It is time to make the grade: Reaching Canadian youth through school-based health centres

School-based health centres exist at the intersection of education and health and are the caulk that prevents children and adolescents from falling through the cracks. Adolescents have unique health needs and are known to demonstrate different and often inconsistent patterns of health care utilization. In Canada, rates of physician visits tend to decline as children approach adolescence (1). While some American adolescents forego care due to lack of insurance, developmental influences known to affect rates of access to care include perceived inconvenience or lack of time to access services, concerns about confidentiality, and perceptions of health care settings and professionals (2). Forty per cent to 60% of Canadian adolescents who are worried about a health-related issue have not consulted a health care practitioner even though they would like to (2). Among adolescents who do access care, many report ongoing unmet health needs (3). Adolescents who do not have a primary care physician have a lower likelihood of receiving any type of health care and of receiving symptom-specific health care, independent of socio-demographic characteristics (4). These data are of particular concern given that many of the factors that influence adolescent morbidity and mortality are potentially modifiable (3). It is, therefore, imperative to explore innovative and collaborative approaches to the delivery of health care to youth. Policy makers, health care professionals and youth service providers should advocate for school-based health centres (SBHCs) to address this urgent need. The provision of health services in schools was pioneered by paediatric and nursing health professionals to address common paediatric health issues in the United States (US) (5). SBHCs evolved during the 1970s to offer expanded health services (including primary health care, chronic illness management, etc) to youth facing health disparities or poor access to care (6). Although one may believe that there is no need for SBHCs in a country with universal health care, many young Canadians either do not have a primary care provider or do not access them (1). SBHCs create an environment of service coordination and collaboration, and typically employ an interdisciplinary team of providers (including, but not limited to, nurse practitioners, registered nurses, physician assistants, social workers, physicians and substance abuse counsellors). They vary based on community need and resources, and deliver clinical services in partnership with a larger health care organization such as a hospital, community health centre, health department or medical practice. To be inclusive, they may have flexible hours to allow access for local high risk youth who may not be enrolled in school. Advisory boards consisting of community representatives, parents, youth and family organizations help to provide planning and oversight (7). SBHCs address the very barriers to care that adolescents commonly report, providing convenient, confidential and customized adolescent services. There are no national data regarding SBHCs in Canada. Only a handful of centres exist across the country: in Saskatchewan, Manitoba, Ontario, New Brunswick and Nova Scotia. This is in stark contrast to the US, where almost 2000 centres currently operate. Approximately 33% of US SBHCs are located in high schools, 24% are located in elementary or middle schools, and 43% are located in alternative schools or schools with a combination of grade levels (5). The American literature on outcomes of SBHCs in high schools tends to focus on three main individual-based outcomes: medical, mental health and educational. Positive findings in these three domains hold particular promise for positioning youth on a healthy and successful developmental trajectory. Adolescents with access to SBHCs visit the emergency department and are hospitalized less often than teens with no access to SBHCs (8). Students who use SBHCs are more satisfied with their health and engage in a greater number of health-promoting behaviours than nonusers (9). Sexually active females are more likely to have received more specific care and to have used hormonal contraceptives if their school has an SBHC (10). Adolescent users of SBHCs appear to have higher use of mental health services than adolescents in the general population, suggesting that barriers experienced in traditional mental health settings (stigma, non-compliance, concern regarding confidentiality, inadequate access) are overcome (11). Adolescents who have received school-based mental health counselling have lower rates of absenteeism and tardiness while attaining higher grade point averages (11). At the population level, the location of SBHCs within schools allows for the delivery of ‘place-based’ health care, which facilitates more effective primary, secondary and tertiary prevention programs (12). Financial outcomes for the health care system are similarly promising; while no Canadian data exist, in the US, SBHCs are estimated to have saved Medicaid approximately $35 per student per year (13). When implementing SBHCs for adolescents, consideration needs to be devoted to sustainable sources of funding, involvement of relevant stakeholders (students, parents, school boards, health care agencies) and varying provincial polices regarding consent, confidentiality and reproductive health services. Several school districts in Canada have indeed begun to experiment with SBHCs as a means to promote student health. In Pickering, Ontario, an SBHC has been established in a local high school with the support of school administrators and under the leadership of The Youth Centre, a community health centre (CHC) dedicated to free and confidential interdisciplinary comprehensive care for youth and young adults. This SBHC is located on the school campus as a satellite of the affiliated CHC, and offers a range of health services including primary care, health prevention services, health education and health advocacy. The SBHC centre is staffed by a nurse practitioner and a dietician from the CHC, which is in turn funded by the Central East Local Health Integration Network. Medical records are shared between the SBHC and CHC and patients can be seen at either site, which limits replication and fragmentation of services and offers adolescents a consistent provider and medical home. This model demonstrates how SBHCs can complement and extend existing primary care and preventive health services by allowing practitioners to be embedded within the environment of their patients, where they can gain insight into the specific needs of the school population and collaborate with education professionals to develop targeted prevention and health promotion measures. Another promising initiative has been implemented in Cape Breton, Nova Scotia, where ‘Youth Health Centres’ exist in several of the region’s high schools and are funded by the Cape Breton District Health Authority. In a 2007 survey administered as part of a larger program evaluation, almost one-half of all students at three schools with these centres reported having used the centre in the past year; the majority of students who accessed a Youth Health Centre were likely to do so again, and students engaging in ‘high-risk’ behaviours were significantly more likely to have accessed services through these centres. The majority of students who used these centres would recommend them to a friend (14). Based on these data, the authors concluded that because high-risk youth are more likely to use them, “SBHCs are in a position to screen for adolescent risk behaviours (for example, as recommended in the Guidelines for Adolescent Preventive Services developed by the American Medical Association), with the possibility of higher screening yield and, thus, efficiency of resource utilization.” (15) Embedding clinics within high schools offers a promising model for delivering effective and accessible interdisciplinary health care to adolescents. SBHCs can offer care that is tailored to the developmental needs of this population, demonstrating compelling benefits for this traditionally hard-to-reach demographic. Adolescence is a time of significant growth and development, encompassing moments of incredible opportunity and others of considerable potential risk. As health care providers, we must recognize and address this duality to support youth in a healthy transition to adulthood and the development of a positive relationship with the health care system. It is incumbent on all of us to embrace innovative models of care such as SBHCs as we advocate for a comprehensive national adolescent health care strategy.

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