Mixed-methods Exploration of Telehealth-supported Long-acting Reversible Contraceptive Services in School-based Health Centers: How Much Added Value?

INTRODUCTION: This study explored adolescent and young adult preferences and experiences with telehealth-supported long-acting reversible contraceptive (LARC) services in New York City school-based health centers (SBHCs) during COVID-19. METHOD: Sequential mixed methods included post-LARC insertion surveys and in-depth interviews. RESULTS: Survey respondents (n = 45) were aged 14-21 years and predominantly Hispanic (53.3%). Only four respondents completed a postinsertion visit via telehealth. Most (82.2%) preferred in-person for future LARC visits; none preferred telehealth. Four themes emerged in interviews (n = 15): LARC self-efficacy and autonomy; SBHC convenience and accessibility; comfort with SBHC providers; and preference for in-person visits despite telehealth benefits. DISCUSSION: Although telehealth theoretically adds value to LARC service delivery, uptake and preference for telehealth in the SBHC context were low. Despite the perceived acceptability of telehealth, adolescents and young adults prefer in-person SBHC visits, suggesting SBHC access may eliminate barriers to care that telehealth seeks to overcome.

Adapting Family Planning Service Delivery in Title X and School-Based Settings during COVID-19: Provider and Staff Experiences.

The COVID-19 pandemic introduced urgent and unique challenges to family planning providers and staff in ensuring continued access to high-quality services, particularly for groups who experience greater barriers to accessing services, such as women with systemically marginalized identities and adolescents and young adults (AYA). While research has documented key adaptations made to service delivery during the early phase of the pandemic, limited studies have used qualitative methods. This paper draws on qualitative interview data from family planning providers and staff in Title-X-funded clinics and school-based clinics-two settings that serve populations that experience greater barriers to accessing care-to (a) describe the adaptations made to service delivery during the first year of the pandemic and (b) explore provider and staff experiences and impressions implementing these adaptations. In-depth interviews were conducted with 75 providers and staff between February 2020 and February 2021. Verbatim transcripts were analyzed via inductive content analysis followed by thematic analysis. Four key themes were identified: (1) Title-X- and school-based staff made multiple, concurrent adaptations to continue family planning services; (2) providers embraced flexibility for patient-centered care; (3) school-based staff faced unique challenges to reaching and serving youth; and (4) COVID-19 created key opportunities for innovation. The findings suggest several lasting changes to family planning service delivery and provider mindsets at clinics serving populations hardest hit by the pandemic. Future studies should evaluate promising practices in family planning service delivery-including telehealth and streamlined administrative procedures-and explore how these are experienced by diverse patient populations, particularly AYA and those in areas where privacy or internet access are limited.

Remote Implementation of a School-Based Health Promotion and Health Coaching Program in Low-Income Urban and Rural Sites: Program Impact during the COVID-19 Pandemic.

BACKGROUND: Adapting existing health programs for synchronous remote implementation has the potential to support vulnerable youth during the COVID 19 pandemic and beyond. METHODS: The Stanford Youth Diabetes Coaches Program (SYDCP), a school-based health promotion and coaching skills program, was adapted for remote implementation and offered to adolescents from low-income communities in the US: an urban site in San Jose, CA and rural sites in Lawrence County, MO, and Central Valley, CA. Participants completed online pre- and post- surveys. Analysis included paired T-tests, linear regression, and qualitative coding. RESULTS: Of 156 enrolled students, 100 completed pre- and post-surveys. Of those: 84% female; 40% Hispanic; 37% White; 28% Asian; 3% African American; 30% other race. With T-tests and regression models, the following measures showed statistically significant improvements after program participation: health knowledge, patient activation, health understanding and communication, consumption of fruits and vegetables, psychosocial assets of self-esteem, self-efficacy, problem-solving, and ability to reduce stress. Technology barriers were frequently reported at Lawrence County site. 96% participants reported making a lifestyle change after program participation. CONCLUSIONS: Remote implementation of health promotion programs for vulnerable youth in diverse settings has potential to support adoption of healthy behaviors, enhance patient activation levels, and improve psychosocial assets.

Impact of school-based malaria intervention on primary school teachers' time in Malawi: evidence from a time and motion study.

BACKGROUND: School-based health (SBH) programmes that are contingent on primary school teachers are options to increase access to malaria treatment among learners. However, perceptions that provision of healthcare by teachers may be detrimental to teaching activities can undermine efforts to scale up school-based malaria control. The objective of this study was to assess the impact of school-based malaria diagnosis and treatment using the Learner Treatment Kit (LTK) on teachers' time. METHODS: A time and motion study was conducted in 10 primary schools in rural Malawi. Teachers who had been trained to diagnose and treat uncomplicated malaria were continuously observed in real time during school sessions and the time they spent on all activities were recorded by independent observers before and after LTK implementation. A structured form, programmed digitally, was used for data collection. Paired sample t-tests were used to assess pre-post differences in average hours teachers spent on the following key activities: direct teaching; indirect teaching; administration; LTK and non-teaching tasks. Multivariable repeated measures mixed regression models were used to ascertain impact of LTK on average durations teachers spent on the key activities. RESULTS: Seventy-four teachers, trained to use LTK, were observed. Their mean age and years of teaching experience were 34.7 and 8.7, respectively. Overall, 739.8 h of teacher observations took place. The average time teachers spent in school before relative to after LTK was 5.8 vs. 4.8 h, p = 0.01. The cumulative percentage of time teachers spent on core teaching activities (teaching and administration) was approximately 76% and did not change substantially before and after LTK. Some 24.3% of teachers' time is spent on non-teaching activities. On average, teachers spent 2.9% of their time providing LTK services daily. Per day, each teacher spent less time on administrative (0.74 vs. 1.07 h, p = 0.02) and non-teaching activities (0.96 vs. 1.41 h, p = 0.01) during LTK compared with the period before LTK. CONCLUSION: School-based health (SBH) programmes are not detrimental to teaching activities. Teachers manage their time to ensure additional time required for SBH services is not at the expense of teaching duties. Programming and policy implications of tasking teachers with SBH does not have substantial opportunity costs. Teachers should continue delivering SBH programmes to promote learners' health.

Rates, Patterns, and Predictors of Follow-up Care for Adolescents at Risk for Substance Use Disorder in a School-Based Health Center SBIRT Program.

PURPOSE: To examine rates, patterns, and predictors of follow-up care for adolescents screened as being at risk for substance use disorder (SUD) in a school-based health center (SBHC) Screening, Brief Intervention and Referral to Treatment (SBIRT) program. METHODS: Electronic health records were extracted of adolescents who received health care services from one of three high school-based health centers implementing SBIRT. Patterns and predictors of engagement in follow-up care within 8 weeks following the week of a positive SUD risk screen were analyzed using item response theory (IRT) modeling. RESULTS: Out of 1,327 adolescents receiving SBHC services, 81.2% completed a health screening questionnaire. Of screened adolescents, 17.7% were positive for SUD risk. Across the 8-week follow-up period, 65.4% of adolescents at risk for SUD received at least one follow-up visit. IRT modeling indicated that high levels of engagement in follow-up care were characterized by contact with a behavioral health care (BHC) provider. The percentage of adolescents having follow-up contact with a BHC provider increased significantly after the onset of the COVID-19 pandemic. Engagement in follow-up care was predicted by risk for depression, history of suicidal behavior, being female, and previous sexual activity. DISCUSSION: SBHCs provide a favorable setting for screening and detecting adolescents at risk for SUD. Adolescents at risk for SUD should receive follow-up contact with a BHC provider. Enhanced follow-up engagement efforts may be warranted for adolescents at risk for SUD without risk for depression or suicidal history, as well as for females and those with previous sexual activity.

School-Based Health Center Utilization During COVID-19 Pandemic-Related School Closures.

BACKGROUND: Little is known regarding utilization of school-based health centers (SBHCs) during prolonged school closures, such as those that occurred during the COVID-19 pandemic. We sought to compare SBHC utilization before and after pandemic-related school closures across a network of SBHCs affiliated with a large Southern Californian urban school district. METHODS: We conducted a secondary analysis of encounter data extracted from electronic health records from 12 SBHCs that remained open despite school closures, including patient demographics and diagnostic and billing codes. We used the Clinical Classifications Software Refined to group encounters for common primary care conditions. Utilization before and during pandemic-related school closures was compared using logistic regression with cluster-robust standard errors to account for clustering within clinics, after adjusting for month of encounter. RESULTS: During the pandemic, study SBHCs conducted 52,530 encounters and maintained ∼4040 encounters/month. The frequency of encounters for annual preventative health exams increased for school-aged patients but decreased for other age groups while the frequency of encounters for mental health problems increased for all age groups. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Despite pandemic-related school closures, SBHCs appeared play a critical role in providing primary care to vulnerable communities. CONCLUSIONS: SBHCs may hold value beyond their co-location with academic instruction.

Examining School Based Health Service Utilization Among Marginalized Youth in Connecticut During COVID.

PURPOSE: This study examines how the coronavirus disease 2019 (COVID-19) is affecting utilization of medical and behavioral health services through school based health centers (SBHC s). METHODS: We leveraged the electronic health records from one of the largest sponsors of SBHCs in the country, and tested differences in SBHC utilization with chi-square tests one year prior to the pandemic (pre-pandemic: March 2019-February 2020) compared to one year into the pandemic period (March 2020-February 2021). RESULTS: A significant difference in SBHC utilization was found between pre-pandemic and pandemic periods (P <.001). 63.5% of SBHC patients accessed medical services pre-pandemic compared to 51.2% during the pandemic. In contrast, 36.5% of SBHC patients accessed behavioral services pre-pandemic compared to 48.8% during the pandemic, representing a 12.3% increase in SBHC behavioral service utilization since the pandemic. CONCLUSIONS: SBHCs may serve as an invaluable means of ensuring youth, particularly those from disadvantaged communities, have access to needed behavioral health services during the current public health crisis.

Examining the factors that impact utilization of school-based mental health services for Mexican American adolescents from a rural, borderland community during the time of COVID-19: A quantitative study

Contemporary educational practices comprise of the integration of school based health centers for the treatment of physical and mental health conditions of their student populations. These conditions must be addressed as they greatly impact academic performance and functioning. However, Mexican American adolescents continue to be a population at risk of missing out on these services because they face unique barriers to accessing them. This study examined factors that impacted the use of mental health services for this group and parental attitudes about mental health services surfaced as an area requiring further exploration as these attitudes can impact service engagement for this group. This quantitative cross sectional study included a convenience sample of 274 parents with the majority identifying as Hispanic or Latino (n = 227) and reporting they live in either Luna or Dona Ana Counties (n = 212). Data was collected via self-administered completion of the Parental Attitudes Towards Psychological Services Inventory (PATPSI) and by completion of a demographic survey. Results revealed a statistically significant multivariate effect for both income and language on the combined PAPSI subscales (Help Seeking Attitudes, Help Seeking Intentions and Stigmatization). Results also indicated that there are differences in parental attitudes about mental health services in parents that make less than 30k per year and identify as non-Latino/Hispanic. This study highlights the idea that parents are essential gatekeepers of mental health services of Mexican American adolescents and educational leaders should inventory these attitudes in order to create more equitable access to school based mental health services for this group. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

School-Based Health Services in Virginia and the COVID-19 Pandemic.

BACKGROUND: Schools have a long history of delivering health services, but it is unclear how the COVID-19 pandemic may have disrupted this. This study examined changes in school-based health services and student needs before and during the pandemic and the factors important for delivering school-based health services. METHODS: A web-based survey regarding the impact of the pandemic on school-based health services was distributed via email to all 1178 Virginia public elementary schools during May 2021. RESULTS: Responding schools (N = 767, response rate = 65%) reported providing fewer school-based health services during the 2020-2021 school year than before the pandemic, with the largest declines reported for dental screenings (51% vs 15%) and dental services (40% vs 12%). Reports show that mental health was a top concern for students increased from 15% before the pandemic to 27% (P < .001). Support from families and school staff were identified by most respondents (86% and 83%, respectively) as very important for the delivery of school-based health services. CONCLUSIONS: Schools reported delivering fewer health services to students during the 2020-2021 school year and heightened concern about students' mental health. Understanding what schools need to deliver health services can assist state and local education and health officials and promote child health.

Mental Health Service Provision at School-Based Health Centers During the COVID-19 Pandemic: Qualitative Findings From a National Listening Session.

INTRODUCTION: School-based health centers (SBHCs) provide health services to more than six million youth annually. When schools throughout the United States closed in spring 2020, many SBHCs were also forced to close physical operations.. METHOD: This study uses qualitative data collected from SBHC representatives nationwide to examine supports and challenges affecting mental health services provision during the COVID-19 pandemic, changes in the provision of these services, and priorities for assessing and supporting student mental health needs in the 2021-2022 school year. RESULTS: Partnerships, community and stakeholder buy-in, and student access were key supports to continuous care throughout the pandemic, whereas lack of available staff and lack of in-person access to students were key challenges. Patients demonstrated increased acuity of presenting mental health problems, more immediate and complex mental health challenges, and greater co-morbidities. DISCUSSION: SBHCs pivoted, even with limited resources, to meet students' increasing needs for mental health care.

Promoting Adolescent Healthy Relationships (The About Us Program): Protocol for a Randomized Clinical Trial.

BACKGROUND: Romantic relationships play a critical role in adolescent development, and by middle adolescence, most young people have been involved in at least one romantic relationship, a context in which most sexual interactions occur. Research suggests adolescents lack positive models and skills related to building healthy relationships. OBJECTIVE: This project aims to test the impact of an innovative healthy relationships intervention, called About Us, implemented in school-based health centers (SBHCs) in California in a randomized controlled trial. METHODS: About Us is being tested using a 7-site, 2-group, parallel randomized controlled trial with a treatment versus control allocation ratio of 3:2 to assess the impact of the intervention relative to the standard of care among adolescents aged 14 to 18 years. Adolescents with active parental consent provide study assent at each of the 3 survey time points: baseline, 3 months postintervention, and 9 months postintervention. A stratified randomization procedure was used to ensure balance in key covariates and screening criteria across intervention groups. Through benchmark intent-to-treat analyses, we will examine the primary outcome of this study-the impact of About Us relative to the standard of care 9 months following the end of the intervention on the prevalence of vaginal or anal sex without condoms in the past 3 months. The secondary outcomes are four-fold: what is the impact of About Us relative to the standard of care 3 and 9 months following the end of the intervention, on (1) the prevalence of abstinence from vaginal or anal sex in the past 3 months, (2) composite scores of relationship communication and positive conflict resolution among participants involved in a relationship at baseline, (3) the prevalence of SBHC service use or information receipt in the past 3 months, and (4) composite scores of condom use intentions and attitudes regarding condoms and other birth control? Additionally, as part of our sensitivity analyses, two additional analyses will be implemented: modified intent-to-treat and complete case analysis. RESULTS: This project (ClinicalTrials.gov #NCT03736876) was funded in 2016 through the Family Youth Services Bureau as part of the Personal Responsibility Education Innovative Strategies program. Baseline data collection took place between February 2018 and March 2020, yielding a total of 5 cohorts and 533 study participants: 316 assigned to treatment and 217 assigned to control. Ongoing follow-up data collection continued through May 2021. CONCLUSIONS: About Us draws on developmental science to create a contextually and developmentally relevant program that addresses motivation and emotional influences in sexual decision-making. The intervention was designed for implementation within SBHCs, an understudied venue for relationship and sexual health promotion interventions. Unfortunately, COVID-19 pandemic restrictions led to school closures, interrupting ongoing programming, and in-person follow-up data collection, which has affected study attrition. TRIAL REGISTRATION: ClinicalTrials.gov NCT03736876; https://clinicaltrials.gov/ct2/show/NCT03736876. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/30499.

School-Based Health Center Operations During the COVID-19 Pandemic: A Preliminary Study.

The coronavirus disease 2019 (COVID-19) pandemic forced schools to close in spring 2020, affecting the ability of school-based health centers (SBHCs) to serve youth and families who relied on their services. This preliminary study aimed to understand the implications of school closures on SBHC operations. Survey data were collected from a convenience sample of representatives from 427 SBHCs, representing approximately one sixth of SBHCs nationwide. When schools closed in spring 2020, 77% of SBHCs closed temporarily, 5% closed permanently, and 12% remained physically open. Telehealth was a crucial strategy used to continue delivering essential services. The percentage reporting any telehealth service offering before and after school closures increased by over 200%. Yet they also reported challenges, including financial and policy restraints. Many SBHCs that closed temporarily did so because their host schools closed, suggesting that making arrangements to remain open if a similar situation to the COVID-19 pandemic should arise might be beneficial. SBHCs are a proven cost-effective model to deliver health care in resource-limited communities. These preliminary study results indicate that SBHCs maintained service delivery following school closures, though many faced challenges. Further research is needed to fully understand the pandemic's impacts on SBHC service provision and health access and outcomes.

The Future of Telehealth in School-Based Health Centers: Lessons from COVID-19.

INTRODUCTION: In response to COVID-19, schools rapidly transitioned to virtual learning. School-based health centers (SBHCs) required immediate shifts from in-person to telehealth services to continue supporting students. METHOD: A qualitative analysis of nationally-led "Listening and Learning" sessions by the School-Based Health Alliance revealed substantial innovation and expansion of telehealth services. RESULTS: Providers and sponsoring organizations shared challenges and mechanisms for troubleshooting barriers during online webinars to provide support, education, and resources to SBHCs. DISCUSSION: Lessons learned during the COVID-19 pandemic demonstrate the value of SBHCs, which continue to target barriers to health care access, protect the most vulnerable, and decrease the spread of disease. Telehealth implementation by SBHCs can support schools and communities, mitigate future strain on the health care system by continuing to keep youth from over-burdened emergency departments and provide needed mental health care. State and federal policy changes can ensure the continued provision of telehealth by SBHCs for disadvantaged youth.