The Promise of School-Based Health Centers to Enhance Youth Mental Health Equity

Abstract

Youth mental health needs are of high concern nationwide [1, 2]. Amplifying these concerns, traditionally medically underserved groups are at elevated risk of lacking access to mental healthcare and experiencing poor mental health outcomes. For instance, Black and Latine/Hispanic children are less likely to be seen by mental health specialists than White children [3]. Psychiatric emergency department use, a proxy measurement for lack of access to preventative care, is highest among Black children [4] and is increasing more rapidly among Latine/Hispanic youth compared to their White peers [5]. Black youth aged 5–12 years are twice as likely to die by suicide as same-aged White youth [4]. In 2020, more than half of sexual and gender minority youth who sought access to mental healthcare were unable to receive services [6]. Social drivers of health (SDOH; e.g., living conditions, traumatic exposures) are root causes of disparities; inequitable distributions of SDOH lead to lower healthcare access and higher disease burden among marginalized communities [7]. The effects of SDOH, in combination with long-standing societal inequities and interpersonal biases, have perpetuated poor mental health outcomes for disadvantaged social groups [8].

If left untreated, mental illness is likely to persist into adulthood, leading to long-term consequences [9]. Parent mental illness is associated with an increased lifetime risk of mental illness for their children and negative effects on child development [10]. This cascade can lead to disparities that persist across generations. Yet, childhood health prevention and intervention services protect against negative health, educational, and economic outcomes for adults [8]; thus, early healthcare for traditionally underserved youth may have the potential to alleviate generational disparities [11].

Public health programs that reduce racial, ethnic, and socioeconomic health disparities typically achieve this goal by addressing SDOH for medically underserved groups, through programs such as early childhood education, parental support, and income assistance [8]. The structural nature of these interventions leverages community partnerships and emphasizes collaboration to alter social, physical, economic, and/or political environments to advance health equity [12, 13].

One such structural intervention is the provision of healthcare within schools to reduce access barriers, such as high costs, lack of transportation, and difficulty navigating the healthcare system [14]. School-based health centers (i.e., school and community health or hospital partnerships; SBHCs) provide comprehensive healthcare, including primary healthcare and often specialty care, delivered by multidisciplinary healthcare teams, to students in schools [15]. About 80% of SBHCs serve Title I schools and most SBHCs address SDOH, such as food insecurity, employment, immigration, and interpersonal relationships, thus providing an avenue to enhancing equity through barrier reduction [15]. Mental health care is the most common form of specialty care in SBHCs, provided by 83% of SBHCs in 2022, most frequently in the form of individual therapy delivered by licensed social workers or counselors [15]. SBHCs use a model of integrated healthcare in which physical and mental health services are provided within the same setting and are coordinated across providers. Research indicates that integrated models facilitate healthcare access and improve mental health outcomes for youth [16, 17].

Evidence suggests that SBHCs provide better healthcare access than community clinics, highlighting the potential of SBHCs to increase the provision of healthcare to traditionally medically underserved populations who experience an elevated lack of access to healthcare. For instance, SBHCs are associated with more primary care visits and lower emergency care use than traditional community healthcare [18]. Analogous patterns exist for SBHC mental health services. Youth who access SBHCs have increased odds of receiving counseling and discussing mental health with professionals than their peers [19]. Results from quasi-experimental studies reveal higher utilization of mental health services and lower mental healthcare costs among students with access to SBHCs compared to those enrolled in schools without SBHCs. These findings indicate that SBHCs can provide accessible and low-cost mental health services [20, 21].

SBHC users are disproportionately underinsured, uninsured, and living below the poverty line, highlighting how SBHCs reach traditionally medically underserved and vulnerable youth [22]. Among students with access to SBHCs, those with public or no health insurance are more likely to utilize SBHC services than those with private insurance [19]. SBHCs also serve racially and ethnically minoritized youth at a disproportionately high rate; across several studies, American Indian, Black, and Latine/Hispanic students are overrepresented in SBHC use [19, 23-25]. Similar patterns are reflected in the use of SBHC mental health services. For example, racially and ethnically minoritized youth are more likely to seek mental health services at SBHCs than White youth [23, 26]. These results illustrate how SBHCs effectively provide care to traditionally underserved groups, emphasizing the potential of SBHCs to alleviate mental health access disparities for these groups.

Qualitative findings paint a promising picture of youth perceptions of SBHCs. Samples of primarily Black and Latine/Hispanic youth described SBHC mental health services as reliable, supportive, effective, convenient, accessible, and confidential [27-29]. Youth shared appreciation for integrated care provided by SBHCs and expressed that without the SBHC, they likely would not have received any mental healthcare [27]. These findings provide insight into the positive perceptions youth report about SBHC mental health services.

In addition to positive regard of SBHCs, findings from the current literature suggest a positive effect of SBHC mental health services directly upon youth mental health outcomes. An analysis of provider-reported outcomes within a sample of 1528 predominantly Black and Latine/Hispanic youth indicated that many mental health concerns (e.g., anxiety, depression, grief, behavior) significantly improved across three or more SBHC mental health visits [30]. Schools with SBHCs that increased mental health services over 2 years demonstrated a significantly larger decline in school-wide rates of youth-reported depressive episodes, suicidal ideation, and suicide attempts than SBHCs that did not increase mental health services (odds ratios ranging from 0.82–0.88) [31]. SBHC mental health services may have a particularly positive effect on groups who experience disparities in mental health outcomes. For instance, sexual minority youth who attended a school with an SBHC had a 30%, 34%, and 43% lower likelihood of reporting a recent depressive episode, suicidal ideation, and suicide attempt, respectively, than sexual minority students attending a school without an SBHC [32]. Thus, evidence suggests that SBHC mental health services are associated with improved youth mental health outcomes, including for sexual minority youth who experience elevated risk for mental health problems [32].

SBHCs offer an avenue to addressing mental health disparities by improving access to healthcare for traditionally medically underserved youth (e.g., youth on public health insurance; Black, Hispanic/Latine, and American Indian youth) and improving youth mental health outcomes, particularly among vulnerable youth. In addition to these benefits, youth describe positive perceptions of mental health services delivered through SBHCs. Below, we provide recommendations for the implementation and sustainment of SBHC mental health services.

Research highlights multidisciplinary collaboration as a key driver of long-term SBHC sustainment [33-35]. School professionals and pediatricians seldom engage in multidisciplinary care coordination, despite reporting it as beneficial, and despite evidence that care coordination directly improves child outcomes [36-39]. Many school professionals lack training on how physical health affects academic and mental health outcomes [36], and medical professionals have limited knowledge of school systems and the complex roles of school professionals [37]. Beyond the context of SBHCs, experts have suggested that pre-service training should be provided on cross-disciplinary collaboration and incorporate best practices for team-based, client-centered care [36]. Pediatricians report low self-efficacy and competence in cross-disciplinary collaboration as a barrier to care coordination, which may be bolstered by sufficient training [37]. Pediatricians also cite limited time for collaboration as a barrier [37]. Experts recommend that collaboration is facilitated through care coordination meetings, which provide a routine opportunity for school professionals and healthcare staff to engage with one another [35, 40].

Lack of funding and revenue are major barriers to SBHC implementation and sustainment and inclusion of mental health services [34, 40]. One SBHC funder offers strategies that have historically been successful for financially sustaining SBHCs: applying early for Medicaid billing, serving a potential population of at least 500 Medicaid-eligible patients in the school, and maintaining visit recommendations of two well-child check-ups and six to eight other visits for each day the SBHC is open [35]. Lack of completed consent forms may inhibit adequate visit rates, so SBHC leaders may wish to consider options for increasing consent rates, such as including consents in back-to-school paperwork and holding SBHC open houses [35]. Other recommendations for financial viability include using a variety of funding sources to safeguard against barriers to funds (e.g., government fiscal limitations) and enhancing funding with private grants, which often have fewer restrictions than federal funding [41].

Although providing services in schools reduces access barriers, school mental health research shows that disparities in access to services can persist for students from minoritized backgrounds [42, 43]. There is evidence that mental health stigma may be a cultural barrier to seeking services [42], suggesting that school-wide mental health literacy education may be beneficial [44]. Additionally, research points to the presence of disparities in counseling outcomes, such as lower rates of treatment retention for racially and ethnically minoritized individuals [45]. Cultural adaptations to therapy can improve client outcomes, and clients' perceptions of therapists' cultural competence are positively associated with therapeutic engagement [46]. As such, SBHC therapists should incorporate cultural adaptations within therapy, such as using cultural metaphors and aligning therapeutic goals with clients' cultural values, to better serve clients from marginalized communities [46]. Relatedly, SBHC therapists should utilize best practices for working with sexual and gender minority youth, given their unique experiences of minority stress and disproportionate levels of mental health symptoms [6]. Evidence-based practices include addressing loneliness and isolation by bolstering social support, providing increased attention to confidentiality, as disclosure of sexual or gender identity may have implications for a child's safety, and engaging in interdisciplinary care coordination to support access to identity-affirming medical care [47].

Implementation of culturally responsive practices is best facilitated by systems-level strategies. For instance, youth and family advisory boards are commonly established in SBHCs to inform goals and service delivery [40, 48]. Youth who participate on advisory boards note that they prioritize culturally responsive practices and draw upon personal experiences in mental healthcare to promote access and engagement for other children [49]. Routine audits of culturally responsive healthcare practices, using context-specific auditing tools, may further bolster their use [50]. Accordingly, SBHC leaders may choose to audit the use of culturally responsive practices that have been developed through family and youth input, in order to promote sustainment [50].

Organizational policies that encourage culturally responsive practices are also related to improved patient experience and health outcomes [50, 51]. Promising policies include training providers in addressing SDOH and providing cultural protocols for use within direct service delivery [50]. Diversifying workforces also demonstrates potential to bolster culturally responsive practices. Strategies include creating and sustaining community partnerships (e.g., with institutions of higher education) to develop pipelines for students from diverse backgrounds to pursue healthcare careers, using diversified and targeted recruitment methods, utilizing mentorship/networking programs to retain employees, and allocating responsibility for diversity efforts (e.g., development of a diversity action plan) [52, 53]. Based on fit for the SBHC and available resources, SBHC leaders may choose to use a combination of these efforts to systematically promote culturally responsive practices. Finally, a robust system for data collection and maintenance is essential to track progress toward service goals and adapt to changes in policy [54].

Data from 2003 to 2024 suggest that there have been few improvements in health outcomes and healthcare access equity in the US despite medical advances and goals that focus on public health equity [55, 56]. Without structural interventions, health disparities persist over time [8, 13]. SBHCs present a method to reduce youth mental health disparities, offering a route to improving generational mental health equity [8, 11]. Further research is needed, given limited research on mental health and education outcomes associated with services and significant variation in implementation practices across SBHCs [15, 57]. However, findings to date suggest that SBHCs improve access to mental healthcare. SBHCs serve youth from marginalized groups (e.g., uninsured and underinsured youth; Black, Latine/Hispanic, and American Indian youth) at disproportionately high rates, highlighting the significant reach of SBHCs to traditionally medically underserved groups. Youth report that SBHC mental health services are convenient, confidential, and accessible, indicating that SBHCs provide acceptable services. Limited studies also point to improved mental health outcomes associated with SBHC services. Taken together, this evidence illustrates the strong potential of SBHCs to enhance mental health equity when implemented with structural support for culturally responsive practices.

The authors declare no conflicts of interest.