Inclusion and Collaborative Design: School-Based Health Centers (SBHC)

Photograph of Christine Robinson
Christine Robinson

by Christine Robinson

Original posted in The Community Psychologist (TCP) Volume 53 (1). Winter 2020

SBHCs, as outlined, are a policy and systems innovation that promotes inclusion. This model, open and accessible to all students in a school, sends a noticeable message of equity, everyone matters. This SBHC prototype intentionally integrates identity, culture, enhanced personal narratives, and a concrete approach to support positive adolescent development. High school graduation is a landmark, signifying one’s ability to navigate a complex institutional system and achieve a certain level of proficiency. It is a benchmark on the road to successful adulthood. The collaboration with community nonprofits and the emerging shared-staffing model provides organizational enhancement, assists in academic attainment, improves health outcomes, and affirms belonging, a crucial developmental attribute for historically marginalized youth.

The Challenge
Several of the health concerns adolescents address are grounded in the social determinants of health and driven by broader social and contextual inequities (Brindis, Loo, Adler, Bolan, & Wasserheit, 2005). In Massachusetts, thousands of students are immigrants and refugees from many countries and personally affected by traumatic transitions. During a tumultuous move to the US, interim education is often nonexistent. The ravages of war, refugee status, family displacement, racist stereotypes, foster care, abuse, neglect, and death, are too familiar in these young lives. After a year of negotiation with nonprofit leaders representing the various racial, ethnic, and linguistic groups in each city, we invited partnership to improve youth outcomes. Nonprofits agreed to help by assisting in the translation of a baseline survey to Haitian Creole, Khmer, Cape Verdean Creole, Spanish, Laotian, and Vietnamese. African American nonprofits were included acknowledging the importance of identity. Evidence from multiple disciplines indicates that inequality can signal to young people that they are unlikely to be able to attain parity with peers (Browman, Destin, Carswell, & Svoboda, 2017).

Collaborative Response to the Challenge of Inclusion
In establishing the first cohort of clinics, we aligned services and staffing with physical and mental health needs, as shown by baseline student survey results. Data were collected from a customized CDC Youth Risk Behavior Survey, a recognized instrument with proven validity and reliability. Questions reflecting the specific interests and concerns of youth and families in the various cities were added. These customized surveys provided a means to collect data about cultural attitudes; all students in attendance on the days of administration were included. Lived experiences of youth on health and a range of health risk behaviors, including homelessness, tobacco, alcohol, and mental health concerns, were gathered. Data were analyzed separately for each school, yielding unique profiles. The analysis provided insight into student realities and perceptions and indicated the need for culturally inclusive staffing arrangements.

Community nonprofits were invaluable in gathering baseline data as many of the teens were not literate, and some languages are spoken and not written. Nonprofit staff assisted in the development of a response process for one-on-one administration with teens who needed help with reading, completing the answer sheet, and translation of various concepts. Through this iterative process, the staff of the nonprofits agreed to continue to work in SBHCs through a range of customized shared staffing agreements. For example, nonprofit staff from nearby agencies came to the schools to provide counseling, translation services, homework help, and support. Youth, mentored by people who shared their identity as exemplified by a shared language, culture, immigration experience, race/ethnicity, religion, and traditions in a time of significant transition, improved academic and health outcomes, and built social cohesion. The nonprofits agreed to participate in a complex referral network, providing a range of services and supports accessible to youth and their families. The staff of the same cultural, racial/ethnic, and linguistic backgrounds bring unique insights, credibility, expertise, and lived experience, easing a rough transition to an unfamiliar environment (Alegría, Ali, & Fuentes, 2019; Fuligni and Tsai, 2015).

Health conditions, anxieties, and behaviors are tightly aligned with cultural identities; re-location is an added stress amid the ongoing developmental tension of adolescence. For example, loss and grieving are treated differently in various cultures. Many youths had experienced the loss of their country of origin, family separation, family members who had been killed, tortured, or injured in war, or family members who struggled to cope with physical and psychological disabilities. These types of challenges compromise one’s ability to focus on academic matters, no matter how gifted a student is (Alegría, Green, McLaughlin, & Loder, 2015). The culturally informed SBHC model provided a familiar language and supportive adults, invaluable to these young scholars. Nonprofit staffs were both support providers and a bridge to families. Family engagement is essential throughout adolescence (National Academy of Sciences, 2019). Public schools are tested to add more culturally fluent staff; it is not unusual for schools to have more than 50 languages spoken, a conundrum for any school system. The knowledge of language and culture was a vital lifeline facilitating routine tasks such as homework completion with a highly nuanced understanding of family disruption and underlying struggles in some young lives.

Reflection on the Effectiveness of the Response
Effective SBHCs were able to move toward inclusion within a process of positive change incorporating the context of diversity (Trickett, 1996). Transformational leadership exemplifies skills of mediation, compromise, and pluralistic teambuilding, thereby creating a model of inclusive school culture, a template for all students to emulate (Day, Gu, & Sammons, 2016). Yet, the professional identities of health and education staffs in the SBHC, worldviews, power differentials, and community tensions are a factor.

1. Mixed loyalties: SBHC shared staff navigated allegiance to the SBHC, their home organizations, and often to racial or ethnic communities.

2. Model impacts school culture: The collaboration with community nonprofits resulted in the inclusion of authentic perspectives, voice, and language in schools. Inclusion affirmed student culture and required a stretch of school culture.

3. Diversity of models: SBHCs varied across each district, bringing to the fore diverse capacities, and models. The clinics are comparable but not identical.

4. Limited resources and agility: It was crucial to have staff familiar with languages, cultures, immigration, and refugee challenges to support high school completion as public schools generally lacked this capacity. The shared staffing model tested staff to become nimble, familiar with multiple organizational structures, including the SBHC, nonprofits, host school, and in cases, the partnering health care systems. Staff was compensated, but member organizations were asked to contribute to community wellbeing with no direct compensation.

5. Power Inequity: Real collaboration requires equal power. Yet, the power dynamics between educational institutions and health institutions are tense at times. Many emerging nonprofits representing historically marginalized populations provide invaluable service but have yet to attain equal respect in the civic space. Though revered by the local community, they lack prestige. The relegation to a contractual status evinces inequity.

6. Culture of Collaboration: The “culture of collaboration” within most SBHC skirts organizational and structural power dynamics. Redressing inequities in the broader community is a goal; however, the SBHC work is siloed, seen as a means of providing care, protection, and a vital bridge for vulnerable lives. The part-time nature of the staff renders them less powerful.

These findings support the necessity to expand inclusive culturally and linguistically appropriate school-based health services. Integrating health services into schools improves access to care that will enhance youth outcomes. However, the process of inclusion, which reflects the increasing diversity of the US, is challenging. This case study demonstrates that it is possible to build institutions premised on the bedrock that everyone matters.

Alegría, M., Alvarez, K., Ishikawa, R. Z., DiMarzio, K., and McPeck, S. (2016). Removing obstacles to eliminating racial and ethnic disparities in behavioral health care. Health Affairs, 35(6), 991-999.

Alegría, M., Ali, N., & Fuentes, L. (2019). Strategies for promoting patient activation, self-efficacy, and engagement. In M. Williams, D. Rosen, & J. Kanter, (Eds) Treatment for ethnic and racial minority clients. Eliminating race-based mental health disparities: Promoting equity and culturally responsive care across settings (p. 61-78). Oakland, CA: New Harbinger Publications.

Alegría, M., Green, J. G., McLaughlin, K. A., and Loder, S. (2015). Disparities in Child and Adolescent Mental Health Services in the U.S. William T. Grant Foundation Inequality Paper. New York, NY: William T. Grant Foundation. Available: https://wtgrantfoundation. org/library/uploads/2015/09/Disparities-in-Child-and-Adolescent-Mental-Health.pdf.

Allison, M. A., Crane, L. A., Beaty, B. L., Davidson, A. J., Melinkovich, P., and Kempe, A. (2007). School-based health centers: Improving access and quality of care for low-income adolescents. Pediatrics, 120(4), e887-e894.

Brindis, C. D., Loo, V. S., Adler, N. E., Bolan, G. A., and Wasserheit, J. N. (2005). Service integration and teen friendliness in practice: A program assessment of sexual and reproductive health services for adolescents. Journal of Adolescent Health, 37(2), 155-162.

Interested in this work? Christine Robinson discusses the PostSecondary Success for Boys and Men of Color in this YouTube video.

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