|
The International Electronic Journal of Health Education
|
[Reprint
(PDF) Version of
this article]
IEJHE, Vol. 2 (1), 18-27, January 1, 1999, Copyright ©
1999
Rural School Health Services: An Assessment of Adolescents' Felt Needs
Carl L. Hanson, Ph.D., CHES1; Mark Kittleson, Ph.D.2; Kathleen
J. Welshimer, Ph.D.2; Dale O. Ritzel, Ph.D.2; Paula L. Woehlke,
Ph.D.3; Fred R. Isberner, Ph.D.4
1 Montana State University - Billings; 2 Health Education
Programs, Southern Illinois University at Carbondale; 3 Educational Psychology,
Southern
Illinois University at Carbondale; 4 College of Applied Sciences and Arts,
Southern Illinois University at Carbondale
Corresponding author: Carl L. Hanson, Associate Professor, Department of Health and
Physical Education, Montana State University--Billings, 1500
North 30th Street, Billings, MT 59101; 406.657.2395 (phone); 405.657.2399
(fax); hpss_hanson@vino.emcmt.edu;
homepage:
http://www.msubillings.edu/fac/hanson
School-based health centers, have the potential of helping adolescents overcome the barriers that
prevent them from receiving needed health services. The
purpose of this study was to determine the felt needs for comprehensive school health services as
perceived by adolescents in a rural high school.
Based upon a conceptual framework for health care utilization, an instrument called the
Adolescent Health Services Inventory was developed to assess (1) what
health services adolescents received, (2) what health services adolescents wanted but could not
receive, (3) what school health services adolescents would likely
use, and (4) how important they perceive it is to have various health services provided in their
school.
Results of the study revealed that most students in this rural high school receive basic medical
care in their community. Over three-fourths of adolescents
reported they received physical exams during the past year yet one in ten students reported they
wanted but were unable to receive stress management services,
weight management counseling, counseling to treat depression, counseling on birth control
methods, tests and treatment for sexually transmitted diseases,
prescription and dispensing of birth control methods and job counseling.
The implications of this study suggest the need to not overlook health education and health
counseling services when developing models for rural school health
care delivery.
Adolescents are faced with numerous health challenges. These challenges, labeled by health
professionals as the social or new morbidities include youth suicide,
homicide, sexually transmitted disease, unintended pregnancy and substance abuse (Glans &
Blyth, 1990). As these morbidities have begun to impact the
adolescent population and influence learning, many national, state and private organizations have
made recommendations on how to improve the condition of
adolescent health (Lavin, Shapiro, & Weill, 1992). These organizations (see: http://www.gwu.edu/~mtg/related/ ) have
agreed that a more comprehensive approach
to addressing child health problems is needed and that health promotion and education should be
centered in and around the schools. The integration of
comprehensive school health programs into schools has become one way of addressing child
health problems. One critical component of this comprehensive model
is school health services (Allensworth & Kolbe, 1987).
Comprehensive school health services, offered through school-based health centers, have
grown in popularity. From a single center in 1970, over 600 are located in
schools throughout the United States today (Schlitt, Rickett, & Montgomery, 1995).
Joycelyn Elders, former United States Surgeon General and long time
advocate of school-based health services, outlined the components of a comprehensive school
health services program (Elders, 1993). These comprehensive
programs include medical, family planning as well as counseling services. However, planning for
these programs should not simply follow preconceived outlines but
should be based upon an understanding of the unmet health care needs of the student population
(Advocates for Youth, 1995). Unmet health care needs of
adolescents may be the result of poverty, lack of insurance, lack of trained providers to address
adolescents' health concerns, lack of parental availability, and
concerns about confidentially (Office of Technology Assessment, 1991).
Program planners should resist the tendency to establish school-based health services based
solely on their professional assessment of adolescent health needs. Such
a projection of needs can lead to services being poorly received and under-utilized (Parcel, Nader,
& Meyer, 1977). To avoid such problems, many professionals
recommend an assessment of perceived or felt needs (Williams & Torrens, 1993). Few
published studies have attempted to identify the felt needs of adolescents for
specific school health services (Hawkins, Spigner, & Murphy, 1990; Making the Grade,
1996). Furthermore, while a number of school-based health centers are
being established in rural areas (Riggs & Chin, 1988), only one published study has
attempted to identify the felt needs of adolescents in rural areas (Rickert, Davis,
Riley, & Ryan, 1997).
School-based services do offer a potential solution to eliminating the barriers that prevent
adolescents from receiving needed services. Given this fact, the purpose
of this study was to assess the felt needs for comprehensive school health services as perceived by
adolescents in a rural high school.
Survey Population
Five hundred and thirty-five adolescents from a rural southern Illinois high school were
surveyed during the Spring of 1994. The high school selected for the study
was located in a town with a population of under 10,000 people with 87% being white and 11%
being black. Seven-hundred and forty-four 9-12 grade students
were enrolled in the school. Five-hundred and forty-five students responded to the survey. Of
the 535 inventories, nearly 60% were completed by adolescents 16
years of age or under. Ninth graders represented the largest portion of adolescents completing
the inventory (see Table 1).
Click
Here to Go to Table 1.
Instrument Development
To fulfill the purpose of the study the Adolescent Health Services Inventory (AHSI) was
developed based upon the conceptual framework for health service
utilization (Aday & Anderson, 1974). The conceptual framework for health service
utilization was initially developed as a guide for studying access to medical care
and suggests that utilization of health care services depends on characteristics of the population.
These characteristics include predisposing, enabling and need
characteristics.
Predisposing and enabling characteristics regarding adolescent use of health services were
identified through a review of the literature. The identified predisposing
factors included age, grade in school, race, sex, and perceived importance of health services
located in the school (attitude). To assess perceived importance, a five point Likert scale was used
The conceptual framework for health service utilization
was
initially developed as a guide for studying access to medical care and suggests that utilization of
health care services depends on
characteristics of the population. These characteristics include predisposing, enabling and need
characteristics.
|
with one representing not important and five representing very important. The identified enabling
factors included family employment, living arrangement, Medicaid
participation, income status, and reasons why adolescents may not be able to use health services.
Need for health services were assessed by determining which
services (or those commonly offered in school-based health centers) adolescents wanted to use
during the past year but for some reason couldn't.
Utilization of health services was characterized by the kind of health service received and the
locations. Therefore, to assess utilization of services, adolescents were
asked to select from a list which services they received over the past year and which of all
available providers they received services from. A list of available
adolescent health service providers was generated through discussions with local health
professionals. Potential utilization of school health services in the future was
then evaluated by assessing the perceived use of specific school health services (Hawkins,
Spigner, & Murphy, 1990). Services were listed opposite a five point
Likert scale and adolescents were asked to circle the best response between one (not likely) and
five (very likely). The services listed in the AHSI were those
commonly provided in schools with a school-based health center (Adelman, Barker, Nelson,
1993; Allensworth, 1994; Kane, 1993).
This instrument was divided into five primary sections that included: (1) health services
received, (2) health service utilization, (3) health services wanted, (4)
utilization of services, and (5) importance of services.
Readability
Using the Flesch-Kincaid readability test, the readability of the initial draft of the AHSI was
determined to be at the seventh grade level. This is the preferred level
of most readers. The Flesch reading ease score was 69. Flesch reading ease scores that range
between 60 and 70 are considered of standard difficulty.
Pilot Study
A pre-pilot and pilot study was conducted. The pre-pilot was conducted with three students
ranging from seventh grade to eleventh grade. The students were
asked to take the AHSI in their home with a parent present in order to determine survey
completion time. It took each student 10-11 minutes to complete the
survey.
Following the pre-pilot, a pilot was conducted using two classes of health education students.
Thirty-eight ninth grade students participated in the pilot. The
teacher of the classes was instructed ahead of time as to the instrument administration procedures.
As the instrument was administered, careful documentation of
teacher introduction time, student comments and completion time was recorded by the primary
researcher. Based on the pilot, minor changes were made in the
survey design and administration procedures.
Data Collection
Data were collected using the same procedures used in the pilot study. Teachers were trained
during a faculty meeting as to the appropriate protocol for instrument
administration. Each teacher was given a packet that included the appropriate number of surveys
for students enrolled in their home room class. The protocol for
administering the AHSI included an introduction that explained the importance of the study, a
statement regarding the voluntary nature of participation, and
procedures for administering the instrument. The procedures section instructed teachers to read
verbatim to students the general instructions and specifics regarding
the voluntary and anonymous nature of the survey. Other instructions for monitoring, answering
questions, and completing the survey were included as apart of the
protocol.
Instrument Reliability
Cronbach's Alpha coefficients were calculated using study data in order to determine
internal-consistency reliability of the AHSI. Each section had an Alpha
reliability of greater than 0.90. To ensure inter-rater reliability in this study, seven percent of the
survey were recoded prior to data analysis.
Statistical Analysis
The Statistical Analysis System (SAS) was used to run descriptive, Chi-square, and
Standardized Residuals. Descriptive statistics were calculated for each survey
question. Statistical analysis using Chi-square and Standardized Residuals was conducted on the
health services received and health services wanted sections of the
ASHA. Standardized Residuals were calculated in order to determine which of the cells of the
Chi-square contingency tables were major contributors to any
identified significance.
Health Services
Received
To determine the utilization of specific health
services, adolescents were asked what health services they received over the past year.
Fifty-percent or more of the
adolescents reported to have received physical exams (77.0%), dental exams (71.0%), shots
(66.4%), care for the flu, colds, earaches, and sore throats (65.6%), and
first aid care (53.3%) in the past year. Less than 12% of the adolescents received such services as
weight management counseling (11.6%), suicide prevention
counseling (11.6%) and physical, sexual, or emotional abuse counseling (11.0%) (see Table 2).
A
summary of services only received by females is found at the
bottom of Table 2.
Click
Here to Go to Table 2
Health Service
Utilization
In order to better understand utilization of services,
students were asked to indicate which health care providers they received health services from
over the past
year. Of the health service providers presented in the AHSI, 37.2% of the adolescents reported
having received services from their private doctor within the past
year and 21.9% from a private dentist. Twenty-eight percent of the adolescents reported having
received services from the county health department while 32.1%
received services from one of two community clinics in the region. Eighteen percent of the
adolescents received services from a hospital emergency room while
6.2% reported having received services from the Family Practice Center at a regional hospital.
Lastly, similar proportions of adolescents received services in the
school from a school nurse (5.8%) as had received services from a regional Adolescent Health
Center (6.0%).
Chi-square statistical procedure was used to analyze
the difference between specific health services received by adolescents in the past year by the
health service
providers. For those Chi-square statistics that were significant at the .05 level, a Standardized
Residual was calculated for each contingency table in order to
determine which of the cells were major contributors to the significance. Even though Chi-square
may indicate a significant difference, Standardized Residuals may
reveal that the significance was in a cell that was not of interest to answering the research
question. Table 3 illustrates a Chi-square contingency table, as produced
by the SAS statistical program for the independent variable (hospital emergency room) by the
dependent variable (physical exams). For example, in order to answer
the research questions for this study, findings were analyzed using the data presented in cell three
and cell four of the Chi-square contingency tables.
Click
Here To Go to Table 3
Chi-square analysis indicated a significant difference
(p<.05) between several of the health care providers and the services adolescents received
during the past year.
Standardized Residual calculations revealed adolescents receiving treatment for sexually
transmitted diseases, counseling on birth control methods, and dispensing of
birth control methods, a significantly higher number of students were receiving services from a
public health provider (i.e., community health center, county health
department, adolescent health center).
Health Services Wanted But Unable to
Receive
In order to assess the need for health services,
adolescents were asked which health services they wanted to use in the past year but could not.
Table 4 illustrates
the services that adolescents were unable to receive. The results indicated that less than 12% of
the adolescents were unsuccessful at obtaining any of the given
health services. The highest percentage (11.8%) indicated that they were unable to receive stress
management services. Stress management services were followed
by weight management counseling (11.4%), counseling to treat depression (11.4%), counseling
on birth control methods (11.2%), tests and treatment for sexually
transmitted diseases (11.2%), prescription and dispensing of birth control methods (10.1%) and
job counseling (9.9%). Physical exams (3.9%) and shots (3.8%) represented the two smallest
percentages of services students were unable to receive. Chi square analysis revealed that there
was no
significant difference between male and female use of these services.
Click
Here To Go to Table 4
Chi square calculations did reveal a difference
between grade level (p<.05) on a variety of issues. More specifically, there were more 9th
graders than 10th, 11th, or
12th graders who wanted but were unable to receive care for skin problems; blood pressure
screening; quit smoking programs; counseling to improve
communication between themselves and teachers; physical, sexual, or emotional abuse counseling;
suicide prevention counseling; and parenting classes.
The results indicated that less than
12% of the adolescents were unsuccessful at obtaining any of the given health services. The
highest percentage (11.8%)
indicated that they were unable to receive stress management services...followed by weight
management counseling (11.4%), counseling to treat depression (11.4%), counseling on birth
control methods (11.2%), tests
and treatment for sexually transmitted diseases (11.2%), prescription and dispensing of birth
control methods (10.1%) and job
counseling (9.9%)
|
Chi-square analysis indicated that all adolescent health
services were significantly different (p<.05) by race with the exception of wanting physical
exams and
counseling to improve communication between parents/family. Twenty-seven of the 31 services
were significantly different at the .001 level. Standardized Residual
calculations revealed that without exception, more non-white adolescents indicated they wanted
but were unable to receive health services than did white
adolescents.
Importance of School Health Center
Services
As a predisposing factor of future health service
utilization, adolescents were asked to indicate on a five point Likert scale how important it is to
have specific health
services available in their school. Mean scores from the five point Likert scale were calculated for
each of the health services (see Table 5). The six most important
services as indicated by the mean scores were information about STDs, including AIDS (4.19),
first aid care (4.01), counseling and information for alcohol problems
(3.91), counseling and information for drug problems (3.90), physical exams (3.61), and shots
(3.61).
Click
Here To Go to Table 5
Likely Utilization of Future School Health
Center Services
In order to assess future utilization of health services,
adolescents were asked how likely it would be for them to use specific health services if they were
offered in
their school. Mean scores were calculated for each of the health services with 1=low likelihood of
use and 5=high likelihood of use. Those services that adolescents
are more likely to use include first aid care (3.52) and physical exams (3.29). The remaining
services revealed mean scores of less than 3.0 indica- ting that adolescents would be less likely to
use these
services if they were offered in their school. The means and standard deviations of the likelihood
of adolescent school health service use by service is presented in
Table 6.
Click
Here To Go to Table 6
Statistical analysis revealed that students in the study
had received basic medical care (i.e., physical exams, dental exams, shots, care for flu., colds,
earaches and
sore throats) through various community service providers. Despite the potential barriers of
receiving health services in this rural community, adolescents were taking advantage of public
health
providers for the provision of sexuality related services (e.g., family planning, treatment of
sexually transmitted
diseases), however, over 1 in 10 adolescents were wanting but were unable to receive sexuality
related services. Adolescents also reported that information about
sexually transmitted diseases was the most important health service to have available in the school
health center. As health professionals, it can not be assumed that
if sexuality related services are provided in rural communities, they are also accessible to
adolescents. In this study, barriers continued to exist that prevented
adolescents from utilizing sexuality related services.
While this study indicated that the majority of
adolescents were not wanting or were able to receive health services in the past year, over one in
ten students
reported unmet health care needs relating to health counseling and health education (see Table 4).
Topping the list of wanted services included stress management,
weight management counseling, and counseling to treat depression. These finding are consistent
with the findings of the National Adolescent Student Health Survey
(National Adolescent Student Health Survey, 1988). Dryfoos (1991) has also indicated that
depression is one of the four major problems that are facing youth
today. This becomes particularly important due to the fact that depression among adolescents is
one of the primary emotional states associated with suicide
attempts (Spirito, Brown, Overholser, & Fritz, 1989). Though not reported as one of the
top services needed in this study, suicide prevention counseling was
reported as being wanted by 49 students (9.2%). Over 16% of the adolescents reported having
received counseling for depression within the past year. Findings
related to weight management counseling are also consistent with the findings of Hawkins,
Spigner, and Murphy (1990). In their study, health education services
for being overweight or underweight were reported as the number one service adolescents felt
they needed.
Consistently more 9th graders as compared to 10th, 11th, and 12th graders, wanted specific
health services (e.g., skin problems, quit smoking programs, counseling
to improve communication, abuse counseling, suicide counseling). These finding suggest that
greater attention may need to be given to addressing the specific
health care needs of adolescents who are just entering high school.
...it was evident that many students were receiving basic
health care services from community providers but also felt
it was important to have some of these health care services also provided in the school.
|
In this study, it was evident that many students were
receiving basic health care services from community providers but also felt it was important to
have some of
these health care services also provided in the school. For example, the highest percentage of
adolescents indicated that they had received physical exams. Also,
adolescents reported that physical exams were the second school health service they would likely
use. When comparing the health services adolescents felt were
important to have in school with the school health services they would likely use, mean scores
were generally lower for the likely usage of health services. This
suggests that respondents felt that many of the services are important to have but they do not
perceive they would ever use them.
These findings should be interpreted in light of the
limitations to the study. For example, generalizability of the study could be limited because the
students who
participated in this study may or may not be representative of students in other rural town high
schools. Also, needs reported by students were perceived/felt needs
and may not be reflective of their actual needs. Actual needs are the needs of the target
population as seem through the eyes of the health professional. Felt or
perceived needs are those needs identified through the eyes of the target population. A common
method of determining perceived/felt needs is through the self
report survey. Other methodologies such as focus groups or nominal group processes might also
provide valuable findings but were not a part of this study.
Implications for Rural School Health
Services
The purpose of this study was to determine the felt
need for comprehensive school health services in a rural high school. These survey results have
important
implications for the establishment of rural school health services programs. First,
emotional/mental health services should be a central focus of those services
provided through a rural school-based health center. Traditionally, the emphasis has been on
addressing the physical needs of students. While the traditional
perception may be that students are lacking the necessary services to meet their physical needs,
emotional/mental health services are extremely important for the
rural school health services program.
Students in this study saw stress management as the
service they most wanted. While stress management is sometimes available through regular health
education
curriculum, it may not be meeting the need of students. Students at this rural high school receive
one semester of health education from a health educator/coach
sometime during their four years of matriculation. As health education programming within the
classroom falls short of meeting the varied health needs of students,
school-based health centers should be sensitive to these needs. For example, school-based health
centers look to incorporate stress management programming into
health center activities.
Second, while adolescents reported wanting
emotional/mental health services made available at school, they also reported they would not be
likely to use them if
offered in their school . Two possible explanations may illustrate the reason for this discrepancy.
One, many students see their friends struggling with health related
issues but do not perceive themselves as ever having a need for health related services. Two,
using emotional/mental health services may be uncomfortable due to
the stigma often attached to using psychological services. Program planners would need to
further explore this discrepancy in an effort to address the barriers to
emotional/mental health services. To reduce anxiety and increase the likely usage of
emotional/mental services as well as other services, educational-orientation
programming for parents and administrators regarding school-based health center services would
be an important activity to consider at the beginning of the school
year. School health center orientation programs that introduce students and parents to the health
center services would help to familiarize these stake holders with
clinic services and protocols. This may also require providing an awareness that treating health
problems requires care for both psycho-social and physical illnesses
(Parcel, Nader, & Meyer, 1977). Providing these orientations can ultimately help build a
normative culture in which all students would feel comfortable receiving
physical and mental/emotional services through a school health center.
Third, a number of adolescents in this rural high
school reported wanting to receive a variety of sexuality related services and felt they would be
important to include
in a school health center. When looking at these data, again there was a discrepancy between the
school-based health services students wanted to receive or felt was
important and what school-based health services they would likely use. During program planning,
planners would again be wise to thoroughly explore this
discrepancy to determine the need for sexuality related services. Certainly, if sexuality services
are implemented, confidentiality would need to be insured in order to
facilitate usage.
In conclusion, school-based health centers offer one
strategy for combating the social morbidities that threaten the health and education of adolescents.
Helping
adolescents receive comprehensive health services within the school can ultimately help them
remain healthier and ultimately achieve their academic potential.
Based on the self-reported responses, adolescents in this study indicted a need for the provision of
certain services within their rural high school.
This study was partially funded by a grant from the Center for Rural Health and Social Service
Development at Southern Illinois University at Carbondale.
Advocates for Youth. (1995). A Guide
to School-Based and School-Linked Health Centers Volume IV: Assessing and Evaluating
School health Center.
Washington, D.C.: Advocates for Youth
Aday, L.A. & Andersen, R. (1974). A
framework for the study of access to medical care. Health Services Research, 9,
208-220.
Adelman, H.S., Barker, L.A., & Nelson P.
A. (1993). A study of a school-based clinic: Who uses it and who doesn't? Journal of
Clinical Psychology, 22(1), 52-59.
Allensworth, D.D. (1994). The
comprehensive school health challenge, volume one: Promoting health through education.
Santa Cruz, CA: ETR Associates.
Allensworth, D.D. & Kolbe, L.J. (1987).
The comprehensive school health program: Exploring an expanded concept. Journal of
School Health, 57, 409-412.
Dryfoos, J.G. (1991). School-based social and
health services for at-risk students. Urban Education, 26, 118-137.
Elders, J.M. (1993). Schools and health: A
natural partnership. Journal of School Health, 63, 312-315.
Glans, J.E. & Blyth, D.A . (1990).
Education research: Competencies for analysis and application. Chicago, IL:
American Medical Association.
Hawkins, W.E., Spigner, C., & Murphy, M.
(1990). Perceived use of health education services in a school-based clinic. Perceptual and
Motor Skills, 70, 1075-1078.
Kane, W.M. (1993). Step by step to
comprehensive school health: The program planning guide. Santa Cruz, CA: ETR
Associates.
Lavin, A.T., Shapiro, G.R., & Weill, K.S.
(1992). Creating an agenda for school-based adolescent health care program. Journal of
Adolescent Health, 62(6), 212-228.
Making the Grade. (1996). Access to
comprehensive school-based health services for children and youth. Washington, DC:
Making the Grade.
National Adolescent Student Health Survey.
(1988). NASHS: Highlights of the survey. Journal of Health Education, 19(4),
4-8.
Office of Technology Assessment. (1991).
Adolescent health - Volume I: Summary and policy options. Washington, DC: US
Government Printing Office.
Parcel, G.S., Nader, P.R., & Meyer, M.P.
(1977). Adolescent health concerns, problems, and patterns of utilization in a triethnic urban
population. Pediatrics,
60(2), 156-164.
Rickert, V.I., Davis, S.O., Riley, A.W., &
Ryan, S. (1997). Rural school-based clinics: Are adolescents willing to use them and what
services do they want?
Journal of School Health, 67, 144-148.
Riggs, S. & Chin, T. (1988). Adolescents'
willingness to use school-based clinic in view of expressed health concerns. Journal of
Adolescent Health Care, 9, 208-213.
Schlitt, J.J., Rickett, K.D., Montgomery, L.L.,
et al. (1995). State initiatives to support school-based health centers; A national survey.
Journal Adolescent Health,
17(2), 68-76.
Spirito, A., Brown, L., Overholser, J., &
Fritz G. (1989). Attempted suicide in adolescence: A review and critique of the literature.
Clinical Psychology Review, 9,
335-363.
Williams, S.J. & Torrens, P.R. (1993).
Introduction to health services. Albany, NY: Delmar Publishers Inc.
[Reprint
(PDF) Version of
this article]
Copyright ©
1999 by IEJHE.
