Myunghee Song Hwang, PhD, CHES; Kathleen Lux Yeagley, RN, PhD, CHES; Rick Petosa, PhD

Psychosocial smoking prevention studies have shown inconsistent results and theory-driven programs have been related to program success. This meta-analysis was used as a judgment tool for resolving these issues by estimating average program effects and investigating the relative efficacy of program types. The present study examined 65 adolescent psychosocial smoking prevention programs (1978 to 1997) among students in Grades 6 to 12 in the United States. Three program modalities (social influence, cognitive behavior, life skill) and two program settings (exclusively school based, school-community-incorporated) were identified as major a priori classifications.

Discussion: Are adolescent psychosocial smoking prevention programs implemented during the past two decades (1978 to 1997) beneficial to public health status and should they be kept? The present meta-analysis provides conclusive evidence that psychosocial smoking prevention programs have been successful in the reduction of adolescent smoking behavior in the United States. The best program effects were achieved by programs using cognitive behavior and life skill modalities and/or comprehensive school-community settings. This meta-analysis study also highlights the maintenance of long-term smoking behavioral effects as well as the dramatic improvement and rapid loss of knowledge effects.

Even though the magnitude of behavior effects was not as large as other outcome variables, the maintenance ability of nonsmoking behavior was best for the primary outcome of smoking prevention programs. If smoking program participants engage in nonsmoking behavior, then the students are likely to be smoke-free for at least 3 years. The behavioral-effects findings are consistent with Toblerís meta-analysis of drug abuse prevention program effects in time.

Journal of the National Medical Association May 2005;Vol.97,No.5

Howard S. Adelman; Lori A. Barker; and Perry Nelson

Proliferation of comprehensive school-based health clinics and centers throughout the 1980s has been rapid. Originating in the early 1970s, these programs have experienced a fivefold increase between 1983 and 1989. At the beginning of 1990, there were at least 150 in operation (86% in high schools, the remainder in middle and elementary schools) and 50 in various stages of planning in over 32 states and the District of Columbia.

Initial program descriptions and evaluations have begun to appear in the literature, and public health and policy researchers have written about the potential importance of the movement. In particular, it has been emphasized that school-based clinics have the potential to serve large numbers of currently underserved populations (e.g., adolescents from lower socioeconomic and ethnic minority backgrounds). Moreover, as the clinics evolve, their focus is expanding to include mental health and psychosocial problems. In studying utilization, it is important to elucidate not only who uses the clinic and why, but who chooses not to and why. Beside the practical implications of such data, surveys can be designed so that the findings also contribute to the growing body of research and theory focused on help-seeking behavior in general.

Reported data on school-based clinic utilization and reasons for use or nonuse. Nearly half the sample indicated clinic use and satisfaction. Almost all used medical services; over one-fourth received psychological counseling. Factors influencing use were ease of access and perceptions that services were helpful and confidential. Frequent users scored highest on measures of psychological distress. Most nonusers indicated they were healthy and didn't need help, but over one-fourth did acknowledge not wanting others to know about their problems. Less than one-fifth indicated parental objections as a factor. In contrast to clinic nonusers, clients reported less availability and satisfaction with help and support from family members.

Journal of Clinical Child Psychology 1993;Vol.22,No.1,52-59

James H. Price; Faith Yingling; Joseph A. Dake; and Susan K. Telljohann

A national sample of 390 junior and senior high school–based centers were mailed an 18-item survey to assess their institutional stages of change regarding smoking cessation education, referral, and prescription nicotine replacement therapy (NRT) services and their perceived barriers and benefits regarding the provision of these services. Nearly half were in the maintenance stage for cessation education programs, one-third were in maintenance stage for referral services, and 12% were in the maintenance stage for NRT. The most frequently cited perceived benefits included an increased awareness of short- and long-term effects of smoking (education programs and referral services) and increasing student access to cessation methods (NRT). The greatest barriers cited were a lack of financial resources (education programs), problems with student transportation (referral services), and staff not having the authority to provide prescription services (NRT). School-based centers can do more to help stop adolescents from using tobacco

Health Educ Behav 2003;30;196

Melanie J. Zimmer-Gembeck, M.S.; Tammy Alexander, M.Ed.; and Robert J. Nystrom, M.A.

Purpose: The goals of this study were to describe student access to health care services, identify populations of students who remained in need of health care services, and highlight particular unmet needs for health care identified by these adolescents.

Conclusions: A majority of high school-age adolescents had visited health care providers within the year prior to study. However, the number of adolescents who reported unmet specific health care needs within the same time period remained substantial.

Journal Of Adolescent Health 1997;21:388-399

Carol Hirschon Weiss; Erin Murphy-Graham; Sarah Birkeland

Abstract: Investigators of the influence of evaluations on policy decisions have noted three main routes to influence: instrumental, conceptual, and political/symbolic. This study, an inquiry into the effect of evaluations of the Drug Abuse Resistance Education (D.A.R.E.) program, found a fourth main way that evaluations exert an influence: imposed use. The Safe and Drug Free Schools office of the U.S. Department of Education obliged districts to select a program that met its Principles of Effectiveness, which most districts construed to mean that the program had to be on the department’s approved list. Because results of D.A.R.E. evaluations repeatedly showed that D.A.R.E.’s effectiveness on knowledge and attitudes was neither sustained nor led to lower use of drugs, D.A.R.E. did not make the lists. Hence, many districts dropped or scaled back D.A.R.E. This kind of imposed use is likely to become more common when government agencies make greater demands for accountability.

American Journal of Evaluation Mar.2005;Vol.26 No.1

E. Kathleen Adams, PhD; and Veda Johnson, MD

Objective: School-based health services have evolved from primarily controlling communicable disease to comprehensive programs with direct services, education, and improvement of the school environment.

School-based health clinics (SBHCs), currently 1157 in number, are used to reach children for preventive and other routine care. Although several studies have examined the costs and effects of such programs, few, if any, have examined their potential to save Medicaid program outlays. The objective of this study was to assess the effect of the Whitefoord Elementary School-Based Health Clinic (WESBHC), located in Atlanta, Georgia, on health care costs paid by Georgia Medicaid over the 1994–1996 period. This clinic has been in operation since late 1994.

Conclusions: The results strongly suggest that the operation of a SBHC can have effects on the child’s use of services and health care expenses. Given that these clinics serve all those who come for care and many of these are low-income children, these savings are likely to accrue to the Medicaid program of the state. As states continue to implement Medicaid-managed care for their child populations, they will need to consider the ability of SBHCs to participate in and receive Medicaid revenues through health maintenance organization networks.

Pediatrics 2000;105:780 –788

Summary: This report contains a brief description of the status of adolescent health in the United States. Background information on the adolescent population is presented, including data on mortality and various health indicators, such as chronic illness, adolescent pregnancy, sexually transmitted diseases, and substance use and abuse. The current health delivery system is examined, with sources of payment, frequency of visits, types of practitioners seen, and visit content briefly discussed. The paper concludes with recommendations for improvement in access to care, clinical training and preventive services.

Ital J Pediatr 2003;29:328-335

Richard D. Crespo, Ph.D.; and George A. Shaler, M.P.H.

Purpose: To assess the capability of school-based health centers (SBHCs) to provide access to health care for rural youth.

Conclusion: When SBHCs are available in rural areas, students use them. In West Virginia, SBHCs have contributed to providing access to health care for rural youth.

Journal Of Adolescent Health 2000;26:187–193

Susan K. McCarthy; Susan K. Telljohann; Barbara Coventry; and James Price

Context: School-based health centers have the potential to increase adolescents’ awareness of, access to and use of emergency contraceptive pills, which can prevent unintended pregnancy following unprotected sex.

Conclusions: School centers that provide all three services have the greatest potential to ensure the successful use of emergency contraceptive pills by adolescents. While the number of centers offering services appears to be increasing, greater efforts are needed to improve students’ awareness of and access to the method so they can make informed decisions regarding their reproductive health.

Perspectives on Sexual and Reproductive Health 2005;37(2):70–77

Paula Armbruster, M.A., M.S.W.; Stephanie H. Gerstein, B.A.; Theodore Fallon, M.D., M.P.H.

Abstract: In an effort to bridge the gap between service need and service utilization, an urban based, university affiliated children's psychiatric outpatient clinic has implemented a program which provides mental health services in inner city schools. When compared with the central clinic populations (N = 304), the school sample (N — 44) was markedly socioeconomically disadvantaged, minority, and as psychiatrically impaired as the central clinic population. School-based mental health services have the potential for bridging the gap between need and utilization by reaching disadvantaged children who would otherwise not have access to these services. Implications for such services are discussed.

Community Mental Health Journal 1997;Vol.33,No.3,June

Mayris P. Webber, DrPH; Kelly E. Carpiniello, MA; Tosan Oruwariye, MD, MPH; Yungtai Lo, PhD; William B. Burton, PhD; David K. Appel, MD

Objective: To compare outcomes including hospitalizations, emergency department visits, and school absenteeism in elementary schoolchildren with asthma who were grouped according to their enrollment at schools that have or do not have SBHCs.

Conclusion: Access to SBHCs was associated with a reduction in the rate of hospitalization and a gain of 3 days of school for schoolchildren who have asthma.

Arch Pediatr Adolesc Med 2003;157:125-129

Heather J. Walter, MD, MPH; Roger D. Vaughan, MS; Bruce Armstrong, DSW; Roberta Y. Krakoff, ACSW; Lorraine Tiezzi, MS; and James F. McCarthy, PhD

Purpose: To compare the demographic, behavioral, psychosocial, and academic characteristics of users vs. non-users of inner city middle school-based health clinics.

Conclusions: Users of these middle school-based health clinics are engaging in behaviors and hold beliefs that place them at risk for serious adverse health outcomes. School-based clinics have the potential to provide essential primary and preventive health care services for these high risk adolescents. Clinic outreach may be necessary to encourage clinic utilization, especially among high-risk students.

Journal of Adolescent Health 1996;Vol.18:344-348

Trina Menden Anglin, MD, PhD; Kelly E. Naylor, PhD; and David W. Kaplan, MD, MPH

Objectives: To explore adolescent students’ use of school-based health and medical care and mental health and substance abuse counseling services and to compare adolescents’ patterns of use of medical, mental health, and substance abuse services located in school-based and traditional settings.

Conclusions: Adolescents attending SBHCs had higher rates of visits for health and medical care than adolescents using traditional sources of medical care. The substance abuse counseling services were commensurate with the estimated prevalences of these problems in this country’s adolescent population. In addition, the mean numbers of visits to mental health counselors in SBHCs compared favorably with adolescent visit rates for mental health services in other settings. Too little information is available about adolescent use of substance abuse services in non-school-based settings to make familiar comparisons. In summary, adolescent users of SBHCs seemed to have higher use of medical, mental health, and probably substance abuse counseling services than did adolescents in the general population. These findings are consistent with the interpretation that SBHCs do enhance adolescents’ access to care for medical, mental health, and substance abuse problems.

Pediatrics 1996;97:318-330

C Rutishauser; A Esslinger; L Bond; and FH Sennhauser

Aim: To study the expectations and experiences of adolescents when in consultation with doctors, particularly with regard to issues of confidentiality.

Conclusion: Physicians should adapt their consultation style to the needs of adolescents by seeing the adolescent patient alone for some time and by assuring them of conditional confidentiality. Furthermore, they should provide opportunities to talk specifically about issues of potential concern to adolescents such as nutrition, drugs and sexuality. To accomplish these tasks, educational curricula in adolescent healthcare are required for physicians.

Acta Paediatr 2003;92:1322-1326

Ellen E. Kisker, Ph.D.; and Randall S. Brown, Ph.D.

Purpose: The purpose of this investigation was to assess the School-Based Adolescent Health Care Program, which provided comprehensive health-related services in 24 school-based health centers.

Conclusions: School-based health centers can increase students' health knowledge and access to health-related services, but more intensive or different services are needed if they are to significantly reduce risk-taking behaviors.

Journal Of Adolescent Health 1996;18:335—343

Robert Wm. Blum, MD, PhD; Trish Beuhring, PhD; Maniio Wunderlich, MD, MPH; and Michael D. Resnick, PhD

Objectives: This study examined the extent to which comprehensive, age-appropriate, adolescent health screening is undertaken in the clinical setting and whether the extent of such screening varies by setting.

Conclusions: Results suggest substantive deficiencies in private practice settings’ implementation of preventive care screening protocols for adolescents.

Am J Public Health 1996;86:1767-1772

Hugh P. Levaux, PhD; Warren H. Schonfeld, PhD; James M. Pellissier, PhD; William M. Cassidy, MD; Sara K. Sheriff; and Catherine Fitzsimoni

Objective: To investigate the economic implications of a 2-dose hepatitis B virus vaccination regimen compared with the current 3-dose vaccination regimen for adolescents in 3 settings: public schools, public health clinics, and private sector settings in the United States.

Conclusions: Improved compliance with a 2-dose regimen would contribute to a higher probability of adolescents’ achieving seroprotection. When the long-term consequences of hepatitis B virus infection are included, the 2-dose regimen would be cost-effective compared with the 3-dose regimen in all settings and cost saving in public health clinic settings.

Pediatrics 2001;108:317–325;

Kimberly Hoagwood, PhD.; and Holly D. Erwin, M.A.

A review of the literature from 1985 to 1995 on school-based mental health services for children was conducted using a computerized data-base search. Of the 5,046 references initially identified, 228 were program evaluations. Three inclusion criteria were applied to those studies: use of random assignment to the intervention; inclusion of a control group; and use of standardized outcome measures. Only 16 studies met these criteria. Three types of interventions were found to have empirical support for their effectiveness, although some of the evidence was mixed: cognitive-behavioral therapy, social skills training, and teacher consultation. The studies are discussed with reference to the sample, targeted problem, implementation, and types of outcomes assessed, using a comprehensive model of outcome domains, called the SFCES model. Future studies of school-based mental health services should (a) investigate the effectiveness of these interventions with a wider range of children's psychiatric disorders; (b) broaden the range of outcomes to include variables related to service placements and family perspectives; (c) examine the combined effectiveness of these empirically-validated interventions; and (d) evaluate the impact of these services when linked to home-based interventions.

Journal of Child and Family Studies 1997;Vol.6,No.4,pp.435-451

Thomas L. Young, MD; and Carol Ireson, RN, PhD

Objective: This study evaluated the quality and cost effectiveness of health care provided in urban and rural elementary school-based telehealth centers, using plain old telephone system (POTS) technology.

Conclusions: Telehealth technology was effective in delivering pediatric acute care to children in these schools. Pediatric providers, nurses, parents, and children reported primary care school-based telehealth as an acceptable alternative to traditional health care delivery systems. The POTS-based technology helps to make this telehealth service a cost-effective alternative for improving access to primary and psychiatric health care for underserved children.

Pediatrics 2003;112:1088 –1094;

Angela Towle; William Godolphin; Samantha Van Staalduinen

Objective: To develop, implement and evaluate a workshop to help adolescents develop independent and active relationships with their physicians.

Conclusion: The workshop is acceptable, do-able, effective and sustainable. The workshop provides a model for providing health care education to adolescents in the community.

Practice implications: Teaching adolescents the importance of good doctor–patient communication encourages them to take ongoing responsibility for their health care and is an alternative route to direct health care education.

Patient Education and Counseling 62 2006;189–192

Keith C. Russell, Ph.D.

Summary: Project DARE (PD) is a continuous intake open custody program for male youth. PD works to develop the attitudes and skills necessary for adjudicated youth to become responsible, accountable law-abiding citizens through an intensive group-based experiential education and wilderness adventure program design. Each youth is referred by a probation officer to a minimum placement term of 45 days, with a preferred placement duration of 120 days. This report presents results of an evaluation of Project DARE that examined three types of rehabilitative outcome: 1) perceptions of the program and process, including what young offenders believed they learned from the experience, 2) changes in their well being utilizing the Youth-Outcome Questionnaire, and 3) rates of re-offending at an average of 16.3 months after release from custody.

Results: Results suggest that the 57 youth study participants indicated a positive attitude towards PD and rated the school program, challenge activities, and relationships with staff as the most important aspects of the program. When asked an open-ended question of what they had learned from PD, four central themes emerged from analysis of their responses: a) Skill Development, such as wilderness expedition and problem-solving skills; b) Sense of Self/Confidence, which referred to an enhanced sense of self confidence from completing difficult challenges; c) Dealing with Frustrations, which referenced newly learned anger management skills; and d) Interpersonal Skills, which referred to learning to live in a community with others. The themes Dealing with Frustrations and Interpersonal Skills were referenced by the majority or participants and reflect two central goals of Project DARE: 1) To help young offenders learn to deal with their anger appropriately and 2) to develop skills that enable them to get along better with others.

Conclusion: PD appears to be an effective intervention to help improve anger management and social skills of young offenders referred to the program. During their stay, a significant improvement in emotional and behavioral well-being was demonstrated as evidenced by significant score reduction on the Y-OQ. However, their discharge scores still reflect youth in need of treatment and further aftercare. Recommendations include increasing resources to help youth transition to family, peer and school/work environments after release from custody, as well as improved aftercare services to help reduce the likelihood of re-offending.

Technical Report 2, Outdoor Behavioral Healthcare Research Cooperative, School of Health and Human Services, University of New Hampshire August 2004

Peter G. Szilagyi, MD, MPH; Jack Zwanziger, PhD; Lance E. Rodewald, MD; Jane L. Holl, MD, MPH; Dana B. Mukamel, PhD; Sarah Trafton, JD; Laura Pollard Shone, MSW; Andrew W. Dick, PhD; Lynne Jarrell, MA, MPA; and Richard F. Raubertas, PhD

Background. The State Child Health Insurance Program (SCHIP) is the largest public investment in child health care in 30 years, targeting 11 million uninsured children, yet little is known about the impact of health insurance on uninsured children. In 1991, New York State implemented Child Health Plus (CHPlus), a health insurance program that became a model for SCHIP.

Objective. To examine changes in access to care, utilization of services, and quality of care among children enrolled in CHPlus.

Conclusions. This statewide health insurance program for low-income children was associated with improved access, utilization, and quality of care, suggesting that SCHIP has the potential to improve health care for low-income American children.

Pediatrics 2000;105:363-371

Peter G. Szilagyi, MD, MPH; Jane L. Holl, MD, MPH; Lance E. Rodewald, MD; Laura Pollard Shone, MSW; Jack Zwanziger, PhD; Dana B. Mukamel, PhD; Sarah Trafton, JD; Andrew W. Dick, PhD; and Richard F. Raubertas, PhD

Background: The legislation and funding of the State Children’s Health Insurance Program (SCHIP) in 1997 resulted in the largest public investment in child health care in 30 years. The program was designed to provide health insurance for the estimated 11 million uninsured children in the United States. In 1991 New York State implemented a state-funded program - Child Health Plus (CHPlus) - intended to provide health insurance for uninsured children who were ineligible for Medicaid. The program became one of the prototypes for SCHIP. This study was designed to measure the association between CHPlus and access to care, utilization of care, quality of care, and health care costs to understand the potential impact of one type of prototype SCHIP program.

Implications: Based on this study of the CHPlus experience, it appears that millions of uninsured children in the United States will benefit substantially from SCHIP programs.

Pediatrics 2000;105:687-691

Jane L. Holl, MD, MPH; Peter G. Szilagyi, MD, MPH; Lance E. Rodewald, MD; Laura Pollard Shone, MSW; Jack Zwanziger, PhD; Dana B. Mukamel, PhD; Sarah Trafton, JD; Andrew W. Dick, PhD; Richard Barth; and Richard F. Raubertas, PhD

Background. The recently enacted State Children’s Health Insurance Program (SCHIP) is modeled after New York State’s Child Health Plus (CHPlus) program. Since 1991, CHPlus has provided health insurance to children 0 to 13 years old whose annual family income was below 222% of the federal poverty level and who were ineligible for Medicaid or did not have equivalent health insurance coverage. CHPlus covered the costs for ambulatory, emergency, and specialty care, and prescriptions, but not inpatient services.

Objectives: To assess the change associated with CHPlus regarding 1) access to health care; 2) utilization of ambulatory, inpatient, and emergency services; 3) quality of health care; and 4) health status.

Conclusion: After enrollment in CHPlus, access to and utilization of primary care increased, continuity of care improved, and many quality of care measures were improved while utilization of emergency and specialty care did not change. Many parents reported improved health status of their child as a result of enrollment in CHPlus.

Implication: This evaluation suggests that SCHIP programs are likely to improve access to, quality of, and participation in primary care significantly and may not be associated with significant changes in specialty or emergency care.

Pediatrics 2000;105:711-718

Kimberly Hoagwood, Ph.D.; Barbara J. Burns, Ph.D.; Laurel Kiser, Ph.D.; Heather Ringeisen, Ph.D.; Sonja K. Schoenwald, Ph.D.

The authors review the status, strength, and quality of evidence-based practice in child and adolescent mental health services. The definitional criteria that have been applied to the evidence base differ considerably across treatments, and these definitions circumscribe the range, depth, and extensionality of the evidence. The authors describe major dimensions that differentiate evidence-based practices for children from those for adults and summarize the status of the scientific literature on a range of service practices. The readiness of the child and adolescent evidence base for large-scale dissemination should be viewed with healthy skepticism until studies of the fit between empirically based treatments and the context of service delivery have been undertaken. Acceleration of the pace at which evidence-based practices can be more readily disseminated will require new models of development of clinical services that consider the practice setting in which the service is ultimately to be delivered.

Psychiatric Services 2001;52:1179–1189

Kenneth R. Ginsburg, MD, MS Ed; Adrian S. Menapace, MSPH; and Gail B. Slap, MD, MS

Objective: To learn from teenagers why they do, or do not, seek preventive health care.

Conclusions: Adolescents know what draws them to services and what offends them. This study documents, in the words of youths, the factors contributing to their decisions to seek care. The results allow health professionals who care for adolescents to consider what they do well and where change may be needed.

Pediatrics 1997;100:922–930

Louise Ann Rohrbach; Christopher L. Ringwalt; Susan T. Ennett; and Amy A. Vincus

Abstract: This paper examines factors associated with the adoption of evidence-based substance use prevention curricula (EBC) in a national sample of school districts. Substance abuse prevention coordinators in public school districts (n 5 1593), which were affiliated with a random sample of schools that served students in grades 5–8, completed a written survey in 1999. Results indicated that 47.5% of districts used at least one EBC in their schools with middle school grades. Substance use prevention coordinators reported they had the greatest input in decisions about curricula. In a multivariate analysis of factors positively associated with district level decisions to adopt evidence-based programs, significant factors included input from a state substance use prevention group, use of information disseminated by the National Institute on Drug Abuse or Center for Substance Abuse Prevention, use of local needs assessment data, consideration of research showing which curricula are effective and allocation of a greater proportion of the coordinator’s time to substance use prevention activities. State and federal agencies should increase their efforts to disseminate information about evidence-based programs, targeting in particular the district substance use prevention coordinator.

Health Education Research 2005;Vol.20 No.5

Peter A. Margolis; Rachel Stevens; W. Clayton Bordley; Jayne Stuart; Christina Harlan; Lynette Keyes-Elstein; and Steve Wisseh

Objective: To improve health outcomes of children, the US Maternal and Child Health Bureau has recommended more effective organization of preventive services within primary care practices and more coordination between practices and community-based agencies. However, applying these recommendations in communities is challenging because they require both more complex systems of care delivery within organizations and more complex interactions between them. To improve the way that preventive health care services are organized and delivered in a community, we designed, implemented, and assessed the impact of a health care system-level approach, which involved addressing multiple care delivery processes, at multiple levels in the community, the practice, and the family. Our objective was to improve the processes of preventive services delivery to all children in a defined geographic community, with particular attention to health outcomes for low-income mothers and infants.

Conclusions: We observed a number of positive effects at all levels of intervention. Policy-level changes at the state and community led to lasting changes in the organization and financing of care, which enabled changes in clinical services to take place. These changes have now been expanded beyond this community to other communities in the state. We were also able to engage multiple practice organizations, reduce duplication, and improve the coordination of care. Changes in the process of preventive services delivery were noted in participating practices. Finally, the outcomes of the family-level intervention were comparable in direction and magnitude to the outcomes of previous randomized trials of the intervention. All the changes were achieved over a relatively brief 3-year study period, and many have been sustained since the project was completed. Tiered, interrelated interventions directed at an entire population of mothers and children hold promise to improve the effectiveness and outcomes of health care for families and children.

Pediatrics Sept.2001;Vol.108,No.3, p.42

K. Schwarz; B. Garrett; J. Lamoreux; YD. Bowser; C. Weinbaum; and M. J. Alter

Objective: To investigate the hepatitis B vaccination rate in homeless children 2 to 18 years old living in Baltimore City. Methods: During a 21-month period, 250 children from homeless shelters were enrolled.

Conclusions: Hepatitis B vaccine coverage is high in homeless children up to 9 years of age, whereas the majority of homeless children 10 years of age and older are unprotected against hepatitis B virus† infection. Tracking the vaccine records in homeless children is labor intensive. Better public health strategies to deliver hepatitis B vaccine to older homeless children are urgently needed.

Journal of Pediatric Gastroenterology and Nutrition Aug.2005;41:225-229

Ruhul Amin, PhD; and Takanori Sato

Context: In response to multiple problems faced by pregnant or parenting teens, or both, many alternative school-based comprehensive programs have been established to provide the teens with multiple services. However, few of these programs have been evaluated to assess their impact on the teens. In this study, we have made a systematic evaluation of such a school-based comprehensive program—the Paquin School Program in Baltimore City—to assess its impact on contraceptive use, future contraceptive intention, and desire for more children. We used data collected from a sample of 371 pregnant and parenting teens who attended the Paquin School Program between 1999 and 2001, and from a sample of 506 comparable teens, who did not attend the Program.

Conclusions: Our findings showed that the percentages of the Paquin School enrollees who were using contraceptives or who expressed intention to use contraceptives in the future were higher than those of their counterpart nonenrollees from the comparison schools. The findings also showed that the use of Depo-Provera and desire for no more children were higher among the Paquin School enrollees than among the enrollees from the comparison schools. Because the Paquin School enrollees self-selected into its program, some unobserved differences between them and their counterpart nonenrollees might have affected the outcomes of this article. However, the consistent patterns of positive outcomes for the Paquin School enrollees with regard to contraceptive use, future intention to use contraceptives, and desire for no more children, compared to those from the comparison schools, seem to suggest that the Paquin School’s alternative comprehensive program has been successful in its effort to promote family planning. One possible reason for this success of the effort to promote family planning is its integration with the multiple services of the comprehensive program of the Paquin School that enables its teens to plan their fertility.

Journal Of Community Health Nursing 2004;21(1),39–47

Peter G. Szilagyi, MD, MPH; Andrew W. Dick, PhD; Jonathan D. Klein, MD, MPH; Laura P. Shone, MSW, DrPH; Jack Zwanziger, PhD; and Thomas McInerny, MD

Background: Although many studies have noted that uninsured children have poorer access and quality of health care than do insured children, few studies have been able to demonstrate the direct benefits of providing health insurance to previously uninsured children. The State Children’s Health Insurance Program (SCHIP), enacted as Title XXI of the Social Security Act, was intended to improve insurance coverage and access to health care for low-income, uninsured children. With limited state and federal resources for health care, continued funding of SCHIP requires demonstration of success of the program. As yet, little is known about the effectiveness of SCHIP on improving access and quality of care to enrollees.

Objectives: To measure the impact of the New York State (NYS) SCHIP on access, utilization, and quality of health services for enrolled children.

Conclusions: Enrollment in the NYS SCHIP was associated with 1) improved access, continuity, and quality of care and 2) a change in the pattern of health care, with a greater proportion of care taking place within the usual source of primary care.

Pediatrics 2004;113:e395-404.

Maria T. Britto, M.D., M.P.H.; Brenda K. Klostermann, Ph.D.; Andrea E. Bonny, M.D.; Shari A. Altum, M.A.; and Richard W. Hornung, Ph.D.

Purpose: To determine whether a multidimensional school-based intervention, which included physical and mental health services, increased adolescents’ use of needed medical care and preventive care and decreased emergency room use.

Conclusion: These results confirm that many adolescents have unmet healthcare needs. Those with poor health status are most likely to report underutilization and unmet needs. These findings underscore the need for comparison groups when evaluating interventions and suggest the need for better understanding of community level changes in perceived healthcare access and use.

Journal Of Adolescent Health 2001;29:116-124

By Mark A. Schuster; Robert M. Bell; Sandra H. Berry; and David E. Kanouse

Context: While making condoms available in high schools has provoked much debate, evidence on the actual effects of such programs on students’ attitudes and behavior is sparse.

Conclusions: The condom availability program appears not to have produced an increase in sexual activity among high school students, and it appears to have led to improved condom use among males. The apparent strong effect on students’ intention to use condoms and on males’ use at first vaginal intercourse suggests that such programs may have a particular impact on the least sexually experienced adolescents.

Family Planning Perspectives 1998;30(2):67–72 &88

Phyllis L. Ellickson, PhD; Daniel F. McCaffrey, PhD; Bonnie Ghosh-Dastidar, PhD; and Douglas L. Longshore, PhD

Objectives: We evaluated the revised Project ALERT drug prevention program across a wide variety of Midwestern schools and communities.

Conclusions: School-based drug prevention programs can prevent occasional and more serious drug use, help low- to high-risk adolescents, and be effective in diverse school environments.

Am J Public Health 2003;93:1830-1836

Lorraine Tiezzi; Judy Lipshutz; Neysa Wrobleski; Roger D. Vaughan; and James F. McCarthy

Abstract: Data from a pregnancy prevention program operating through school-based clinics in four New York City junior high schools suggest that an intensive risk-identification and case-management approach may be effective among very young adolescents. Among students given a referral to a family planning clinic for contraception, the proportion who visited the clinic and obtained a method rose from 11% in the year before the program began to 76% in the program's third year. Pregnancy rates among teenagers younger than 15 decreased by 34% over four years in the program schools. In the fourth year of the program, the pregnancy rate in one school that was unable to continue the program was almost three times the average rate for the other three schools (16.5 pregnancies per 1,000 female students vs. 5.8 per 1,000).

Family Planning Perspectives July/Aug.1997;v29,n4, pp.173-176,197

Janice D. Key, M.D.; E. Camille Washington, M.D.; and Thomas C. Hulsey, M.S.P.H., Sc.D.

Purpose: To evaluate the change in emergency department utilization before and after enrollment in a school-based clinic (SBC).

Conclusions: Accessible, prevention-oriented health care provided in a SBC can decrease the utilization of episodic health care in an emergency department.

Journal Of Adolescent Health 2002;30:273-278

John S. Santelli, M.D.; M.P.H., Robert J. Nystrom, M.A.; Claire Brindis, Dr.PH.; Linda Juszczak, D.N.Sc., M.P.H., Cpnp; Jonathan D. Klein, M.D., M.P.H.; Nancy Bearss, M.P.H.; David W. Kaplan, M.D., M.P.H.; Margaret Hudson, M.P.H.; and John Schlitt, M.S.W.

Purpose: To describe the state of reproductive health services, including access to contraception and health center policies, among school-based health centers (SBHCs) serving adolescents in the United States.

Conclusions: SBHCs provide a broad range of reproductive health services directly or via referral; however, they often face institutional and logistical barriers to providing recommended reproductive health care.

Journal of Adolescent Health 2003;32:443-451

Heather J. Walter, MD, MPH; Roger D. Vaughan, MS; Bruce Armstrong, DSW; Roberta Y. Krakoff, ACSW; Lorraine Tiezzi, MS; and James F. McCarthy, PhD

Objective: To describe the utilization of school-based health care services by urban minority middle school students. Conclusions: Middle school-based clinics can provide a wide range of primary and preventive health care services for large numbers of medically underserved youths. The provision of mental health services may fill a critical need among inner city adolescents. Clinic outreach may be necessary to maximize utilization, especially among high-risk students.

Pediatric Adolescent Medicine Nov.1995;Vol. 149:1221-1225

Claire D. Brindis, Dr.PH.; Jonathan Klein, M.D., M.P.H.; John Schlitt, M.S.W.; John Santelli, M.D., M.P.H.; Linda Juszczak, D.N.Sc., M.P.H; and Robert J. Nystrom, M.A.

Purpose: To examine the current experience of school-based health centers (SBHCs) in meeting the needs of children and adolescents, changes over time in services provided and program sponsorship, and program adaptations to the changing medical marketplace.

Methods: Information for the 1998-1999 Census of School-Based Health Centers was collected through a questionnaire mailed to health centers in December 1998. A total of 806 SBHCs operating in schools or on school property responded, representing a 70% response rate. Descriptive statistics and cross-tab analyses were conducted.

Conclusions: SBHCs have demonstrated leadership by implementing medical standards of care and providing accountable sources of health care. Although the SBHC model is responsive to local community needs, centers provide care for only 2% of children enrolled in U.S. schools. A lack of stable financing streams continues to challenge sustainability. As communities seek to meet the needs of this population, they are learning important lessons about providing acceptable, accessible, and comprehensive services and about implementing quality assurance mechanisms.

Journal Of Adolescent Health 2003;32S:98-107

Bonnie Gance-Cleveland, PhD, PNP, RNC; Deborah K. Costin, MA; Julie A.K. Degenstein, RN, BSN

School-based health centers have been proposed as an avenue to provide health care for vulnerable youth. Colorado has 45 school-based health centers that provided 50,000 visits to 18,600 vulnerable youth in the 1998–1999 school year. Sustainability of the centers, however, depends on the ability to obtain an ongoing stream of revenue including managed care contracts, which in turn depend on the center’s ability to meet the standard of care in the community. School-based health centers should meet standards of care similar to those of community health centers including certification, credentialing of providers, and a systematic evaluation of the outcomes of services. This article reports on a statewide quality improvement program that established certification standards for school-based health centers, verified the credentials of providers at the centers, and measured quality of care in centers across the state.

J Nurs Care Qual Vol.18,No.4,pp.288–294

Michael B. Brown; and Larry M. Bolen

School-based health centers are fast becoming a part of mainstream health care in the United States. The centers provide enhanced access to comprehensive physical and mental health services for children and families. Although originally established in urban areas, they can also have a significant impact on service delivery for children in rural and suburban areas. This manuscript describes the role and primary functions of school-based health centers, describes several important issues in developing and implementing the centers, and reviews the effectiveness of services provided through school-based health centers. School psychologists are in an excellent position to provide leadership for the establishment of school-based health centers. Participation in school-based health services delivery enables school psychologists to expand their role and broadens both their client population and the range of services.

Psychology in the Schools 2003;Vol. 40(3)

Michael J. Mason, PhD

Abstract: A review of school-based health clinics is provided with special attention to the role of mental health services. An historical account of the development of school-based health clinics is delineated as well as a description of school-based health clinics’ purpose and unique role in providing health care for children and adolescents. Critical policy issues are reviewed, such as managed care’s role in the school-based health clinics, research issues, and funding concerns.

Journal of Health & Social Policy 1998;Vol.10(2)

Joy G. Dryfoos

Abstract: In the last three years, comprehensive school-based clinics have proliferated throughout the United States: There are currently 138 clinics in 30 states and the District of Columbia, and at least 65 more are in the planning stage. Clinic programs differ widely in their organizational structure, operating costs, range of services and funding sources. Although some clinics are funded by private foundations, increasingly, programs are being initiated by local public health departments supported by state funds. Only 10-25 percent of all clinic visits are for family planning services. While all of the clinics provide counseling on family planning, most of the state-funded clinics either prohibit the use of funds for contraceptive supplies and abortion referral or allow grantees to decide what to do about the issue of pregnancy prevention. To date, no study has found that rates of sexual activity increase among students who participate in clinic programs. There is some evidence indicating that participation in school-based clinics may have a positive impact on contraceptive practice.

Family Planning Perspectives Jul.-Aug.1988;Vol.20,No.4,pp.193-196+198-200

Lois T. Flaherty; and Mark D. Weist

Through a variety of state and local funding and administrative arrangements, expanded school mental health (ESMH) programs have been developed in nearly half of the 176 Baltimore City schools over the past decade. These programs augment existing services provided by the school and help to ensure that a comprehensive range of services (assessment, prevention, case management, treatment) are available to youth in special and regular education. Baltimore’s leadership in the emerging ESMH field led to the development of the Center for School Mental Health Assistance (CSMHA), one of two national centers that provide support and technical assistance to promote comprehensive mental health programs for youth in schools. This paper shares experiences associated with the growth of ESMH programs in Baltimore and activities and initiatives of the CSMHA.

Psychology in the Schools 1999;Vol.36(5)

John Santelli, M.D., M.P.H.; Madlyn Morreale, M.P.H.; Alyssa Wigton, M.H.S.; and Holly Grason, M.A.

The purpose of this review was to assist policy makers, program managers, SHC clinicians, and researchers in assessing the ability of SHCs to meet the primary care needs of adolescents.

Journal Of Adolescenth Health Vol.18,No. 5

Douglas Kirby; Cynthia Waszak, Julie Ziegler

Abstract: An evaluation of the reproductive health programs of six diverse school-based clinics measured the impact of the clinics on sexual behavior and contraceptive use. All six clinics served low-income populations; at five of them, the great majority of the students served were black. An analysis of student visits by type of care given found that these clinics were not primarily family planning facilities; rather, they provided reproductive health care as one component of a comprehensive health program. Student survey data collected in the clinic schools and nearby comparison schools (four sites) or collected both before the clinic opened and two years later (two sites) indicated that the clinics neither hastened the onset of sexual activity nor increased its frequency. The clinics had varying effects on contraceptive use. Providing contraceptives on site was not enough to significantly increase their use; in only one of the three sites that did so were students in the clinic school significantly more likely than students in the comparison school to have used birth control during last intercourse. However, condom use rose sharply at one clinic school that had a strong AIDS education program and was located in a community where AIDS was a salient issue. At another clinic school, where pregnancy prevention was a high priority and staff issued vouchers for contraceptives, the use of condoms and pills was significantly higher than in the comparison school. A third clinic school--which focused on high-risk youth, emphasized pregnancy prevention and dispensed birth control pills--recorded a significantly higher use of pills than its comparison school. Although the data suggest that the clinics probably prevented small numbers of pregnancies at some schools, none of the clinics had a statistically significant effect on school-wide pregnancy rates.

Family Planning Perspectives Jan.-Feb.1991;Vol.23,No.1,pp. 6-16

Allison Gruner Gandhi; Erin Murphy-Graham; Anthony Petrosino; Sara Schwartz Chrismer; Carol H. Weiss

In an effort to promote evidence-based practice, government officials, researchers, and program developers have developed lists of model programs in the prevention field. This article reviews the evidence used by seven best practice lists to select five model prevention programs. The authors’ examination of this research raises questions about the process used to identify and publicize programs as successful. They found limited evidence showing substantial impact on drug use behavior at post-test, with very few studies showing substantial impact at longer follow-ups. The authors advocate additional long-term follow-up studies and conclude by suggesting changes in the procedures for developing best-practice lists.

Evaluation Review Volume 31 Number 1 Feb.2007;43-74

Douglas Kirby; Michael D. Resnick; Blake Downes; Thel Kocher; Paul Gunderson; Sandra Pothoff; Daniel Zelterman; Robert Blum

Abstract: School-based clinics in St. Paul have provided comprehensive health services, including reproductive health care, for almost two decades. This study examines the effects of those clinics on the birthrates in their respective schools, using a newly developed methodology with numerous advantages over previous methods for estimating student birthrates. Confidentially matching the names of female students from school records with the names of mothers on birth records at the Department of Health provided birthrates for each of the St. Paul public high schools with clinics for each year between 1971 and 1986. The results show that birthrates fluctuated dramatically from one year to the next, but school-wide birthrates were not significantly lower in the years immediately following the opening of a clinic than in the years preceding it.

Family Planning Perspectives Jan.-Feb.1993;Vol.25,No.1,pp. 12-16

Claire Brindis, Dr. PH.; Cynthia Kapphahn, M.D., M.P.H.; Virginia McCarter, Ph.D. and Amy L. Wolfe, M.P.H.

Purpose: 1) To examine variations among students with different health insurance coverage in their use of school-based clinics (SBCs), reasons for not receiving health care when needed, and reasons for using or not using SBCs, and 2) to determine if insurance status is a significant factor in predicting SBC use, after controlling for demographic variables and health status.

Conclusions: SBC users represent a variety of insurance groups. Health care reform efforts need to take into account the special needs of adolescents and the challenges they face in accessing care that go beyond financial barriers to care. SBC have been shown to provide a convenient and acceptable source of care, as well as offering the opportunity to provide preventive and primary care services to at-risk youth.

Journal Of Adolescent Health 1995;16:18-25

Kate Fothergill M.P.H.; and Elisa Ballard, M.A.

Purpose: To examine the nature of the linkages between school-linked health centers (SLHCs) and schools; the centers’ services, staffing, financing, and other operational details; and the advantages of this model of care.

Conclusions: The report describes a community-based model of care that is designed to provide affordable, age-appropriate, confidential, convenient care to adolescents, a population that traditionally has been very hard to reach. The SLHC’s ability to provide reproductive health care makes it an attractive option for communities trying to prevent pregnancy and sexually transmitted diseases among adolescents. To firmly conclude that the SLHC is an effective model for improving adolescent access to services, more research is needed on adolescents’ use and nonuse of SLHCs and other models of care; the cost of SLHCs compared to other models of care; and how SLHCs can sustain themselves financially, particularly in a managed care environment.

Journal Of Adolescent Health 1998;23:29–38

R. Nat Natarajan

Purpose: The purpose of this paper is to analyze the opportunities and challenges in the healthcare sector for learning and transferring from other sectors the concepts, best practices, and tools for improving quality, safety, and productivity.

Design/methodology/approach: In this paper, the various approaches for improving quality, safety, and productivity are considered. How these approaches are being used in healthcare are analyzed. The obstacles to their successful implementation in healthcare are discussed.

Findings: The paper finds that there are many approaches, best practices, tools, and technologies for improving quality and safety which have proved their worth in other industries that are relevant for the healthcare sector. There are some characteristics of the healthcare industry that distinguish it from other industries. Although the managerial processes in the healthcare industry are similar to those of other industries, the prevalent norms, culture, practices, and the regulatory framework can promote or hinder efforts to improve performance. These characteristics influence the extent to which the best practices in other industries are relevant and transferable to the healthcare sector.

Originality/value: In this paper, prospects for utilizing the opportunities are assessed. The paper identifies a number of obstacles to the transfer of best practices to the healthcare sector. Insights are provided into factors that are critical to addressing those obstacles. These are of value to the practitioners in healthcare and to the academics, who want to pursue further research on this topic.

The TQM Magazine 2006;Vol.18,No.6,pp.572-582

Linda Juszczak, D.N.Sc., M.P.H.; Paul Melinkovich, M.D.; and David Kaplan, M.D., M.P.H.

Purpose: To assess the role that school-based health centers (SBHCs) play in facilitating access to care among low-income adolescents and the extent to which SBHCs and a community health center network (CHN) provide similar or complementary care.

Conclusions: This study supports the view that SBHCs provide complementary services. It also shows their unique role in improving utilization of mental health services by hard-to-reach populations. The extent to which community health centers and other health care providers, including managed care organizations, can build on the unique contributions of SBHCS may positively influence access and quality of care for adolescents in the future.

Journal Of Adolescent Health 2003;32S:108-118

Amitai Ziv, MD; Jack R. Boulet, PhD; and Gail B. Slap, MD

Recent guidelines for adolescent primary care call for the specification of clinical services by three adolescent age subgroups. Yet analyses of office visits have either merged adolescence into one stage or divided it at age 15 years.

Objective: To explore the utilization of physician offices in the United States by early (11-14 years), middle (15-17 years), and late (18-21 years) adolescents.

Conclusions: Adolescents underutilize physician offices and are more likely to be uninsured than any other age group. Visits are short, and counseling is not a uniform component of care. As adolescents mature, their providers, presenting problems, and resulting diagnoses change. The data from the National Ambulatory Medical Care Survey support a staged approach to adolescent preventive services, targeted to the needs of three age subgroups.

Pediatrics 1999;104:35ñ-42;
The Answer Is at School: Bringing Health Care to Our Students
Children's Mental Health: Current Challenges and a Future Direction
From the Margins to the Mainstream: Institutionalizing School-Based Health Centers
Issues in Financing School-Based Health Centers: A Guide for State Officials
Medicaid, Managed Care, and School-Based Health Centers: Proceedings of a Meeting with Policy Makers and Providers
Minors and the Right to Consent to Health Care
National Survey of State School-Based Health Center Initiatives: School Year 1995-96
Nine State Strategies to Support SBHCs - Executive Summary
The Picture of Health: State and Community Leaders on School-Based Health Care
Public Relations As a Catalyst for School-Based Healthcare
School-Based Health Centers: Surviving A Difficult Economy
School-Based Health Centers and Managed Care: Seven School-Based Health Center Programs Forge New Relationships
School-Based Services and Adolescent Health: Past, Present, and Future
State Initiatives to Support School-Based Health Centers: A National Survey
State Policy Context for School-Based Health Centers, with special focus on the development of mental health and dental health services, 2001
Student-Friendly Care: The case for school-based health centers by Nina Hurwitz and Sol Hurwitz

25 Years of School-Based Health Centers
JAMA March 3,1999;281:781-785
A Comparison Study of an Elementary School-Based Health Center: Effects on Health Care Access and Use
Arch Pediatr Adolesc Med Mar.1999;153: 235-243
School-Based Health Center Utilization: A Survey of Users and Nonusers
Arch Pediatr Adolesc Med Aug.1998;152:763-767
Economic Evaluation of a Metropolitan-Wide, School-Based Hepatitis B Vaccination Program
Public Health Nursing Vol.17No.3,pp.222-227
Managed Care and School-Based Health Centers: Use of Health Services
Arch Pediatr Adolesc Med Jan.1998;152:25-33
The Growth of School-Based Health Centers and the Role of State Policies: Results of a National Survey
Arch Pediatr Adolesc Med Nov.1999;153:1177-1180
Health Status and Service Use: Comparison of Adolescents at a School-Based Health Clinic With Homeless Adolescents
Arch Pediatr Adolesc Med Jan.1998;152 20-24
The Health of Latino Children: Urgent Priorities, Unanswered Questions, and a Research Agenda
JAMA Jul.2002;288:82-90
Foregone Health Care Among Adolescents
JAMA Dec.1999;282:2227-2234
Searching for the “Ideal” Adolescent Healthcare Visit
Adv Stud Med Feb.2004;4(2B):S142-S148
Managing the Complexity of Best Practice Health Care
Journ Nurs Care Qual 2001;15(2):1-8


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