foundation was a pioneer in the funding of a national school health program (DeAngelis, 1981). It had four major goals: 1. To increase available preventive health services. 2. To improve the health status of children. 3. To reduce inappropriate use of and increase appropriate access to health services. 4. To provide a school-based ambulatory pediatric-care program that is economically and organizationally feasible as a model for dissemination (p.345). This program provided the basic elements of primary care combined with health education at the school site. Schlitt and Lear (1995) indicated that there were approximately 650 SBCs throughout the country by 1994. These clinics have gained the support of the American Academy of Pediatrics, the American School Health Association, and the National Association of School Nurses (Terwillinger, 1994). These organizations support school-based clinic programs to supply comprehensive health services to students who lack access to primary care. SBCs continue to proliferate today due to the increasing social, psychological, and economic problems adolescents face in addition to any physical impairments (Velsor-Friedrich, 1995). Importance of School-Based Clinics Adolescents need comprehensive health care. That care needs to be delivered at sites that are accessible to help youth safely navigate the complexities of adolescence. School-based clinics provide such access (Office of Inspector General, 14 1993, Ounce of Prevention Fund, 1994; U.S. General Accounting Office [GAO], 1994). ool based clinics in Albuquerque, New Mexico underwent a task force study to justify their existence (Pacheco et al., 1991). The study showed that SBCs represented a major source of health care for adolescents. SBCs were established in Maryland, California, Mississippi, Florida, and Colorado in 1990. The DHHS (1993b) reported favorable outcomes from these clinics. The clinics resulted in a 20% decrease in students sent home from school due to illness or injury over non- clinic users. Substance abuse treatment resulted in an 80% reduction in school suspensions. These two results were the reason for a dramatic decrease in school absenteeism. The Ounce of Prevention Fund (1994) established SBCs in the Chicago area. Studies of these clinics indicated three positive outcomes. First, increasing numbers of clinic visits by adolescents were seen. Secondly, in the communities served by the clinics, fewer than 8% of the teenage moms had low birth weight babies compared to an overall 13% rate of low birth weight. Thirdly, large numbers of students received health education and maintenance care that resulted in early diagnosis of problems and prevention of long-term sequelae. The U.S. General Accounting Office (GAO, 1994) conducted case studies of SBCs in California, New Mexico, and New York. Results indicated that SBCs eliminated access problems. Convenient location, minimal or no existing fee, and no 15 transportation problems provided ease in accessing health care for these youth. Parents of students who were enrolled at these clinics saw the services as being beneficial. Another justification for SBCs came from several studies done to examine pieferences in health care services (Malus, LaChance, Lamy, Macaulay, & Vanasse, 1987; Blum, 1989; Goldsmith, 1991; Weathersby, Lobo, & Williamson, 1995). These studies concluded that teenagers frequently did not have their concerns addressed when they visited their primary care physicians in traditional care settings. Adolescents stated that they did not feel comfortable in traditional primary care settings. These settings were not congruent with youths’ attitudes and beliefs (Gonzales et al., 1985). They also concluded that adolescents have outgrown the pediatrician, but do not fit into settings that cater to adult populations. SBCs fill this gap- The SBCs studied had high utilization rates. Alexander (1990) attributed this to the immediate availability of the clinics to answer teenagers health concern and crises. David Kaplan, M. D., chief of adolescent medicine at the University of Colorado School of Medicine in Denver, was quoted by Goldsmith (1991) in support of SBCs: “The fact that we have such high utilization from the student body tells me that we’re doing something right - if we weren’t meeting the needs of the students, they wouldn’t be coming in”(p- 2459). 16 Opposition to School-Based Clinic* There have been a number of studies giving evidence to the controversies SBCs face (Council on Scientific Affairs, 1989; Council on Scientific Affairs, 1990; Goldsmith, 1991; Rienzo & Button, 1993). Sexuality issues appeared as the main reason foi opposition. Included in sexuality issues are counseling and distribution of contraceptive devices and/or prescriptions, and abortion discussion and encouragement. Parental consent issues ranked second in frequency. Opponents felt that SBCs attempted to undermine parental authority by eliminating the need for parental permission in the sensitive areas of teenage sexuality and mental health (Rienzo & Button, 1993; Harold & Harold, 1993). Other opposition focused on the theme that schools should stick to academics and not be responsible for the psychosocial problems of the times (Rienzo & Button, !993; Uphold & Graham, 1993). Ongoing funding issues presented further obstacles (GAO, 1994; Lear, Montgomery, Schlitt, & Rickett, 1996). Educators believed that the finances involved in maintaining SBCs would overtax existing inadequate educational budgets (Uphold & Graham, 1993). Historically, SBCs received private and public grants to begin their programs. When these grants expired, educators did not want schools subsidizing the cost of student health services. Other arguments reported by Rienzo & Button (1993) were that liability has become an increasing concern for schools, a concern that the services provided were actually not needed, that the services were too costly, and that they were not effective. 17 Another criticism (Blum et al„ 1982) was that SBCs tailed to teach youth how to access community health services because the clinics isolated them. Services Provided and Costs The services provided in SBCs should be tailored to the needs of the individual communities they serve (Council on Scientific Affairs, 1989; Rienzo, 1994, Burch & Palanki, 1995). To determine what services were needed, the preferences of both students and parents were identified. The OTA (1991b) concluded that adolescents required services in the areas of problem treatment, problem prevention, and health promotion. The results of a survey summarized by Hyche-Williams and Waszak (1990) listed the many services provided at SBCs. Health promotion services consisted of physical examinations, immunizations, sports physical examinations, psychological and social assessments, and prenatal care. Problem treatment and diagnostic services centered on the treatment of illness and injuries, substance abuse counseling, mental health counseling, the diagnosis and treatment of eating disorders, gynecological examinations, sexually transmitted disease testing and treatment, and pregnancy testing and counseling. In the area of problem prevention, weight management, nutrition education, and birth control counseling and referral, along with career counseling, were offered. In addition to these services, Waszak & Neidell (1991) found that laboratory tests, pediatric care of infants of adolescents, dental services, dispensing of medications, and Early and Periodic Screening, Diagnosis and 18 Treatment (EPSDT) screenings were done. Then stud, included SBCs in 33 states. Nationwide, Nudel (1992) found that services provided in SBCs cost approximately $50 to $150 per student per year. The DHHS (1993) reported costs as much higher, services cost between $122 and $500 per user per year depending on the clinic location and frequency of visits. Staffing and Clinic Hours To encourage clinic usage by adolescents, the services should be located where the teenagers spend their days. Typically, SBCs have hours that coincide with the school day and the school year (Nudel, 1992; Office of Inspector General. 1993; DHHS, 1993). Several studies specified that staff in SBCs be trained to deal with the unique problems of adolescence (Office of Inspector General, 1993; DHHS, 1993). All SBCs are staffed by full-time nurse practitioners or physician assistants. Pediatricians or family practitioners provide additional medical coverage approximately 3 to 4 hours a week. Full- time clerical, medical assistant, and health educator personnel staff the clinics. In addition, part-time mental health providers, psychologists, social workers, medical directors, nutritionists, and HIV counselors complete the staffing patterns in various SBCs around the country. Funding Options Financial support of the first SBCs was provided by the state health department in Massachusetts where the clinics was located. Later, trustees of the 19 Robert Wood Johnson Foundation in 1977 provided financial support nationally to improve health services for school age children (DeAngelis, 1981). Now there are many more options for funding a SBC. Alexander (1990) identified possible sources of funding as coming from grants, medical schools, private sources, community groups, and the school budget. Wazsak and Neidell (1991) reported the operating budgets of 152 SBCs with percentages from the following sources: state health sources, 24%; local school districts, 8%; local governments, 12%; state human services, 3%; private funds, 18%; community health centers, 7%; maternal and child health block grants, 17%; and, Title XX, 3%. Other sources, which totaled less than 9% included EPSDT, medicaid and Title X, private insurance, and patient fees. Analysis of funding sources in 1993 by the DHHS indicated similar findings. Potential sources of federal funding for SBCs were released by the Center for Population Options (Steinschneider, 1993). It listed four sources of health care block grants: the Maternal and Child Health Services Block Grant, the Preventive Health and Health Services Block Grant, the Substance Abuse Prevention and Treatment Block Grant, and the Community and Mental Health Services Block Grant. In addition, other potential sources were found in Medicaid. Steinschneider (1993) also identified a few state-controlled sources of federal funds. These sources included drug-free schools and communities state grants, supplemental food programs for women, infants and children, social services block grants, and child care and development block grants. 20 U. S. Geneial Accounting Office (GAO) confirmed that these same federal funding sources still existed. Also, medicaid has provided increasing funds to SBCs that performed its EPSDT program. In addition, Family Planning programs (Title X) supplied federal dollars in varying amounts. The Health Security Act of 1993, President Clinton’s health reform bill, included a public health service component which would have awarded grants to develop SBCs (GAO, 1994). The reliable support of the Robert Wood Johnson Foundation has continued to remain a constant in the funding of SBCs (DeAngelis, 1981; Oda, DeAngelis, Meeker, & Berman, 1985;Nudel, 1992; DHHS, 1993b). Schlitt and Lear (1995) reported expanded federal financial support from existing sources. Maternal and Child Health block grants experienced increases of 45% in their funding dollars while an increase of 140% was seen in general fund dollars over the preceding 2 years. This expansion in dollars was necessary to meet the needs of approximately 650 SBCs in existence across the country by 1995. However, with continued expansion evident, new sources of financial support were necessary. Managed care reimbursement has the potential as a future funding source for SBCs. Schlitt and Lear (1995) found that in Boston SBCs were part of a health maintenance organization (HMO) network. They expect that this unique situation will appear more commonly once health care reform is completed 21 Summary This literature review has pointed out many health concerns of today’s youth. These health concerns are complicated by various barriers to accessing the care adolescents need. Although opposition has existed to school-based clinics in certain geographical areas, and in regard to specific types of services provided, much research has indicated support for their concept. Further work is needed to solve funding problems especially with regard to the challenges health care reform presents. T1 Chapter III Research Methodology The purpose of this research study was to assess adolescents’ preferences for high school-based health care services. This chapter presents the research design, sample, and instrumentation. Informed consent, analysis of the data, and proposal development are also discussed. Research Design This researcher used a non-experimental design. It was a quantitative study using a survey approach. Sample Participants in this study came from a rural high school that had an enrollment of 807 students in grades 9 through 12. Students had been previously assigned to home rooms and a sample size of 157 students was selected. Surveys were distributed by four home room teachers and the students were requested to complete the survey during this time period. One hundred and seventeen students completed the survey for a 75% rate of completion. No identifying information was requested on the surveys, and completion of the survey was voluntary. This site provided a convenient sampling of high school adolescents varied as to their grade level and gender. Informed Consent Permission to administer the survey (Appendix A) was given by the principal 23 of the high school under the condition of anonymity and voluntary participation. Informed consent from the students was assumed if the student answered the survey questions. Instrumentation The instrument was adapted from a survey sample from Hadley, Lovick, & Kirby s (1986) manual School-Based Health Clinics: A Guide to Implementing Programs. A question was added to the survey to ensure that all recommendations from the Guidelines for Adolescent Preventive Services (American Medical Association, 1992), also known as GAPS, were included. A question concerning contraceptive methods was removed at the request of the principal of the high school where the survey was administered. Home room teachers read a prepared script (Appendix B) that introduced the researcher, told the students what was being studied, and asked the students to answer the survey. The 12-item survey (Appendix C) included demographic questions, questions related to accessibility of health services, and questions concerning the types of services preferred. The survey was distributed by home room teachers who also collected the completed surveys prior to the end of the home room period. The students were instructed not to sign the questionnaire to insure that their answers would remain anonymous and confidential. A pilot study was done in order to establish clarity of the questions and to assist in the development of a spreadsheet for data collection. To accomplish this, the researcher administered the survey to six high school students who attended 24 confirmation preparation classes at a community Catholic church. These students did not attend the high school where the research was done. The researcher made minor revisions for question clarity as a result of the pilot test. Analysis of the Data Descriptive statistics were utilized to analyze the data. Percentages and means were calculated to describe and analyze the data from this study. Proposal Development With the information generated from this study, it was possible to develop an initial proposal for a school-based clinic (Appendix D). The proposal included a brief statement of the problem, the results of the needs assessment, statistics showing an increased pattern of usage of health room services, program plan and goals, expected costs, and possible funding sources. Summary In summary, the purpose of this research study was to assess adolescents’ preferences for high school-based health care services. A convenient sample of 117 subjects was selected from a high school in northwestern Pennsylvania. The students completed a questionnaire, researcher modified, from Hadley, Lovick, & Kirby s (1986) manual. The data was then analyzed using descriptive statistics and an initial proposal for a school-based clinic was written. 25 Chapter IV Results This chaptei provides the results of the study to determine adolescents’ perceived health needs. Data on demographics, accessibility, and preferences for general health care and counseling/health education by high school students is included in these results. The researcher conducted this study during an extended home room period in November of 1997 at a high school in northwestern Pennsylvania. One hundred and fifty-seven surveys were distributed by six randomly selected home room teachers from grades 9 through 12. The surveys were collected at the end of the home room period. One hundred and seventeen students responded for a response rate of 75%. Demographics Survey respondents were similar in demographics to the high school student population with most being Caucasian (97%). Table 1 showed that 54% were male and 46% were female. The mean grade of the student who responded was 10.5 completed years of school. Following the first three demographic questions, question four of the survey asked: Where do you usually get your medical care (Table 2)? Sixty-two percent of students reported a private physician as their major source of health care, 24% responded that a medical clinic was their source of care, and 6% did not get care. Sources of dental care were similar. Sixty percent received care at a private dentist, 32% at a dental clinic, and 8% did not get care. Fifty percent stated 26 Table 1 Demographic Data n % Male 63 54% Female 54 46% Black 1 1% White 114 98% Qth 33 28% 10,h 19 16% 11th 27 23% 12th 38 33% Gender Race Grade in School Note. Percentages rounded to nearest whole number. 27 Table 2 Sources of Care Source of medical care n % Sources of dental care n % Private physician 72 62% Private dentist 71 60% Medical clinic 28 24% Dental clinic 37 32% Emergency room 9 8% 9 8% Don’t get care 7 6% Other 0 0% Don’t get care Note. Percentages rounded to nearest whole number. Table 3 How health care is paid Resources n % Medicaid 11 9% Parents pay 28 24% Pay lower fee 4 3% Pay myself 2 2% Pre-paid health plan 13 12% Private insurance (parent’s policy) 59 50% Note, Percentages r^d^th^arest whole number. 28 that their parents’ insurance policies paid for their care (Table 3). Accessibility Several questions on the survey addressed medical care accessibility. The mean number of times students received medical care during the last year was 3.2. Most of them (69 /o) got to their medical appointments by riding with a parent and 37 /o by driving themselves to their appointments. Thirty-eight percent felt that there were times when they should have had medical care but did not get it. Reasons why varied and supported the findings in the literature, as shown in Table 4 (Gonzales, 1985; Council on Scientific Affairs, 1990; OTA, 1991b). Eleven percent responded that office hours were not convenient and 6% did not have money to pay for medical services. Others (9%) responded that they did not want to see their family doctor for their problem. Another 9% stated that they did not want to miss school to seek medical care. Question 11 asked if students felt that medical services should be offered at school (Table 5). Seventy percent responded that medical services should be provided at school while 30% felt they should not. Results on General Health Care and Counseling/Health Education Students’ interest in general health care services was high (Tables 6 and 7). The medical services most students preferred at school included treatment of minor injuries and illnesses, and availability of physical examinations for sports, drivers licenses, and working papers. Students also responded in high percentages on several counseling issues preferring health and nutrition education, smoking cessation 29 Table 4 Accessibility Data n % 37 32% 6 5% 81 69% 0 0% 10 8% 45 38% Office hours not convenient 13 11% Did not want to see family doctor 10 9% Did not have money to pay fee 7 6% Did not want to miss school 11 9% 4 3% Transportation Drive a car Ride with a friend/relative Ride with a parent Take a bus Walk or ride a bike Times you should have had medical care and did not go Reasons why you did not go No transportation Note. Percentages rounded to the nearest whole number. 30 Table 5 Accessibility at School n % 82 70% 35 30% Should medical services be offered at school Yes No Note. Percentages rounded to the nearest whole number. programs, drug and alcohol counseling, and weight management programs (Table 7). Considerable numbers of students (50% to 65%) preferred counseling for jobs, pregnancy, and mental health concerns; testing for chronic health problems, pregnancy detection with referral for prenatal care; and referrals for more serious illnesses. Several areas of low interest were evident from the students responses (Tables 6 and 7). These were dental care, prescribed medications, laboratory tests and health screenings, growth concerns, and parenting education. When student surveys were examined for responses by sex, male respondents were more interested in general health care services than female respondents. More male than female students preferred screening and treatment for STDs; however, more female than male students preferred pregnancy detection and referral for prenatal care. More males preferred job counseling and more females preferred 31 Table 6 General Health Care Students Kind of care n % Treatment for minor injuries 103 88% Treatment for minor illnesses 90 77% Routine physicals (including sports physicals) 81 69% Other physicals (drivers license, working papers) 70 60% Referrals for serious illness or injury 61 52% Tests for chronic health problems (BP, asthma, etc.) 58 49% Pregnancy detection and referral for prenatal care 53 45% Immunizations 48 41% Treatment for skin problems 47 40% Screening and treatment for STDs 43 37% Laboratory tests and health screenings 34 29% Prescribed medications 34 29% 25 21% Dental care Note. Percentages rounded to the nearest number. 32 Table 7 Counseling and Education Students Counseling for: n % Health education 84 72% Nutrition education 79 68% Smoking cessation programs 78 67% Drug and alcohol abuse programs 77 66% Weight reduction programs 72 62% Job counseling 65 55% Pregnancy counseling 63 54% Mental health counseling 59 50% Sexuality counseling 55 47% Learning or school-related concerns 53 45% Family counseling Parenting education Growth concerns Note. Percentages rounded to the nearest whole number. 52 44% 40 34% 36 31% 33 weight reduction programs. These were the differences found to exist between the sexes in the study. Based on the findings from this study, an initial proposal for school-based health services (Appendix D) was written. The services proposed included the students preferences for general health care, health education, and counseling. Summary Most students (70%) preferred that medical services be offered at school.This study had a response rate of 75% with a total of 117 high school students completing the questionnaire. The responses to the questions addressing accessibility indicated that 62% seek care at a private physician and 24% at a medical clinic. Similarly, 60% seek dental care at a private dentist and 32% at a dental clinic. Most students got to their appointments by riding with a parent. 34 Chapter V Discussion This chapter summarizes the results of this study. Conclusions are discussed and recommendations are made for future research. Summary The purpose of this study was to assess adolescents’ preferences for high school-based health care services. The results of this study aided the development of an initial proposal for high school-based health services. A review of the literature included health problems of today’s youth, barriers to access, historical background, importance of school-based clinics, opposition to school-based clinics, services provided and costs, staffing and clinic hours, and funding options. Several studies support the idea of SBCs as a possible solution to problems of accessibility for adolescents (Gonzales, 1985; Council on Scientific Affairs, 1990; OTA, 1991; GAO, 1994). School-based clinics have provided numerous favorable outcomes when addressing problems of youth (DHHS, 1993b; Ounce of Prevention, 1994; GAO, 1994). Studies have also demonstrated support for the services that SBCs can provide. (Council on Scientific Affairs, 1990; Rienzo, 1994; Weathersby, Lobo, & Williamson. 1995). One hundred and fifty-seven surveys were distributed to high school students with a return of 75%. Descriptive data were sources of health and dental care. elicited concerning gender, race, and Data showed that respondents had sought medical 35 care an average of 3.2 times during the last year with 69% of their parents supplying the transportation to care. Thirty-eight percent of respondents felt there were times when they should have had medical care and did not access it for varied reasons. Seventy percent of the respondents were in support of medical services being provided in school. Students were interested in various medical, health education, and counseling services being offered at school. Each option under medical services/health education and counseling was selected by at least 21% of the students. The range in preference for a particular service extended to a maximum of 88%. This study did substantiate Orem’s self-care theory of nursing. Orem (1995) asserts that self-care requisites can be identified as the reason for engaging in selfcare. The theory also states that people exhibit health deviation self-care requisites and seek interventions to restore their ability to care for themselves. With 70% of the respondents wanting health services at school, adolescents not only want to seek compensation for their self-care deficits, but also desire a convenient way to accomplish this goal. School-based services would enable adolescents to maintain their ability to care for themselves. Conclusions Results from this study demonstrated that 62% of the respondents received medical care by a private doctor. This is lower than the 72% to 76% reported in the literature. Conversely, 6% of the respondents in the study reported that they did not get care while only 3% is reported in the literature. Several explanations are offered 36 for these findings. The community may consist of a population deficient in or lacking in health insurance benefits. Over one-third of the students surveyed are on Medicaid or self pay. Accessibility of services and cost also present problems for this population. The survey demonstrated support for various school-based services. The high percentage of students interested in these services was surprising when given the fact that 62 /o received care from a private physician. The health care providers serving this community may not be meeting the needs of the adolescent population. Perhaps this is due to lack of training in adolescent problems as the literature suggests (OTA, 1991b), or adolescent hesitancy to share their concerns with individuals not well known to them. Adolescents were also hesitant to see their family doctor. Possible confidentiality concerns may explain this hesitancy. Staff who work in SBCs may get to know their students especially well because they provide daily services where the students spend much of their time. These students frequently develop trusting relationships with staff in schools. Adolescents are striving for independence and SBCs provide them the opportunity to seek medical care conveniently on their own. The services of most interest to the students were not surprising. Services for routine health maintenance, health promotion, and health education rated high in consideration for school-based services. The large percentages interested in educational strategies could be the result of the present health curriculum at school. A need may exist for more specific information that can be provided confidentially to 37 the students who are interested. Nurse practitioners can provide these services at school. They can become the trusted health care providers that are experts in adolescent problems. Nurse practitioners can provide all the services preferred by the students in this study. Frequently students and their parents complain that the usual health services provided at schools can only identify problems for referral. Other health care providers must then be consulted for treatment. Health problems would be better served if they could be both identified and treated at school. Nurse practitioners can perform these functions. The convenience of nurse practitioner services would permit adolescents to receive treatment for problems immediately rather than having to make and keep another appointment. The importance of such services for working or single parent families is obvious. Recommendations Planning school-based health services is a complex process. The information gained from the survey indicated strong support by high school students for comprehensive health services. The support and preferences of students however, are only one part of the planning process. More research needs to include parents’ preferences in planning health services for their children. Their preferences should also be surveyed. This would have a two-fold purpose: besides determining their preferences, the survey would inform the community about school-based health services and gather support for these programs. 38 search should be extended to also include teacher and administrators input. Educators have opinions on what they view as valuable services for adolescent health problems. They should be surveyed to gather this information and staff support for those sei vices to be piovided at school. Additional questions could also be asked addressing the need for health services for staff members at schools. School-based health services could be designed to meet the health promotion, disease prevention, and acute and chronic health needs of the education staff who work in high schools. Services wanted and needed by the entire school community must be identified if planning for health care services is to be successful. Funding for services is another vital area for exploration. Reimbursement options for SBCs should be pursued. With the rapid changes occurring in the health care delivery system, medicaid and private insurances along with grants appear as possible funding options. Financial stability of services offered is a strong consideration when initiating new programs. Schools do not want to assume the financial responsibility for providing comprehensive health services when they already are operating under tight budget constraints. Finally, although this study showed interest for comprehensive school-based health services, interest does not always equate with usage. Additional research should be done to determine if services would actually be utilized.. 39 References Adams, G. R., Gullotta, T. P., & Markstrom, C. (1994). Adolescent life experiences (3" ed.). Pacific Grove, CA: Brooks/Cole Publishing. Alexander, E. (1990). School-based clinics: Questions to be answered in the planning stages. High School Journal, 73(2), 133-138. 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Adolescent health: A report to the U.S. Congress. Journal of School Health, 65(5), 167-174. Fry-Bowers, E. K. (1997). Community violence: Its impact on the development of children and implications for nursing practice. Pediatric Nursing. 23(2), 117-121. Fuchs, V. R., & Reklis, D. M. (1992). America’s children: Economic perspectives and policy options. Science, 255^ 41-45. Goldsmith, M. F. (1991). School-based health clinics provide essential care. Journal of American Medical Association, 265(9), 2458-2460. Gonzales C., Mulligan, D., Kaufman, A., Davis, S., Hunt, K., Kalishman, N., & Wallerstein, N. (1985). Adolescent health care: Improving access by school-based service. Journal of Family Practice. 21(4), 263-270. Hadley, E. M. Lovick, S. R., & Kirby, D. (1986). School-based clinics: A guide to implementing programs^ Washington, D.C.: Center for Populations Options. 42 (ERIC Document Reproduction Services No. ED 326937) Harold, R. D„ & Harold, N. B. (1993). School-based clinics: A response to the physical and mental health needs of adolescents. Health & Social Work, 8(1), 65- 74. Hyche-Williams, H. J., & Waszak, C. (1990). School-based clinics: Update 1991 Houston, TX: Washington Center for Population Options. (ERIC Document Reproduction Service No. ED 325968). Igoe, J. (1991). Empowerment of children and youth for consumer self-care. American Journal of Health Promotion, 6, 55-65. Institute of Medicine. (1996). Primary care: America’s health in a new era. Washington, D.C: National Academy Press. Jones, F. (1997). Community violence, children, and youth: Considerations for programs, policy, and nursing roles. Pediatric Nursing, 23.(2), 131-137. Kann, L., Warren, C. W., Harris, W.A., Collins, J. L., Williams, B. D., Ross, J. G., & Kolbe, L. J. (1996). Youth risk behavior surveillance-United States, 1995. Centers for Disease Control Surveillance Studies,_45(55-4), 1-26. Kazdin, A. (1993)- Adolescent mental health: Prevention and treatment programs. American Psychologist, 4L 837-842. Lear, J. G, Montgomery, L. L„ Schlitt, J.1, & Riokett, K. D. (1996). Key issues affecting school-based health centers and medicaid. Tmtmal of School Hegltlt. 66(3), 83-88. 43 Lovick, S. R„ & Stem, R, F. (1989). School-based eHnics 1988 update: A doser look M the numbers, Houston, TX: Center for Populations Options. (ERIC Document Reproduction Service NO. ED 325967) Malus, M., LaChance, P. A., Lamy, L, Macaulay, J., & Vanasse, M. (1987). Priorities in adolescent health care: The teenager’s viewpoint. Journal of Family Practice, 25(2), 159-162. Nudel, M. (1992). Health for hire. The American School Board Journal, 179(10), 36-38. Oda, D. S., DeAngelis, C., Meeker, R., & Berman, B. (1985). Nurse practitioners and primary care in schools. Journal of Maternal and Child Nursing, 10(2), 127-131. Office of Inspector General. (1993). School-based health centers and managed care, Washington, D.C.: U.S. Government Printing Office. (ERIC Document Reproduction Service NO. ED 370950). Orem, D. (1995). Nursing: Concepts of practice. St. Louis: Mosby-Year Book, Inc. Ounce of Prevention Fund. (1994). Keeping students on track: Comprehensive health care andeducation for American teenagers. New York: A. T.&T. Foundation. (ERIC Document Reproduction Services NO. ED 382359). Pacheco, M„ Powell, W„ Cole, C„ Kalishman, N., Benon, R., & Kaufman, A. (1991). School-based clinics: The politics of change. Journal of School Health, 44 61(2), 92-94. Passarelli, C. (1994). School nursing: Trends for the future. Journal of School Health, 64(4), 141-146. Rew, L. (1995). Adolescents’ perceived barriers to healthcare services. Journal of.Child and Adolescent Psychiatric Nursing. 8(4),5-13,15-16. Rienzo, B. (1994). Factors in the successful establishment of school-based clinics. The Clearing House. 67,(6Y 356-362. Rienzo, B. & Button, J. W. (1993). The politics of school-based clinics: A community-level analysis. Journal of School Health. 63(6), 266-272. Schlitt, J. S., & Lear, J. G. (1995). Medicaid, managed care and school-based health centers: Proceedings of a meeting with policy makers and providers. Princeton, N.J.: Robert Wood Johnson Foundation. (ERIC Document Reproduction Services NO. ED 398504). Schmittroth, L. (1994). Statistical Record of Children. Detroit: Gale Research, Inc. Sinclair, B. P. (1997). Advanced practice nurses in integrated health care systems. Journal of Obstetrical, Gynecological and Neonatal Nursing. 26(2), 217- 223. Steinschneider, J. (1993). Potential sources of federal support for school­ based and school-linked health clinics. Washington, DC: Center for Population Options. (ERIC Document Reproduction Services NO. ED 365893). 45 Terwilliger, S. H. (1994). Early access to health care services through a rural school-based health center. Journal of School Health. 64(71 284-289. U.S. Department of Health & Hu man Services. (1990). Healthy People 2000: National-health promotionanddiseasejrev^^ Washington, DC: U.S. Government Printing Office. U.S. Department of Health & Human Services. (1993a). Child health USA 192. Washington, DC: U.S. Government Printing Office. U.S. Department of Health & Human Services. (1993b). School-based clinics that work. Washington, DC: U.S. Government Printing Office. U.S. General Accounting Office. (1994). Health care reform: School-based health centers can promote access to care. Gaithersburg, MD: U.S. General Accounting Office. (ERIC Document Reproduction Service NO. ED 388901). U.S. Office of Technology Assessment. (1991a). Adolescent health. Volume 1. Washington, DC: U.S. Government Printing Office. U.S. Office of Technology Assessment. (1991b). U.S. adolescents face barriers to appropriate health care. Washington, DC: U.S. Government Printing Office. Uphold, C. R, & Graham, M. V. (1993). Schools as centers for collaborative services for families: A vision for change. Nursin^Outi^ 204-211. Velsor-Friedrich, B. (1995). Schools and health, Part II: School-based clinics. Journal of Pediatric Nursing, l.QG)> 62-63. 46 Waszak, C. and Neidell, S. (1991). School-based and school-linked clinics update. Washington. DC: Center for Populations Options. (ERIC Document Reproduction NO. ED 341899). Weathersby, A. M., Labo, M. L., & Williamson, D. (1995). Parent & student preferences for services in a school-based clinic. Journal of School Health, 65(1), 1417. 47 Appendixes Appendix A 1901 FREEPORT ROAD • NORTH EAST, PENNSYLVANIA 16428 • TELEPHONE (814) 725-8671 48 November 3,1997 TO WHOM IT MAY CONCERN: REF: Questionnaire Permission Janice Brabender has my permission to distribute her survey to students of the North East High School requesting them to fill out a questionnaire on preferences for high school health services. I understand that this project is a requirement for her MSN degree at Edinboro University of Pennsylvania. I have reviewed the survey and the procedure to be used when distributing this survey. It is understood that the students decision to participate is completely voluntary. If you should have any further questions or concerns about Mrs. Brabender’s research, please feel free to contact me. Sincerely, ^0 Robert D. Rhodes Principal RDR/kw "Serving Students in The Heart of The Grape Country” An Equal Rights and Opportunities School District 49 Appendix B Introduction Script Dear Student: Most of you know me as the Mrs. Brabender. I am a student in Edinboro University’s masters degree nurse practitioner program. I am doing a research study that examines the health needs of high school students today. Before going any further with this project, I need to know what you feel are the health needs of high school students and what you feel should be offered at school. This survey is a way for you to give me your ideas on this subject. Your participation in this survey is completely voluntary. If you decide to participate there is no need for you to put your name on this survey, but it should be completed and returned during homeroom. Your answers will remain anonymous and confidential. By answering this survey you have volunteered to participate in this study. 50 Appendix C STUDENT SURVEY 1. What grade are you in this year? 2. Are you male or female? (Circle one) 3. Are you: Black White □Other 4. Where do you usually get your medical care? □don’t get care emergency room at hospital □medical clinic private doctor □other 5. How many times in the last year have you received medical care? 6. How do you usually pay for your medical care? 7. How many times have you been seen in an emergency room in the last year? times Medicaid parents pay pay lower fee pay myself pre-paid health plan private insurance (parent’s) times 8. Where do you usually get dental care? □dental clinic □don’t get dental care private dentist 9. How do you get to your medical appointment? □drive a car □ride with a friend/relative ride with a parent □take a bus □walk or ride a bike 51 10. Were there any times when you felt that you should have seen a doctor/nurse practitioner/ physician’s assistant when you did not go? 10a. If yes, why didn’t you go?(Check ALL that apply) 11. Do you think there should be medical services at your high school? 1 la. Why? □yes □no □didn’t want to miss school □didn’t know where to go □ didn’t have money to pay □there was no transportation available □office or clinic hours were not convenient □other □yes □no 12. Please check ALL of the services that you feel should be offered at your high school health room. MEDICAL SERVICES □treatment of minor illnesses (colds, sore throats, etc.) □treatment of minor injuries (cuts, bruises, sprains, strains, etc.) □ referrals for more serious illnesses or injuries □routine physical examinations including sports physicals □other physicals (drivers license and working papers, etc.) □ immunizations □ laboratory tests and health screenings □screening and treatment for STDs □treatment for skin problems(acne, rashes, etc.) □tests for high blood pressure, diabetes, and other chronic problems □ prescribed medications □ pregnancy detection and referral for prenatal care □dental care 52 HEALTH EDUCATION/COUNSELING □ nutrition education □health education □weight reduction programs □ drug and alcohol abuse programs □ smoking cessation programs □ growth concerns □family counseling □ mental health and psycho-social counseling (depression, anger management) □ sexuality counseling □ pregnancy counseling □ parenting education □job counseling □ learning or school-related concerns 53 Appendix D Initial Proposal for School-Based Health Services Goals 1. To biing adolescents into a system of organized and accessible health care. 2. To reduce adolescent morbidity and mortality within this community. Problem Adolescents face many obstacles when seeking health care today. They are the only age group to have an increase in mortality rates (Uphold & Graham, 1993). Their risk-taking behaviors impact both mortality and morbidity (Blum, 1987; Council on Scientific Affairs, 1989; Fuchs & Reklis, 1992). Despite their potential health hazards, adolescents access health care less frequently than any other age group (Council on Scientific Affairs. 1990). Ne.eds Assessment One hundred and fifty-seven students from the local high school were surveyed on their preferences for school-based health services. The instrument was adapted from a survey sample from Hadley, Lovick, & Kirby’s (1986) manual SchoolBased Health Clinics: A Guide to Implementing Programs. One hundred and seventeen surveys were returned for a response rate of 75%. Seventy percent responded that medical services should be offered at school. Thirty-eight percent stated that there were times when they should have had medical care but did not. Reasons why they did not go included: 11% responded that office hours were not 54 convenient, 6% did not have money to pay for the services; 9% stated that they did not want to miss school to see a doctor; and another 9% responded that they did not want to see their family doctor. Seventy percent responded that medical services should be provided at school. The services students preferred at school (88%-65%) were treatment of minor injuries and illnesses, availability of routine physical examinations including exams for sports, drivers licenses, and working papers. They also preferred counseling in the areas of health, nutrition, smoking cessation, drug and alcohol, and weight management programs. Considerable preference (45%-65%) was indicated for testing for chronic health problems such as asthma and diabetes, pregnancy detection, and counseling for jobs, pregnancy, and mental health concerns. Little preference (21 %-45%) was indicated for dental care, prescribed medications, laboratory tests, and health screenings, growth concerns, and parenting education. Increased Pattern of Usage Statistics are displayed in Graph A showing an increased pattern of health room usage over the last four years since the 1993-94 school year. Figures were adjusted to exclude those students whose presenting complaint was requesting tylenol These figures also do not include the number of students seen for physical examinations or health screenings. Program Plan The 12 month plan proposed includes comprehensive health services provided 55 by a staff that includes a full-time nurse practitioner and secretary/receptionist, and a part-time consulting physician. During the school months a part-time mental health counselor, and drug and alcohol counselor would also provide services. The services to be provided include, but are not limited to the following: treatment of minor illnesses and injuries, referral for more serious injuries and illnesses, routine physical examinations, screening and treatment for STDs, treatment for skin problems, tests for chronic health problems such as asthma, pregnancy detection and referral for prenatal care, counseling for nutrition, health, weight reduction, drug and alcohol abuse, smoking cessation, mental health concerns, pregnancy counseling and learning or school-related concerns. Costs The costs that follow are estimates based on current rates paid by the school district for existing positions. It is assumed that overhead costs will be provided by the school district. Personnel: 1 full-time Certified Registered Nurse Practitioner $55,000 1 full- time receptionist/secretary $24,000 1 part-time Physician consultant $5,000 1 part-time mental health counselor 1 part-time drug and alcohol counselor Hamot provided GECAC provided 56 Equipment: Supplies $10,000 Office computer $3,000 Funding Options Several options exist as possible sources of funding for school-based health services. The Robert Wood Johnson Foundation (DeAngelis, 1981) continues to fund SBCs. Other sources include both federal and state grants, private sources, community groups, and Medicaid. Managed care reimbursement is a potential funding source as health care reform continues into the 21st century. 57 GRAPH A Patterns of Usage (/> 35 CD C Z5 30 c 25 £Z CD cd CD 20 o 15 E Z 10 I 1993-94 students seen 58 Bibliography American Medical Association. (1992). Guidelines for Adolescent Preventive Services, Chicago: Author. Blum, R. (1987). Contemporary threats to adolescent health in the U. 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