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• Published: 17 November 2017

Improving access to school health services as perceived by school professionals

• Janine Bezem   ORCID: orcid.org/0000-0002-0553-6547 1 , 2 ,
• Debbie Heinen 1 ,
• Ria Reis 3 ,
• Simone E. Buitendijk 4 ,
• Mattijs E. Numans 3 &
• Paul L. Kocken 2  

BMC Health Services Research volume  17 , Article number:  743 ( 2017 ) Cite this article

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The organisation of health assessments by preventive health services focusing on children’s health and educational performance needs to be improved due to evolving health priorities such as mental health problems, reduced budgets and shortages of physicians and nurses. We studied the impact on the school professionals’ perception of access to school health services (SHS) when a triage approach was used for population-based health assessments in primary schools. The triage approach involves pre-assessments by SHS assistants, with only those children in need of follow-up being assessed by a physician or nurse. The triage approach was compared with the usual approach in which all children are assessed by physicians and nurses.

We conducted a cross-sectional study, comparing school professionals’ perceptions of the triage and the usual approach to SHS. The randomly selected school professionals completed digital questionnaires about contact frequency, the approachability of SHS and the appropriateness of support from SHS. School care coordinators and teachers were invited to participate in the study, resulting in a response of 444 (35.7%) professionals from schools working with the triage approach and 320 (44.6%) professionals working with the usual approach.

Respondents from schools using the triage approach had more contacts with SHS and were more satisfied with the appropriateness of support from SHS than respondents in the approach-as-usual group. No significant differences were found between the two groups in terms of the perceived approachability of SHS.

Conclusions

School professionals were more positive about access to SHS when a triage approach to routine assessments was in place than when the usual approach was used. Countries with similar population-based SHS systems could benefit from a triage approach which gives physicians and nurses more opportunities to attend schools for consultations and assessments of children on demand.

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Cognitive performance and educational achievements in children benefit from good health and health-related behaviours [ 1 , 2 ]. The integration of preventive health services in the education system helps to detect health problems in school children and furthers early interventions intended to improve health and, therefore, cognitive outcomes [ 3 , 4 , 5 , 6 , 7 ]. Health services available in schools (School Health Services, SHS) include prevention, early detection and intervention in the area of school children’s physical, social and - increasingly - mental health [ 3 , 4 ].

Research shows that equal access to SHS and SHS quality need to be improved for all groups of children. Furthermore, SHS should be tailored to health priorities such as overweight and mental health [ 4 , 8 , 9 ]. Health system issues relating to staff shortages in SHS, high workloads and inadequate demarcation of the position and responsibilities of SHS in educational institutions need to be addressed [ 4 , 10 ].

These health system issues have challenged SHS to find innovative models which allow an efficient delivery of health services to school age children. In the Netherlands, community-based SHS professionals usually visit schools a few times a year to carry out routine assessments based on a pre-defined age schedule in which children between the ages of four and eighteen receive four routine health assessments from SHS physicians and nurses, sometimes supported by SHS assistants.

Physicians conduct the assessment in the youngest age group. Nurses conduct the assessments for older age groups, an approach that is also common in many other countries. The SHS delivers services free of charge. Interdisciplinary collaboration between professionals in the health-care and educational systems is organised in both approaches in multi-disciplinary school-based networks based on shared competencies, roles and responsibilities.

A novel approach was developed to conduct the routine health assessments based on triage and task-shifting among SHS professionals [ 11 ]. In this two-step triage procedure, pre-assessments were delegated to SHS assistants who had received specific training. Only children in need of follow-up were assessed by a SHS physician or nurse, which led to less involvement of physicians and nurses in the routine assessments. This created time for physicians and nurses to visit schools regularly and provide additional consultations that were tailored to children’s specific needs in response to requests from school professionals, parents and children themselves.

Triage and the shifting of tasks between health-care professionals have been used primarily in primary health care and emergency health-care services worldwide. Research shows that triage and task-shifting have several benefits: the optimal use of the skills and expertise of health-care professionals, reduced workloads for physicians and nurses, improved access to health care and greater patient satisfaction [ 12 , 13 , 14 , 15 ]. A pilot study examining the triage approach in SHS showed equal attendance levels of about 90% for health assessments in a comparison of the triage and usual approaches. Fewer children were referred for extra assessment by SHS or for treatment by external health services in the triage approach [ 11 ]. Another study showed that routine health assessments in a triage approach seemed to detect health problems as effectively as the usual approach [ 16 ].

The aim of this study was to explore how school professionals in primary schools experience access to population-based SHS systems when a triage approach is used for routine health assessments. We compared these perceptions with those of school professionals working with the usual SHS approach. In this study, school professionals are primary school teachers and care coordinators. The latter are teachers who also support children with specific needs.

We studied the views of school professionals about access to SHS because we know accessibility affects health service utilisation, consumer satisfaction and the quality of care [ 17 , 18 , 19 , 20 ]. Accessibility factors relating to health services include approachability, acceptability, availability, affordability and appropriateness of care [ 19 ]. The triage system specifically targeted the improvement of two aspects of access to preventive health services: approachability and the appropriateness of care. ‘Approachability’ refers to consumers’ ability to gain access to the service and to identify the existence of some form of service, and the terms also refers to the fact that a service can be reached, and the fact that it has an impact on health. ‘Appropriateness’ of care relates to the adequacy of the health services provided and this is linked to the willingness to use the services [ 19 ]. Acceptability, availability and affordability are less relevant for preventive services like SHS, which should be offered to whole populations of children proactively. This manuscript addresses the following research question: what is the impact on the school professionals’ perception of the approachability and appropriateness of SHS support for primary-school children when the triage approach is used rather than the usual approach?

We conducted a cross-sectional survey of access to SHS as perceived by school professionals (in other words, as stated above, primary school teachers and care coordinators). We compared school professionals who had worked with the triage approach in SHS and those who had worked with the usual approach.

In the triage approach, SHS assistants follow a strict pre-assessment protocol to preselect children. The pre-assessment of the children is carried out based on: SHS records, questionnaires completed by school teachers and parents, and face-to-face screening. The assistants prioritise referral to SHS for children with suspected health-care needs. The next step is a follow-up assessment by a physician or nurse. Pre-assessment and follow-up assessments are part of the triage assessment procedure (see Fig.  1 ). In the usual approach to routine assessments, a physician or nurse assesses all children. In the triage and usual approaches, school professionals can refer children with suspected risk factors for an assessment by a SHS physician or nurse.

Process of routine health assessments by school health services (SHS); triage and usual approach

Participants

Four distinct urban and non-urban areas in the Netherlands participated in the study. An urban and a non-urban area were selected for the triage and the usual approaches. One triage SHS had recently introduced the triage approach and the other SHS had done so five years before the study began. The two SHS in the approach-as-usual group had been working with this approach for a long time.

A two-step procedure was completed to select the study population. In the first step, 600 primary schools from the four geographical SHS regions were selected at random. In the second step, the school care coordinators and teachers in four school years (Kindergarten and school years 1, 4 and 6 (US system): children aged 5, 6, 9 and 12 years respectively) were selected from every school for inclusion in the study (1249 employees for the triage approach and 729 for the usual approach). Schools specifically for children with special needs, school professionals who had worked for less than six months at the school, and professionals other than teachers or care coordinators were excluded from the study. To ensure adequate power in the data analysis, we adopted a predefined significance level of 5% and statistical power of 80%. With a total population of about 1400 schools (in other words, all schools in the four SHS regions that were eligible for participation in the study), the minimum sample size was 300 schools. Assuming a school response rate of 50%, a sample of 600 schools was enough to ensure adequate power.

Data collection

Data were obtained using a digital questionnaire sent by e-mail. Firstly, professionals at schools known to the SHS were approached to obtain the e-mail addresses of the respondents. In the triage group, e-mail addresses for most of the school care coordinators were available to the SHS. In the approach-as-usual group, we contacted school heads to obtain the e-mail addresses of the respondents. To maximise the response rate, a pre-notification letter was sent by e-mail to the school board and two reminders were sent to non-respondents [ 21 ]. The questionnaires were sent and returned in June and July 2012. Additional information about topics in terms of involvement in school networks or school size was collected through online searches.

The questionnaire items were based on the Consumer Quality Index [ 22 , 23 ]. The concepts in this index were translated for use in this study. The questionnaire was developed with an expert group of SHS professionals. The questionnaire was pre-tested in a group of six school care coordinators. This resulted in only small changes in the wording of sentences and word selection.

This is a general accepted procedure when questionnaires tailored to the study group are not available.

Three scales were established to measure school professionals’ perceptions of access to SHS: two scales for approachability and one for the appropriateness of SHS support (see Table  1 ; for a full overview of the questions and the scales, see Additional file  1 ). The two scales for approachability were: a five-item scale ‘SHS approachability for contact and feedback’ and a two-item scale ‘SHS approachability for support for health issues’. In addition, a three-item scale ‘appropriateness of SHS support for children with specific needs’ was established. The answer categories used five-point Likert scales for the statements (ranging from ‘strongly disagree’ to ‘strongly agree’) or four-point Likert scales for the questions (ranging from ‘never’ to ‘always’). A question about the number of contacts between the school and SHS professionals was added to measure the contact frequency between the school and SHS in the previous six months. The answer categories were 0, 1–2, 3–4, 5–6 and >6 times.

The demographic and descriptive data relating to schools and school professionals were collected using the questionnaire and online searches of the schools’ characteristics, including the involvement of SHS in school-based networks, school size, municipality size, position of the school professional (teacher or school care coordinator), and number of years working at the current school. The socio-economic status of the school population was determined on the basis of the postal codes of the schools and was based on education, income and employment status of the inhabitants of the school area.

Data analysis

We used descriptive analyses and chi-square tests to assess differences between the background characteristics of schools and school professionals in either the triage group or the approach-as-usual group.

Scales were constructed using multiple steps. At first, we converted the answer categories of the ordinal variables into quantified (continuous numeric) variables for all subsequent analyses using categorical principal component analysis (for further details, see [ 24 ]). Secondly, the quantified variables were clustered into scales using a principal component analysis. The discriminant validity of the scales was tested using the eigenvalues of the factors and the associated scree plot. According to the Guttman-Kaiser criterion, factors with an eigenvalue greater than one were retained. Thirdly, drawing on research [ 19 , 20 ] and the principal component analysis, we constructed three scales: ‘SHS approachability for contact and feedback’, ‘SHS approachability for support for health issues’ and ‘appropriateness of SHS support for children with specific needs’ (see Table  1 ). The reliability of the scales was analysed using Cronbach’s alpha coefficients or Pearson’s correlation coefficients.

Our next step was to analyse the differences between school professionals’ perceptions of access to SHS in the triage and approach-as-usual conditions using multilevel regression analysis with contact frequency, the approachability of SHS and the appropriateness of support as outcome variables and the approach (triage or usual approach) and differences between background characteristics as the independent variables. A multilevel regression analysis was required because of the lack of independence between school professionals in individual schools [ 25 , 26 ]. The size of the differences between the triage approach and usual approach was given using standardised regression coefficients with 95% confidence intervals. SPSS Statistics was used to analyse the data (SPSS 21.0 for Windows, SPSS Inc., Chicago, IL).

Figure  2 shows the questionnaire responses for the triage and usual approach. Data relating to four school professionals and eight schools in the triage group, and twelve school professionals and seven schools in the usual approach group, had to be excluded due to non-conformity with our inclusion criteria or because the professionals could not be reached due to an incorrect e-mail address.

Response flow diagram; triage and usual approach

The response rate was 73.3% for the schools in the triage group and 48.8% for the schools in the approach-as-usual group. The response from the professionals was 35.7% in the triage group and 48.6% in the approach-as-usual group (see Fig.  2 ). The most frequently stated reason for not participating in the study was a lack of time.

Our data showed a difference between the schools using the two approaches in terms of the municipality size (Table  2 ). Schools in the triage group were situated less often in municipalities with fewer than 40,000 residents than schools in the approach-as-usual group. No other differences were found between the triage and approach-as-usual group in terms of the background characteristics of schools such as the participation of SHS in school-based networks, the socio-economic status of the school population or school size.

Our study showed a difference in contact frequency and school professionals’ perceptions of the appropriateness of SHS support between the two study groups (triage and usual approach) (Table  3 ). The school professionals in the triage group reported significantly more contact with SHS professionals than professionals in the approach-as-usual group. In addition, we found differences in perception with respect to the appropriateness of support provided by SHS professionals. More school professionals in the triage group than in the approach-as-usual group thought the support provided by SHS for children with specific needs was appropriate. The main difference between the schools relates to the scale item ‘SHS makes an important contribution to the detection of problems’. The values of the standardised betas in Table  3 reflect the strength of the measured relationship. The association between the SHS approach and the frequency of contact between the school and SHS is stronger than the association with the appropriateness of support provided for children with specific needs.

No impact was found on the perceived approachability of SHS evidenced by the response from school professionals on the scales ‘SHS approachability for contact and feedback’ and ‘SHS approachability for support for health issues’ in the comparison of the triage group with the approach-as-usual group.

The aim of this study was to explore how school professionals in primary schools experience working with a triage approach to the routine assessments conducted by school health services (SHS) and to make a comparison with school professionals who were offered the usual SHS approach. An difference was found between the two groups in the perceived appropriateness of support from SHS and the contact frequency between school and SHS professionals. These differences may be linked to the differences between the two approaches. In both approaches, SHS professionals visit schools both using a predefined schedule and when necessary. A triage assessment procedure creates time for physicians and nurses to visit schools regularly to conduct additional assessments of children with specific needs when asked to do so by school professionals, parents and children themselves. The procedure also creates more possibilities to cooperate in school-based networks. The triage approach contributes to the sharing of information between school and health professionals about children with specific needs and the early detection of health problems, and this may explain the positive evaluation of the appropriateness of SHS support. On the other hand, it is possible that children are missed in the assessments by assistants in the triage approach, and parents are less involved in the first step of the triage procedure. However, school professionals are in contact with almost every child daily, making it possible to identify children with health-related problems. Other studies show that the efficiency and responsiveness of the health care system are known to be linked to the approachability and expertise of health-care professionals [ 12 , 27 , 28 ]. The perceived approachability of SHS will not have changed because dedicated professionals are active in the Dutch SHS system in both approaches.

Strengths and limitations

A strength of our study is that we sent questionnaires to a random sample of schools. Respondents completed the digital questionnaires anonymously and this may have improved the reliability of the results. The background characteristics of the study groups were similar, except for the municipality sizes, which we corrected for in the analyses.

A methodological limitation is the low response rates, although this is not uncommon in surveys of both schools and professionals in those schools. The results may have been positively affected by the higher response rates from schools and school professionals who were positive about access to SHS. We expect schools and school professionals who are satisfied with either approach or who have had more contact with SHS professionals to be more willing to participate in the study. This would imply an overestimation of the findings for our outcome measures, appropriateness of care and contact frequency.

A difference in the response rates was found between the schools. We found that more schools located in relatively larger municipalities in the triage group responded than schools in those municipalities in the approach-as-usual group. Although we corrected for this in the analyses, the higher scores for appropriateness and contact frequency may suffer from bias due to the more frequent and severe health problems in children living in a more urban area, leading to more SHS activities. On the other hand, there were no differences between the schools in terms of socio-economic status. Because this is an important factor for the health status of children and the correlation with urbanisation, we expect that differences in levels of urbanisation to have a minor effect in schools using the triage and usual approaches.

We were not able to analyse differences between the characteristics of schools or professionals in the response and non-response groups because the background characteristics of the non-response group were not available.

Another possible cause of bias is that the outcomes of the triage approach may have been affected by the fact that the triage approach had not been in place for as long as the usual approach. The professionals using the triage approach have less experience with this novel method, and this could lead to contact frequency and the appropriateness of care being underestimated. Triage can reasonably be expected to have a stronger impact on appropriateness of care and possibly on approachability when it has been in place for a longer period of time.

Finally, we used a self-report questionnaire based on an existing instrument to measure school professionals’ perceptions of approachability and the appropriateness of support from SHS. Further questionnaire development and research into the validity of the questionnaire are recommended.

Implications for school health services

SHS systems are available in many countries, and they are often delivered by nurses. The efficiency and quality of these SHS systems need to be optimised to improve children’s health and development and to tailor SHS to school systems [ 4 , 10 ]. A change in the organisational model of SHS is needed for the efficient use of resources available in the system and to solve the problem of a shortage of SHS physicians and nurses. Most countries with a high level of staffing have introduced reforms in the last five years, including triage and task-shifting [ 4 ]. The benefits of task-shifting are already widely known in health care. We studied the impact of introducing triage and task-shifting to SHS because there has not yet been enough research in this field of health care. Our study showed that the use of a triage approach by SHS could be advisable in countries with similar population-based SHS systems involving routine assessments conducted by physicians and nurses. The involvement of assistants in the routine assessments could improve the efficiency of SHS. A triage approach used by population-based SHS systems could create opportunities for nurses and physicians to increase the contact frequency with schools to deliver care on demand and to enhance the collaboration and relationship between school and health professionals. This improved collaboration between schools and health professionals is expected to contribute to the early detection of health-related school problems and to benefit children with specific needs.

Implications for research

An examination of more objective outcome measures such as lower school absenteeism for the support provided by schools and SHS professionals for children with specific needs is advised to enhance our understanding of the benefits of investment in collaboration between the two systems. Further research is also recommended into the position and responsibilities of SHS and school professionals with a view to improving collaboration between the two systems to improve children’s health and well-being. Parents’ experiences with the triage approach represent another area requiring study.

School professionals had more contacts with SHS professionals and were more positive about the appropriateness of support from SHS when a triage approach to routine assessments was in place than when the usual approach was used. Countries with similar population-based SHS systems could benefit from a triage approach which gives physicians and nurses more opportunities to attend schools for consultations and assessments of children on demand.

Abbreviations

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Acknowledgements

We thank the personnel of the schools, the Municipal Health Service Noord- and Oost-Gelderland, Municipal Health Service Hollands Noorden, Municipal Health Service Drenthe and Municipal Health Service Gelderland-Midden for participating and Dr. P. van Dommelen for statistical advice.

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Contributions

JB developed the triage approach, contributed to the development of the triage protocols, contributed to the conception and design of the study, the acquisition and interpretation of data, and the drafting of this manuscript. DH contributed to the conception and design of the study, carried out the analysis and interpretation of the data, and revised the manuscript. RR contributed to the intellectual content and revision of this paper, and critically reviewed the manuscript. SB contributed to the intellectual content and revision of this paper, and critically reviewed the manuscript. MN contributed to the intellectual content and revision of this paper, and critically reviewed the manuscript. PK contributed to the conception and design, the analysis and interpretation of the data, and the review and revision of the manuscript. Finally, all authors read and approved the final manuscript.

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Correspondence to Janine Bezem .

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Participants completed the digital questionnaires anonymously. They gave written consent to participate in the study when they completed the questionnaire.

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Additional file

Additional file 1:.

Questions and scales in the online questionnaire. Description of questions, answer categories and score range in the online questionnaire. (DOCX 12 kb)

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Bezem, J., Heinen, D., Reis, R. et al. Improving access to school health services as perceived by school professionals. BMC Health Serv Res 17 , 743 (2017). https://doi.org/10.1186/s12913-017-2711-4

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The Role of School Health Services in Addressing the Needs of Students With Chronic Health Conditions: A Systematic Review

Zanie c. leroy.

1 School Health Branch, Division of Population Health, Centers for Disease Control and Prevention, Atlanta, GA, USA

Robin Wallin

2 Parkway School District, St. Louis, MO, USA

Associated Data

Children and adolescents in the United States spend many hours in school. Students with chronic health conditions (CHCs) may face lower academic achievement, increased disability, fewer job opportunities, and limited community interactions as they enter adulthood. School health services provide safe and effective management of CHCs, often for students with limited access to health care. A systematic review to assess the role of school health services in addressing CHCs among students in Grades K–12 was completed using primary, peer-reviewed literature published from 2000 to 2015, on selected conditions: asthma, food allergies, diabetes, seizure disorders, and poor oral health. Thirty-nine articles met the inclusion criteria and results were synthesized; however, 38 were on asthma. Direct access to school nursing and other health services, as well as disease-specific education, improved health and academic outcomes among students with CHCs. Future research needs to include standardized definitions and data collection methods for students with CHCs.

School health services may play a key role in managing the daily needs of students with chronic health conditions (CHCs). Although these health conditions can vary widely in concept and definition, CHCs are typically accepted as having potential for functional limitations, including dependency on medication, assistive devices, or routine medical care ( van der Lee, Mokkink, Grootenhuis, Heymans, & Offringa, 2007 ). The school nurse or a designated provider is often responsible for coordinating and conducting health assessments, as well as planning and implementing individualized health-care plans for safe and effective management of CHCs, often for those who may have limited access to health care. These health services are designed to help with access or referrals by linking school staff, students, families, community, and health-care providers together to promote the health care of students in a healthy and safe school environment ( Association for Supervision and Curriculum Development [ASCD] & Centers for Disease Control and Prevention [CDC], 2014 ). The school-based health center (SBHC) is another model that represents an important interdisciplinary approach to providing comprehensive physical and mental health care for students. SBHCs typically deliver primary care services and may include reproductive, dental, and acute care services for students and may also coordinate with external community providers ( Brown & Bolen, 2008 ).

The purpose of this systematic review is to assess the role of school health services or SBHCs in addressing five CHCs among school-aged youth in Grades K–12: asthma, food allergy/anaphylaxis, diabetes, seizure disorders, and poor oral health. These are examples of conditions that are commonly seen, possibly affect academic achievement, or use significant resources when addressed at school. There are position and policy statements, guidance documents, tool kits as well as issue briefs from a number of organizations with expertise in this area; however, a synthesis of primary, peer-reviewed literature addressing CHCs in school settings is lacking ( American Academy of Pediatrics, 2004 , 2016 , 2009 , 2012 ; National Association of School Nurses, 2013 , 2014 ). We examine the relationship between the provision of school health services (through either traditional school nursing or SBHCs) and the health and academic outcomes of students with CHCs.

A comprehensive literature search was conducted in the following medical, public health, and education databases for articles published during 2000–2015: ERIC, PubMed, Web of Science, and CINAHL (Cumulative Index to Nursing and Allied Health Literature). Examples of key words and phrases used included the following: asthma, food allergies, anaphylaxis, diabetes, seizure disorders, epilepsy, oral health, dental caries, dental pain, individual health plan, school nurse role, academic performance, grades, attendance, medical home, insurance, emergency care, inhaler, epinephrine, care coordination, and referrals. A comprehensive list of the key words and phrases is given in Table 1 . Examples of health outcomes included clinical symptomatology and measurements (e.g., peak flow [PF], spirometry), well-being and quality of life, medication administration, compliance with individual care plans, and health-care utilization, including primary care, specialist care, and emergency department (ED) visits or hospitalizations. Academic outcomes included academic performance, attendance, grades, and standardized test scores.

Key Words for Chronic Health Conditions in School Settings. a

The search yielded a total of 2,438 abstracts. The abstracts were screened by two trained reviewers for the following inclusion criteria: U.S. based and published in English; original scientific study with student health or academic outcomes as noted above; applicability to school settings (i.e., public or private, Grades pre-Kindergarten–12; no stand-alone pre-Kindergarten programs); and describing one of the preselected CHCs (i.e., asthma, seizure disorders, diabetes, food allergies/anaphylaxis, or poor oral health). Duplicates were removed, and four articles could not be identified because of missing author or journal information. We excluded studies that only measured knowledge acquisition or behavioral changes in students or that did not have at least one clinical or academic outcome as an end point.

A stepwise process of selecting and assessing articles for synthesis followed. Initially, 390 abstracts met screening criteria for a full, detailed review, and one additional study from the reference list of one of these included articles was added to our review ( Figure 1 ). An abstraction form was developed to summarize the following information from each article: purpose, study design, sample size, demographics (including measures of socioeconomic status), disease severity classification, geographic setting, methods, details of applicable interventions, outcome measures, data analysis, significant and nonsignificant results, limitations, and conclusions. Missing information was coded as not documented . Thirty-two articles were simultaneously reviewed by the authors and evaluated for concordance at each step of the process for quality control. Discordance was adjudicated by discussions with a third, senior reviewer. Subsequently, 352 articles were excluded for the following reasons: not original research studies, that is, guidelines, literature reviews, policy briefs, or commentaries ( n = 89); not directly about school health services ( n = 83); were descriptive studies ( n = 69); did not measure student health or academic outcomes ( n = 68); not specific to the CHCs being reviewed or targeted all students regardless of having condition ( n = 14); not appropriate age or grade level ( n = 11); were feasibility or validation studies ( n = 7); were related to prevention trials ( n = 6); or not U.S.-based studies ( n = 5). Finally, 39 studies were eligible for synthesis of results ( Figure 1 ). All information were entered into the Microsoft Excel 2013 database. The data abstraction form is available upon request from the lead author.

Article classification system.

We reviewed 39 articles that examined the effects of school health services on health or academic outcomes in children with the five selected CHCs: asthma, seizure disorders, diabetes, food allergies/anaphylaxis, or poor oral health. The vast majority focused on asthma ( n = 38) and were in urban settings ( n = 32). Only one study focused on oral health. Study designs varied, including 13 quasi-experimental, 12 longitudinal cohort (3 retrospective), 10 experimental (randomized controlled trials), 2 mixed methods (1 cohort and cross-sectional and 1 quasi-experimental and cross-sectional), 1 case–control, and 1 cross-sectional. Seventeen of the studies were in elementary schools, three in high schools, and eight addressed full K–12 populations; sample sizes ranged from 4 to 9,307 students. Socioeconomic status was not consistently documented: 17 studies documented free or reduced lunch data, including 13 with a population of 50% or higher free or reduced lunch, and 12 studies documented Medicaid/Children’s Health Insurance Plan (CHIP) in at least 50% or more of students.

Below are results from studies with statistically significant findings synthesized by study type for health outcomes and by type of academic achievement for academic outcomes. Results are summarized in order of study strength for those with statistically significant findings at the p ≤ .05 level; details for all studies in the review (including those without significant results) are presented in Table S1 which is available online.

Health Outcomes

Student-level health outcomes across the studies were categorized by clinical symptoms and measurements (26 studies), medical management (21 studies), and health-care utilization (25 studies). There were seven experimental, seven quasi-experimental, nine cohort, and four other study types.

Experimental Studies

Direct clinical interventions, such as providing medications or directly observed therapy (DOT) at school, led to improvements, including fewer symptom days, fewer days with activity limitations or change in family plans, fewer nighttime symptoms, decreased exhaled nitric oxide for students with asthma, decreased days using rescue inhalers, and a decrease in the likelihood of having three or more acute office or ED visits for asthma ( Halterman et al., 2012 ; Halterman, Szilagyi, et al., 2011 ; Halterman et al., 2004 ).

Studies that focused on providing care coordination or case management (CM) saw mixed results. In one study, students in CM schools had significantly fewer urgent care or ED visits for each semester and during the entire school-year; they also had fewer hospital days ( Levy, Heffner, Stewart, & Beeman, 2006 ). Conversely, another study showed that at 2 years, students in the control group (no CM) had fewer hospitalizations during the preceding 12 months ( Bruzzese et al., 2006 ).

A comprehensive program that included case finding, clinical linkages, disease-specific education, and school environmental assessments found that both treatment and control groups showed an increase in being hospitalized over time. However, for a subgroup with direct access to study physicians ( Table S1 ), the rate of increase was slowing more rapidly ( Bartholomew et al., 2006 ). Additionally, a program using an asthma education curriculum for children and engaging caregivers showed reductions in day- and nighttime symptoms of asthma ( Clark et al., 2004 ).

Quasi-Experimental Studies

A combination of education, providing medication, and DOT led to a larger increase in PF readings, fewer days with asthma symptoms, and more urgent medical visits in treatment students than in controls ( Velsor-Friedrich, Pigott, & Louloudes, 2004 ). However, with the addition of nurse practitioner follow-up visits, both groups had PF increase over time with no significant differences between the groups ( Velsor-Friedrich, Pigott, & Srof, 2005 ). Also, the provision of PF readings to health-care providers along with direct requests from school nurses led to an increase in asthma action plans placed on file for students ( Pulcini, DeSisto, & McIntyre, 2007 ).

In a study to assess the effects of care provided at SBHCs there were 33% fewer ED visits after opening an SBHC, and students enrolled in the SBHC had 43% fewer ED visits compared to students not enrolled as well as a 2.4-fold decrease in the risk of hospitalization ( Guo et al., 2005 ). There were also subsets of students in the SBHC group under the Managed Care Organization and CHIP program whose use of the ED decreased by 5.7% and 24.0%, respectively, versus other Medicaid students. Another study focused on case identification and screening of children with asthma found that younger children, those with a parent reported regular care asthma physician, those who had visited the ED during the past year, and those reporting more medication use were more likely to make a postreferral asthma visit ( Yawn, Wollan, Scanlon, & Kurland, 2003 ). In addition, more children in this intervention group made an asthma-related visit and had higher rates of medication changes than in the control group.

Asthma education showed an improvement in the percentage of students who were in control of their asthma from baseline to second posttest at 14 weeks: from 56% to 76%, using the Asthma Control Test ( Kouba et al., 2013 ). In a different study, a program teaching self-management of asthma led to improved inhaler skills for treatment students and significantly decreased hospital stays over time, when individual growth trajectories were considered ( Horner & Brown, 2014 ). However, there were no differences between treatment and control groups.

Cohort Studies

Providing medications and a combination of DOT and motivational interviewing led to an overall reduction in asthma symptoms, an increase in symptom-free days, fewer days of slowing down or stopping usual activities, decreased rescue inhaler use, and decreased exhaled nitric oxide levels at a 2-month assessment versus baseline in a cohort of students with asthma ( Halterman, Riekert, et al., 2011 ). An alternative method of providing direct care through mobile access was assessed in two studies. A comprehensive clinical approach that delivered services via two mobile “asthma vans” throughout the school-year and summer, with 24-hour on-call access to a physician, showed improved daytime and nighttime symptoms, exercise symptoms, pulmonary function tests, and rescue inhaler use from baseline. Moreover, 82% of children “felt better,” and ED visits and hospitalizations were decreased at follow-up ( Patel et al., 2007 ). In a different program, children using a mobile asthma clinic for at least 1 year had ED visits decrease from 38% to 16%, multiple (≥2) ED visits decrease from 23% to 6%, and hospitalizations decrease from 19% to 3% ( Liao, Morphew, Amaro, & Galant, 2006 ).

In a school where CM was instituted, intervention students in Years 1 and 2 of the program were more likely to have medications and PF measured at school during the following year; however, severity classifications of asthma both increased and decreased as a result of CM in Years 1–2 and 2–3 ( Taras, Wright, Brennan, Campana, & Lofgren, 2004 ).

Education through the “Kickin’ Asthma” program—an asthma curriculum that focused on appropriate medication use and providing PF monitors and inhalers to students with asthma—was reported in two studies ( Magzamen, Patel, Davis, Edelstein, & Tager, 2008 ; Patel Shrimali, Hasenbush, Davis, Tager, & Magzamen, 2011 ). Results included improved individual morbidity scores; a decrease in days with activity limitations and physician visits for asthma symptoms during 2 years; and a decrease in sleep disruption, ED use, and hospital visits during 3 years. Additionally, improvements were found across all three medication use categories: initiated reliever use when “feeling symptoms” and “before exercise” and initiated controller use when “feeling fine.” Other disease-specific educational efforts were also studied. One intervention using bilingual workshops for children and their families and providing asthma training workshops for school nurses led to decreased asthma morbidity days per week, decreased steroid use, decreased ED use (from 35% to 4%), and a decrease in hospitalization (from 11% to 2%; DePue et al., 2007 ). Another program using web-based education and an external organization to monitor students’ daily asthma diaries found a 34% decrease in nighttime symptoms and a 66% decrease in unscheduled physician visits at 6 months as well as a 69% decrease in daytime symptoms and 100% decrease in nighttime symptoms at 12 months ( Tinkelman & Schwartz, 2004 ).

A study assessing SBHCs found that children attending the comparison schools without SBHCs were more likely than those in schools with SBHCs to have been hospitalized for asthma, 17.1% versus 10.5%, respectively ( Webber et al., 2003 ). A follow-up study found improvements in medication management, reduced number of community provider visits, and halving of ED use for students enrolled in SBHCs compared to non-SBHC control schools ( Webber et al., 2005 ).

Other Studies

In a case–control study, children at the Kunsberg School (Denver, Colorado), a specialized school for children with chronic medical conditions, showed a decrease in follow-up asthma visits by 76% and in ED visits by 55%, compared to controls ( Anderson et al., 2004 ). Hospitalizations per year were also lower among children at Kunsberg, during post-enrollment versus preenrollment periods in the school. An at-risk subset of children with asthma at Kunsberg also saw a decrease in inpatient hospital days and the elimination of intensive care unit stays.

A study using mixed methods to assess the initiation of a school-based health center with special emphasis on asthma found a decrease in having to change family plans in their longitudinal population, increased specialist visits and decreased hospital admissions in their cross-sectional population, and decreased nighttime awakenings in both their longitudinal and cross-sectional populations ( Lurie, Bauer, & Brady, 2001 ). In another mixed methods study, a comprehensive program that included asthma education for students with asthma, CM, and asthma training for staff showed that the odds of asthma being well controlled was 55% higher among intervention students than among comparison students in the quasi-experimental arm of the study ( Rasberry et al., 2014 ). In the cross-sectional arm of the same study, pulmonary function tests improved at follow-up among poorly controlled asthma students; however, there was a decrease among well-controlled asthma students. In addition, descriptive frequencies showed 44.3% of students moved from the poorly to well-controlled classification, whereas 17.5% of students moved from the well- to poorly controlled classification.

A cross-sectional study that assessed SBHC adherence to National Heart, Lung, and Blood Institute (NHLBI) asthma care guidelines found that older children were more likely to have documented PF, more follow-up visits, and asthma education; there was also a nonsignificant trend toward increasing provider adherence ( Oruwariye, Webber, & Ozuah, 2003 ). Oruwariye and colleagues also found that the use of PF meters was associated with a greater likelihood to having seen a specialist and to have had one or more ED visits during the preceding year.

Academic Outcomes

A total of 26 articles examined some component of academic performance as part of their outcome measures, including 9 experimental studies, 6 quasi-experimental studies, 9 cohort studies, 1 mixed methods (cohort and cross-sectional) study, and 1 cross-sectional study. Twenty-four studies included attendance alone, 4 included grades, and 2 included test scores. Some studies included more than one category ( Table S1 ).

Of 24 articles that examined attendance, 14 showed statistically significant ( p < .05) reductions in school days missed and 5 described positive trends in attendance, despite either no significance testing or not reaching threshold; the remaining 5 studies showed no change at all. Interventions for those who showed positive changes in attendance included access to direct clinical services during the school day (13 studies) and asthma education curricula (e.g., “Kickin’ Asthma”, “Open Airways for Schools”) provided to students or their caregivers (6 studies). One study showed that gains in students with asthma who received school-based care were not maintained if they were exposed to second-hand cigarette smoke in the household ( Halterman et al., 2004 ).

Four studies addressed grades. One intervention that focused on direct clinical services showed higher posttest grades for three subjects, but not in reading or math, among a subset of the student population that had physician access to develop an asthma action plan, obtain medication, and have a report sent to their community provider ( Bartholomew et al., 2006 ). Engelke and colleagues showed a non-significant reduction in grade point average (GPA) among students who received CM. The largest average gain in GPA was when the goal of improving psychosocial support of the family was met; the largest decrease was when children did not meet the goal of disruptive classroom behavior ( Engelke, Swanson, & Guttu, 2014 ).

Two interventions based on asthma education curricula showed improvement in grades. One study showed higher grades for science among children in the treatment group, but not for reading, mathematics, or physical education; the other study showed a positive change in GPA for students from sixth to eighth grade in the treatment group versus controls, in an overall picture of decline for all students ( Clark et al., 2004 , 2010 ).

Test scores

There were two studies that addressed standardized test scores. Bartholomew et al. (2006) found an improvement in state reading and writing test scores in their subset of students with direct physician access. Another study showed no difference in standardized test scores for English or math among students exposed to nursing CM versus controls ( Moricca et al., 2013 ).

Direct access to school nursing and other health services improved clinical outcomes and reduced absences among children with CHCs. Across several studies, improvements in clinical symptoms, medication adherence, and health-care utilization were seen when interventions, such as directly observed therapy, access to medications, and active retrieval of action plans from physicians (particularly for asthma), were implemented by school nursing staff.

There is a call for increasing the proportion of elementary, middle, and senior high schools that have a full-time, registered, school nurse to student ratio of at least 1:750 (HealthyPeople.gov). In addition, the American Academy of Pediatrics recently issued a policy statement recommending at least one full-time nurse in every school ( Holmes et al., 2016 ). Over the past several decades, children with CHCs and complex health needs have been integrated into the general education system, in addition to being seen in special education settings ( McClanahan & Weismuller, 2015 ). Children and adolescents in the United States spend many hours in school; thus, managing CHCs can present challenges for school systems, including educators, clinicians, and staff, who are in daily contact with students. CHCs early in life can adversely affect school performance—a reciprocal relationship between education and health may be reinforced, leading to greater disparities in each ( Fiscella & Kitzman, 2009 ).

In many instances, disease-specific educational programs can provide knowledge and skills for students to better manage their CHCs, leading to better outcomes. The education programs in the studies reviewed typically focused on understanding developmentally appropriate physiology, prevention of behavioral or environmental factors that may trigger symptoms, how medications work, how students can stop symptoms from worsening, and when to ask adults for help. Programs with a culturally appropriate component for caregivers can also reinforce specific messages at home and in other settings.

Decreasing chronic absenteeism among students with CHCs has several merits. Daily attendance strongly affects standardized test scores as well as the graduation and dropout rates of students ( Balfanz & Byrnes, 2012 ). Chronic absenteeism may lead to possible decreased job readiness, limited future earning potential, and decreased quality of life for these students. In addition, some schools are funded on the basis of average daily attendance; a decrease in funding based on chronic absenteeism among a fraction of the student body can have far-reaching consequences on resources that serve all students.

Limitations

There were several limitations noted in this review. First, there were very few studies that actually measured health and academic outcomes among students with the selected CHCs. Second, almost all studies looked at asthma and were typically in urban areas with low socioeconomic status; therefore, these interventions may not be generalizable to other conditions or settings. Third, there were many variations in data collection methods as well as measurements for health and academic outcomes. For example, if disease severity was assessed in asthma studies, some used the National Institutes of Health NHBLI definition, whereas others used severity indicated on the student’s asthma action plan by their primary health-care provider, and others relied on school nurse professional judgment. In addition, some studies had direct measurements, such as PF and spirometry, or had access to medical records, whereas others used symptom surveys and student or parent recall of health-care utilization within a defined time period. Absenteeism data were often recorded from student/parent surveys as “days missed” and seldom verified or linked directly to the specific CHC as the reason for absence. Fourth, there may have been additional factors that altered the impact of school-based interventions on student outcomes, such as environmental exposures, medication compliance, family engagement, access to primary or specialty care outside of the study, access to community organizations, or additional educational opportunities related to managing the CHC. Finally, in comprehensive programs that employ multiple modalities, such as direct clinical intervention and disease-specific education, we cannot determine the individual component that contributed to the change in student outcomes or if it must be delivered in combination.

School Nursing Implications

School nurses work across multiple systems, including education, health care, public health, insurance, and community agencies, to assure that student needs are met ( McClanahan & Weismuller, 2015 ). Although inadequate staffing and time may impose barriers in school settings, leveraging community partnerships may help ease this burden, especially when working with local health plans, universities, or other organizations ( Taras et al., 2004 ; Tinkelman & Schwartz, 2004 ).

This systematic review helps to identify effective interventions that school nurses can employ to support students with CHCs. Many studies addressed the positive effect of specific educational strategies for improving the health and well-being of students with asthma, which is clearly within the school nurse scope of practice. Of particular interest to school nurses is the demonstrated positive effect of having a comprehensive program for managing asthma, which includes CM ( Rasberry et al., 2014 ). When it comes to care coordination, school nurses are uniquely poised to facilitate communication between schools and health-care providers, resulting in improved collaboration for medical management, including obtaining asthma action plans ( Pulcini et al., 2007 ). Additionally, access to SBHCs can have significant implications for students with CHCs, particularly asthma. School nurses are in an ideal position to provide referrals to SBHCs and other community health providers, thus improving access to care and ensuring better chronic disease management overall. Additionally, school nurses could benefit from developing motivational interviewing skills, a strategy that was shown to improve asthma symptoms in students ( Halterman, Riekert, et al., 2011 ).

Further research is needed to examine the relationship between addressing CHCs in school settings and student outcomes. In particular, studies are needed on school health service interventions that apply across many CHCs, as often there are universal approaches, despite condition-specific requirements. Many articles in our review were excluded because of their descriptive nature or lack of specific effects on student health or academic performance (versus intermediate end points such as changes in knowledge or behavior). Furthermore, the majority of the literature focuses on students with asthma. We need more accurate definitions of CHCs as well as systematic data collection methods at the student level, such as that being established through the nationwide Step Up and Be Counted initiative ( Galemore & Maughan, 2014 ; Maughan et al., 2014 ; Selekman, Wolfe, & Cole, 2016 ). Recently, costs and prevalence of selected CHCs among school-aged children were estimated; however, this was based on national telephone survey data with inherent biases ( Miller, Coffield, Leroy, & Wallin, 2016 ). A solid, data-driven evidence base can encourage resource allocation for school health services, increase capacity for prevention strategies at earlier stages, reduce morbidity, and create positive, long-term health and academic outcomes for students. Finally, this review points to the need for more research to study the effectiveness of care coordination activities and interventions that school nurses employ in managing a variety of student chronic health concerns. Current research is limited and focuses primarily on the management of asthma.

Supplementary Material

Acknowledgments.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Biographies

Zanie C. Leroy , MD, MPH, is with the School Health Branch, Division of Population Health, Centers for Disease Control and Prevention, Atlanta, GA, USA.

Robin Wallin , DNP, RN, CPNP, NCSN, is with the Parkway School District, St. Louis, MO, USA.

Sarah Lee , PhD, is with the School Health Branch, Division of Population Health, Centers for Disease Control and Prevention, Atlanta, GA, USA

Author’s Note

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

The online appendices are available at http://journals.sagepub.com/doi/suppl/10.1177/1059840516678909 .

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Issues related to designing and conducting school health education research

• PMID: 6565120

Investigators interested in conducting school health research face many important challenges. First, an appropriate research course for school health must be charted so the most important research issues are addressed in a systematic way. Second, there is a continuing need to develop scientifically sound research methods that can be used in the school setting. Third, there is the immediate need to identify ways of overcoming the usual problems encountered in the conduct of school health research. This paper focuses on the third challenge, via an analysis of the research design and measurement issues that most frequently confront school health researchers. The research design issues addressed include randomization of experimental units to treatments and selection of the appropriate statistical unit of analysis. The measurement issues addressed included use of existing versus newly developed instruments, use of norm-referenced versus criterion-referenced instruments, use of self-report techniques, and appropriate use of affective instruments. Following an analysis of the issues a series of relevant questions are posed.

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