Addressing the Need For Establishment of School-Based Health Centers to Provide Reproductive Health Care in Philadelphia: A Meta-Analysis

Philadelphia College of Osteopathic Medicine Philadelphia College of Osteopathic Medicine

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Addressing the Need For Establishment of School-Based Health Addressing the Need For Establishment of School-Based Health

Centers to Provide Reproductive Health Care in Philadelphia: A Centers to Provide Reproductive Health Care in Philadelphia: A

Meta-Analysis Meta-Analysis

Annam Humayun

Philadelphia College of Osteopathic Medicine

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Reproductive Health Care in Philadelphia: A Meta-Analysis" (2019).

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Running head: SCHOOL-BASED HEALTH CENTERS IN PHILADELPHIA !1

Addressing the Need For Establishment of School-Based Health Centers to Provide Reproduc-

tive Health Care in Philadelphia: A Meta-Analysis

Annam Humayun

[email protected]

May 13, 2019

Philadelphia College of Osteopathic Medicine

A capstone submitted in partial fulfillment for the degree Master of Science in Biomedical Sci-

ences-Public Health Concentration!

SCHOOL-BASED HEALTH CENTERS IN PHILADELPHIA !2

Abstract

TITLE:

Addressing the Need for Establishment of School-Based Health Centers to Provide Repro-

ductive Health Care in Philadelphia: A Meta-Analysis

OBJECTIVE:

Currently, the communities of Philadelphia, which have predominantly African American resi-

dents, suffer from massive racial and ethnic health disparities. Children in these communities are

at high risk of dropping out of school while also lacking access to reproductive health care. This

myriad of unfortunate circumstances perpetuates the cycle of poverty that residents in these low-

income communities have been experiencing for decades. School-based health centers are a po-

tential answer to this problem. The objective of this meta-analysis is to review published studies

and carry out a meta-analysis to assess potential benefits and feasibility of SBHCs in the Phil-

adelphia public school system as well any concerns that may arise with their provision.

METHOD:

A literature review and analysis was conducted through an online search of databases and gov-

ernment websites including Medline, PubMed, National Institute of Health, Google Scholar, Na-

tional Center for Biotechnology Information, Center for Disease Control, and Google Scholar. A

Google search for local credible news sources was also performed. The database searches were

completed using the following search terms: SBHCs,”; “school-based health center”; “health in-

equity in schools”; “reproductive health care in schools". Abstracts were reviewed for relevance,

and those remaining were critically reviewed.

SCHOOL-BASED HEALTH CENTERS IN PHILADELPHIA !3

EXPECTED OUTCOME:

The review of the relevant literature should reveal several benefits to implementing SBHCs as

well as whether there is feasibility in establishing SBHCs in Philadelphia’s public school system.

These findings can have an important implication for addressing the reproductive health care

needs of underserved youth in low-income areas.

SCHOOL-BASED HEALTH CENTERS IN PHILADELPHIA !4

Introduction

Adolescents are known to be the most difficult age group to get into the doctor's office. It

is even more challenging in Philadelphia, where healthcare access is minimal. Even though the

Affordable Care Act gave health insurance to an unprecedented amount of people, there is still

the issue of actually being in close enough proximity to a primary care provider for there to be

geographical access to health care. “The odds of being in a low access area were 28 times greater

for census tracts with a high proportion of African Americans than in tracts with a low proportion

of African Americans” (Brown, Polsky, Barbu, Seymour, & Grande, 2016). About one-third of

Philadelphia’s low-access areas are neighborhoods that have at least 80 percent African Ameri-

can populations with north Philadelphia being one of these areas. However, the study also found

that “Philadelphia as a whole is not lacking in total number of primary care providers” (Brown et

al., 2016). This finding makes the presence of health disparities in Philadelphia even more worri-

some.

The child poverty rate is around 40% in the city, and almost every child in North and

West Philadelphia lives at or below the federal poverty line (Westervelt, 2013). There are com-

munities with predominantly African American residents who already suffer from massive racial

and ethnic health disparities. For example, African American children and adolescents with

asthma had more hospitalizations, disability, and a higher mortality rate compared with that of

White children and adolescents with asthma (Guo, Wade, & Keller, 2010). The children in these

communities are highly at risk of non-completion of school and dropping out, which continues

the vicious cycle of poverty that residents in these low-income communities have experienced

for decades.

SCHOOL-BASED HEALTH CENTERS IN PHILADELPHIA !5

Since teenage years are a time for high-risk behaviors that can lead to unintended preg-

nancies and contraction of sexually transmitted diseases, the high rate of teen pregnancy in the

U.S. is a significant public health issue with harmful consequences for both mother and child.

“Pregnant teens are more likely than older women to receive late or no prenatal care, have gesta-

tional hypertension and anemia, and achieve poor maternal weight gain” (Meade & Ickovics,

2005). There are also many long term consequences of teen motherhood, which include lower

educational attainment, lower levels of employment and income as well as higher rates of marital

instability compared to older mothers. Meanwhile, females with STDs are at increased risk of

cervical cancer, pelvic inflammatory disease, involuntary infertility, and premature death. These

are some of the many dangers that female high school students face when lacking access to re-

productive health care as well as regular STD screenings.

Chlamydia, a sexually transmit-

ted disease (STD), is the most com-

monly reported infectious disease in

the city of Philadelphia (“Chlamydia

Surveillance", 2017). It is contracted

through having vaginal, anal, or oral

sex with an individual who has

Chlamydia ("Chlamydia", 2017). Even

if a person has been treated for

Chlamydia in the

past, they can be re-

Figure 1. Rate of Chlamydia infection in Philadelphia, PA by neighborhood (2017).

Adapted from “Annual Report” by Philadelphia Department of Public Health.

SCHOOL-BASED HEALTH CENTERS IN PHILADELPHIA !6

infected with Chlamydia. The initial destruction caused by Chlamydia is usually not recognized,

but severe health issues can eventually manifest as a result. Treatment of Chlamydia is relatively

easy and is cured with a week-long course of antibiotics. The 15-19-year-old population in Phil-

adelphia is the most commonly affected. It is also most rampant in the areas of Philadelphia that

are suffering from incredible economic disparity and lack of access to healthcare.

In a study titled “High School Dropouts and Sexually Transmitted Infections”, the rela-

tionship between dropping out of high school and the likelihood of contracting a sexually trans-

mitted infection (STI) was analyzed. Both girls and boys who drop out were found to have much

higher rates of becoming infected with an STI than those who stay in school (Anderson & Port-

ner, 2014). Interestingly, dropping out of high school is associated with a nine to ten times per-

cent increase in the likelihood that a female student will contract an STI in comparison to a male

student. One theory states that high school dropouts enter relationships with a much different

population compared to their non-dropout counterparts. Females, who drop out, pair up with

much older males and therefore have a higher risk of contracting an STI. Whatever the reason

may be, female students are at greater risk than males according to the data present. This is a

huge issue in itself but even more significant when coupled with the fact that there is also the

danger of passing on Chlamydia to a baby during childbirth if the mother is infected with it

("Chlamydia", 2017). If untreated, Chlamydia can also spread to the uterus and fallopian tubes,

causing pelvic inflammatory disease which can permanently damage a woman’s reproductive

system. This can lead to infertility, ectopic pregnancies, and an increased likelihood of contract-

ing and spreading human immunodeficiency virus, also known as HIV. These are some of the

severe health implications if Chlamydia is not treated. Some of these issues may also lead to fe-

SCHOOL-BASED HEALTH CENTERS IN PHILADELPHIA !7

male students cutting their education shorter. While being the most common infectious disease, it

is just one of the many STDs plaguing the teenage population in Philadelphia.

In a study called “Programs to increase high school completion: a community guide sys-

tematic health equity review”, it was stated that “High school completion is an established pre-

dictor of long-term morbidity and mortality” (Hahn & Knopf, 2015). Consequentially, there is

also a positive relationship between the lack of high school completion and STI contraction, as

previously stated. To reduce the spread of STI’s, it is imperative to become aware of the determi-

nants of STI’s due to their consequence on health and economy. This study shows that:

Certain STIs can lead to cancer, infertility, or even death. Treating STIs and their complications

place a substantial stress on health expenditures; estimation of the costs of STIs are at $17 billion

per year. A focus on young people is vital because nearly half of STIs contracted occur among

individuals 15 to 24 years of age, and teens and young adults account for almost 30 percent of

new HIV infections annually (Anderson & Portner, 2014). The lack of STD prevention has dire

effects on the economy and the overall well being of Philadelphia residents.

School-aged children, who are in the midst of their physical and mental development, are

particularly vulnerable to their environment. Since they spend the majority of their day at school,

the school climate has a significant impact on students. “The National School Climate Center

uses the term ‘school climate’ to describe ‘the quality and character of school life,” reflecting the

internal social norms, values organization, and teaching and learning practices within the

school.” ("School Climate, Student Success and the Role of School-Based Health Care", 2018).

School climate can have long term consequences on overall well-being and quality of life. It can

SCHOOL-BASED HEALTH CENTERS IN PHILADELPHIA !8

lead to fostering academic success as well as social and emotional growth or reinforcing negative

lifestyle factors.

Currently, many Philadelphia schools are in unacceptable condition. An estimated $4.5

billion is needed to bring every school and athletic field in the city up to code (Petrillo, 2019). In

2013, 23 schools were closed in Philadelphia to avoid a projected $1.35 billion budget deficit

over five years due to a cut of more than $400 million in state funding. However, the stability of

leadership has helped make dramatic improvements in recent years. State funding has increased

while district governance has transferred from the state-run School Reform Commission to a

city-run board. Dr. Hite has been the superintendent of Philadelphia public schools since 2012

(Hurdle, 2019). The latest score in the districts annual School Progress Report rose for the third

consecutive year from 33 percent in 2014-2015 to 42 percent in 2017-2018. This advancement

indicates improvement in the areas of student achievement and progress, college and career

readiness, and school “climate.” Attendance and parental involvement are measurements of

school “climate” (Hurdle, 2019). Even so, most recent reports are showing that only 46% of stu-

dents are attending 95% or more of school days and only 69% of students in district-led and al-

ternative schools are graduating (Hurdle, 2019).

A school-based health center (SBHC) is a physicians office located in a school or on

school grounds that provides a range of medical care and services such as immunizations, repro-

ductive health care, preventative care, and dental care among others. Reproductive health care

services include gynecological exams, HIV testing and counseling, emergency contraception,

condoms, pregnancy testing, and STD diagnosis and treatment (Santelli & Nystrom, 2003). SB-

HCs can act as a health hub for the entire community since school employees, as well as resi-

SCHOOL-BASED HEALTH CENTERS IN PHILADELPHIA !9

dents of the neighborhood, can use its services. SBHCs were first introduced after the success of

a model in the 1970s that addressed lack of prenatal care and birth complications for teenage

mothers at public high schools in Minnesota (Keeton, Soleimanpour, & Brindis, 2012). The pro-

gram was such a success that it gained national attention and brought the models potential to

light. SBHCs were an answer to issues of health inequity and lack of access to health care for

children in underserved communities. Once health care and education policymakers saw the val-

ue of school-based health delivery in meeting the need for greater access to health care among

adolescents, funding and community-based efforts increased to facilitate the growth of SBHCs

across the country. By 1988, there were around 120 SBHCs in the United States (Keeton,

Soleimanpour, & Brindis, 2012). Although the number of SBHCs in the country has been grow-

ing throughout these past years, Philadelphia public schools do not have any SBHCs. The pur-

pose of this study is to evaluate whether the establishment of SBHCs would be feasible and ben-

eficial in Philadelphia public school systems.

Methods

A literature review and analysis was conducted through an online search of databases and

government websites including Medline, PubMed, National Center for Biotechnology Informa-

tion, Center for Disease Control, National Institute of Health, and Google Scholar. A Google

search for credible local news sources was also performed. The search was limited to articles

from 2000-2019. Search strategies used subject headings and keywords such as “SBHCs”;

“school-based health center”; “health inequity in schools,”; “reproductive health care in

schools”. Abstracts were reviewed for relevance, and those remaining were critically reviewed.

SCHOOL-BASED HEALTH CENTERS IN PHILADELPHIA !10

Analyses were done to look at policies affecting SBHCs, benefits of SBHCs, and feasibility of

SBHCs.

Results and Discussion

This study has shown that school-based health centers are an excellent method to reach

high school students in Philadelphia to provide access to reproductive health care services to

prevent STDs and unwanted teen pregnancy. There is evidence of increased contraceptive use

among students with access to an SBHC (Keeton, Soleimanpour, & Brindis, 2012). A study has

also shown a decrease in pregnancy rates in schools with an SBHC on site (Santelli & Nystrom,

2003). A higher number of prenatal care visits as well as a decreased likelihood of delivering low

birth weight babies has also been shown to be a consequence of SBHC utilization (Bersamin,

Fisher, Gaidus, & Gruenewald, 2016).

The establishment of SBHCs is proven to result in the improvement of educational and

health outcomes for disadvantaged students. Research has shown that the provision of SBHCs

leads to a reduction in rates of school suspension or high school noncompletion along with an

increase in grade promotion and grade point averages (Knopf et al., 2016). There has also been a

substantial increase in immunizations and other preventive services along with a minor increase

in the number of students who reported a regular source of health care (Knopf et al., 2016). Most

importantly, there was a significant overall reduction in ED visits and hospital utilization (Knopf

et al., 2016).

SBHCs address problems regarding transportation, lack of nearby providers, lack of

providers accepting public insurance, and parental difficulties in getting time away from work to

take a child to the doctor (Guo, Wade, & Keller, 2010). The establishment of SBHCs indirectly

SCHOOL-BASED HEALTH CENTERS IN PHILADELPHIA !11

helps parents retain employment and helps employers increase worker productivity. Healthcare

inequities are known to lead to poor health outcomes, which in turn lead to poor educational out-

comes. These are some of the significant strides made in health care access through the estab-

lishment of SBHCs.

Partnerships

There is a wide range of steps needed to be taken to implement successful SBHCs in in-

ner city schools in Philadelphia. Firstly, there needs to be a relationship established between the

health and education system to improve access to primary and preventive care services (Keeton,

Soleimanpour, & Brindis, 2012). “SBHCs are most often sponsored or operated by a local health

care organization such as a community health center (CHCs; 28%), hospital (25%), or local

health department (15%)” (Keeton, Soleimanpour, & Brindis, 2012). School systems, nonprofit

organizations, mental health agencies, or universities also sponsor SBHCs. There are many po-

tential partners in the area, including hospitals such as Children’s Hospital of Philadelphia,

Shriners Hospital for Children, Hahnemann University Hospital, etc. Also, there needs to be

community support behind the implementation of SBHCs into local high schools. Town-hall

style meetings with parents of students, school administrators, state officials and representatives

of local hospitals and clinics are a great way to have all the key stakeholder in the room at the

same time to address any concerns. This method ensures that everyone is included in the process

and while strengthening the relationship between the school and the students’ parents. School

and community factors are critical in supporting, or impeding, the opening and maintenance of

an SBHC (Bersamin et al., 2016).

SCHOOL-BASED HEALTH CENTERS IN PHILADELPHIA !12

Funding

States and federal public health agencies play a huge role in the implementation of SB-

HCs by contributing “funding for SBHCs, setting program standards, collecting evaluation data

to demonstrate impact, and advocating for long-term sustainable resources” (Schlitt, Juszczak, &

Eichner, 2008). Pennsylvania is one of thirty-two states that does not invest in SBHCs ("18 State

Governments Commit Resources to SBHCs”, 2014). There needs to be significant state-level po-

litical and advocacy activities to support the establishment of SBHCs. A special task force needs

to be put together to write state legislative proposals, budgets, and policy study reports (Schlitt,

Juszczak, & Eichner, 2008). In the past, “legislative and executive task force reports from 13

states recommended state-level support of SBHCs as remedies to intractable public health con-

cerns such as poor adolescent health outcomes, infant mortality, and teen pregnancy” (Schlitt,

Juszczak, & Eichner, 2008). The policy written could include incentives for SBHCs to produce

positive health and educational outcomes as well as incentives for hospitals and clinics to work

in SBHCs. Tax credits are provided for individuals and organizations who develop and sustain

policies and programs to keep SBHCs afloat. There would also need to be a collaboration with

health insurance companies to set up a model for reimbursement.

The most cost-efficient option would be the Federally Qualified Health Center (FHQC)

model. It would be the best for long-term sustainability since FHQC management would have

“the expertise to administer a medical office and economies of scale in obtaining medical sup-

plies” (Sprigg, Wolgin, Chubinski, & Keller, 2017). It can be seen in figure 2 that this type of

SBHC has had the most growth in comparison to other models. An SBHC with an FQHC status

would also not run the risk of running out of funding if the state budget can’t afford to allocate

SCHOOL-BASED HEALTH CENTERS IN PHILADELPHIA !13

funds to SBHCs one particular year. An FHQC is also open to the public and not just students.

This model relies heavily on billing

public health insurance programs as

does the model using state grants.

However, the SBHC model using

state grants as funding would only

cater to students making it

the most student-friendly

option.

These funding models can be implemented independently from one another, but using

multiple sources of funding has proved to be a success. Depending on the funding model chosen

to start an SBHC, different policies will need to be implemented to bring SBHCs to life in Phil-

adelphia. Execution of the development of SBHCs requires advocacy for the policy and coordi-

nation between multiple stakeholders. Each SBHC model brings various sets for pros and cons

with it. The most prosperous SBHCS have a stable base of operations funding from the govern-

ment and community partners as well as allocated staff time for overseeing of operations (Swider

& Valukas, 2004). As health inequity remains an issue for the youth of Philadelphia, various pol-

icy options and their feasibility should be considered by the Philadelphia Board of Education.

Mayor Jim Kenney is proposing a $5 billion budget with considerable investments in

Philadelphia schools. He plans to distribute $214 million to the school district and pledges to in-

Figure 2. Cumulative Change in SBHC Sponsor Type from 2001-2017.

Adapted from “2016-17 National School-Based Health Care Census”.

SCHOOL-BASED HEALTH CENTERS IN PHILADELPHIA !14

crease school spending by $700 million over the next five years (Vargas & McCrystal, 2019). He

also intends to open five community schools in the next fiscal year and increase the number of

pre-K slots from 2,250 to 3,300. It would be immensely beneficial to children of Philadelphia to

direct some of the budgets towards facilitating the start-up of school-based health centers. Stud-

ies show that the economic benefit of SBHCs exceeds the operation cost and results in net sav-

ings to Medicaid (Ran, Chattopadhyay, & Hahn, 2016). SBHCs are financed and sustained

through a variety of sources. These sources include reimbursement from public insurance pro-

grams and private health plans; contributions from school districts and other partners; local,

state, and federal grants (“Funding School-Based Health Care”).

It would be a step in the right direction for the state of Pennsylvania to allocate funds to

bring health care access to public high schools, especially in North and West Philadelphia. This

would include STD testing, prescribing medications for STDs, and pregnancy testing in school

without the students having to visit the doctor’s office to be treated. Increasing the number of

SBHCs is a promising strategy to provide health care access to the youth. It is an alternative form

of health care delivery that has proven to be more effective due to the many barriers that children

face in accessing health care.

Concerns

When it comes to SBHCs, a source of concern may be regarding social and ethical feasi-

bility. Many parents are not in support of SBHCs providing reproduction health services. Over

60% of SBHCs are prohibited from providing contraception on site even though contraception is

legal, and adolescents are guaranteed the right to contraception under state law and judicial opin-

ion (Santelli & Nystrom, 2003). These prohibitions are usually put in place by the school district,

SCHOOL-BASED HEALTH CENTERS IN PHILADELPHIA !15

the SBHCs sponsoring organization, state-level limitations, and concerns about the acceptability

of dispensing contraception by the surrounding community (Keeton, Soleimanpour, & Brindis,

2012). Local community groups may show intense opposition based on moral traditionalism and

family value leading to a culture war seeping into the school environment (Bersamin et al.,

2016).

Conclusion

SBHCs have been repeatedly proven to be effective at improving school climate and

promoting student wellness. There needs to be an increase in funding as well as policy changes

to establish SBHCs that operate at their highest potential to address the needs of our communi-

ties. Prevention of high school dropout, reduced emergency room visits, and promotion of repro-

ductive health care are a few of the benefits of implementing SBHCs.

The literature supports the establishment of school-based health centers in Philadelphia as

an efficient to deliver much-needed health care services to underserved youth. The prosperity of

school-aged children depends not only on the quality of their education but also their health.

SBHCs are effective in addressing a variety of issues that can reduce health disparities across

various races and ethnic groups. They can be a means to treat a hard-to-reach patient population

to meet their physical and mental health needs. Philadelphia would greatly benefit from the pro-

vision of school-based health centers.

SCHOOL-BASED HEALTH CENTERS IN PHILADELPHIA !16

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