on school based health care at fairview elementary school

From Paper to Policy: On Proposing School-Based Health Care at Fairview Elementary School

A Needs Assessment Featuring the PRECEDE/PROCEED Model

CATHOLIC CHARITIES BLOOMINGTON & INDIANA UNIVERSITY SCHOOL OF PUBLIC HEALTH

Spring 2015

Authored by: Julius Lee

Spring 2015 From Paper to Policy

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TABLE OF CONTENTS

EXECUTIVE SUMMARY 4

PRECEDE/PROCEED MODEL 5

PRECEDE

PHASE 1: SOCIAL ASSESSMENT 6-8

PHASE 2: EPIDEMIOLOGICAL, BEHAVIORAL,

AND ENVIRONMENTAL ASSESSMENT 9-12

PHASE 3: EDUCATIONAL AND ECOLOGICAL ASSESSMENT 13-16

PHASE 4: ADMINISTRATIVE AND POLICY ASSESSMENT

AND INTERVENTION ALIGNMENT 17-23


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TABLE OF CONTENTS

PROCEED

PHASE 5: IMPLEMENTATION 24-32

PHASE 6: PROCESS EVALUATION 33-35

PHASE 7: IMPACT EVALUATION 35-36

PHASE 8: OUTCOME EVALUATION 36-37

CONFOUNDING ISSUES/VARIABLES 38-39

BIBLIOGRAPHY 40-44


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APPENDICES 45

APPENDIX A: GEOGRAPHICAL MAPS

FAIRVIEW GEOGRAPHICAL GRID

MONROE COUNTY COMMUNITY SCHOOL CORPORATION FEEDER SCHOOLS FLOW CHART

BLOOMINGTON TOWNSHIP EDUCATIONAL AND CULTURAL ASSETS

BLOOMINGTON TOWNSHIP TRANSPORTATION ASSETS

BLOOMINGTON TOWNSHIP FOOD AND GAS FACILITIES

BLOOMINGTON TOWNSHIP PARKS AND RECREATIONAL ASSETS

APPENDIX B: GRANTS AND FUNDING OPPORTUNITIES

PERSONAL RESPONSIBILITY EDUCATION PROGRAM (PREP) COMPETITIVE GRANTS UNDER

THE AFFORDABLE CARE ACT

AFFORDABLE CARE ACT (ACA) GRANTS FOR SCHOOL-BASED HEALTH CENTER CAPITAL

EXPENDITURES

USDA TEAM NUTRITION TRAINING GRANTS

HEALTHY TOMORROWS PARTNERSHIP FOR CHILDREN PROGRAM

MONROE COUNTY HEALTH DEPARTMENT

CITY OF BLOOMINGTON, INDIANA HOUSING AND NEIGHBORHOOD DEVELOPMENT

DEPARTMENT: COMMUNITY DEVELOPMENT BLOCK GRANT (CDBG)

INDIANA HOUSING AND COMMUNITY DEVELOPMENT AUTHORITY: NEIGHBORHOOD

ASSISTANCE PROGRAM

FUNDS FOR SUPPORT FOR EXPECTANT AND PARENTING TEENS, WOMEN, FATHERS AND THEIR

FAMILIES

JACK HOPKINS SOCIAL SERVICES FUNDING COMMITTEE

TITLE V MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT PROGRAM

MATERNAL AND CHILD HEALTH PUBLIC HEALTH CATALYST PROGRAM

R40 MATERNAL AND CHILD HEALTH RESEARCH PROGRAM (MCHR)

COMMUNITY ACCESS TO CHILD HEALTH (CATCH) PLANNING GRANTS

NATIONAL INSTITUTE OF HEALTH (NIH) RESEARCH GRANT PROGRAM (PARENT R03)

COMMUNITY FOUNDATION

o PRECISION HEALTH NETWORK FUNDING INITIATIVE

o COMMUNITY IMPACT FUNDING INITIATIVE

o MATCHSTICK

PARTNERSHIPS WITH STATE MEDICAID AND CHILDREN’S HEALTH INSURANCE

PROGRAM (CHIP)

APPENDIX C: SUPPLEMENTAL RESEARCH: ON SCHOOL-BASED HEALTH CARE AT A LOCAL TITLE I

ELEMENTARY SCHOOL—A FEASIBILITY STUDY


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Executive Summary

For the third consecutive year, students at Fairview Elementary School have failed the

Indiana State Test of Educational Progress, a benchmark exam mandated by the department of

Education to measure their reading, writing, comprehension, and mathematical skills. Upon

revealing the test scores last year, the Fairview community met to define and discuss why the

children are faltering the exam. Suggestions such as afterschool tutoring, mental health services,

and a revamp of the Coordinated School Health Program were implemented, but it is too soon to

evaluate their success.

Catholic Charities Bloomington and the Indiana University School of Public Health

proposes the Fairview Health Care Center, a School-Based Health Care (SBHC) that would

provide on-site acute and preventive care to children and their families. Based on prior research

found in the supplementary section, students who attend a school with a SBHC have reported a

greater rapport with their teachers, reduced absenteeism, and stronger academic achievement as

compared to schools without said facility.

This Needs-Based Assessment maximizes the PRECEDE/PROCEED Model to identify

the social, ecological, and epidemiological factors affecting the students, supportive policy on

their behalf, and our premise on why the facility should be available to this vulnerable

population. Supplemental information includes geographical descriptions of boundaries,

community assets or social capital, funding opportunities, and a Feasibility Study conducted

prior to this assessment.


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Template—PRECEDE/PROCEED Needs Assessment Model (L. Green, & Kreuter, M., 2005)


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PRECEDE

Phase 1: Social Assessment

For the third consecutive year, Fairview Elementary School’s students have faltered on

their mandated exams by the Indiana Department of Education (IDOE) and consequently earned

an F as an accountability grade. This is in accordance with the House Enrolled Act 1750 which

produced Public Law 221 (PL221). To measure progress, P.L. 221 places Indiana schools into

one of the five categories based upon student performance and improvement data from the state’s

ISTEP+ assessments in Grades 3-8 and End Course Assessments in Algebra I and English 10(I.

D. o. Education, 2011). The five categories correspond with the letters A through F, with the

following descriptions:

A (Exemplary Progress)

B (Commendable Progress

C (Academic Progress)

D (Academic Watch)

F (Academic Probation—High Priority) (I. D. o. Education, 2011)

Schools in the lowest P.L. 221 category (Academic Probation) face a series of interventions

that are designed to provide the additional support needed to improve student achievement.

These consequences become more serious the longer schools remain in the bottom category(I. D.

o. Education, 2011).


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Similarly, federal school accountability, known as Adequate Yearly Progress (AYP), was

first established in 2001 with the passage of the federal No Child Left Behind (NCLB) Act(I. f.

Q. o. Education, 2013). Although the NCLB has expired in 2007, the Indiana House of

Representatives are now implementing legislation to take over schools suffering from six

consecutive years of academic failure to four. This bill contains two major components:

Accelerate school takeover by “special management teams” through contracts with the

State Board.

Creates transformation zones—a model currently used in Evansville and IPS

(Indianapolis Public Schools) that allows outside entities to operate schools

(Association, 2015)

Concern has not been raised on the personal health of each student, whether their

socioeconomic conditions enable or inhibit their health, thereby adversely affecting their

academic achievement. Given that an estimated 88% of students qualify for free or reduced

lunch, students qualify for Healthy Indiana Plan- also known as Medicaid. Study after study

shows that they are more likely to report poor health, to see doctors less often (even when they

are sick), to go without preventive care, and to turn to emergency room when in need of

treatment(J. F. McKenzie, Pinger, R.R., & Kotecki, J.E., 2012). Apparently, school health is a

complex issue plagued by lack of resources, ambiguity of who should be in charge of children’s

health (community vs school) and ultimately who should pay for school health efforts(L. M.

Vaughn, Jacquez, F., Zhao, J., & Lang, M., 2011). Questions should be raised if an onsite

preventive health care facility, known as School Based Health Care (SBHC), would improve the

health status of children. For example, if acute care is required, what are the parent’s preferences


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in terms of healthcare services for their child? Should a SBHC be operated beyond the academic

school year? What funding is available for an SBHC? These concerns should be addressed to

implementing a school-based healthcare facility at Fairview, because it could positively affect

the academic outcomes and health behaviors of the students, thereby improving their success rate

in passing state mandated exams. Further, it could improve their overall quality of life.

Catholic Charities Bloomington and the Indiana University School of Public Health will

facilitate a needs assessment to evaluate the health of Fairview students. A needs assessment is

used to create and promote change by engaging the community to identify priorities, to use and

build on strength already present, and to give power to the community participants (Hancock,

2008; L. M. Vaughn, Jacquez, F., Zhao, J., & Lang, M., 2011). Furthermore, involving

community members to explore the meaning and reason for change can lead to increased

commitment and ownership in the action for change (Hobbs, 1987; L. M. Vaughn, Jacquez, F.,

Zhao, J., & Lang, M., 2011). The goal of this PRECEDE/PROCEED needs assessment is to

facilitate a school-based healthcare program that maximizes local and state resources for

preventive and/or urgent care onsite during the academic school year.


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Phase 2: Epidemiological, Behavioral, and Environmental

Assessment

In 2014, Bloomington ranks 8th

in the state in terms of health outcomes, quality and

length of life. (R. W. J. Foundation, 2014) An estimated 88% has graduated from high school,

while 78% of the populations have completed some college. There is an estimated 20% of

children living in poverty and 31% in single-parent households. 13% of the population became

pregnant during their teens, and 7.1% are reported as low birth rate. Although 18% were reported

as uninsured in 2014, Indiana has recently expanded Medicaid to cover the adults who cannot

qualify for Universal health coverage.

In 2010, census data reports there were 141,210 citizens in Bloomington,, Indiana(U. C.

Bureau, 2009). The majority of the population is comprised of Caucasian American Non-

Hispanic (87.8%), with Asians (6.0%), African American Non-Hispanic (3.5%),and persons of

Latino or Hispanic Origin (3.2%) composing much of the rest of the population. American-

Indian and Alaska Native persons comprised of 0.3% of Monroe County(U. S. C. Bureau, 2013).

Indiana Health Indicators from 2011 indicated the infant mortality rate for Bloomington,

Indiana is 5.5 per 1,000 live births. Teen births, ages 15 to 19 years is estimated as 14.9 per

1,000 females, while premature births are 9.6 per 1,000 females. These infants are characterized

as babies who were born premature before 37 weeks gestation. Low birth weight is characterized

as newborns born weighing 5.5 lbs or less, and Bloomington’s rate is 7.4 per 1,000 live births.

Additionally, mothers who smoke during pregnancy is rated at 15.3 per 1,000 live births(Health,

2011).


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We find an importance to address maternal and child health in the context of

neighborhood conditions. There should be an acknowledgement and correlation between the two

parameters, which thus justifies the Maternal and Child Health Federal-State Partnership. The

outcome objective is to address health disparities between women and children and to improve

them by 2018. These measures are the groundwork for health promotion and education, and will

support later measures for children as recommended by Health People 2020. For the purpose of

this needs assessment, we will address the following:

Title V-Maternal Child Health

National Performance Measures:

State 2013 Results: State 2018 Goal:

The percentage of mothers who

initiate exclusive breastfeeding

60% 70%

Percentage of pregnant women on

Medicaid who smoke

27% 28.5%

The percent of children with special

health care needs age 0 to 18 whose

families report the community-based

service systems are organized so they

can use them easily.

65.9% 74%

The infant mortality rate per 1,000

live births

6.7% 6.4%

Percent of children without health

insurance

8% 6%(I. D. o. Health, 2015b)

Fairview Elementary School is located in the center of Bloomington Township.

According to the 2010 Monroe County Health Assessment Atlas, the median age is 25 and under

with the graduation rate greater than 88.1%(Department, 2010). The median household income is

less than $25,000, thus making the household eligible for low-income services such as

Supplemental Nutrition Assistance Program (SNAP), Medicaid, and subsidized housing. Indiana

University Health and Volunteers in Medicine are accessible to this community, and Riley

Pediatrics is located West and North of the vicinity. Bloomington Township is located minutes

from a major grocer, a pharmacy, a cooperative food store, the public library, two recreational

parks, a children’s museum, and numerous social and faith-based organizations. Each


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Wednesday, the public library’s Bookmobile visits the Crestmont community (part of

Bloomington township) from 4:45-5:30. From March through November, the Farmer’s Market

operates every Saturday at City Hall; here, patrons can purchase fresh fruits and vegetables,

eggs, poultry and other items using cash or their SNAP Card. A point-of-sale (POS) machine

exchanges the participant’s monetary value for tokens which allows them to make a purchase.

Additionally, the Community Garden project is North of the campus where participants can

purchase a plot for a nominal fee. The Bloomington “B-line” walking trail also connects most of

these facilities running North to South of the community. Bloomington and Rural Transit bus

services operate throughout the community Monday through Saturday. Finally, Ivy Tech

Community College and Indiana University are both accessible to residents in this community.

At Fairview Elementary School, the 2013-14 academic year indicated a total enrollment

of 385 students; with 183 females and 202 males enrolled from the Head start Program to Grade

Six. Overall, 253 are White or Caucasian, 56 are African American Non-Hispanic, 24 are

Hispanic, 3 are Asian, and 1 is American Indian. There are 48 students who list themselves as

multiracial. Out of this population, 316 are eligible for free lunch and 23 qualify for a reduced

lunch(I. D. o. Education, 2015). For three consecutive years, their attendance rate has remained

constant at an estimated 94%, a slight increase from 93% during the 2010-11 academic year.(I.

D. o. Education, 2014d). Currently, as part of their improvement plan, their student faculty ratio

is 1:17 in Kindergarten and first grade, 1:20 in second grade, and 1:22 in grades three through

six(Lane, 2015).

Onsite, students receive healthcare provided by a nurse and licensed psychologist.

According to the Monroe County Community School Corporation (2015), School nursing

interventions with students who have acute and/or chronic health concerns improve student


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health and provide a positive impact on school achievement and success. School nurses assist

students to develop the skills necessary for successful self-management. School nurses provide

health promotion, disease prevention education and activities for students, staff and families.

While supporting goals to maintain optimal health and encouraging attitudes conducive to

lifelong positive health practices, school nurses effectively impact the community as a

whole(Schilling, 2015).

The school nurse and psychologist are part of the coordinated school health program

(CSHP), which is an organized set of policies, procedures, and activities designed to protect,

promote, and improve the health and well-being of students and staff, thus improving a student’s

ability to learn(J. F. McKenzie, Pinger, R.R., & Kotecki , J.E., 2012). Despite the CSHP,

students are faltering the Indiana Test for Educational Progress (ISTEP). ISTEP test scores from

2014 indicate failure for Fairview students from grades three through six. The following table

illustrates the number that passed and failed the English Language Acquisition (ELA) and the

Math portion of the state exam, and the total number of students per grade level(I. D. o.

Education, 2014c).


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Grade ELA Pass

N=

ELA

Percent

Pass

Math Pass

N=

Math

Percent

Pass

Both Math

and ELA

Percent

Pass

Total

Number of

Students

Per Grade

Level

3 29 63.0% 26 55.3% 54.3% 58

4 20 51.3% 18 45.0% 35.9% 42

5 12 46.2% 15 57.7% 40.0% 31

6 26 56.5% 32 63.6% 45.7% 51


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Phase 3: Educational and Ecological Assessment

Eighty-eight percent of Bloomington students graduate with a high school diploma or

equivalent. Students who continuously attend Fairview progress to Tri-North, Bloomington High

School North, or alternate schools such as the Academy of Science and Entrepreneurship, or the

Bloomington Graduate School. Conversely, twelve percent of Bloomington’s students are not

graduating from high school. Questions should be raised to address predisposing factors that

inhibits their achievement.

The personal health of each student and their family’s Socioeconomic Status (SES) may

affect their academic capabilities; in particular, they may experience illness more than their

counterparts. SES is important to health at all levels of status an in general, the more advantage

individuals are, the better their health, and the more disadvantaged individuals are, the greater

their chances of increased morbidity and mortality(Alder, 1997; Kidder, 2007; Sanders

Thompson, 2012; Zlotnick, 2009).

Maladaptive neurological development may affect children’s cognitive development—

specifically their ability to read. Reading Disability (RD) is a brain-based developmental

disorder associated with deficits in phonological processing, especially phonological awareness,

the metalinguistic understanding that spoken words are made of smaller units(Bradley, 1978;

Lyon, 2003; Pugh, 2014; Snowling, 1981). In a research study with 75 children ages six through

ten, the Yale University Reading Center examined the effects of various tests on a child’s neuro-

metabolites. This study examines neurochemistry early in the process of learning to read, which

is critical for understanding the functional significance of neuro-metabolite-reading

relations(Pugh, 2014).Through the use of several tests and Magnetic Resonance Spectroscopy,

they found a correlation between neutron-metabolites and reading performance. Analyses


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showed that Cho and Glu concentrations were inversely correlated with reading and related

linguistic measures such that high concentrations were associated with poorer

performance(Pugh, 2014). Generally, this pre-disposing factor may justify the faltering of the

ISTEP exam among Fairview students.

Whereupon it was learned that 70 percent of Fairview’s student were not reading at grade

level, the school administration decided to take steps to help move the school forward(Murray,

2014b). Last year, the Herbert Presidential Scholars facilitated a literacy program to improve the

children’s reading capabilities. According to the Indiana Daily Student, the students who will

participate in the program are ones the Fairview community believes will benefit from the

program the most..” (Murray, 2014a)

Abby Englert, coordinator for the Herbert Scholars, says Indiana University students

volunteer for ten weeks to work selected students. The students are taught reading pedagogy

from an instructor, then works closely with an estimated 22% of the student body four days. The

Herbert Presidential Scholars collaborates with Cox Scholars, and the Banneker Center to

provide assistance after school and four days a week. Students are arranged in a classroom by

grade level, with fifth and six grade students working together. Given the pending acquisition of

Fairview by the state government, Abby says that mathematics is also included in tutorial

services. She added that if the acquisition happens, her hope is to continue the program as a

means to providing academic improvement.

Abby mentions that sometimes the children need help beyond the academic ambits, and

will converse with the students on personal matters that are occasionally intervened by the social

worker. Hearing this suggest a need for health services that enables the children to address and

resolve their problems. In doing so, the children are enabled to focus on their academics.


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Although a social worker and psychologist are available on-site, Abby says that the children

connect with the mentors—perhaps feeling comfortable to disclose their problems. Abby says as

children, the mentors have also faced adversity and can empathize with their mentees.

Presumably, the Fairview Literacy Program’s mentors are both a reinforcing factor in terms of

moral support and education, and likewise aiding the children in becoming resilient.

Resilience can be categorized among education and health; educational resilience has

been defined as “the heightened likelihood of success in school and other life accomplishments

despite environmental adversities brought about by early traits, conditions, and

experiences(Reiss, 2005; J. E. Richardson, 2008). Considering health, resilience is a function of

culturally sensitive, integrated structural and programmatic processes for children(Mykota, 2005;

J. E. Richardson, 2008). Whereas the Fairview Literacy Program directs their efforts towards

educational resilience, Catholic Charities Bloomington strives to improve their mental health.

Last year, Catholic Charities was concerned with the mental stability of the students

following the news of their faltering on the ISTEP. According to Marsha McCartney, the

partnership between Fairview and Catholic Charities is we (Catholic Charities) have seen

children at Fairview for a number of years. She says:

We’ve had a relationship with Fairview in that way; and two of our employees were at

Fairview. I’m unsure who talked with us, but initially, Tammy Miller (then Interim

Principal) suggested how great it would be to have services at Fariview- including

medication supervision and pediatric assessment by Mary Balle. Mary and I started to

talk with Tammy, and if Mary is do the medicine distribution, then we would want others

to screen the best referrals, and would we do that. Mary and I started to talk with Tammy

and the social workers who were there at the time. So we developed this plan to see how

it might work even though we were at the end of the school year. We got a list of students

who were referred, and of course Tammy left, Dr Hunter (principal) came, and we re-

vamped it once school started.


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Promoting tutorial services through collaboration with outside agencies, a quality

education both during and after school, personal health and mental health to selected students,

and overall moral support all serves as constructs for Social Cognitive Theory (SCT). Social

cognitive theory specifies a core set of determinants, the mechanism through which they work,

and the optimal ways of translating this knowledge into effective health practices(A. Bandura,

2004). In relation to promoting health in schools, Social Cognitive Theory considers the macro

and micro factorials of the individual, as they are equally relevant to health promotion. In this

model of reciprocal causality, behavioral patterns, and environmental influences all operate an

interacting determinants that influence one another bi-directionally(Bandura, 2001; J. F.

McKenzie, Neiger, B.L., Thackeray, R., 2013b). Once these factors are evaluated, health

promotion and education are effective with the supportive framework of the family and

community. Comprehensive approaches that integrate master health programs with family and

community efforts are more successful in promoting health and in preventing detrimental habits

than are programs in which the schools try to do it alone(A. Bandura, 2004; Perry, 1992).

Self-efficacy in children is an important factor of Social Cognitive Theory, because it is

the beliefs about personal ability to perform behaviors that bring desired outcomes(McAlister,

2008). Seemingly, there is an uncertainty among the Fairview students’ self-efficacy: this focal

belief is the foundation of human motivation and action. Unless people believe they can produce

desired effects by their actions, they have little incentive to act or to persevere in the face of

difficulties(A. Bandura, 2004).


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Phase 4: Administrative and Policy Assessment, and Intervention

Alignment

In spite of the individual challenges that inhibit cognitive development among students at

Fairview Elementary School, domestic policy such as Healthy People 2020 attempts to mitigate

them by health education and promotion. Healthy People 2020 provide objectives for healthcare

providers and communities to improve health outcomes and decrease health disparities(Inman,

2011). These objectives are variable in that they are designed to complement the mission

statement and goals set forth by the health care provider. According to their website, this

framework includes a new component specific to early and middle childhood (EMC)

development, and the educational and community-based objectives (ECBP). This needs

assessment will focus on the following objectives in the context of Coordinated School Health:

EMC-1: (Development) Increases the proportion of children who are ready for school in

all five domains of healthy development, physical development, social-emotional

development, approaches to learning, language, and cognitive development(Promotion,

2015).

ECBP-2 Increase the proportion of elementary, middle, and senior high schools that

provide comprehensive school health education to prevent health problems in the

following areas: unintentional injury; violence; suicide; tobacco use and addiction;

alcohol or other drug use; unintended pregnancy, HIV/AIDS, and STD infection;

unhealthy dietary patterns; and inadequate physical activity(Promotion, 2015).


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The Monroe County Community School Corporation promotes these objectives in the

Coordinated School Health Program. According to the CDC (2015), the eight components of

Coordinated School Health are: Health Education; Physical Education; Health Services;

Nutrition Services; Counseling, Psychological and Social Services; Health and Safe School

Environment; Health Promotion for Staff; and Family/Community Involvement. Together, these

components guide people involved in school health planning to think broadly about how to

prevent health related barriers to learning, and promote health for the entire school

community(Authority, 2015).

At the beginning of 2015, Lisa Petscher was appointed health manager over the

Coordinated School Health. In a phone interview, she says:

“Indiana University Health Bloomington, Indiana University School of Public Health,

Premier Health Care, Bloomington Hospital Foundation, Community Foundation of Monroe

County, and MCCSC, all of these sectors came together and decided to bring back this position

that was cut due to the budget problems prior to 2008. This is where I am come in, my title is

manager of Coordinated Health, in addition to helping the schools start health initiatives , find

funding for them to make them sustainable, I will also as a district and as a whole that we are

meeting state mandates concerning health. A lot of times health gets put aside, all because

pressures regarding standardized testing. So making sure somebody- which is myself- that health

is in the conversation and that schools are being held accountable for that. Anything under the

health umbrella falls under my realm: the health education, physical activity, school health

services including the nurses and health aids, school nutrition services including what food is

served during the day the vending machines and afterschool programming, school

counselling/social services, over-arching culture/environment of the schools, to make sure the

school presents itself in a manner that is welcoming and safe and the staff making sure they have

health promotion and services as needed. Every school has a health wellness coordinator that

works at the individual building level. In addition to that, there is family and community

involvement and I think this position is fortunate to be funded through all of these different sectors

because we can then have a two-way relationship where I can call on them as needed for

resources, and then this gives them an opportunity to be engaged for extend their outreach in the

schools, their families, and the communities.”

Due to the nascent of Coordinated School Health in Monroe County Community School

Corporation, it is too soon to implement an outcome evaluation. For instance, the health and

wellness coordinator is voluntary at each school and the proxy meets with Lisa twice a year. Yet

Freddie Holmgren, Wellness and Fitness specialist from the MCCSC Health and Wellness


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Center, corresponds with the teachers via email with quarterly challenges. These challenges

“trickle down” from the teachers to their students. Specifically, Lisa says: “Freddie sent out a

challenge such as a 10,000 steps challenge, and one of the teachers at the elementary school got

her students involved, and they were trying to reach that goal as well.” In a phone conversation,

we notified Freddie to inquire the success rate of her quarterly challenges, and discovered she is

new to her position.

Without specifying which Health People 2020 objective, we have asked Lisa how the

Healthy People 2020 objectives support the vision of Coordinated School Health. She answers

in the context of formative evaluation:

“most of the people who funded this collaboration.. it is their work, and that they look to

them to see where they should set their goals and how high to reach, and knowing what’s

important globally as well as in the community while keeping this an eye on the big picture. This

program is very new, so we’re still working on which indicators do we measure to see how

effective this program was, and we’ve look to a number of different programs that has something

similar and organizations such as the World Health Organization, and to see what’s important

here.”

Overall, the Coordinated School Health program shows promise in reducing health

behaviors and increasing health education among students. However, unless objectives are

specific, measurable, achievable, realistic and relevant, and time-bound, formative evaluation on

the effectiveness of this program may not occur. This may result in continued academic failure

among the students, and health behaviors that will continue into adulthood. Given the effort

required to make school policy changes to influence health, research is needed to test the premise

that promoting student health will also support academic achievement(Ickrovics, 2014). This

research is evident in the School-Based Health Care (SBHC) program.


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The SBHC is a model of pediatric primary care delivery that offers a comprehensive

services provided by a multidisciplinary team on school grounds(Brindis, 2003; Care, 2010;

Juszczak, 2003; Keeton, 2012; Larson, 2014). The SBHC’s integration within the school

community has allowed for increased access to health and mental health care, especially for the

hard-to-reach and high-risk adolescent population, as well as minority and lower socioeconomic

pediatric populations (Allison, 2007; Brindis, 2003; Care, 2010; Keeton, 2012; Larson, 2014;

Soleimanpour, 2010; Wade, 2008). Currently, there are 1,900 SBHC’s nationwide located in

urban, rural, and suburban communities(Care, 2010; Larson, 2014). In Indiana, there are 87

SBHC facilities, but there is a dearth of research (Care, 2015).

Given SBHC is mandated throughout Illinois, we have examined the impact of this public

policy on its constituents. In corresponding with proxies from the Illinois Department of Human

Services, we have learned that specified services are sponsored by the Illinois Department of

Education and considered School-Based Linked Health Care. Apparently, there is an association

between Medicaid and Education due to the implementation of the Medicare Catastrophic

Coverage Act (Public Law 100-360); Illinois has actively supported this relationship since 1992,

through the School-Based Linked Health Services program, (S. Illinois, 2015). School-Based

Linked Health Centers (SBLHC) are underwritten by the Illinois Department of Healthcare and

Family Services (IDHS). To become certified, each agency must meet the standards established

by IDHS in 77 IL. Adm. Code, Part 2200(Services, 2002). Each child is also assigned an

Individualized Education Program (IEP) which thereby approves specific services. Covered

services include: audiology, developmental assessments, medical equipment, medical services,

medical supplies, nursing services, occupational therapy, physical therapy, psychological


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services, school health aide, social work, speech/language pathology, and transportation(S.

Illinois, 2015).

In contrast, School-based Healthcare centers are not sponsored by the Illinois Department

of Education. However, they provide similar services with the premise “every child deserves a

medical home.” The goals are:

Improve the quality of health care and child health outcomes

Assure appropriate utilization of health care services

Reduce the usage of the emergency room for routine medical care

Improve access to care through the availability of a provider network and

expansion of providers

Provide the most appropriate and cost-effect level of care(ILHS, 2008).

Maternal health is afforded to mothers for 60 days and after a baby is born. “Mom and

Babies” offers inpatient and outpatient care including delivery(I. D. o. H. a. F. Services, 2015).

Further, perinatal depression screening is available. It is estimated that 10-20 percent of women

in the United States who give birth experience a major depression during pregnancy or within a

year after delivery; the prevalence may be higher in women with low socioeconomic

status(ILHS, 2008). Further, providing this service has been mandated as Public Act 95-0469(I.

D. o. H. Services, 2015). After the child is born, single mothers/ parents have the option of

enrolling their child/children into the “All Kids” health insurance. “All Kids” is Illinois’ program

for children who need comprehensive, affordable health insurance, regardless of family income,

immigration status or health condition(S. o. Illinois, 2015). Further, children who qualify will

receive coverage up until 18 years of age.


24

Our research has found that the EverThrive Illinois Coalition for School Based Health

Care (ICSHC) is an advocacy group in support of health care for both pregnant mothers and

children through the school setting. According to their website, ICSHC’s goal is to represent

institutions and individuals who support, receive, and provide health care in schools and school-

linked programs((ICSHC), 2015). Additionally, their mission is to provide leadership, resources,

training and technical assistance to enable school health centers to deliver high quality services,

become financially stable and play an active role in public policy. Further, they advocate for

local, state and national policies and funding to integrate school health centers into health and

education systems((ICSHC), 2015).

Through EverThrive’s 2015 policy, they explain the predisposing, enabling and

reinforcing factors affecting their clientele and how their mission and goals are supportive of

existing services. This includes SNAP (Supplemental Nutrition Assistance Program), the

Affordable Care Act, and immunizations. EverThrive Illinois envisions an Illinois that works

toward equity and social justice, fosters the development of healthy families and provides fair

access to quality health care(E. Illinois, 2015). Furthermore, EverThrive addresses income

inequality as a construct of health disparities among their target population. This includes:

Support policies and programs that lessen the economic disparities that exist for

women, children and families.

Advocate for policies and programs that improve educational opportunities for

lower income families.

Support a fair tax structure and adequate revenue for Illinois, advocating for no

harmful or inequitable cuts to vital programs and services for families.

Support policies to raise the minimum wage (E. Illinois, 2015)


25

We found it important to examine the total Medicaid spending during fiscal year 2012,

monthly enrollment for children in both Illinois and Indiana, and the overall infant mortality rate

in both Illinois and Indiana. In Illinois, total Medicaid spending was $13,392,553,588, whereas

in Indiana, it was an estimated $7,486,196,206(K. F. Foundation, 2015b). This funds the monthly

enrollment of 1,573.8 children in Illinois, and 570.5 in Indiana(K. F. Foundation, 2015a). We

also evaluated the infant mortality rate from 2011, which is 6.6 per 1,000 live births in Illinois(I.

D. o. P. Health, 2015), and 7.7 per 1,000 live births in Indiana(I. D. o. Health, 2015a).

Coincidentally, both rates exceed the Health People 2020 infant mortality goal- which is 6.0 per

1,000 live births(I. D. o. Health, 2015a).


26

PROCEED

Phase 5—Implementation

Given our target population—children—is a vulnerable population, we believe this is an

intervention in the community. These interventions seek more intensive or profound change in a

subpopulation, usually within or from a specific community site such as a workplace, hospital or

clinic, nursing home, or school; this approach is targeted and setting specific(L. W. K. Green,

M.W., 2004). On a macro level, the Bloomington community (e.g., Indiana University’s

Fairview Literacy Program, Catholic Charities Bloomington) is interested in helping Fairview

students academically by providing a literacy program, mental health services, and the eight

components of the Coordinated School Health Program. On a micro level, however, Fairview’s

attempt to promote the “Artful Learning” curriculum is not working to the advantage of

academic achievement, especially with regards to the Indiana State Test of Educational Progress

(ISTEP). Additionally, Fairview Elementary risk government takeover should the majority of

students fail the ISTEP exam this school year. We believe the children’s health status is in direct

proportion of their academic success; therefore, a school-based health care facility would

mitigate their health disparities, reduce absenteeism, and elevate their academic achievement.

To better understand the socio-environmental conditions that affect this target population we

suggest applying this needs assessment and facilitating a steering committee. This volunteer-

based committee would consist of an external evaluation team consisting of: two pediatricians,

one attorney, two parents, two educators (a primary and intermediate grade-level educator), one

interpreter, the health educator from Monroe County Community School Corporation, one proxy

from the Monroe County Health Department, and two professors from Indiana University (one


27

professor from the School of Public Health, one professor from the Department of Medical

Sciences). These partnerships not only enhance the health of the populations they serve, but they

benefit their academic health institutions by educating health professionals for the future(Smego,

1996). The advantages to an external committee are:

Known expertise.

The responsibility for conducting the program becomes the work of another.

Sometimes external personnel are more respected than internal personnel simple because

they are from the outside.

Bring global knowledge to the program because they have worked with a variety of

entities and cultures(Harris, 2001; J. F. McKenzie, Neiger, B.L., Thackeray, R., 2013a).

The creation of an external group is the starting point of MAP-IT (Mobilize, Assess, Plan,

Implement and Track), a framework promoted by the US Department of Health and Human

Services. MAP-IT: A Guide to Using Healthy People 2020 in Your Community offers guidance

on mobilizing partners, assessing the needs of your community, and creating and implementing a

plan to reach Health People 2020 objectives, and guidance to track your community’s progress

(Hatcher, 2014; U. S. D. o. H. a. H. Services, 2015). We have selected MAP-IT because of the

Healthy People 2020 objectives mentioned earlier in phase four, and the overall format will

further progress the PROCEED section of the needs assessment model.

We will conduct our assessment within the context of research, to ascertain valuable data

from previous studies, to facilitate our research under guidance from our professors from Indiana

University, and to promote further research in School-Based Health Care among marginalized

communities. We will use focus groups or community forums to facilitate a discussion;

according to Krueger and Casey (2000), focus groups are carefully planned series of discussion

where participants usually are selected on the basis of a shared set of attributes. They are


28

designed to obtain thoughts, feelings, opinions, insights, attitudes, misconceptions, and/or beliefs

about a defined area of interest(Kreuger, 2008). Our participants are parents/guardians and other

stakeholders who are relevant to the Fairview community. To obtain their support, we will gather

a convenience sample of informants that will consist of a minimum of 12 adults age 18 or older.

Our moderator will ask questions that are pre-approved from the Institutional Review Board at

Indiana University, and each participant will receive a gift card from Kroger.

Our external committee will then analyze the responses for emergent themes from our

participants. This information will be applied to further developing the SBHC under constructs

that are recommended by our external group and the Centers for Disease Control and Prevention.

Before the 2016-17 school year, we will collaborate with both the MCCSC School Board and

Fairview’s Administration to identify an area specific to SBHC. If feasible, we will facilitate a

pilot study with the assistance from our external committee to assess the usage of the health care

medium. If impractical, we will suggest the Ronald McDonald Care Mobile, a fleet of state-of-

the-art mobile healthcare vehicles that deliver cost-effective medical, dental, and health

education services directly to vulnerable youth in six countries(M. s. Corporation, 2015).

We will establish a Board of Directors who will oversee operations and facilitate

activities on behalf of the health care center. This includes establishing bylaws, becoming

incorporated, applying for 501c status, and selecting personnel(Smego, 1996). Concurrently, we

will begin fundraising by facilitating a Capital Campaign and seeking local, state, and national

resources. Based on the cost of medical supplies, facility renovations, operating costs, wages,

and liability insurance, we will set our funding floor at $2 million. The following illustrates our

fiscal spending:


29


30

Facility Renovations 87%

Medical Supplies 1%

Operating Expenses 1%

Liability 1%

Wages 8%

Miscellaneous 1%

In-Kind Donations 1%

The Fairview Health Care Center


31

Asset Type Amount

Facility

Renovations $ 1,000,000

Medical Supplies $ 12,000

Operating Expenses $ 15,000

Liability $ 14,700 Wages $ 185,000 Miscellaneous $ 7,500 In-Kind

Donations $ 10,000

If we raise 2 million in the Capital Campaign, we estimate a surplus of $755,800. Our in-kind

donations will consist of monetary donations and partnerships with Indiana University Health—

Bloomington Hospital, and Riley Children’s Hospital in Indianapolis. After the first year, we will

apply for United Way of Monroe County so as to sustain our Health Care Center each fiscal year.

Likewise, we will consult the Monroe Community Foundation to create an endowment so that

the Fairview Health Care Center will continue in perpetuity.

The following is a list and description of potential funding opportunities:

Grant Name: Funding

Opportunity

Number:

Description: Amount: Deadline: Renewable:

Personal Responsibility

Education Program

(PREP)-Affordable Care

Act

HHS-2015-

ACT-ACYF-

AK-0984

Support projects such

as pregnancy

prevention, sex

education for you

between ages 10 and

19 years, abstinence,

preventing sexually

transmitted infections,

and parental education

for youth under age

21.

$900,000 May 5, 2015 Yes

Affordable Care Act

Grants for School-Based

Health center Capital

Expenditures

93.501 To expand school-

based health center

capacity to provide

primary health care

services for school-

aged children.

$350,000 Not Applicable

(N/A)

No

FY2015 Team Nutrition USDA-FNS- To expand and $350,000 May 19, 2015 No


32

Training CNTN-

FY2015

enhance training and

educational activities

to support

implementation of

USDA nutrition

standards for meals

and snacks offered

through Child

Nutrition Programs.

Health Tomorrows

Partnership for Children

Program

N/A Promotes maternal and

child health in

innovative

community-based

programs that improve

access to care and

reduce health care

costs through health

promotion, prevention

and early intervention.

$50,000 June 30, 2015 No

Monroe County Health

Department

N/A Provides funding for

preventive health and

health promotion.

$20,000 June 30, 2015 Yes

City of Bloomington,

Indiana Housing and

Neighborhood

Development

Department—

Community Development

Block Grant

N/A To solve local

problems that meet a

national objective as

defined by Housing

and Urban

Development (HUD)

Funding

ceiling is 15%

December 5,

2015

Yes

Indiana Housing and

Community Development

Authority—

Neighborhood Assistance

Program

Indiana Code

6-3.1-9

Provides funding to

implement new and

existing services to

disenfranchised

communities.

$14,136 March 27, 2015 Yes

Expectant and Parenting

Teens, Women, Fathers,

and their Families

AH-SP1-15-

001

Improves the

educational, health,

and social outcomes

for expectant and

parenting teens,

women, fathers, and

their families.

$800.000 May 18, 2015 Yes

Jack Hopkins Social

Services Funding

N/A Provides funding to

improve the human

condition of

Bloomington residents

in the long run.

$30,000 March 30, 2015 Yes

Maternal and Child

Health Title V Block

Grant

Maternal and

Child Health

Public Health

Catalyst

Program

Centers of

Excellence in

Maternal and

Child Health in

Education,

Science and

Practice

HRSA-15-097

HRSA-15-133

To improve health and

well-being of all of

America’s mothers,

infants, children, and

youth—including

children and youth

with special healthcare

needs and their

families.

Variable July 20, 2015 No


33

Maternal and Child

Health Research

Program R40

155794 To improve healthcare

delivery and services,

and to promote the

health and well-being

of maternal and child

populations.

$300,000 December 5,

2015

No

Community Access to

Child Health (CATCH)

Planning Grants

92969 Supports pediatricians

to collaborate with

their communities so

that all children have

access to needed

health services and a

medical home.

$12,000 July 21, 2015 at

2:00 PM

Yes

NIH Small Research

Grant Program

118462 Supports small

research projects that

can be carried out in a

short period of time

with limited resources.

$100,000 July 15, 2015 No

Community Foundation

of Monroe County:

Precision Health

Network

Initiative

Community

Impact Funding

Initiative

The Matchstick

Initiative

(Following the

first year of

operation)

N/A Designed to assist

with the development

of community health

education and health

outcomes.

Designed to Fuel

innovative ideas and

lasting impact within

our community by

granting funds to

nonprofits for the

purpose of meeting

our community’s most

pressing needs or

seizing upon its most

compelling

opportunities.

Helps local agencies

grow operating

endowments by

providing matching

funds.

Varies April 20, 2015

August 24, 2015

January 30,

2016

Yes

The Mission of the Fairview Healthcare Center is to provide children and their families an

onsite facility for acute and preventive healthcare, including dental care, mental health, and

maternal health services. This includes children who have transferred in or out of the school

district, and children whose families are recently homeless or suffering from chronic

homelessness. Our only requirement is that children and their families are enrolled in Hoosier

Healthwise- also known as Children’s Health Insurance Program (CHIP)- and Medicaid for

adults. Families who are not enrolled will be provided assistance, including an interpreter for

Spanish speaking populations, or the Deaf and Hard of Hearing communities.


34

We will evaluate or track our program’s success with the use of goals and SMART

Objectives. Our goals are as follows:

To reduce chronic absenteeism among our target population

To promote preventive healthcare

To provide prenatal, perinatal, and post-partum care to mothers, including

perinatal depression screening.

To create a liaison between Fairview Elementary School, the Parents or

Guardians, and Riley Pediatrics

To provide mental health services.

To provide pregnancy and sexually transmitted infection prevention, promote

abstinence, and provide resources to teens who become parents.

Our objectives will support our mission statement and goals in that they are SMART; as

explained in phase four, SMART Objectives are Specific, Measurable, Achievable, Realistic and

Time- Phased. Based on our research and interviews with key informants, the following is our

process, learning and behavioral objectives:

Type of Objective: Description: Process At the beginning of the academic school year

2016-17, the Fairview Healthcare Staff will

meet privately with parents during orientation.

Brochures will be distributed along with

immunization records for each child, and

parents will tour the facility plus offer

feedback on their child’s health status. Also,

the Self-assessment process of the School

Health Index will be administered to the

community.

Impact (Learning) The Fairview Healthcare staff will collaborate

with the physical education teacher and others

to promote the Healthy People 2020 goals and

objectives. The staff will facilitate an

Individualized Educational Program (IEP) for

all students.

Impact (Behavioral) The Fairview Healthcare and Elementary

school staff will collaborate to promote healthy

living among their population. This also

includes supporting their families by teaching

them about healthy nutrition, exercising,

reducing stress, and increasing coping


35

mechanisms.

Impact (Environmental) By the end of 2017, the parents will learn

sustainability opportunities such as gardening

and recycling in their community. Based on

each student’s IEP, students will be

coordinated with services specific to their

learning and personal interests. This outcome

is due to the collaboration of the Fairview

Healthcare Center and supportive services that

foster sustainable living.

Outcome Objective At the end of 2017, the success of the Fairview

Healthcare Center will be determined by the

School Health Index (Planning for

improvement process), test scores from the

Indiana State Test of Educational Progress

(ISTEP), and the grades of all students. For

each grade level, our target is at least 65% of

the students should successfully pass the

ISTEP after 2017, and 70% after Year 2018.

We believe our mission statement, goals and objectives will all support the Indiana State

Board of Education’s Title 511 Article 7—Special Education. Accordingly, Article 7 specifies a

protocol should be met by a school or school system that will positively affect the student’s

academic pursuits. Similar to Illinois’ Department of Education, it recognizes the Individualized

Education Program (IEP) in the context of accomplishments known as benchmarks. An

Individualized Education Program, or “IEP” means a written document, developed, reviewed,

and revised by the CCC in accordance with 511 IAC 7-42, that describes the following: 1) how a

student will access the general education curriculum, if appropriate, and 2) the special education

and related services needed to participate in the educational environment(I. D. o. Education,

2014b). Benchmarks establish expected performance levels for students assessed against

alternative achievement standards that allow for regular checks of progress that coincide with the

reporting period for informing parents of the student’s progress toward achieving the annual

goals delineated in a student’s IEP(I. D. o. Education, 2014a).


36

Phase 6- Process Evaluation

We want to ensure the Fairview Healthcare Center is meeting its objectives and goals.

We desire accountability to our stakeholders and subsequent sponsors so that it will continue in

perpetuity. To ensure assurance, we will facilitate a process evaluation, which investigates how a

program is executed in order to assess and improve implementation(Golden, 2014). Process

evaluations should be embedded in trial evaluations to use consistent measures to assess

implementation fidelity, acceptance, and reach. However, they also need to go beyond these by

collecting qualitative contextual data, which will help answer the questions: what works, for

whom, in what circumstances, and why(Bonell, 2012; Langford, 2014). We will address the

following questions:

1. What features of the Fairview Healthcare are not meeting the goals and objectives set

forth by the external group? Why not?

Reasoning: Underserved populations also disproportionately rely on schools to meet

child-health needs because they are less likely to have family-level health resources such

as a regular source of care, health insurance, and access to quality health care.(Smedley,

2008; L. M. Vaughn, Jacquez, F., & Zhao, J., 2011). To address health disparities in

underserved populations, health intervention and prevention programs must capitalize on

the opportunities available in the school setting(L. M. Vaughn, Jacquez, F., & Zhao, J.,

2011).

Reasoning: Health habits are rooted in familial practices. But schools have an important

role to play in promoting the health of a nation. This is the only place where all children

can be easily reached (Al. Bandura, 2004)

2. What percentage of students suffer from chronic absenteeism? Why?

Reasoning: Low income increases the likelihood that youth will not be insured, see a

dentist, and have to use emergency rooms as treatment sites. These same health issues

trickle into school and so manifest themselves in learning disabilities, short attention

spans, poor attendance, and academic performance(J. W. Richardson, 2008).

Reasoning: Regular school attendance and educational attainment are known to predict

later health in adulthood(Cann, 2014; Kuh, 1993; Wadsworth, 1997).

3. How much staff time and SBHC resources did intervention implementation require

(Golden, 2014)?


37

4. What percentage of students has transferred in/out of Fairview Elementary School?

Choose one of the two questions- or both- for follow up

5. With students who have transferred in: what percentage of medical records arrive within

days of their admittance?

6. With students who have transferred out: what percentage of medical records were sent to

their elementary school nurse or pediatrician?

Reasoning: Medical Records Verification using PowerSchool

PowerSchool is a widely used web-based student information system, supporting 10

million students in all 50 states and over 65 countries. PowerSchool enables educators to

make data-driven decisions that impact student performance while creating a

collaborative environment for parents, teachers and students to work together.

Because students’ health data….are entered into the students’ records, they are portable-

if a student starts at one elementary school and moves to another mid-year or in/out of the

district, all of the health data moves with the child’s academic record and is fully

available at the new school immediately. Data are also retained over time for all children;

if a student drops out or moves out of the district and returns, for example, his or her data

is re-activated(Project, 2013).

The process evaluation provides data on the quality and fidelity of delivering the

interventions. Such data can help develop corrective actions(Issel, 2014). These questions

incorporate quantitative and qualitative data collection, thereby providing both objective and

subjective data. Additionally, it will answer any concerns addressed in the self-assessment

process of the School Health Index—particularly the weaknesses of previous health services

provided to the children.


38

Phase 7: Impact Evaluation

At the end of the first year, we recommend planning for improvement process: the second

assessment of School Health Index to determine the effectiveness of the Fairview Healthcare

Center. Whereas the self-assessment process provided insight in terms of the strengths and

weaknesses of the health program, this can provide feedback to facilitate an impact evaluation,

an evaluation that focus on the immediate observable effects of a program (e.g., awareness,

knowledge, attitudes, skills, environment, and behaviors) leading to the intended outcomes of a

program(L. W. Green, & Lewis, F.M., 1986; J. F. McKenzie, Neiger, B.L., & Thackeray, R.,

2013). According to the CDC (2015), using the School Health Index will:

Enable schools to identify strengths and weaknesses of health and safety policies and

programs.

Enable schools to develop an action plan for improving student health, which can be

incorporated into the School Improvement Plan.

Engage teachers, parents, students, and the community in promoting health-enhancing

behaviors and better health(Prevention, 2015).

Promoting the School Health Index at Fairview Elementary would provide the external

committee, the administration, and stakeholders a response as to whether the healthcare center

has provided effective improvement since the beginning to the school year. Particularly, the

planning for improvement process:

Enables you to identify recommended actions your school can take to improve its

performance in areas that received low scores. It guides you through a simple process for

prioritizing the various recommendations. This step will help you decide on a handful of

actions to implement this year. Finally, you will complete a School health Improvement

Plan to list the steps you will take to implement your actions(Prenvetion, 2015).


39

Promoting the School Health Index’s “planning for improvement” section would describe

the success of the Fairview Healthcare program, and similarly areas where improvement is

needed. This feedback is critical for subsequent funding, community and stakeholder support,

and the overall longevity of the school-based health care center. Further, this information can be

disseminated to our funding partners and Indiana University who may desire feedback for

subsequent research.

Phase 8: Outcome Evaluation

Throughout the intervention, we utilized formative evaluation to ensure that goals and

objectives, and social cognitive theory are salient and efficacious. Similarly, we would calculate

an outcome evaluation over a longer period of time. An outcome evaluation is long-term in

nature and generally takes more time and resources to conduct than impact evaluation(J. F.

McKenzie, Neiger, B.L., & Thacckeray, R., 2013). As mentioned in phase five, we will evaluate

each student and create an IEP that’s specific to their cognition. Shared characteristics among the

students will result in similar control groups, and we will monitor the effectiveness of health care

on their progress. We will also evaluate the students who matriculate at kindergarten and remain

at six grades. Students who transfer from Fairview Elementary School will no longer qualify for

the Fairview Healthcare Center. Rather, their records will be sent to the school via the

PowerSchool database, which was described earlier. New students or transfer will receive

placement into a controlled group that’s specific their transference into the school, but will also

receive an IEP. We believe their academic progress would compromise the internal validity of

the controlled groups who attended Fairview since their matriculation in kindergarten.


40

In addition to an IEP, each student will receive a pre-test and post-test to quantify school-

readiness and academic progress. These scores, their academic progress, and the passing of

standardized tests will provide substantial evidence regarding the Healthcare center’s

effectiveness. Additionally, this feedback is instrumental in implementing additional goals, and

enhancing or modifying services to meet the student’s needs.

Notably, Fairview Elementary School will become the first Title I Elementary School in

Bloomington to facilitate a School-based Health Care program. As a result, we consider external

validity as the number of parents who opt out of services provided at the Fairview Healthcare

facility. In an interview with one parent regarding her child’s pediatrician, the mother strongly

feels that only Dr. Debra K. McDaniel of Riley Pediatrics is the best and only pediatrician for her

child. Thus, we will not undermine the parent’s choice, but would enroll their children into a

specific control group when they feel otherwise about our program.


41

Confounding Issues/Variables

Throughout this assessment, a few confounding issues developed that ultimately was not

included. In terms of correspondence, we made every effort to notify parents, key informants and

many organizations to support our research, but did not receive the response we were hoping for.

Had answers been provided, it would alter the calculus of this assessment.

Regarding the Fairview Literacy Program, we were concerned about impact evaluations.

Our follow-up questions included:

o Are there goals set for the children with a specific time frame?

o Is there subsequent correspondence between the mentors and teachers to discuss

the outcomes after each class, including where improvement is needed?

o In spite of the children’s challenges, what keeps them motivated to keep trying?

o What percentage of students improved academically because of the program?

We reviewed the local newspaper regarding the parent’s frustration with the ISTEP

test(Carlton, 2015). Apparently, parents are temporarily withdrawing their children and opting

for homeschooling during the said exam. If the parent “opt out” for the child taking the test,

he/she will earn a failing grade, but it will not affect Fairview Elementary School in terms of the

number of students failing the exam overall. We were concerned about this issue, but found it

could not be addressed in our assessment due its complexity.

Recently, Dr. Judith DeMunth, Superintendent with the Monroe County Community

School Corporation, suggested to Governor Mike Pence of Indiana that the ISTEP should be

administered to students at the end of the school year, as the current date does not account for

missed school days due to the winter break or during severe winter weather. Dr. DeMunth

further suggests that the current assessment procedure is not working to the benefit of both the


42

student and teachers. Feedback however, has not been provided from Governor Pence, which is

why this was not addressed I our assessment.

Due to budgetary constraints, we were only able to interview three parents and two key

informants. Although we attempted to notify the parents who collaborate with both Fairview

Elementary School and Catholic Charities, this sampling pool resulted in two interviews.

Despite this, we collaborated with other agencies including the Monroe County Community

School Corporation, the Monroe County Health Department, Riley Pediatrics, the Indiana

Department of Health, the Illinois Department of Human Service, the Illinois Department of

Education, Indiana University, and Whitney Thomas at Fairview Elementary School.


43

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44

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Appendix A—Geographical Maps

This study includes geographical maps to indicate the boundaries of the Bloomington

Township District(University, 2010), and Fairview Elementary School(M. C. C. S. Corporation,

2015), assets or social capital(University, 2010), and the recommended trajectory for middle and

high school(Corporation, 2013). We believe this information is critical to stakeholders in

identifying the services afforded to the community, and the need for additional services to

improve their living standards.

Appendix B

We believe these funding opportunities are best representations of our mission, goals and

objectives. They are taken from local, state and national resources and offers suggestions for

further information.


49


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Appendix C—Supplemental Section

From Paper to Policy: On Proposing School-Based Health Care at Fairview

Elementary School

A Needs Assessment Featuring the PRECEDE/PROCEED Model

Spring 2015

Julius Lee


51


52

TABLE OF CONTENTS

INTRODUCTION 50-51

LITERATURE REVIEW 52-62

METHODOLOGY 63-65

DISCUSSION 66-70

LIMITATIONS 71

BIBLIOGRAPHY 72-73

TIMELINE 74-75

BUDGET 76-77

APPENDIX A—STUDY INFORMATION SHEET 78-79

APPENDIX B—FOCUS GROUP QUESTIONNAIRE 80-85

APPENDIX C—DEMOGRAPHIC QUESTIONNAIRE 86-87

APPENDIX D—RECRUITMENT LITERATURE 88-91

APPENDIX E—PAYMENT FORM 92-93


53

Introduction

School-based health centers (SBHCs) operate in nearly 2,000 schools in the United

States{Healthcare, 2009 #1;Walker, 2010 #2}.Typically providing some combination of primary

health, immunization, reproductive, and mental health services, SBHCs are intended to improve

availability of these services to children and youth who are traditionally underserved within

community health and mental health settings{Brown, 2003 #3;Walker, 2010 #2}. SBHCs have

been shown to increase access to care for high-risk groups, such as those living in high-poverty

communities, those with no health insurance, and ethnic minority youth{Allison, 2007

#4;Gance-Cleveland, 2005, Benefits of a School-based Health Center in Preschool; Juszczack,

2003, Use of Health and Mental Health Services in a Large`, Urban School District; Kaplan,

1996, Elementary School-based Health Center Use; Wade, 2008, Access and Utilization Patterns

of School-based Health Centers at Urban and Rural Elementary and Middle Schools; Silberberg,

2009, Making the Case for School-based Health: Where do We Stand?;Wade, 2008,

Improvements in Health-related Quality of Life Among School-based Health Center Users in

Elementary and Middle School; Walker, 2010, Impact of School-Based Health Center Use on

Academic Outcomes}. In partnership with schools, SBHCs could have a profound effect on

learning outcomes, which include but are not limited to poor concentration in school, attendance,

and disturbances of normal sequential cognitive development if SBHCs could build a bridge

between the health and the educational lexicon{Richardson, 2007, Building Bridges Between

School-Based Health Clinics and Schools}.

In a report from 2010-2011, there is an estimated 31 SBHCs in Indiana that receives

$2,444,594{Alliance, 2010-2011, Key SBHC Data by State}. These 31 SBHCs only represent

one-third of Indiana’s 92 counties- with some cities or towns consisting of several SBHC.


54

Further research is needed to evaluate the benefits of SBHCs particularly in Title I Elementary

Schools, because there is in addition a preponderance of evidence that academic performance is

related to health issues such as absenteeism (particularly with asthmatic youth) and conditions

such as attention deficit hyperactivity disorder, attention deficit disorder, and lead poisoning (all

of which are associated with disruptive behavior, shortened attention spans, and participation in

extracurricular activities {Guo, 2000, The Mechanisms Mediating the Effects of Poverty on

Children's Intellectual Development; Fletcher, 2004, Children's Lack of Access to Health Care as

a Barrier to Academic Performance: a Brief Summary of Issues; Geierstanger, 2004, School-

Based Health Centers and Academic Performance: Research`, Challenges`, and

Recommendations ;Raphael, 2005, Poverty and Children are a Lethal Combination; Schettler,

2000, In Harm's Way: Toxic Threats to Child Development; Richardson, 2007, Building Bridges

Between School-Based Health Clinics and Schools}). Interestingly, research is limited regarding

the parent’s perspective on the value of SBHCs and the reduction of the aforementioned health

inequities. Past studies examining preventive care from the parent perspective have been largely

quantitative and focused on information needs, satisfaction with care, and provision of services

(Radecki, 2009). Through the use of focus groups, the goal of this research is to determine their

viewpoint in terms of quality health care for their child, and answer the following research

questions:

1. What benefits would the SBHC provide parents during the school year?

2. Do parents believe a SBHC improve their child’s academic outcome?

3. In what way does a school-based health care program foster community

participation and thus support health and wellness in their students?


55

Literature Review

Physiological Development and Probable Causation

Neurological development is significant during in-utero development because it

determines physiological and cognitive development, adaptability or maladaptive behavior.

Shonkoff (2010) suggests that illnesses such as rubella or fetal alcohol syndrome can disrupt

neurological development and result in subsequent cognitive impairment during early childhood.

When early influences have been positive, physiological systems are typically healthy and

adaptive. When influences have been adverse, systems may be dysfunctional and lead to

impaired learning, maladaptive behavior, illness, disability, and a shortened lifespan {Shonkoff,

2010, Building a New Biodevelopmental Framework to Guide the Future of Early Childhood

Policy} By comparison, Duncan et.al (2010) proposes neurological development to be critical

during these years, yet associates social conditions to developmental determinants. First, family

income had consistently larger associations with measures of children’s cognitive ability and

achievement than with measures of behavior, mental health, and physical health. Second, family

economic conditions in early childhood appeared to be more important for shaping ability and

achievement than did family economic conditions during adolescence. And third, the association

between income and achievement appeared to be nonlinear, with the biggest impacts at the

lowest levels of income {Duncan, 1997, Consequences of Growing Up Poor; Duncan, 2010,

Early-Childhood Poverty and Adult Attainment`, Behavior`, and Health}. Economic deprivation

in early childhood could create disparities in school readiness and early academic success that

persist or widen over the course of childhood{Cunha, 2005, Interpreting the Evidence on Life


56

Cycle Skill Formation; Duncan, 2010, Early-Childhood Poverty and Adult Attainment`,

Behavior`, and Health}. Moreover, this adversity, also known as toxic stress, can result in further

academic impairment beyond the early childhood parameter.

Toxic stress is defined as the excessive or prolonged activation of the physiologic stress

response systems in the absence of the buffering protection afforded by stable, responsive

relationships{, 2011, Harvard University ;Garner, 2012, Early Childhood Adversity`, Toxic

Stress`, and the Role of the Pediatrician: Translating Developmental Science into Lifelong

Health}. Garner continues by describing the three tiers of toxic stress and how they can disrupt

the fluidity of neurological development and result in pathology, thereby implying a strong need

for pediatric primary care. Given the extent to which costly health disparities in adults are rooted

in these same unhealthy lifestyles and persistent inequalities, the reduction of toxic stress in

young children ought to be a high priority for medicine as a whole and for pediatrics in particular

{Shonkoff, 2009, Neuroscience`, Molecular Biology. and the Childhood Root of Health

Disparities: Building a New Framework for Health Promotion and Disease Prevention;

Braverman, 2009, Health Disparities Beginning in Childhood: a Life-Course Perspective;

Garner, 2012, Early Childhood Adversity`, Toxic Stress`, and the Role of the Pediatrician:

Translating Developmental Science into Lifelong Health}

Theoretical Lens: Eco-bio-developmental Framework

To counter toxic stress, Garner suggests applying an eco-bio-developmental (EBD)

framework. Applying the EBD framework to the challenges posed by significant childhood

adversity reveals the powerful role that toxic stress can play in disrupting the architecture of the


57

developing brain, thereby influencing behavioral, education, economic, and health outcomes

decades and generations later{Shonkoff, 2010, Building a New Biodevelopmental Framework to

Guide the Future of Early Childhood Policy;Garner, 2012, Early Childhood Adversity`, Toxic

Stress`, and the Role of the Pediatrician: Translating Developmental Science into Lifelong

Health}.

When stress is not countered, the effects can last through adulthood. Duncan et. al (2010)

describes the effects in the context of economics, morbidity, attainment, and health behavior.

Throughout their longitudinal study from birth through age 37, adults who suffer from toxic

stress during childhood did not complete their high school education, may have been

incarcerated, and have a lower income than their counterparts. In contrast to children whose

families had incomes of at least twice the poverty line during their early childhood, poor children

complete 2 fewer years of schooling, work 451 fewer hours per year, earn less than half as much,

received $826 per year more in food stamps as adults, and are more than twice as likely to report

poor overall health or high levels of psychological distress. Further, poor children have BMIs

(Body Mass Index) that are 4 points higher than those well above the poverty line, and are almost

50% more likely to be overweight as adults {Duncan, 2010, Early-Childhood Poverty and Adult

Attainment`, Behavior`, and Health}. Similarly, Shonkoff and Garner (2012) discuss these

disparities in an effort to justify early intervention—namely with pediatric health care. The

pediatric medical home of the future could offer more than the early identification of concerns

and timely referral to available programs, as enhanced collaboration between pediatricians and

community-based agencies could be views as a vehicle for testing promising new intervention

strategies rather than simply improving coordination among existing services{Shonkoff, 2012,

The Lifelong Effects of Early Childhood Adversity and Toxic Stress}.


58

Shonkoff acknowledges the challenges pediatricians face amid promoting children’s

health in the context of public policy. Although chronic difficulty in securing access to indicated

services is an important problem facing most practicing pediatricians, the limited evidence of

effectiveness for many of the options that are available (particularly in rural areas and many

states in which public investment in such services is limited) presents a serious problems that

must be acknowledged and afforded greater attention . Moreover, at this point in time, the design

and successful implementation of more effective models of health promotion and disease

prevention for children experiencing significant adversity will require more than advocacy for

increased funding. It will require a deep investment in the development, testing, continuous

improvement, and broad replication if innovating models of cross-disciplinary policy and

programmatic interventions that are guided by scientific knowledge and led by practitioners in

the medical, educational, and socials services worlds who are truly ready to work together (and

to train the next generation of practitioners) in new ways {Leslie, 2010, Members of Vision of

Pediatrics 2020 Task Force. Peering into the Future: Pediatrics in a Changing World; Starmer,

2010, Members of Vision of Pediatrics 2020 Task Force. Pediatrics in the Year 2020 and

Beyond: Preparing for Plausible Futures; Shonkoff, 2012, The Lifelong Effects of Early

Childhood Adversity and Toxic Stress}


59

Well-Child Care and School-Based Health Care Models

Nationwide, well-child care (WCC) services are available to support pediatric growth and

development. These services are available to all families but are specifically directed towards

marginalized communities who live at or below the poverty level. Well-child care includes an

array of services ranging from developmental screening to physical exams. Many parents,

however, do not have their psychosocial, developmental, and behavioral concerns

addressed{Schuster, 2000, Anticipatory Guidance: What Information do Parents Receive? What

Information Do They Want? ;Trigg, 1989, Listening Carefully. Improving Communication

About Behavior and Development; Bethell, 2004, Measuring the Quality of Preventive and

Developmental Services for Young Children: National Estimates and Patterns of Clinicians'

Performance; Coker, 2009, Low Income Parents' View on the Redesign of Well-Child Care},

many children do not receive screening for developmental delay, and many pediatricians do not

have the time, training, or financial incentives to provide recommended preventive

services{O'Conner, 2005, What to Say and When? Prioritizing and Prompting Preventive

Services (abstract);Hochstein, 2001, A Comparison of Barriers to the Provision of

Developmental Assessments and Psychosocial Screenings During Pediatric Supervision

(abstract);Coker, 2009, Low Income Parents' View on the Redesign of Well-Child Care}. As a

result, two focus groups were conducted both locally and nationally to evaluate the benefits of

well-child care from the parent’s perspective.

Coker et al. (2009) uses a convenience sample for Los Angeles residents in both the

clinical setting and through the use of mail. Potential participants were encouraged to contact the


60

study coordinator or participating pediatric center. To gain a variance in perspective, certain

conditions were needed to be fulfilled. Eligible parents spoke English or Spanish and had a child

6 months to 5 years of age. This age range was chosen to capture perspectives of a variety of

parents, from those just beginning WCC for children 0 to 3 years of age to those who had

completed it{Coker, 2009, Low Income Parents' View on the Redesign of Well-Child Care}.

Similarly, Radecki et al. (2009) facilitated recruitment in Chicago, Albuquerque and San Diego

to gain a diverse variety of perspectives. We recruited parents by flyers distributed in local

schools, libraries, health centers, churches, and day care centers rather than through physician

offices to ensure participants with a broad range of pediatric providers{Radecki, 2009, What Do

Families Want from Well-Child Care? Including Parents in the Rethinking Discussion}. Both

studies overlapped in the same objective: if we consider changes in the content and delivery of

preventive health care to better meet the needs of families, it is imperative to include the

consumers of that care, namely parents, in the conversation{Radecki, 2009, What Do Families

Want from Well-Child Care? Including Parents in the Rethinking Discussion}. Further, unlike

the local focus group who gained 56 participants, the national focus group received 101

participants. Both however, were supported by mothers. Additionally, both asked open-ended

questions to gain feedback on pediatric services. In contrast, Coker et al. itemizes the concerns of

the parents and include key directives for the moderator to further the discussion. The following

are a list of questions from the local focus group:

Topic One: Understanding/Knowledge of Well-Child Visits

Who has recently gone for one of these well-child visits? What are some of the

different things that happened during these visits? (Write down these items that

the group gives on a dry erase board or large piece of paper taped to the wall)

(If the group does not have any nonmedical items such as checking for

development, helping with parenting issues, etc. ask) What about other things like


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checking to make sure your infant is developing normally or helping with

parenting issues like [age-appropriate topics: feeding, dealing with tantrums, toilet

training]? [Probe] Are there more examples of these types of services that your

[baby/child] might get at these visits?

Topic Three: Alternative Systems of Care—Timing and Locations

Do you know how often doctors want you to bring your infant or child in for a

well visit? (Get Response before Going On) Right now, parents go to the doctor

for visits at 2 months of age, 4 months, 6 months, 8 months, 12 months, 24

months, and 36 months (Write on Board) Do you think this is too often, not often

enough, or just right? (Probe) Why not more/less often? (Probe) Which categories

do you think that your children should not receive more or less often?

Are there other places that you can think of where you might like these well-child

care services to be given? [Probe if few responses] What about grocery stores or

discount superstores like Target or Walmart? What about at daycare centers of

schools? At home visits? At places in your neighborhoods, like community

centers or churches. [Probe} There are some clinics in stores across the country

like Wal-Mart and Target where you can use a nurse for regular healthcare things

like getting shorts or blood tests for your child. You could even get a physical

exam there. These are usually just walk-in clinics, or places where you don’t need

an appointment. You are even seen by nurses or doctor assistants, but if needed,

they can give prescriptions too. Have you heard of these clinics? Have you seen

them at your local store? Some names are Redi-Clinic, Minute Clinic, and Take

Care Clinic. Would you be interested in using these clinics for your child? Why or

Why Not? [Probe} Can you think of any reasons why you would not want to use

these clinics for your child? [Probe] What sounds good to you about these clinics?

What about them does not sound good? {If someone has gone to one of these

retail-based clinics, they can share their experience}

Are there some types of services that are better at locations outside of the doctor’s

office or clinic? What are these and why? (Probe) How would you feel about

getting some of these services in places outside of the doctor’s office or a clinic?

(If it hasn’t come up in earlier discussion, then ask Why?) What would be some of

the problems of having some of these types of services given to you at these other

places? What are some of the good things about doing things this way? {Coker,

2009, Low Income Parents' View on the Redesign of Well-Child Care}

In contrast, although Radecki’s questions fostered an active discussion, critical thinking

questions were utilized towards the parent so that s/he could reflect on her/his needs as well.

They are as follows:


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Theme: Current Well-Child Care Experiences

What do you wish your doctor/health care provider had talked to you about at

what point in your child’s life but hasn’t? Have you tried to find information from

other sources?

Describe what a “perfect” well-child visit would be like for you and your family.

Theme: New Ways to Think About Well-Child Care

What do you think about getting information about your child’s growth and

development in other than a personal visit with your pediatrician (e.g. pediatric

nurses and nurse practitioners, social service providers, educators)? Are there

ways that you would like to get information about your child’s development and

behavior using technology such as the telephone, e-mail, or the Internet?

How can your child’s doctor best help you do a good job as a parent? {Radecki,

2009, What Do Families Want from Well-Child Care? Including Parents in the

Rethinking Discussion}

Moreover, these focus groups facilitate critical thinking in terms of providing the best

service for the child without sacrificing the parent’s needs overall. This includes communication,

awareness of appointments, and options for health care delivery that could be easier for the

parent in terms of transportation. These questions will also serve as a framework for focus

groups that will be conducted locally, which will be discussed later in the methodology section.

Although a dichotomy exists between school-based health care and the school structure,

Strolin-Goltzman (2010) suggests they are complimentary and not independent of each other.

This includes a rapport between the students and staff of the SBHCs, the high value in academia

as a result of a health facility in the school, and the SBHCs overall service to the community at

large. In summary, SBHCs are not only involved in the provision of health-related services, but

often also provide other services to the larger school community that may enhance the overall

learning environment{Strorlin-Goltzman, 2010, The Relationship Between School-Based Health

Centers and the Learning Environment}.


63

In contrast to Strolin-Goltzman’s belief that there’s a codependency between both,

Richardson (2010) believes their objectives are distinguishing determinants which therefore

results in their independence. Though it seems clear that SBHCs and schools could be partners,

the challenge lies in convincing educational leaders that time spent collaborating, space

allocation, and funding of SBHCs will not detract from student-related compliance dictated by

mandates such as No Child Left Behind (2001){Richardson, 2007, Building Bridges Between

School-Based Health Clinics and Schools}. Moreover, funding could be the reason why there are

only thirty-one SBHCs in Indiana.

Despite this dilemma, the World Health Organization (WHO, 2014) believes that school

should serve the child holistically through parameters that are tantamount to their development.

The Health Promotion Schools framework is based on an eco-holistic model, recognizing the

physical, social, mental, emotional and environmental dimensions of health and well-being

(Parsons, 1996) {Langford, 2014, The WHO health Promoting School Framework for Improving

the Health and Well-Being of Students and Their Academic Achievement (Review)}Moreover,

these values should be articulated throughout the school curriculum and the child’s community,

because otherwise they will lose credibility. To achieve this, schools should take into account the

views and opinions of the families and communities they serve, and encourage their support and

participation in health promoting activities {Langford, 2014, The WHO health Promoting School

Framework for Improving the Health and Well-Being of Students and Their Academic

Achievement (Review)}

There is a unique difference between a SBHC in a rural community compared to an urban

community. Wade et al. (2008) provides quantitative data to support the use in both communities

during a three year school period. Examples used were ethnicity, morbidity, and the use of public


64

or private health insurance. In this study, students with public health insurance or no health

insurance were more likely to utilize SBHC and had significantly higher rates of utilization

compared with students who had private insurance, suggesting improved access for these

disadvantaged groups{Wade, 2008, Access and Utilization Patterns of School-based Health

Centers at Urban and Rural Elementary and Middle Schools}. And, among social and

economically disadvantaged families, parents who are likely in lower-paying jobs with less

freedom and autonomy would not have the ability or flexibility in their work schedule to take

time off to bring their child to the doctor for health problems{Wade, 2008, Access and

Utilization Patterns of School-based Health Centers at Urban and Rural Elementary and Middle

Schools}.

By comparison, a four year longitudinal study discussed the residual benefits of SBHC on

academia—notwithstanding funding. Walker, et al. (2010) acknowledges a student’s morbidity,

but also how the SBHC’s service provides acute and immediate care to resolve it and therefore

reduce absenteeism. The results indicate that, with low to moderate effect sizes, SBHC use is

significantly associated with GPA (grade point average) and attendance gains, and that these

effects are moderated by type of use. We found that medical use was most strongly associated

with increases in attendance and mental health use was more strongly associated with increases

in GPA{Walker, 2010, Impact of School-Based Health Center Use on Academic Outcomes}.

Parental involvement is also a significant determinant in a child’s health and

consequently their academic achievement. This includes their support during the school day,

after school activities such as the PTA (Parent Teacher’s Association) and even during

homework. Bartel (2010) supports her premise through the context of the Title I Elementary

School. Whether construed as home-based behaviors (e.g., helping with homework), school-


65

based activities (e.g., attending school events), or parent-teacher communication (e.g., talking

with the teacher about homework), parental involvement has been positively linked to indicators

of student achievement, including teacher ratings of student competence, student grades, and

achievement test scores{Hoover-Dempsey, 1997, Why Do Parents Become Involved in their

Children's Education?;Bartel, 2010, Home and School Factors Impacting Parental Involvement

in a Title I Elementary School}. Parental support may facilitate success or failure of a school-

based health care center—of which will be determined in this research.


66

Conclusion

Health and education are strongly connected: healthy children achieve better results at

school, which in turn are associated with improved health later in life(Langford, 2014).

Therefore, determining a health intervention model for a child will be significant to their

development. The World Health Organization (WHO) suggests that children spend a large

proportion of their time at school and thus schools have the potential to be a powerful domain of

influence on children’s health(Langford, 2014). However, further research is needed to

determine if the school structure is ideal or impractical to providing acute care in direct

comparison to the pediatric clinic or health care center. These concerns would be best addressed

in qualitative research designs that include focus groups and are comprised of adults with

children from birth to age 12. Although this age group respectfully excludes adolescents,

research suggests that these critical years determine subsequent development in terms of

cognition and adaptive behaviors.


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Methodology

School-based health care programs should be fundamental to all schools based on children

attending school nearly eight hours daily. Likewise, the parents of attending children would

value the use of on-site primary care facility for existing and/or sudden illnesses. Based on the

conducted literature review, focus groups should be facilitated at the local Title I Elementary

School to identify the parent’s response and evaluate its success if implemented.

In conducting this research, focus groups are optimal because they will provide parental

insight regarding the personal health of their child and options on how appropriate healthcare.

According to Krueger and Casey (2000), focus groups are carefully planned series of discussions

where participants usually are selected on the basis of a shared set of attributes. They are

designed to obtain thoughts, feelings, opinions, insights, attitudes, misconceptions, and/or beliefs

about a defined area of interest. Additionally, they take place in an informal, permissive,

nonthreatening environment, and each group conducted with a small number of people by a

skilled moderator who uses a detailed protocol{Krueger, 2000, Focus Groups: A Practical Guide

for Applied Research}.

At most, sixty participants will be recruited for the focus groups conducted at the local

elementary school. Materials such as the demographic questionnaire, focus group questions, and

recruitment literature were evaluated and approved at the Institutional Review Board (IRB) at the

Midwestern University. Following said approbation, these materials and the IRB protocol

number were disseminated to the principal and administrators at the school corporation. Focus

groups will be scheduled at the convenience of the administration, and the co-investigator will

regularly meet with the principal investigator and elementary school principal to discuss all

work.


68

At the beginning of each meeting, the moderator will read my narrative on why I am

conducting the research. He/she will then begin distributing the consent form and demographic

questionnaire to evaluate gender, race, highest education obtained, the number years their child

has attend the local elementary school, and age of child/children. In lieu of the person’s name, a

pseudonym—or number—will be used for identification. Participants at any time during the

discussion may opt out of questions or refuse to participate entirely.

After this data is collected, the moderator will inform the participants the interview will be

recorded. Before beginning the interview the moderator will ask if there are any questions the

participants have of the researcher. If there are none, they will continue with the opening general

question. The moderator will then summarize the points of the focus group and close the

discussion by asking if there are any questions. A final information sheet will be distributed to

acquire the mailing information for the participant’s address for the Kroger gift card.

The principal investigator and co-principal investigator will code all responses for emerging

themes and outliers. A code in qualitative inquiry is most often a word or short phrase that

symbolically assigns a summative, salient, essence-capturing, and/or evocative attribute for a

portion of language-based or visual data{Saldana, 2013, The Coding Manual for Qualitative

Researchers}. This information will then be analyzed with the socio-ecological framework.

According to Sallis et al. (2008), the core concept of an ecological model is that behavior has

multiple levels of influences, often including intrapersonal (biological psychological),

interpersonal (social, cultural), organizational, community, physical, environmental, and policy.

Ecological models are believed to provide comprehensive frameworks for understanding the

multiple and interacting determinants of health behaviors{Sallis, 2008, Ecological Models of

Health Behavior}. After a meticulous analysis, the information will be presented to the


69

elementary school principal and administrators for further discussion and potential

implementation.


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Discussion

To date, four interviews were completed: two parents at said elementary school (please

see the appendix for the questions), one parent at Catholic Charities Bloomington, and a mental

health counselor between Riley Pediatrics, Catholic Charities Bloomington, and said elementary

school. No demographic information was gathered for the mental health counselor. Regarding

the parents, all three interviews were married women who had an associate’s degree or higher,

were Caucasian, one aged between 35 and 39, and the others age 40 or above. Two have children

who were in primary (defined as kindergarten to grade three) while the other was in intermediate

elementary school (defined as grades four through six). One parent was un-employed, self-

employed, and employed. Furthermore, two of the parents lived in the Bloomington Township

district, and the other parent lived outside of the district. One parent would drive her child to

school, while the other two would walk or bike via the Bloomington-line Trail (B-line Trail).

The general consensus is these parents are pleased with the local elementary school due to its

diversity and the artful learning program. When asked to define the artful learning program, the

parent says:

Artful Learning Program (A curriculum designed by Leonard Bernstein that incorporates Art

and Music in reading, writing, and mathematics. Each semester, the students have a theme that

discusses an artist. This program progresses through each grade. It aids also in diversity.

The mental health counselor also applauded the diversity at the elementary school in that the

staff supported both her transgender and foster child. Although the children are no longer

students, she says:

the social worker, nurse, and staff was very supportive in terms of mental and behavioral components of my children. As a foster parent, I experienced the behaviorisms of the child prior to adoption, and then the psychosomatic responses following adoption. I also have a child that is transgender, and was transitioning during


71

her tenure. Thanks to the staff, they would support both children and provide interventions whenever there were substitute teachers, and overall keeping them safe.

When asked whether the parents drive to the pediatrician, all three parents said yes. Two of

the parents visit Riley Pediatrics, which is within proximity of the neighborhood, while the third

mother drives to another pediatrician. Appointments generally last an hour, and longer should

further tests are necessary.

It is important to note that two interviews were conducted within two weeks of the

commencement of school. In contrast, the third interview was conducted the last week in

February. That said, only one child has been sick at school and missed school once, whereas the

other child was absent for over twenty days due to a kidney aliment. Because the child missed

over twenty days of school, the parent was referred to the social worker and warned that

subsequent absences without valid reasoning will result in referral to the Department of Family

and Child Services (DCFS). Despite said notice from the pediatrician, the parent was

reprimanded.

The mental health counselor commented on the lack of communication between Riley

Pediatrics, the local elementary school, and sometimes the parent(s). She explained that both

Riley Pediatrics and the local elementary school work independently of each other, but

the correspondence is limited. If you have a kid that comes in and they’re ill (e.g., ear infection),

they may send them to Riley Pediatrics and them a note is written to excuse them from school.

Chronic conditions are not conversed between them and the school nurse. The doctors are

saying, “here’s what we need medically and here’s a doctor’s note for the kid to be out twelve

until he gets better,” while the teachers and school nurse are saying “here’s what we need

academically.” And oftentimes there isn’t a release note indicating they need to be given the

medication three times a day, which can put a stress on a school being responsible to give the

medication. The school can call and say “here’s an issue we want you to look at without a

release of information, and most of the times there isn’t a release of information between the

two, unless the parent intervenes. For instance, if the child is ADHD and needs medication, but

the parent doesn’t know or does not want the school to know much about the child’s

medication. And the school may not know about the side effects until they reveal themselves at


72

the start of school. There isn’t a continuous line of communication between the staff,

pediatricians, and the parent.

All three parents mentioned they pick their children up from school when sick, with two

mentioning they leave work upon notice. Two parents would appreciate a pediatrician on site.

One parent says:

If the pediatrician was communicate with me via telephone, I could hear his voice and talk

with my son to detect what’s wrong, that’s different. “Is it a wet cough?” He would know what

that meant, and then monitor and get back with me in an hour.

The third parent praised her pediatrician in terms of her care when her daughter had a kidney

ailment; it’s for this reason she prefers her pediatrician at the pediatric center.

It was asked what type of care would they prefer for their child and why? One parent

described:

“I like the idea of getting the opportunity to receive the vaccinations. Because last year, son was

in fifth grade and the community health nurse came and gave all vaccinations to everyone. I loved it

because it saved time, and the $85.00 when it was state mandated unless you had religious objections.

They all got Bat-man ban-aids and it was done. I would love that option It also taught the child that

“shots are not a big deal” and it lessens the anxiety with their child. That would be great if there were

wellness checks made available at the school.”

In contrast, one parent commented on what doesn’t want for her child; she says:

“If they are stable and don’t require an epinephrine pen. I want to be called no matter what,

but broken bones should be cared for by the emergency room or urgent care facility. I wouldn’t

leave that to the pediatrician because even when I have been to the pediatrician they would send

me to the orthopedist for an X-ray.”

Finally, we asked about mental health care provisions to their child, and one parent

summarized it in the context of the Indiana State Test of Educational Progress, and the departure

of principal Tommy Richardson.

I would like to be able to participate in that service. If there was a death of a student or faculty

member here, I really believe that in part of growing a community is that grieving together and

solving a problem together , but I wouldn’t want to be subjugated to just a student with an adult. I

would like for it to be integrated in those types of settings. Like if we had a vigil, we had sessions,

and we can all grieve together and then we can all hear the same information together. So that as a

parent, I could help support with the counselors and they would give me tools to deal with it at


73

home, because grieving doesn’t just stop within the walls here, it goes wherever you are. So I

would appreciate to be a part of that. And there’s a heads up from the teachers and “I referred your

child, he’s having issues with this, I have referred him to a counselor, would you like to come

meet?” I would be okay for him to meet separately for a set week because he’s almost twelve, so

he can speak his mind and he has good boundaries but then I would want to meet with both of

them and she can say “look these are the issues and I talked to him to here’s what he said to me,

let’s meet together.” I would like to be as integrated as possible and not an in-school setting. It

should be a community outreach, because sometimes the kids will tell what’s really bothering

them before they tell their parents—say bullying-- because they’re afraid…..

The mental health counselor also alluded to the use of a case manager at the elementary

school so as to serve as a liaison between the pediatric center, elementary school and parent. She

believes that a health counselor would build trust between the parent, the elementary school, and

Riley Pediatrics, and override any extenuating circumstances- such as when there was a

tremendous turnover of staff.

Yes, considering the collaborative health care model, the case manager would keep the

school and pediatric health care abreast of the child’s health care needs. If we could have

someone to go back and forward, their very basics could be met rather than the parents

visiting the emergency room for urgent and primary care. If you have a kid going to the

emergency room for multiple breaks, MCCSC and Riley Pediatrics won’t know the

problems due to lack of communication, thus being unable to intervene.

She continues:

There has been a tremendous turnover in the staff, thus affecting the relationship between

the parents and teachers and staff. If the parent has suffered adversity, they may not wish

to discuss their challenges with the new teacher or staff member. With the turnover, the

respect isn’t there because they don’t know the staff. These staff has to “relearn” all of

these things.

The parent discusses a mental health counselor in relation to the principal’s resignation. She says:

As long as there’s communication going back and forth for like there’s an in-school- but if there’s

a big school issue…..like we should have counseling when Tommy Richardson our principal left

abruptly. And at that point we really could have used some mental health (counseling) because the

kids were just really getting attached, and then he left….And nobody really knew why. And then

the Blonde-haired lady (as described by the son) (Interim Principal Tammy Miller) who yells at

him all the time showed up and tried to change everything they have been doing. And then the

parents were getting upset.

My son has two parents who are totally involved, who makes the time, I mean we didn’t have our

kids until later on purpose, but what about the kids where that is not the construct. That is what I


74

worry about; they don’t even have the words to talk about it, and that’s why we need a mental

health professional here.

Conclusion/ Limitations

Since this feasibility was conducted, we attempted a convenience sample at our elementary

school by attending the open house and parent/teachers association meeting. Our response rate

was two parents, which resulted in further advertisement of our study. Leaflets were distributed

in newsletters to parents, indirect communication through other social service agencies, and

through direct communication. Other options included notifying other social service agencies to

encourage collaboration, but their response was less than favorable.

On January 12, 2015, the co-investigator began his internship with Catholic Charities

Bloomington, a social service agency who collaborates with the Title I Elementary School. Their

provisions include counseling, therapy, diagnostic mental exams, and other services. The co-

investigator agreed to facilitate interviews with the school’s parents who collaborate with

Catholic Charities, and the interviews would be presumably successful. Further, an amendment

was sent to the Institutional Review Board to include Catholic Charities, and to modify the

interview protocol from focus groups to a single interview. In doing so, privacy was ensured to

each participant.

Our interview goal became a limitation due to budgetary constraints and the response rate.

Notwithstanding, the women whose children attend the elementary school are concerned about

their child’s health- regardless if care is provided at a pediatric center or on-site. Similarly, the

mental health counselor provided a lens from whence her children attended, to providing health

services to the attending children. Further research is needed to promote SBHC in any—or all—

Title I Elementary Schools in marginalized communities.


75

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Timeline

May 20, 2014: Submit proposal to Dr. Obeng

June 2, 2014: If approved, notify Monroe County Community School Corporation to

present research. If approved, commence IRB application.

June 9th

, 2014. Upon IRB approval, begin correspondence with Fairview Elementary

School to draft plan for notifying parents or guardians.

June 16th

, 2014 through August 6, 2014: Continue reviewing literature to add to existing

research. Build on Introduction and Methodology sections.

Consult Dr. Obeng for additional instruction.

August 8th

, 2014: Present research at McNair Symposium.

August 11th

: Attend PTA Meeting to Introduce my Research and the Purpose of the

Focus Groups. Further, inquire about suggested recruitment at local social service

agencies.

September, 2014: Present Preliminary research at the National McNair Research

Conference (Unless Instructed Otherwise)

October 1, 2014: Complete Focus Groups and commence analysis and coding. Complete

the last section of the research paper.

November 21, 2014: Present Research at the Indiana University Undergraduate Research

Conference

January, 2015: Continue research with Needs Assessment with Catholic Charities

Bloomington and the Indiana University School of Public Health


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January 2015: Submit an Amendment to the Institutional Review Board to change the

interview protocol and to include Catholic Charities as an interview site.

February 8-10th

, 2015 If approved, present research at the Ethnographic and Qualitative

Research Conference

March 2015: Interpolate Feasibility Study as Supplementary Material for Needs

Assessment


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Budget

Purchase 60 gift cards in the amount of $5.00 from Kroger. This will equal $300.00

Revision: 10 gift cards in the amount of $5.00 from Kroger; This will equal $50.00


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Study Information Sheet

IRB STUDY #1405047790

INDIANA UNIVERSITY STUDY INFORMATION SHEET FOR

On the Value of Acute Primary Care at Title I Elementary Schools

You are invited to participate in a research study of the need for a school-based health care center at Fairview Elementary School. You were selected as a possible subject because your child or children is/are enrolled . We ask that you read this form and ask any questions you may have before agreeing to be in the study.

The study is being conducted by Julius Lee and Cecelia S. Obeng PhD from the Department of Applied Health Sciences at Indiana University. It is funded by the Ronald McNair Scholars Program.

STUDY PURPOSE

The purpose of this study is to learn more about your child or children’s health care needs and if they can be provided with an on-site pediatrician here at Fairview Elementary School. We want to know if a school-based health care center is created, what would you want and not want provided to your child.

PROCEDURES FOR THE STUDY:

If you agree to be in the study, you will do the following things:

You will participate in a focus group of five or more adults aged 18 or older. This focus group will be held at Fairview Elementary and will last thirty minutes. Participation is voluntary.

CONFIDENTIALITY

Efforts will be made to keep your personal information confidential. We cannot guarantee absolute confidentiality. Your personal information may be disclosed if required by law. Your identity will be held in confidence in reports in which the study may be published. All focus groups will be recorded and data will be saved at Indiana University Department of Applied Health Science. Once the data has been analyzed, all materials will be destroyed.

Organizations that may inspect and/or copy your research records for quality assurance and data analysis include groups such as the study investigator and his/her research associates, the Indiana University Institutional Review Board or its designees, the study sponsor, the Ronald McNair Scholars Program and the Department of Applied Health Sciences, and (as allowed by law) state or federal agencies, specifically the Office for Human Research Protections (OHRP) and the Food and Drug Administration (FDA) [for FDA-regulated research and research involving positron-emission scanning], the National Cancer Institute (NCI) [for research funded or supported by NCI], the National Institutes of Health (NIH) [for research funded or supported by NIH], etc., who may need to access your medical and/or research records.


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PAYMENT

You will receive a $5 payment for taking part in this study in the form of a gift card from Kroger. Upon participating in the focus group, your name and address will be collected and a gift card will be mailed to you. Please allow four to six weeks for delivery.

CONTACTS FOR QUESTIONS OR PROBLEMS

For questions about the study, contact the researcher Julius Lee or Cecelia S. Obeng at 812-856-0502.

For questions about your rights as a research participant or to discuss problems, complaints or concerns about a research study, or to obtain information, or offer input, contact the IU Human Subjects Office at (317) 278-3458 or [for Indianapolis] or (812) 856-4242 [for Bloomington] or (800) 696-2949.

VOLUNTARY NATURE OF STUDY

Taking part in this study is voluntary. You may choose not to take part or may leave the study at any time. Leaving the study will not result in any penalty or loss of benefits to which you are entitled. Your decision whether or not to participate in this study will not affect your current or future relations with Fairview Elementary School, the Monroe County Community School Corporation, or Indiana University and the Department of Applied Health Science.


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Demographic Questionnaire

Anonymous


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Demographic Questionnaire

Appendix B

Please answer each question.

1) Gender

a) Female

b) Male

c) Transgender

2) Race or Ethnic Origin

a) Caucasion American, White—Non Hispanic

b) African American, Black—Non Hispanic

c) Hispanic or Latino American

d) Asian American

e) Other

3) Age

a) 18-21

b) 22-25

c) 26-29

d) 30-33

e) 34-37

f) 38 and older

4) Marital Status

a) Single

b) Married

c) Divorced

d) Widowed


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5) Smoker

a) Yes

b) No

6) What best describes your current living situation?

a) Living with parents

b) Living alone

c) Living with a roommate

d) Living with a spouse and children

e) Living with a domestic partner and her/his children from a previous

relationship.

7) What is the highest level of Education you have completed?

a) Less than high school

b) Graduated high school

c) GED degree

d) Some vocational or technical school

e) Completed vocation or technical school certificate

f) Some college

g) AA degree (two year college degree)

h) BA or BS (four year college degree)

i) Some graduate school

j) Completed graduate degree


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8) Employment

a) Unemployed

b) Employed

c) Self-Employed

9) Considering all of your employment, how many hours per week do you usually

work?

a) I am not currently employed

b) Less than 10 hours

c) 10-20 hours

d) 21-30 hours

e) 31-40 hours

f) More than 40

10) How many children do you have?

a) One child

b) Two

c) Three

d) Four


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11) Are you a step-parent?

a) Yes

b) No

12) Are you a foster parent?

a) Yes

b) No

13) Do You have Health Insurance

a) Yes

b) No


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Appendix C—Focus Group Questions

Theme: General Questions Concerning Fairview School

1. What do you like most about Fairview Elementary School?

2. What does your child like most about Fairview?

3. How far do you live from Fairview?

(Probe: If they live far, ask how their child travels to school)

Theme: General Child Wellness

4. How often does your child visit your pediatrician?

5. How far do you live from the pediatrician?

6. Do you drive to the office? (Probe: Ask if any get the bus, cab or walk)

7. How long are the appointments? (Probe: Ask if walk-in hours are available)

8. If your child needs a prescription, where do you go? (Probe: Offer CVS or

Kroger as examples)

Theme: Child Illness and School

9. In the past two weeks, how often was your child sick at school? (Correlated with

Question 10)

10. In the past two weeks, how many days was your child absent from school?

11. When your child is sick is at school, do you immediately take him/her to the

pediatrician? Probe: Why or Why not?

12. If your child is sick at school, do you leave work to pick him/her up?


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13. If there was a pediatrician at Fairview, what care would you want for your child?

14. Why?

15. In terms of pediatric care at Fairview, is there anything you do not want for your

child?

16. Why Not?

Follow Up Questions:

If necessary, return to questions that generated a follow up question.


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Appendix D—Recruitment Literature

Parent and Teacher Association—Recruitment Letter

Hello, my name is Julius Lee and I am a senior majoring in Community Health at Indiana

University. I am also an undergraduate researcher with the Ronald E. McNair Scholars Program.

I am working on a feasibility study concerning a preventive health care program here at Fairview

in that it would provide health care to your children. Specifically, if your child gets sick in class,

or at home, would an onsite pediatrician in addition to the school nurse be ideal.

My research project requires the participation of parents or guardians of children only attending

Fairview School, who will participate in a focus group. This group will answer questions

concerning preventive health care for their child or children. Also, you will answer questions on

what type of care would you want provided to your child. Lastly, you will answer questions

concerning your satisfaction with Fairview Elementary School.

As a thank you, you will receive a $5 gift card from Kroger.

Do you have any questions?


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School-Based Health Care at Fairview

Join Us for a Discussion on: Place: For More Information, Contact Julius Lee at 812-856-0502 or [email protected]


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YOUR OPINION MATTERS:

JOIN US FOR A DISCUSSION ON SCHOOL-BASED HEALTH CARE HERE AT FAIRVIEW ELEMENTARY SCHOOL Date and Time: Place: For More Information, contact Julius Lee at 812-856-0502 or [email protected]


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Join Us for a Discussion on Health Care and Your Child When: Time: Place: For More Information, Contact Julius Lee at the Department of Applied Health Science 812-856-0502 or [email protected]


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Appendix E—Payment Form

A FEASIBILITY STUDY ON THE USE OF SCHOOL-BASED HEALTH CARE AT FAIRVIEW ELEMENTARY SCHOOL

PAYMENT AND LOCATING INFORMATION FORM

PLEASE COMPLETE AND RETURN THIS FORM

PART A: PAYMENT FORM

We want to be sure you receive your payments promptly! Please complete the section below with the

mailing address where you would like us to send your payments, and your most current email address.

Print Name: ___________________________________________________

Address: ______________________________________________________

City: ______________________ State: __________ Zip Code: _________

Home Phone: (____) ____________ Cell Phone: (____) ____________

Email Address: _________________________________________________

Signature: ____________________ Date: _______________

PART B: ALTERNATE CONTACT INFORMATION


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Just in case we lose touch with you before the study is complete, please provide the name and phone

number of a significant person in your life who does not live with you and will know how to reach you if

you move or change phone numbers.

Name of Family Member or Close Relation/Friend (who does not live with you):

________________________________________________________________ Phone Number: (_____) _______________

Thank you very much for your help! IRB Protocol Number 1405047790

on school based health care at fairview elementary school

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