Racial group differences in utilization of school-based health centers: An exploration of the role of referral routines

Background: Unlike community-based settings, where youth often enter services via parents' initiative, school staff serve as the primary referral source for school-based health centers (SBHCs).1 However, a growing body of literature indicates that school staff perceptions of students' health concerns and behaviors are often racially biased.2,3 Purpose: Drawing on institutional theory, this study investigates the role of school staff referral practices in SBHC utilization patterns.4,5 Significance: It is critical that SBHCs employ culturally responsive outreach and enrollment strategies that effectively identify students with unmet need.6 Methods: We linked school referral information to student data from an epidemiological survey administered at 15 urban high schools with SBHCs (71% response rate, n=8,604).7 Using multilevel modeling techniques, we estimated the relationships between SBHC use, student race, and referral practices, controlling for student demographics and need for services (e.g., engagement in risky health behaviors). Results: Controlling for demographics and need, Black (OR=2.38) and Latino (OR=2.1) youth were more likely than Asian students to access their SBHC. High referral rates were associated with increased SBHC use overall (OR=1.26). Among racial subgroups, referrals predicted utilization for Black students only (OR=1.6). Conclusions: The over-referral of Black students to SBHCs, coupled with the underrepresention of Asian youth, may indicate racial bias.3,8 Alternatively, these patterns may reflect efforts to connect Black students to additional support in the face of intractable school climate and engagement problems that disproportionately impact this population.3,8,9 Universal screening and health education programs may be more effective strategies to identify students with unmet health need.