Estimating the Relationship Between School-Based Health Center (SBHC) Utilization and Youth Development Assets By Race

Purpose: Emerging research indicates that participation in school-based health centers (SBHCs) is positively related to student attendance and grades.  One recent study documented positive relationships between SBHC utilization and youth development assets (e.g. caring adult relationships), suggesting they may be a key mechanism through which SBHCs promote students’ academic achievement.  However, it is not clear whether this relationship holds across subgroups of students targeted by SBHCs, whose primary aim is to address the unmet health and mental health needs of historically underserved populations. In light of research and theory suggesting cultural influences on help-seeking and service utilization, the historical context of racial mistreatment in the U.S. educational system, and evidence of pronounced racial group differences in SBHC service use, a consideration of program impact by racial subgroups is warranted.  To test the hypothesis that service outcomes would vary by students’ racial backgrounds, this study estimated the association between utilization of SBHCs and assets by student race. 

Methods:  This secondary data analysis of an epidemiological survey (California Healthy Kids Survey) considered results from student surveys administered at 15 urban high schools with SBHCs in the spring of 2009 (70% response rate, n=7314).  Consistent with administrative data, forty-two percent of the sample reported utilizing their SBHC.

         Measures: Dependent variables were composites of student-reported school assets (e.g., caring relationships, high expectations, and meaningful participation). The primary independent variable captured students’ frequency of service use with five response categories (never, 1 or 2 times, 3 to 5 times, 6 to 10 times, and more than 10 times).  Covariates included student and school socio-demographic background characteristics and student early risk behaviors prior to service initiation.

            Analytic Approach: Propensity scoring methods (PSM) were used to estimate relationships between SBHC use and assets.  Initial differences observed in covariates were not evident after PSM procedures were implemented.

Results:  Students’ use of services was positively associated with all school-based developmental assets (Cohen’s ds ranged from .10 to .50). However, there were differences in the strength of the relationship between SBHC utilization and assets by race/ethnicity, depending on the type of asset measured and frequency of service use. Among African American students, positive relationships between SBHC utilization and assets were only evident at high rates of service use (more than 10 times). For Latino students, moderate SBHC utilization (3-5 and 6-10 times) was associated with assets. Finally, among Asian students, only very low service use (1 or 2 times) or very high service use (more than 10 times) was positively associated with assets. 

Conclusions and Implications:  Theories of cultural influences on adolescent service use and treatment outcomes suggest three possible explanations for differences in the relationships between SBHC utilization and school-based assets by race: (1) different pathways to services (e.g., voluntary or coercive), (2) varied levels of service engagement, (3) service type (e.g., medical vs. behavioral). Results suggest the need for further clarification of the interplay between student racial and ethnic background, pathways into service use and types and doses of services and academically-related outcomes.