Wednesday, November 13, 2013

Health Risks, Race, and Adolescents’ Use of School-Based Health Centers: Policy and Service Recommendations

School-based health centers (SBHCs) have been implemented in many educational sites to address the health and behavioral health needs of students, especially in low-income communities of color where high rates of unmet needs stem from various barriers (e.g., social, economic, geographic)1. Previous research has shown there are racial differences in SBHC access with Black and Latino students being overrepresented and White and Asian students being underrepresented.2,3 Though some researchers suggest disparities in unmet needs explains these patterns of use4-8, others have found that racial differences continue after controlling for need severity, and both youth and caregiver characteristics8-15. The underrepresentation of Asian youth is particularly perplexing given research findings that this youth group’s needs are not being met by other service providers in the community16. Using a multi-level social-ecological framework, authors Anyon, Moore, Horevitz, Whitaker, Stone, and Shields explore SBHC use both by health risk and racial group, paying particular attention to Asian youth.

Methods and Sample

The authors analyzed data from the 2007 Youth Risk Behavior Survey (YRBS) administered in San Francisco. This anonymous survey, administered through the Center for Disease Control’s Youth Risk Behavior Surveillance System, was administered to random sample of high schools in the district. Though the local school district has 15 schools with SBHCs, due to this random sampling, only nine of the SBHC schools were included. The final sample of students (N=1700) included participants from schools with and without SBHCs.

Independent Variables
  •  Race: 56.7% Asian, 17.7% Latino, 8.8% White, 5.6% Black, 11.3% multiracial
  •  Health risks:
    • 30.6% reported sexual activity (lifetime)
    • 35.9% reported symptoms of depression or suicidality (past 12 months)
    • 61.8% reported marijuana, alcohol, or cigarette use (lifetime)
    • 24.9% reported having asthma
  • Gender: 50.3% male, 49.7% female
  • Family structure: 70.6% live with both parents, 29.4% other living arrangement
  • Grade level: 27.7% 9th grade, 22.8% 10th grade, 21.8% 11th grade, 27.6% 12th grade
  • Grades: 32% mostly A’s, 38.7%, mostly B’s, 20.9%, mostly C’s, 5.5% mostly D’s, 2.9% mostly F’s
  • Preference for English language: 94.7% took survey in English, 5.3% took survey in another language
Dependent Variable
  • SBHC Use: 40% visited at least once in the past year

The results indicate that students with health and behavioral health needs are accessing SBHC services, which suggests that SBHCs are effective in responding to adolescents who experience depressive symptoms, use substances, and engage in sexual activity. When controlling for health risks and demographic covariates, however, findings indicate racial disparities exist. Consistent with the authors’ prediction, Asian students were less likely to access SBHC services than their Black and Latino peers.


Anyon and colleagues suggest that, despite research showing Asian youth typically experience lower levels of health risks than Black and Latino youth, the present study indicates that cultural or contextual factors around race may impact SBHC utilization beyond just health risks.17,18 This may be due to cultural norms against help-seeking behavior, lack of appropriate programming (e.g., culturally, linguistically), or how referrals are made. In terms of the latter, the authors suggest that the “model minority” stereotype may be dissuading adults in the school from making SBHC referrals for Asian students. Given this, the authors suggest schools with SBHCs address both the unique needs of Asian students as well as potential barriers to their service utilization. Specifically, training staff on how to identify health risks among Asian students, tailoring programming to be more culturally specific, and decreasing the language barrier between Asian students and SBHC staff may be impactful in addressing Asian students’ underutilization of SBHCs.18

For More Information
The full article is located in The Journal of Behavioral Health Services & Research (Volume 40, Issue 4). You can learn more about Dr. Anyon and her work on her faculty page and her DU portfolio.

Anyon, Y., Moore, M., Horevitz, E., Whitaker, K., Stone, S., & Shields, J.P. (2013). Health risks, race, and adolescents’ use of school-based health centers: Policy and service recommendations. The Journal of Behavioral Health Services & Research, 40(4), 457-468.

1 Brindis, C.D., Klein, J., Schlitt, J., Santelli, J., Juszczak, L., & Nystrom, R.J. (2003). School-based health centers: Accessibility and accountability. Journal of Adolescent Health, 32(6), 98-107. doi: 10.1016/S1054-139X(03)00069-7
2 Amaral, G., Geierstanger, S., Soleimanpour, S., & Brindis, C. (2011). Mental health characteristics and health-seeking behaviors of adolescent school-based health center users and nonusers. Journal of School Health, 81(3). 138-145. doi: 10.1111/j.1746-1561.2010.00572.x
3 Walker, S.C., Kerns, S.E.U., Lyon, A.R., Bruns, E.J., & Cosgrove, T.J. (2010). Impact of school-based health center use on academic outcomes. Journal of Adolescent Health, 46(3), 251-257. doi: 10.1016/j.jadohealth.2009.07.002
4 Slade, E.P. (2003). The relationship between school characteristics and the availability of mental health and related health services in middle and high schools in the United States. The Journal of Behavioral Health Services and Research, 30(4), 382-392. doi: 10.1007/BF02287426
5 Sturm, R., Ringel, J., & Andreyeva, T. (2003). Geographic disparities in children’s mental health care. Pediatrics, 111(4), 308-315. doi: 10.1542/peds.112.4.e308
6 Glied, S., Hoven, C.W., Moore, R.E., Garrett, A.B., & Regier, D.A. (1997). Children’s access to mental health care: Does insurance matter? Health Affairs, 16(1), 167-174. doi: 10.1377/hlthaff.16.1.167
7 Burns, B.J., Costello, E.J., Erkanli, A., Tweed, D.L., Farmer, E.M.Z., & Angold, A. (1997). Insurance coverage and mental health service use by adolescents with serious emotional disturbance. Journal of Child and Family Studies, 6(1), 89-111.
8 Burns, B.J., Costello, E.J., Angold, A., Tweed, D., Stangl, D., Farmer, E.M., & Erkanli, A. (1995). DataWatch: Children’s mental health service use across service sectors. Health Affairs, 14(3), 147-159. doi: 10.1377/hlthaff.14.3.147
9 Zimmerman, F.J. (2005). Social and economic determinants of disparities in professional help-seeking for child mental health problems: Evidence form a national sample. Health Services Research, 40(5), 1514-1533. doi: 10.1111/j.1475-6773.2005.00411.x
10 Wu, P., Hoven, C.W., Bird, H.R., Moore, R.E., Cohen, P., Alegria, M., Dulcan, M.K., Goodman, S.H., Horwitz, S.M., Lichtman, J.H., Narrow, W.E., Rae, D.S., Regier, D.A., & Roper, M.T. (1999). Depressive and disruptive disorders and mental health service utilization in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 38(9), 1081-1090. doi: 10.1097/00004583-199909000-00010
11 Elster, A., Jarosik, J., VanGeest, J., & Fleming, M. (2003). Racial and ethnic disparities in health care for adolescents: A systematic review of the literature. Archives of Pediatric and Adolescent Medicine, 157(9), 867-874. doi: 10.1001/archpedi.157.9.867
12 Bui, K., & Takeuchi, D. (1992). Ethnic minority adolescents and the use of community mental health care service. American Journal of Community Psychology, 20(4), 403-417. doi: 10.1007/BF00937752
13 McCabe, K., Yeh, M., Hough, R.L., Landsverk, J., Hurlburt, M.S., Culver, S.W., & Reynolds, B. (1999). Racial/ethnic variations across five public systems of care for youth. Journal of Emotional and Behavioral Disorders, 7(2), 72-82. doi: 10.1177/106342669900700202
14 Cuffe, S.P., Waller, J.L., Addy, C.L., McKeown, R.E., Jackson, K.L., Moloo, J., & Garrison, C.Z. (2001). A longitudinal study of adolescent mental health service use. Journal of Behavioral Health Services & Research, 28(1), 1-11. doi: 10.1007/BF02287230
15 Kataoka, S.H., Zhang, L., & Wells, K.B. (2002). Unmet need for mental health care among U.S. children: Variation by ethnicity and insurance status. The American Journal of Psychiatry, 159(9), 1548-1555. doi: 10.1176/appi.ajp.159.9.1548
16 Garland, A.F., Lau, A.S., Yeh, M., McCabe, K.M., Hough, R.L., & Landsverk, J.A. (2005). Racial and ethnic differences in utilization of mental health services among high-risk youths. American Journal of Psychiatry, 162(7), 1336-1336. doi: 10.1176/appi.ajp.162.7.1336
17 Grunbaum, J., Lowry, R., Kann, L., & Pateman, B. (2000). Prevalence of health risk behaviors among Asian American/Pacific Islander high school students. Journal of Adolescent Health, 27(5), 322-330. doi: 10.1016/S1054-139X(00)00093-8
18 Anyon, Y., Whitaker, K., Shields, J.P., & Franks, H. (2013). Help-seeking in the school context: Understanding Chinese American adolescents’ underutilization of school health services. Journal of School Health, 83(8), 562-572. doi: 10.1111/josh.12066

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