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CHAPTER SIX
Practitioners Discuss the Nuts and Bolts of Advancing Prevention Programming Within School-Based Health Centers
Introduction
The draft final report was developed primarily by experts in problem behavior prevention, child health behavior change, and program evaluation with MTG senior staff providing substantial guidance regarding the school-based health center (SBHC) movement. In the final phase of the study, two focus groups of SBHC practitioners and administrators met to comment on the report as well as to discuss challenges and opportunities for SBHC prevention programming. The focus group participants, who included center directors, physicians, nurse practitioners, social workers, health educators, and state agency staff, discussed the following questions:
- Should SBHCs be involved in prevention?
- What is the current status of prevention programming within participants' centers and what challenges have they experienced in providing such services?
- What steps can be taken to move school-based health centers forward in the area of prevention?
Should School-Based Health Centers Be Involved in Prevention Programming?
The majority of focus group participants agreed that SBHCs are uniquely positioned to reach out to young people at high risk -- especially those who have little or no access to primary care -- and implement strategies that can help curb risk behaviors before they are entrenched.
Most discussants noted that their centers already have prevention programming in place without clearly identifying the activities as "formal programs." For this reason, almost all said there needs to be an effort to clarify the very meaning of the term prevention in the context of SBHCs, along with setting forth more specific steps and criteria for what prevention entails.
Participants, for the most part, agreed that the long-term objective for prevention programming in SBHCs is a comprehensive approach centered around all aspects of prevention, including individual counseling, group counseling, classroom instruction, home/parent involvement, and community participation. It was agreed that each component of any effective prevention curriculum be in written format with goals clearly defined. Curriculum materials must be structured yet simple and easy to follow.
For most school-based health centers, many interim steps will have to be taken before they can reach this long-term goal. Given this reality, and the knowledge that many formal and informal prevention activities are already being offered in centers, participants agreed that the most useful first steps for SBHCs that have not thought through their prevention efforts would be to identify the types of prevention activities in which they are already engaged, and calculate how to move their efforts to the next level.
What is the Current Status of Prevention Programming within Participants' SBHCs and what Challenges Have They Faced in Providing Such Services?
All practitioners were actively involved in delivering individualized and/or group-oriented prevention efforts. Participants voiced a number of common challenges to running effective prevention programming. Among them are funding adequacy, staff preparation, support from host schools, securing family and community involvement, and ability to measure program effectiveness. They also offered some creative ways in which their centers are addressing these challenges. Highlights from this discussion are described below:
Funding
Challenges. All emphasized the need to identify new sources of funding and the ability to maintain a stable funding base in order for SBHCs to run effective prevention programs. Many participants reported their struggles with getting funding for prevention programming. Most noted that the typical private or public health insurance plan does not reimburse for problem-related prevention services. Even when funding is available, some participants recalled instances in which schools diverted their prevention funding to other activities.
Action suggested. Educating SBHC funders, sponsoring organizations, and other supporters to the value of adding a prevention component to a center's core program is crucial. Some participants have also taken active steps to work with school staff in developing prevention activities, including involving them in the administration of prevention programs.
There was some disagreement, however, over the most important sources of funding. While some felt that prevention programs could not be sustained without state dollars, others placed a greater importance on community funding. Still others suggested that state funds be channeled into maintaining core programs while non-traditional funding sources should be sought for prevention programming.
Staffing
Challenges. Participants agreed that the technical competency of staff is crucial to the operation of effective prevention programs. In addition to having prevention expertise, many believed that staff must be able to adapt prevention curricula to the circumstances of the specific SBHC. If additional staff are needed for successful implementation, plans on how to recruit, select and train new staff must be made before action is taken.
Discussants also noted that the most effective SBHC staff members are the ones that inspire and energize not only students who visit the center, but teachers, school administrators, parents, and community members on whose support SBHC prevention programs depend. Many, however, pointed to the problem of staff fatigue and frustration when their prevention efforts do not produce immediate results or fall victim to external obstacles, such as inadequate funding.
Action suggested. To address the technical difficulties and emotional strains of staff involved in prevention efforts, SBHC directors should develop support groups and find ways for their staff to communicate with staff at other SBHCs. A listserve for SBHC prevention staff was suggested to facilitate this communication.
School, Teacher, Community Support
Challenges. In reflecting on the experiences of their own centers, participants identified gaining the support of school administrators, teachers, parents, and community leaders as a major challenge to successful prevention programming.
Action suggested. In one school, center staff developed and distributed teacher surveys on prevention programming they believe is most needed for their students. At another center, staff are working with teachers to eliminate scheduling conflicts by conducting prevention programs at the very beginning and end of the school year. Staff also familiarize themselves with student schedules and seek to release students from class (if needed) during elective rather than required classes. Other centers offer blood pressure checks and other health services to teachers, increasing their exposure to the center and its purpose. Regarding ways to secure family and community involvement, one participant gained community support and buy-in for a center nutrition program by sending parents home a variety of healthy recipes -- often written in the parents' native language and tailored to their native dietary traditions.
What Steps Can Be Taken to Move School-Based Health Centers Forward in the Area of Prevention?
Two practical recommendations emerged from the discussions to move school-based health centers forward in the area of prevention programming:
1. Refining the Prevention Readiness Checklist. Participants noted that the Prevention Readiness Checklist could be an exceptionally useful tool in helping SBHCs to plan for , implement, and monitor a variety of prevention activities. A number of revisions were recommended to strengthen the tool, the most important of which are the following:
- The checklist's readiness components should be ranked according to whether they are necessary for an SBHC to run a successful prevention activity or whether they are desirable but not essential.
- The checklist should contain a self-assessment instrument to help SBHCs measure the extent to which prevention activities are already included in the activities of a SBHC, and specific steps that a center can take to advance its prevention programming to a higher level.
2. Providing More Information on Prevention Curricula. Participants found the description of successful programs in the report useful in thinking about prevention activities for their own SBHCs. Some, however, were looking for more information on staffing, resources, and costs for each of the interventions listed, as well as information on how to purchase the curricula. In response, the Urban Institute has compiled complete and up-to-date contact information for each of the twenty-one evaluated programs described in the report (see Appendix 6). This information included descriptions of program scope and content, curriculum costs, and training and implementation information including availability of continuing education credit for trainees.
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