Original article
Impact of a school-based intervention on access to healthcare for underserved youth

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Abstract

Purpose: To determine whether a multidimensional school-based intervention, which included physical and mental health services, increased adolescents’ use of needed medical care and preventive care and decreased emergency room use.

Methods: A total of 2832 seventh- through twelfth-grade students in six public urban intervention schools and 2036 students in six demographically matched comparison schools completed a previously validated survey regarding health status and healthcare utilization in spring 1998 and 1999. Bivariate analyses examined the association between intervention status and Year 1/Year 2 outcomes. The multifaceted intervention included programs such as anger management groups, substance abuse prevention, tutoring, home visits, and enhanced school health services. Stepwise multivariate logistic models tested differences between the intervention and comparison groups across years, controlling for potential confounding variables [gender, age, race/ethnicity, maternal education, grade in school, school district (city or county), health status, and chronic health problems]. The interaction term for Group × Year was used to test the effect of the intervention. Multivariable modeling was also used to determine student factors independently associated with healthcare utilization.

Results: Respondents had a median age of 15 years, 56% were female, 51% were white, 42% were black, and 34% reported chronic health problems. In both years, over 45% of students in both groups reported not seeking medical care they believed they needed. The proportion with missed care in the intervention schools did not change, whereas the proportion with missed care in the comparison schools increased. Emergency room use decreased slightly in the intervention schools and increased slightly in the comparison schools between Year 1 and Year 2. There were no major changes in healthcare delivery in this area during the year, demonstrating the volatility of adolescents’ perceived access to care. Among the student factors, health status, having a chronic condition, and being in a higher grade were independently associated with students’ report of not seeking care they believed they needed.

Conclusion: These results confirm that many adolescents have unmet healthcare needs. Those with poor health status are most likely to report underutilization and unmet needs. These findings underscore the need for comparison groups when evaluating interventions and suggest the need for better understanding of community level changes in perceived healthcare access and use.

Section snippets

The Children First Plan

The Plan is a 3-year pilot intervention program designed to improve outcomes for children and families in high-risk schools and neighborhoods in Hamilton County, Ohio. The Plan was developed by the Family and Children First Council, a multidisciplinary organization of over 80 local agencies and institutions serving children and youth. Based on an extensive needs assessment, including community input, the Council identified four priorities for the Plan: reducing school absences and discipline

Population

The target population for the student survey consisted of all seventh- through 12th-grade students enrolled in regular classes in the intervention and comparison schools. Precise participation rates could not be calculated owing to lack of exact enrollment and attendance data for the days that the survey was administered. The response rate calculations that follow are based on best-guess estimates. The overall proportion of enrolled students who completed useable surveys was approximately 42%.

Results

Participant characteristics, stratified by intervention versus comparison group and by year, are summarized in Table 1. The groups were similar with respect to gender, health status, and the presence of one or more chronic health conditions over both years. Although the median age was 15 years in all groups and the median grade was ninth, the nonparametric testing demonstrated that the intervention students were older in Year 2 and that the grade level was higher for both the intervention and

Discussion

Students in these schools, especially those with fair or poor health status, report high levels of unaddressed healthcare needs. The proportion who reported not seeking medical care they believed they needed in the past year was almost double the lifetime rate of 27% found in the Commonwealth Fund’s recent national survey [11]. This disparity likely reflects the disadvantaged status of the poor and middle-class urban public school students in our population. There was a 6% absolute increase in

Acknowledgements

This project was supported by the Family and Children First Council of Hamilton County, Ohio and by Children’s Hospital Medical Center and the Institute for Health Policy and Health Services Research, University of Cincinnati, Cincinnati, Ohio. The authors thank the staff and students of the participating school districts for their participation, and Carol Muir for assistance with manuscript preparation.

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