Students Speak Out

Letters From the Director

Linking Primary Care and Public Health for Students Living in Disadvantaged Communities

Our health care system’s increasing focus on prevention has led to growing awareness of the link between the health care that people receive in the clinic and the public health practices that keep them healthy where they live, work, learn, play and worship. A strategic mechanism for advancing this integration is our nation’s school-based health centers (SBHCs), which deliver health care to students in some of the nation’s most unhealthy communities. Our professional development program, now starting its second year, is preparing these centers to seize this opportunity to improve health, equity and educational outcomes.

Beyond increasing students’ access to health care, SBHCs also address social barriers to health and educational success and promote lifelong healthy behavior. Many SBHCs are located in marginalized communities that are mired in poverty and face racism, health disparities, high dropout rates and other inequities. Integrating public health practices into the clinical setting enables SBHCs not only to provide one-on-one primary care but also to support the entire student population by addressing the root causes of health issues rather than just the symptoms. With this shift, SBHCs become a leading means of integrating primary care and public health, which will also help ensure that students are in school, healthy, safe, and preparing for graduation.

In public health, we look at all the factors that impact health, even those that may seem disconnected at first glance. In schools, looking through a public health lens means considering whether students have enough to eat, have electricity at home or feel the need to carry a gun along an unsafe route to school. It means knowing when students avoid school because they can’t wash their clothes, are depressed or are being bullied. It lets us see students and their families with much more clarity and brings new allies and tools into focus to respond to the challenges.
A great example lies in how SBHCs address asthma, the most common chronic disease affecting youth in the United States, and one that is exacerbated by poverty, adverse living conditions, a lack of medical care, stress and even violence according to Williams et. al.

Uncontrolled, asthma jeopardizes school attendance and learning. The reasons are complex. Siblings share expensive medications and no one gets enough. Breathing troubles make it hard to sleep, so students are exhausted and can’t concentrate. The stigma of asthma impacts adolescents’ confidence and friendships and can lead to anxiety and depression. Researcher Charles E. Basch describes asthma as a key contributor to the “causal pathways” to dropping out.

Primary care and medications are important, but they aren’t enough. Long-term treatment and prevention require that we address social and economic conditions, including the legacy of poverty and racism. And that’s public health.

Consider what could happen in a school-based health center. A student comes in with breathing troubles, and center clinicians provide medication to open his airways. Then they trade their stethoscope for their public health lens and look for the cause of the problem. The student’s home may be cold and damp, infested with bugs, or without electricity to power his nebulizer. Using this insight, SBHC staff members might contact the local health department to advocate for home services, work with the housing authority to identify better living options or tap other community resources until they find the right combination of support.

Now imagine that the SBHC sees 20 students each week with asthma. The public health lens would consider: “What’s going on here? Is there a common exacerbator or a common solution that will help all the students?” The solution may lie in a request to the local health department to perform home and community assessments, or an agreement to keep the school open later for students without electricity at home. It might lead to partnerships with faith and community-based organizations, youth-serving organizations, neighborhood associations, legislators and policymakers, the local chamber of commerce, and others — whomever it takes.

This approach empowers clinicians to treat the cause rather than repeatedly treating the symptoms. We call it “breaking down the clinic walls.” It also levels the playing field for students — ensuring the social barriers to their health do not also impede their educational success.

To strengthen centers’ ability to integrate primary care and public health, the Center for School, Health and Education launched a professional development program last spring in partnership with the School-Based Health Alliance and with funding from the Centers for Disease Control and Prevention.
Sixteen SBHC leaders from Connecticut, Illinois and Michigan explored strategies to create schoolwide interventions (including engaging students to design solutions), the connection between health and educational outcomes, and ways to identify and engage new partners. Participants reported that the training underscored how much impact SBHCs can have on educational success.

“We already know our students well and understand the challenges they face. Now we can use that knowledge to put together more lasting solutions for each student as well as the whole student body,” says Madeline Chaffee, a health educator at Family Centers Inc. in Stamford, CT. “It’s daunting, but I’ve learned that we don’t have to do it alone. Great organizations exist in our community; our role is to connect the dots and advocate for our students.”

The next three program sessions will engage 45 SBHC leaders in early 2015. Updated professional development content includes recent research in adolescent neuroscience and an increased focus on strategies for engaging and empowering youth. At the request of participants, the next round will also increase opportunities for collaboration among the group.

We look forward to using this forum to share case studies, key learning and success stories. We also encourage you to consider how you can help build the link between public health and primary care in your local health and education communities. And we’d like to hear from you.

Interested in participating in the Building Public Health Capacity in SBHC Leaders program? Would you like additional information? Contact

I also invite you to stay connected on our website, Facebook and on Twitter at @stopdropout.

Thank you for your support as we work to ensure health, equity and graduation for all students.



Terri D. Wright, MPH, PhD

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