Robert J. Nystrom

Adolescents report their need for and use of health care services

PURPOSE The goals of this study were to describe student access to health care services, identify populations of students who remained in need of health care services, and highlight particular unmet needs for health care identified by these adolescents. METHODS Students in Grades 9-12 attending 50 schools in Oregon completed the Youth Risk Behavior Surveillance Survey (YRBS). Questions requesting adolescents to report their need for specific types of health care, and access to general and specific types of care were added to the core YRBS. Multivariate logistic regression analysis was used to determine independent relationships between student or community characteristics and health care access or unmet needs for care. RESULTS Almost 14,000 adolescents completed surveys, of whom 75% reported visiting one or more health care provider within the last 12 months. Nineteen percent of adolescents reported that they had not received 1 or more of 10 specific types of care when needed in the last year. Females, some racial/ethnic minorities, rural, and sexually active adolescents were more likely to report unmet needs for health care. Most frequently, adolescents reported they needed but did not receive care for an illness (7%) or for personal or emotional problems (6%). In addition, about 400 (3%) students reported they needed birth control that they did not receive. CONCLUSIONS A majority of high school-age adolescents had visited health care providers within the year prior to study. However, the number of adolescents who reported unmet specific health care needs within the same time period remained substantial.

School-based health centers: accessibility and accountability

PURPOSE To examine the current experience of school-based health centers (SBHCs) in meeting the needs of children and adolescents, changes over time in services provided and program sponsorship, and program adaptations to the changing medical marketplace. METHODS Information for the 1998-1999 Census of School-Based Health Centers was collected through a questionnaire mailed to health centers in December 1998. A total of 806 SBHCs operating in schools or on school property responded, representing a 70% response rate. Descriptive statistics and cross-tab analyses were conducted. RESULTS The number of SBHCs grew from 120 in 1988 to nearly 1200 in 1998, serving an estimated 1.1 million students. No longer primarily in urban high schools, health centers now operate in diverse areas in 45 states, serving students from kindergarten through high school. Sponsorship has shifted from community-based clinics to hospitals, local health departments, and community health centers, which represent 73% of all sponsors. Most use computer-based patient-tracking systems (88%), and 73% bill Medicaid and other third-party insurers for student-patient encounters. CONCLUSIONS SBHCs have demonstrated leadership by implementing medical standards of care and providing accountable sources of health care. Although the SBHC model is responsive to local community needs, centers provide care for only 2% of children enrolled in U.S. schools. A lack of stable financing streams continues to challenge sustainability. As communities seek to meet the needs of this population, they are learning important lessons about providing acceptable, accessible, and comprehensive services and about implementing quality assurance mechanisms.

Reproductive health in school-based health centers: findings from the 1998–99 census of school-based health centers

PURPOSE To describe the state of reproductive health services, including access to contraception and health center policies, among school-based health centers (SBHCs) serving adolescents in the United States METHODS We examined questionnaire data on provision of reproductive health services from the 1998-99 Census of School-Based Health Centers (response rate 70%). We examined 551 SBHCs in schools with high or middle school grades. We used logistic regression to define factors independently associated with services and policies. RESULTS Most SBHCs (76%) were open full-time; over one-half (51%) of centers had opened in the past 4 years. Services provided, either on-site or by referral, included gynecological examinations (95%), pregnancy testing (96%), sexually transmitted disease (STD) diagnosis and treatment (95%), Human Immunodeficiency Virus (HIV) counseling (94%), HIV testing (93%), oral contraceptive pills (89%), condoms (88%), Depo-Provera (88%), Norplant (78%), and emergency contraception (77%). Counseling, screening, pregnancy testing, and STD/HIV services were often provided on-site (range 55%-82%); contraception was often provided only by referral (on-site availability = 3%-28%). SBHCs with more provider staffing were more likely to provide services on-site; rural SBHCs and those serving younger grades were less likely to provide these services on-site. Over three-quarters (76%) of SBHCs reported prohibitions about providing contraceptive services on-site; the sources of these prohibitions included school district policy (74%), school policy (30%), state law (13%), and health center policy (12%). While SBHCs generally required parental permission for general health services, many allowed adolescents to access care independently for certain services including STD care (48%) and family planning (40%). Older SBHCs were more likely to allow independent access. CONCLUSIONS SBHCs provide a broad range of reproductive health services directly or via referral; however, they often face institutional and logistical barriers to providing recommended reproductive health care.

Correlates of gambling among eighth-grade boys and girls.

BACKGROUND This study examined the correlates of gambling behavior among eighth-grade students. METHODS Children (n = 15,865) enrolled in publicly funded schools in Oregon completed the 2008 Oregon Healthy Teens survey. Multivariate logistic regression analyses assessed the combined and independent associations between risk and protective factors with active gambling among male and female youth separately. RESULTS Approximately 17% of eighth-grade girls and 33% of eighth-grade boys had gambled during the past 3 months. Most health risk behaviors were positively associated with gambling. However, gambling was also positively associated with frequent physical activity participation and, among boys, eating 5 daily servings of fruits and vegetables. Logistic regression analyses identified significant differences among risk and protective factors between active gamblers and non-gamblers. Regardless of gender, relative to active gamblers, non-gamblers were more likely to hold strong personal health beliefs, be uninvolved in antisocial behavior, exhibit good safety behaviors, and not have experienced a mouth injury while playing sports during the past year. Female gamblers were more likely to be active tobacco users, to speak a language other than English at home, and engage in more than 2 hours a day of screen time than non-gamblers. Male gamblers were more likely to be physically active, Hispanic, use alcohol, and perceive lower levels of social control in their neighborhoods than non-gamblers. CONCLUSIONS Gambling may be a topic that is appropriate for inclusion in school programs targeting health risk reduction among eighth-grade students.

Planning and Sustaining a School-Based Health Center: Cost and Revenue Findings from Oregon

Objective. Research concerning school-based health center (SBHC) costs and revenues is limited. This article discusses Oregons SBHC State Program Office methodology and findings regarding costs and revenues for planning and operating Oregon SBHCs. Methods. A variety of data sources and case studies conducted in five Oregon SBHC systems were used to calculate startup and annual operations costs. All Oregon SBHCs completed a survey providing 2005–2006 revenue data. Revenue data were further linked to 2005–2006 client utilization data, such as the number and age of unduplicated clients, public and private insurance status, and medical sponsor type. Results. Startup costs for Oregon SBHCs depended largely on the status of available space. Median, minimum, and maximum annual operations costs were calculated for core, intermediate, and expanded models of service delivery, and depended mostly on provider hours and types. Centers with federally qualified health center medical sponsors rely heavily on revenue from billing public insurance programs. Billing revenue depends on the percent of uninsured visits. School socioeconomic indicators such as the percent of students eligible for free and reduced lunch may be good indicators for the percent of student clients with public insurance. Conclusions. The methodology employed may encourage other state SBHC agencies or organizations to adopt research designs to collect and analyze cost and revenue data. On a practical level, the findings provide state and local policy makers and communities planning SBHCs with preliminary estimates for the costs of startup and annual operations, and some understanding of income sources and billing revenue projections.

Health Risks of Oregon Eighth-Grade Participants in the "Choking Game": Results From a Population-Based Survey

OBJECTIVE: To examine the risk behaviors associated with participation in the “choking game” by eighth-graders in Oregon. METHODS: We obtained data from the 2009 Oregon Healthy Teens survey, a cross-sectional weighted survey of 5348 eighth-graders that questioned lifetime prevalence and frequency of choking game participation. The survey also included questions about physical and mental health, gambling, sexual activity, nutrition, physical activity/body image, exposure to violence, and substance use. RESULTS: Lifetime prevalence of choking game participation was 6.1% for Oregon eighth-graders, with no differences between males and females. Of the eighth-grade choking game participants, 64% had engaged in the activity more than once and 26.6% >5 times. Among males, black youth were more likely to participate than white youth. Among both females and males, Pacific Islander youth were much more likely to participate than white youth. Multivariate logistic regression revealed that sexual activity and substance use were significantly associated with choking game participation for both males and females. CONCLUSIONS: At >6%, the prevalence of choking game participation among Oregon youth is consistent with previous findings. However, we found that most of those who participate will put themselves at risk more than once. Participants also have other associated health risk behaviors. The comprehensive adolescent well visit, as recommended by the American Academy of Pediatrics, is a good opportunity for providers to conduct a health behavior risk assessment and, if appropriate, discuss the dangers of engaging in this activity.

Shifting the Paradigm in Oregon from Teen Pregnancy Prevention to Youth Sexual Health

Oregons work on teen pregnancy prevention during the previous 20 years has shifted from a risk-focused paradigm to a youth development model that places young people at the center of their sexual health and well-being. During 2005, the Oregon Governors Office requested that an ad hoc committee of state agency and private partners develop recommendations for the next phase of teen pregnancy prevention. As a result of that collaborative effort, engagement of young people, and community input, the Oregon Youth Sexual Health Plan was released in 2009. The plan focuses on development of young people and embraces sexuality as a natural part of adolescent development. The plans five goals and eight objectives guide the work of state agencies and partners addressing youth sexual health. Oregons development of a statewide plan can serve as a framework for other states and entities to address all aspects of youth sexual health.

Health Service Integration in Oregon School-Based Health Centers: Meeting the Mental Health Needs of Young People

School-based health centers (SBHCs) break down traditional barriers encountered by young people in the healthcare system. Along with physical health services, all of Oregons SBHCs provide some level of mental health services. As more evidence reveals the connection between mental and physical health, integrated care systems that improve health outcomes for those with mental health concerns become increasingly important. Oregons SBHCs have varying levels of ability to address physical and mental health service integration, based on community resources and logistical limitations. Using data from an assessment of Oregons SBHC mental health system, this article offers recommendations for how more integrated services in an SBHC can help fill gaps to better meet young peoples mental health needs in Oregon.