摘要：Objectives. We studied the direct and indirect effects of school-based health centers (SBHCs) on the health and health behaviors of middle and high school students. Methods. We used a prospective cohort design to measure health outcomes annually over 2 consecutive years by student self-report. Cohorts of middle school and high school students were recruited from matched schools with and without SBHCs. Data were obtained from 744 students in both year 1 and year 2 of the study. We used 2-level hierarchical linear models to estimate the effects of the presence of SBHCs at the school level and of SBHC use at the student level. Results. At year 2, users of SBHCs experienced greater satisfaction with their health, more physical activity, and greater consumption of healthy food than did nonusers of SBHCs. Conclusions. Students who used SBHCs were more satisfied with their health and engaged in a greater number of health-promoting behaviors than did students who did not use SBHCs. These findings indicate that SBHCs are achieving their goal of promoting children's health. At school-based health centers (SBHCs), multidisciplinary teams of providers, including physicians, nurse practitioners, registered nurses, physician assistants, and social workers provide a comprehensive range of primary care, preventive care, and early intervention services to children from elementary school through high school. SBHCs located in medically underserved areas have helped increase access to and utilization of primary care services among a wide variety of students, including low-income, 1 urban, 1 – 3 rural, 2 , 4 , 5 female, 5 and African American 5 students. SBHC utilization rates are highest among children with public insurance or no insurance. 5 Thus, SBHCs serve as an important health care safety net for disadvantaged and medically underserved youth. Most students who use SBHCs do so infrequently, averaging slightly more than 1 visit per year. An analysis of the diagnostic categories associated with SBHC visits paints a portrait of the typical SBHC user as a student who occasionally visits the SBHC for the treatment of an acute illness or to receive a physical examination. 6 In addition to providing direct health care services, SBHC staff members engage in a wide range of other activities to promote student health. A recent study found that 20% of all clinical activity in a sample of SBHCs was devoted to patient, classroom, and group education activities and to contacts with parents and school staff. 7 Such activities hold the promise of spreading the effects of SBHCs to students who do not directly receive SBHC health care services. The strongest evidence for the impact of SBHCs on the health of the children they serve is found among children with chronic diseases. For children with asthma, SBHC use is associated with fewer hospitalizations, 8 , 9 fewer visits to emergency rooms, 8 , 10 and better school attendance. 9 The evidence for the health benefits of SBHCs for children in the general population is less compelling. A study sponsored by the Robert Wood Johnson Foundation's School-Based Adolescent Health Care Program 11 compared the health status and health outcomes of 9th- and 10th-grade students in schools with SBHCs to a national random sample of 9th- and 10th-grade students attending schools without SBHCs. The presence of SBHCs in schools had no significant effect on the overall health status or health outcomes of students. A second study, 2 , 5 funded by the Health Foundation of Greater Cincinnati, compared the health-related quality of life of students in 4 elementary schools with SBHCs to students in 4 comparison schools without SBHCs. SBHC users reported significant improvement in student-reported quality of life over 3 years when compared with students in non-SBHC schools. It is worth noting that, whereas the Robert Wood Johnson Foundation–funded study compared all students in schools with SBHCs to a national random sample of students in schools without SBHCs, the Health Foundation of Greater Cincinnati–funded study involved a comparison among 3 groups of students: students in schools without SBHCs, students in schools with SBHCs who used their school's SBHC, and students in schools with SBHCs who did not use their school's SBHC. Distinguishing between SBHC users and nonusers within the same school is critical because it allows for analysis of the direct effects of SBHC services on users. The purpose of this study was to extend understanding of the effects of SBHCs on the general population of school-aged children by analyzing the impact of SBHCs on a range of health and health behavior outcomes among middle and high school students over a 2-year period. In particular, we sought to answer the following research questions: (1) What is the direct impact of SBHC use on middle and high school students' health and health behaviors? (2) What is the indirect impact of having an SBHC in a school on the health and health behaviors of students in that school, regardless of whether students use SBHC services? To answer these questions we used multilevel modeling to model school-level (i.e., SBHC status) and individual-level (i.e., student use of SBHCs) predictors of health separately.
