Enhancing access to health care and improving student outcomes are longstanding challenges in rural communities. Identifying solutions has been elusive, but school-based health centers (SBHCs) have shown promise.
New Cornell research shows students miss less class time in rural upstate New York schools that host comprehensive health clinics - the first findings to confirm such benefits in rural areas. The work is also informing a legislative proposal to expand access to these clinics.
Analyzing more than 66,000 students in a four-county region over four years, the researchers found that children on average were 15% less likely to be at risk of chronic absenteeism in districts with school-based health centers that can treat them onsite, run by a nonprofit hospital system, compared to those in districts without clinics. Lower absenteeism is associated with a range of better academic outcomes.
The impact on attendance was strongest among elementary students, who are more likely to miss school if an adult must keep them home or remove them to see a doctor. Accessing quality health care is often more challenging in rural areas, the researchers said, where distances to providers may be longer, public transit is more limited and health care professionals are scarcer.
"These students tend to miss fewer classes and fewer days of school when there's a clinic in the building," said John Sipple, professor in the Department of Global Development in the College of Agriculture and Life Sciences. "Rather than the school nurse calling a parent to pick up their child, the child can be treated right in the school and often can go back to class."
Sipple led the data analysis reported in "School-Based Health Centers and School Attendance in Rural Areas," published May 13 in JAMA Network Open. The first author is Dr. Chris Kjolhede, a pediatrician and co-director of the SBHC program operated by Bassett Healthcare Network, based in Cooperstown, New York, which is in the study region. Wendy Brunner, an epidemiologist and director of the Center for Rural Community Health at the Bassett Research Institute, is the corresponding author.
The research is part of a larger initiative investigating health disparities among rural youth via a $3 million National Institutes of Health grant, led by Sharon Tennyson, professor of public policy and economics in the Cornell Jeb E. Brooks School of Public Policy. Sipple and Brunner are among the co-investigators.
School-based health centers have primarily been studied in urban areas where most are located, including two-thirds of New York state's roughly 160 SBHCs. Sipple said the four adjacent counties studied - Chenango, Delaware, Otsego and Schoharie - provided a natural experimental sample of very similar districts except for school-based clinic access. All 52 schools spanning 32 districts were relatively small, with mostly white and lower-income student populations; but 18 schools (in 14 districts) housed Bassett clinics providing physical, mental and dental health services.
The study data tracked more than 30,000 students in schools with clinics and 36,000 in schools without them, from 2015-2019. In calculating the students' odds of becoming chronically absent (missing more than 10% of enrolled days), the researchers controlled for factors such as age, gender and wealth.
"We had lots of data to compare students who attend schools with a school-based health center versus those that don't in the surrounding region," Sipple said. "Our goal was simply to measure, are kids in school more when there's a clinic? And the answer is yes, they are. And research has shown that lower absenteeism extrapolates to better academic achievement, from test scores to graduation rates."
In previously published research investigating the same region, the team found that students enrolled in schools with clinics received more medical care, including more preventative treatment for asthma, and relied less on emergency room visits. Recognizing the clinics' benefits to rural families, the Brooks School's State Policy Advocacy Clinic has helped draft legislation proposing to expand their access to the younger siblings of enrolled students. Sipple said policies should facilitate opening more school-based clinics, easing funding and staffing issues.
"Expanding the number of school-based health centers should be a priority to enhance the well-being of urban and rural communities," Sipple said.
In addition to Sipple and Tennyson, Cornell scholars involved in the research include Mildred Warner, M.S. '85, Ph.D. '97, professor of global development in CALS and of city and regional planning in the College of Architecture, Art and Planning; Elaine Wethington, professor emeritus of human development and sociology in the College of Human Ecology; and Xue Zhang, M.S. '16, Ph.D. '19, assistant professor of behavioral health at Penn State University.
