School-based health centers and the utilization of primary care in rural communities.

Introduction: School-based health centers (SBHCs) in rural communities improve students' access to primary care, but evidence on service utilization patterns is limited.

Methods: 2011-2017 healthcare encounter data for students (ages 5-18) who used primary care were analyzed to compare utilization patterns (total number of office visits, well-child, immunization, chronic-condition visits) in a four-county rural region of New York. Students were categorized into no-SBHC-access (living in school districts without SBHCs) and SBHC-access (living in districts with SBHCs). Students with SBHC access were further categorized into SBHC-non-users (with SBHC access but not using SBHCs), SBHC-only-users (only using SBHCs), and hybrid-users (using SBHCs and other primary care providers).Treatment effects of SBHC-access and usage categories were estimated, adjusting for age, sex, year, community-level socioeconomic factors, and student/school district random effects. Hybrid-users' visits were stratified by site (SBHC versus non-SBHC clinic). Analyses were performed in 2025.

Results: Students with SBHC access included 24% SBHC-non-users, 52% SBHC-only-users, and 24% hybrid-users. Compared to the no-SBHC-access category, SBHC-access was associated with greater primary care utilization. Results differed within SBHC-access: hybrid-users had the highest utilization, while SBHC-non-users had the lowest. SBHC-only-users had more office visits and were more likely to have immunization visits than students without SBHC access. Hybrid-users had more office visits and immunizations at SBHCs than other primary care clinics.

Conclusions: SBHCs increased overall office visits and immunization visits among students using primary care in this rural region. Promoting SBHC enrollment and use is important as effects were seen only among students who utilized the SBHC.