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

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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
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Services, Chicago: Author.

Blum, R. (1987). Contemporary threats to adolescent health in the U. S.
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Council on Scientific Affairs. (1989). Providing medical services through
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Council on Scientific Affairs. (1990). Providing medical services through

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Fuchs, V. R., & Reklis, D. M. (1992). America’s children: Economic

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