Developing a Culturally Relevant Integrated Health Assessment for School-Based Clinics in the Rural South

Background

Residents of rural communities are often more vulnerable to health and behavioral health problems due to limited access to health care, poverty-related stressors, and pre-existing chronic health conditions. Schools are well-positioned to narrow this gap because they provide easy access to services for students and reduce stigma associated with receiving services (Bronstein, Mellin, Lee, & Anderson, 2019). A key step in improving access to care in schools is an effective assessment process. Yet, few schools implement a universal assessment due to resource limitations and logistical challenges. The purpose of this study is to describe the process of creating a brief integrated health and behavioral health assessment that is culturally relevant for health clinics in the rural South.

Methods

The present study employed participatory action methods in the context of a university-community partnership with rural school-based clinics. The clinics had implemented a universal assessment tool but were experiencing challenges in completing the assessments. The partnership aimed to develop a more efficient, culturally relevant assessment tool. The partnership included school clinic personnel, a university faculty member, and a graduate student, who was embedded in the health clinics for three months and completed the following activities:

1. Attended agency trainings to learn how the clinics operated.
2. Interviewed clinic personnel about their experience administering existing assessments and strengths and challenges in the assessment process.
3. Directly administered assessments to students.
4. Attended bi-monthly team meetings in which clinic personnel discussed challenges in administering the assessments.
5. Maintained a log of feedback from clinic personnel and insights gained from administering the assessments.

The research team analyzed the graduate student’s logs for content regarding strengths and challenges in the existing needs assessment process. Themes were then shared with school clinic personnel, whose feedback was integrated into the final recommendations.

Results

Observations recorded in the logs were organized into two domains: content and administration procedures.

Content: Practitioners indicated that the existing risk assessment was too lengthy and was not culturally relevant for rural schools. Questions about sexual health, substance use, and gun ownership and safety should be included in an assessment in ways that account for contextual differences in the rural South. In addition, they recommended adding questions that are particularly important for rural contexts, such as challenges with transportation.

Administration: Recommendations to improve administration included administering the assessments in small groups. They suggested that a reporting feature be added to the assessment process to provide rapid reports on students who need services.

Conclusions and Implications

In response to these findings, the health clinics developed a brief 30-item assessment to identify students in need of health and behavioral health services within the first six weeks of school. The tool is currently being piloted in multiple clinics with students ages 11 to 18 years. The new tool has significantly reduced the time required to complete assessments and refer students for services.

This study demonstrates the importance of research grounded in the knowledge, experience, and culture of rural communities to improve service delivery.