The changing paradigm of community health: the role of school-based health centers

Adolescence, Spring, 1995 by Thomas P. Gullotta, Lynn Noyes

INTRODUCTION

Providing health services in public schools is not a recent occurrence. In the 1890s health programs were launched in response to the large number of immigrant children who arrived in the United States and its "gateway" cities suffering from infectious diseases such as tuberculous. The earliest school health interventions were undertaken by physicians. It was not until the 1930s that schools began to promote standardized health screenings and first aid, with referrals to private physicians for additional care. This model of care began to change in the 1940s when urban schools began to increase their nursing staff to provide day-to-day and follow-up care to young people.

Disputes over the provision of that health care to enrolled students are also not recent. Although school health nursing services started in New York City, in 1902, an expanded role for school-based health care was heatedly denounced by the American Medical Association during the 1920s as socialized medicine (Garfinkel, 1993; Tyack, 1992). Care during those "golden" years of low technology healing was provided by medical personnel without the armory of laboratory tests, technological wizardry, and medicines that have revolutionized the health care field. With the development of this technology, the rapid increase in medical sub-specialities, and the cost associated with medical care, access to care has been restricted. This generated a new model of school-based health care that is the focus of this article.

Access to Care

In 1990, nearly 10 million people under the age of 18 had no medical insurance (DHHS, 1993). In 1991, young people living in poverty were almost twice as likely to see a physician in a hospital setting as in an office (DHHS, 1993). In that same year, youth from families earning less than $20,000 averaged almost twice as many hospital days per 1,000 persons as those from higher earning families (DHHS, 1993). Further, for youth between the ages of 5 to 17, there was a relationship between income and lost school days; as income increased the number of days missed due to illness decreased (DHHS, 1990).

Interestingly, difficulty in accessing health care is not only a problem of the impoverished. Highest utilization rates of physicians (typically at hospital emergency rooms) were by Medicaid clients. Next, were privately insured individuals, while the poorest served were the noninsured "working poor" whose employers could presumably no longer afford to provide health care benefits (DHHS, 1990). While Medicaid physician utilization rates may appear to be a harbinger of good health, it needs to be recognized that visits by Medicaid clients for acute episodic care at hospital emergency rooms differs significantly from the client-patient continuity of care relationship that has developed between privately insured patients and their primary care physicians.

Adolescent Demographic and Health Risk Factors

Against this backdrop of difficulty in accessing appropriate health care for youth, a second scenario unfolds. In recent years, the United States adolescent population has declined as a percentage of the total population, and its socioeconomic status has changed. Presently, 68.2% of the population of the United States is over the age of 21; youth between the ages of 10 to 21 constitute only 17.1% of the population. Of interest is the fact that the percentage of United States citizens over the age of 65 (12.6%) currently exceeds the percentage of youth between the ages of 10 to 17 (11%; U.S. Census Bureau, 1992). It should be noted that at the time of the American revolution the average age was 18 (Adams & Gullotta, 1983). Further, it is expected that this "greying" of the United States will continue well into the next century. From this data, two conclusions can be drawn. First, it appears that in the next century there will be fewer than two working adults for every social security recipient in contrast to the nearly three workers in the labor force today. Second, it can be seen that the United States cannot afford to lose the future work productivity of a single adolescent if it wishes to remain a significant economic power.

Complicating this demographic picture is the fact that one in four young people presently live in poverty in the United States. Since 1970, this number has grown with each decade. In 1970, 41.5% of black children and 10.5% of white children lived below the poverty line. This percentage increased in 1980, with 42.1% of black children, 13.4% of white not Hispanic children, and 33% of Hispanic children living in poverty. Recent 1990 census data reveals a continuation of this discouraging trend, with 44.7% of black, 15.6% of white not Hispanic, and 38.2% of Hispanic youth living in poverty (U.S. Census Bureau, 1992).

Further compounding this problem is the fact that while most adolescents are physically healthy (although an estimated 2 million have chronic conditions that impede activity), young people are at significant risk for certain dysfunctional behaviors and poor decision making that can have lifelong negative consequences (Gans, Blyth, Elster, & Gaveras, 1990; Adams, Gullotta, & Markstrom, 1994). For example, the development of habits leading to the misuse of alcohol, cigarettes, and other harmful substances occur during adolescence. In 1991, between the ages of 12 to 17, 20.3% of young people used alcohol in the previous month; 10.8% used cigarettes; and 4.3% used marijuana. For 15- to 17-year-olds, percentages for alcohol, cigarettes, and marijuana use were 35%, 21%, and 9%, respectively (DHHS, 1993).