not need any services or had another source of care. Students who used the services cited convenience in scheduling, transportation, and confidentiality as their main reasons.

The recent focus on immunization suggests another important role for school-based clinics—the ability to respond rapidly to epidemics and crises in the health system. The New York State Department of Health recently created a pilot immunization project involving outreach efforts by three state-funded school health centers in New York City elementary schools (Bosker, 1992). Many immunizations were provided at low cost, not only to school children but also to their younger siblings. However, the highest-risk families failed to respond, which prompted the providers to recommend a better-orchestrated annual immunization campaign, more appropriate educational materials, and central coordination and support.

When the California Healthy Start evaluation looked at all clients, including adults, it found an increase from 19 to 26 percent in the number of core families who had children participating in the California Health and Disability Program within six months of enrolling in a Healthy Start intervention (Wagner et al., 1994). A reduction in health care due to illness or injury (from 36 to 29 percent) was also reported.

Parents at the Walbridge Caring Community school reported fewer problems with health care access. They also were more likely than parents in a comparison school to report that it was easy for students to get help with health problems (96 versus 59 percent) and that the school helped a lot with their own health care needs (47 versus 25 percent) (Philliber Research Associates, 1994).

School Related

Advocates of SBHCs assert that achievement and graduation rates should increase when health services are made accessible. Washington Senator Brock Adams claimed at a Senate hearing that a school clinic in Seattle's Ranier Beach High School "prevented 40 students from dropping out of school and significantly reduced the number of youth sent home from school" (Adams, 1992). In the San Fernando (California) High School, school-based clinic users were half as likely to drop out of school as were nonusers (9 versus 18 percent) (Bureau of Primary Health Care, 1993). A study of a clinic located in an alternative school and run by a health department is a unique example of an evaluation that focuses entirely on school performance (McCord et al., 1993). Students who used the clinic were twice as likely to stay in school and nearly twice as likely to graduate or be promoted than non-registered students. The more visits that students made to the clinic, the higher their graduation or promotion



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