School-Based Health Centers and the Utilization of Primary Care in Rural Communities

Abstract

Introduction:

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

Methods:

The 2011–2017 electronic health record data for students (aged 5–18 years) who used primary care were analyzed to compare utilization patterns (total number of office visits, well-child, immunization, chronic-condition visits) in a 4-county rural region of New York. Students were categorized into no-SBHC-access (living in school districts without SBHCs) and SBHC-access (living in districts with SBHCs). Students with SBHC-access were further categorized into SBHC-non-users (with SBHCs access but not using SBHCs), SBHC-only-users (only using SBHCs), and hybrid users (using SBHCs and other primary care providers). Treatment effects of SBHC-access and usage categories were estimated, adjusting for age, sex (defined in health record), year, community-level socioeconomic factors, and student/school district random effects. Hybrid-users’ visits were stratified by site (SBHCs versus non-SBHCs clinic). Analyses were performed in 2025.

Results:

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

Conclusions:

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

INTRODUCTION

Access to primary care is critical to the health and well-being of children and youth. The American Academy of Pediatrics recommends annual physical examinations, preventive screenings, and immunizations.¹ In addition, states may require immunizations and health examinations to attend school or participate in sports.² Providing primary healthcare services within schools through school-based health centers (SBHCs) is a strategy aimed at expanding access to care for vulnerable student populations.^3–5 A key characteristic of SBHCs is the ease of access for the populations that they serve owing to the location within the school and the provision of healthcare services regardless of students’ insurance status.^5–8

SBHCs improve healthcare access and health outcomes for medically underserved children, including well-child visits, vaccination rates, and chronic-condition management, but the evidence is drawn mostly from urban schools.^9–13 Because availability of care is often geographically bounded,^14,15 SBHCs may be a particularly important facilitator of healthcare access in rural areas, especially for students who otherwise have no healthcare provider.^13,16–18 Studies of rural SBHCs have documented increased access to primary and preventive care.^17,19,20 Important open questions are how students in rural communities utilize SBHCs and what association exists between different types of SBHC utilization and various forms of primary care services.

This study adds to the literature by comparing school-age children’s utilization of primary care services, including the number of office visits, recommended preventive care and chronic-condition visits, in rural school districts with differential access to SBHCs over the period of 2011 to 2017. Utilizing a unique data set of patient encounters with primary care providers from the regional healthcare network’s electronic health record (EHR) system, this study was able to observe students’ location, healthcare visits, and service types. Students living in a school district without SBHCs were categorized as having no SBHC access, and those in districts with an SBHC were categorized as having SBHC access. SBHC access was further categorized on the basis of SBHC usage: never used SBHCs, only used SBHCs, or used both SBHCs and other primary care facilities. The study hypothesized that among students who used primary care, SBHC access would be associated with greater primary care utilization, with the relationship being especially important for students relying on SBHCs as their sole source of care.

METHODS

Study Sample

The study site includes a single healthcare network serving a 4-county rural region of New York. The school districts are geographically isolated from major urban centers and face social and economic challenges common in many rural areas of the northern U.S. All 4 counties are rural and federally designated as primary care health professional shortage areas.^21,22 The network is the predominant healthcare provider in the region, offering primary and specialty care clinics, emergency departments, and hospitals. During 2011–2017, the network operated 19 SBHCs in 15 of 38 school districts and was the only provider of school-based health care in the region. School districts with and without SBHCs were similar in size and socioeconomic characteristics, with high levels of economic disadvantage.²⁰

All SBHCs were clinics embedded in the schools and offered comprehensive primary care services, including annual well-child visits, immunizations, care for acute and chronic conditions, and reproductive care. SBHCs operate every school day, with care available during summers and vacations. All school districts with SBHCs had either a single school building or 2 buildings located within walking distance, serving all grade levels. Thus, the SBHCs could provide services to all students in the district. The healthcare network reported that 74%–93% of students in school districts with SBHCs were enrolled. Additional information on the study site is provided in Appendix 1 (available online).

Measures

The unit of analysis was unique student by calendar year. The analysis data set contained students with at least 1 primary care visit in a year. Primary care visits were defined as visits to a primary care clinic, including SBHCs, pediatrics, and family medicine clinics. The data set was built from the network’s EHR system and included International Classification of Disease (ICD)-Clinical Modification (CM) diagnosis codes, encounter site (SBHC or other primary care clinic), visit date, patient age, and sex for each visit. Unique patient identifiers facilitated linking multiple encounters to the same individual. To ensure consistency in defining a school district’s SBHC status, 2 school districts that opened SBHCs during the study period were excluded. The data set captured 91% of students appearing in the overall EHR from 2011 to 2017.

Primary care utilization was measured by the total number of office visits and the occurrence of a well-child visit, immunization visit, or chronic-condition visit. Visit types were identified using ICD, both Ninth and Tenth Revision, CM diagnosis codes: well-child visits (V20.2/Z00.129), immunization visits (V03–06/Z23), and chronic-condition visits (asthma: 493/J45; ADHD: 314.0–214.9/F90; depression: 296.20–296.35, 311/F32, F33 F43.21; anxiety: 300.00–300.29, 301.4/F41, F43.22, F43.23; and obesity: 278.0/E66). Multiple ICD-CM diagnosis codes can be recorded during a single visit; for example, well-child and an immunization visit can occur together as part of the same office visit.

Address data from the EHR were geocoded to school districts. Students living in a school district without an SBHC were categorized as having no SBHC access, and those in a district with a SBHC were categorized as having SBHC access. SBHC access was further categorized as SBHC nonuser (living in a district with SBHCs but visited only non-SBHC network primary care clinics in a year), SBHC-only user (used SBHC exclusively in a year), and hybrid user (visited SBHC and other network primary care clinics in a year). About 3% of students categorized as no SBHC access but with recorded SBHC visits were omitted owing to potential address miscoding and enrollment selection concerns. Another 2% of students who moved between districts in the sample period were also excluded.

Covariates included demographics (sex and age) and community socioeconomic characteristics by year from 2011 to 2017. About 94% of students are White,²⁰ so race is not a meaningful covariate. Data on age and sex were from EHR. Economic status and household environment can be related to children’s access to care.^23,24 Because the EHR does not include individual-level socioeconomic data, indices of economic vulnerability and household vulnerability were constructed at the ZIP code level using factor analysis (Appendix 2, available online). Economic vulnerability captured unemployment rate, poverty rate, and inflation-adjusted per capita income (reverse coded). Household vulnerability captured the percentage of single-family households, renter-occupied housing, and households without vehicles. Data for these indices were obtained from the American Community Survey (5-year estimates) from 2011 to 2017. Factor scores were created for each year and merged with the EHR data using ZIP codes.

Statistical Analysis

Descriptive statistics were calculated to compare primary care utilization by (1) whether students had SBHC access or not and (2) different types of SBHC usage among students having SBHC access, examining 95% CIs. Hybrid users’ visits were stratified by SBHC visits and non-SBHC visits. Average treatment effects of SBHC were calculated to estimate the additive change in each predicted outcome (total number of office visits and probability of a well-child, immunization, and chronic-condition visits), comparing (1) students with SBHC access (treatment group: SBHC-access, SBHC nonusers, SBHC-only users, hybrid users) with students with no SBHC access (control group) and (2) SBHC visits (treatment) with non-SBHC visits (control) among hybrid users. STATA (Version 18) was used in Spring 2025 to conduct the analysis, and the marginal effect command was used to quantify the treatment effect of SBHC access and different categories of SBHC usage.

Negative binomial regression was run for number of office visits because it is a count variable and highly skewed. Multivariable logistic regression was used for binary outcomes (whether students had any well-child visit, immunization visit, or chronic-condition visit). Estimates incorporated age, sex, ZIP code–level socioeconomic and household vulnerabilities, and year, along with interaction terms between SBHC and other covariates to calculate the treatment effect. Age was centered at 5. Estimated models incorporated student/school district–level random effects. Bonferroni correction for multiple testing was applied.²⁵ The significance threshold was adjusted to p<0.0125 to account for 4 outcomes to control Type I errors rate at 5%.

Sensitivity analyses were conducted to test the robustness of the results. Student age was coded as their maximum age during a year; analysis using their minimum age was also conducted (Appendix 3, available online). The 2015 Child Opportunity Index was used as an alternative to the author-constructed vulnerability indices used in the main analysis (Appendix 4, available online). Results from both analyses were consistent with those of the main results. This study was approved by the Cornell and Mary Imogene Bassett Hospital IRBs (IRB0147835).

RESULTS

Among 83,208 students with at least 1 primary care visit from 2011 to 2017, 39,422 (47%) had no SBHC access. Among the remaining 43,786 students with SBHC access, 24% never used SBHCs in a year (SBHC nonusers), 52% exclusively used SBHCs (SBHC-only users), and 24% used both SBHCs and other network primary care clinics (hybrid users). This distribution was consistent across years and sex (Table 1).

Table 1.

SBHC Access by Year, Sex, and Socioeconomic Vulnerability, 2011–2017

Student characteristics	Students without SBHC access, n	Students with SBHC access, n	Students with SBHC access: SBHC nonusers, %	Students with SBHC access: SBHC-only users, %	Students with SBHC access: Hybrid users, %
Total	39,422	43,786	24	52	24
Year
2011	5,354	6,276	25	50	25
2012	5,536	6,254	23	52	25
2013	5,541	6,302	24	52	24
2014	5,690	6,155	24	51	25
2015	5,726	6,261	24	52	24
2016	5,870	6,249	25	51	24
2017	5,705	6,289	24	53	23
Sex
Male	19,388	22,288	25	52	23
Female	20,034	21,498	23	52	25
Age, year, median	12	12	12	12	12
Socioeconomic vulnerability, mean (95% CIs)
Economic vulnerability	0.30 (0.29, 0.31)	−0.27 (−0.28, −0.26)	−0.32 (−0.34, −0.30)	−0.18 (−0.19, −0.17)	−0.40 (−0.42, −0.38)
Household vulnerability	0.24 (0.23, 0.25)	−0.22 (−0.23, −0.21)	−0.28 (−0.29, −0.26)	−0.13 (−0.14, −0.11)	−0.36 (−0.37, −0.34)

Data source: Electronic Health Record Data 2011–2017, American Community Survey, 2011–2017.

Note: Economic and household vulnerability are ZIP code-level factor scores (Appendix 2, available online). These scores are standardized, with a mean of 0 and a SD of 1.

SBHC, school-based health center.

Table 2 reports primary care utilization by SBHC access and usage categories and the proportion of SBHC visits versus non-SBHC visits among hybrid users. Hybrid users had the highest rates of utilization, with a higher median and average number of office visits per year and a higher proportion having a well-child visit or a chronic-condition visit than SBHC-only users, SBHC nonusers, and those with no SBHC access.

Table 2.

Descriptive Statistics by SBHC Access, 2011–2017

SBHC access categories	N	Number of office visits, median (IQR)	Number of office visits, mean (95% CIs)	Well-child visit, ≥1, mean (95% CIs)	Immunization visit, ≥1, mean (95% CIs)	Chronic-condition visit, ≥1, mean (95% CIs)
All	83,208	2 (1–4)	3.07 (3.05, 3.09)	0.66 (0.66, 0.67)	0.34 (0.34, 0.35)	0.20 (0.20, 0.20)
No-SBHC access	39,422	2 (1–3)	2.60 (2.58, 2.62)	0.66 (0.65, 0.66)	0.28 (0.27, 0.28)	0.19 (0.19, 0.19)
SBHC access	43,786	3 (1–5)	3.50 (3.47, 3.52)	0.67 (0.66, 0.67)	0.40 (0.40, 0.41)	0.21 (0.20, 0.21)
SBHC nonusers	10,459	2 (1–3)	2.34 (2.30, 2.38)	0.64 (0.63, 0.65)	0.24 (0.23, 0.24)	0.18 (0.18, 0.19)
SBHC-only users	22,657	2 (1–4)	3.22 (3.19, 3.26)	0.62 (0.62, 0.63)	0.43 (0.42, 0.43)	0.18 (0.18, 0.19)
Hybrid users	10,670	4 (3–7)	5.21 (5.15, 5.27)	0.79 (0.78, 0.79)	0.51 (0.50, 0.52)	0.28 (0.27, 0.29)
Hybrid users: SBHC visits	10,670	2 (1–3)	3.10 (3.05, 3.15)	0.37 (0.36, 0.38)	0.42 (0.41, 0.43)	0.15 (0.15, 0.16)
Hybrid users: non-SBHC visits	10,670	1 (1–4)	2.11 (2.07, 2.14)	0.43 (0.42, 0.44)	0.12 (0.12, 0.13)	0.18 (0.18, 0.19)

Data source: Electronic Health Record Data 2011–2017.

SBHC, school-based health center.

Immunization visits were more frequent among SBHC users, with 43% of SBHC-only users and 51% of hybrid users having an immunization visit in a year, compared with 28% of those with no SBHC access and 24% of SBHC nonusers (Table 2). Among hybrid users, 42% used SBHCs for immunization visits, and only 12% used alternative sites. There were no significant differences in well-child visits between SBHC access and no SBHC access. However, among students having SBHC access, hybrid users had the highest percentage of well-child visits. Among 79% of hybrid users with well-child visits, 53% of them only used SBHCs, 45% only used non-SBHCs, and only 2% used both for such visits. This indicated very little duplicate care.

Tables 3 and 4 show average treatment effects, indicating additive change in the number of office visits and probability of a well-child, immunization, or chronic-condition visit, comparing SBHC access with no SBHC access (Table 3) and comparing SBHC visits with non-SBHC visits among hybrid users (Table 4) after controlling for covariates and school district/student random effects. Full model results are shown in Appendix 5 (available online). The estimated random effects show significant school district–level variation for all office visits, well-child visits, and immunization visits (Appendix 5, available online), suggesting that differences across school districts may influence utilization of preventive and general care. However, school district–level variation was not found to be significant for chronic-condition visits, indicating that this type of care may be less affected by school district context and more affected by individual, family, or other community-level factors (Appendix 5, available online).

Table 3.

Average Treatment Effect of SBHC Access and Different Types of SBHC Usage

Compared with no SBHC access	Mean number of office visits (95% CIs)	Well-child visit, ≥1, probability (95% CIs)	Immunization visit, ≥1, probability (95% CIs)	Chronic-condition visit, ≥1, probability (95% CIs)
SBHC access	0.76 (0.70, 0.81)	0.01 (0.004, 0.03)	0.11 (0.10, 0.12)	0.01 (0.004, 0.02)
Non-SBHC users	−0.15 (−0.21, −0.09)	−0.02 (−0.04, −0.005)	−0.02 (−0.04, −0.01)	0.00 (−0.01, 0.02)
SBHC-only users	0.61 (0.55, 0.66)	−0.02 (−0.03, −0.01)	0.14 (0.13, 0.15)	−0.01 (−0.02, 0.01)
Hybrid users	2.38 (2.28, 2.48)	0.13 (0.11, 0.14)	0.21 (0.20, 0.23)	0.07 (0.06, 0.09)
n	83,208	83,208	83,208	83,208

Data source: Electronic Health Record Data 2011–2017, American Community Survey 2011–2017.

Note: Boldfaces indicate statistical significance (p<5%).

Models control for age, sex, household vulnerability, economic vulnerability, year, and random effects at student and school district levels. Bonferroni correction is used to adjust for multiple testing.

SBHC, school-based health center.

Table 4.

Average Treatment Effect of SBHC Visits Among Hybrid Users

Primary care utilization	SBHC visits, compared with non-SBHC visits
Number of office visits, mean (95% CIs)	0.97 (0.91, 1.04)
Well-child visit, ≥1, probability (95% CIs)	−0.07 (−0.08, −0.05)
Immunization visit, ≥1, probability (95% CIs)	0.29 (0.28, 0.31)
Chronic-condition visit, ≥1, probability (95% CIs)	−0.03 (−0.04, −0.02)
n	10,670

Data source: Electronic Health Record Data 2011–2017, American Community Survey 2011–2017.

Note: Boldfaces indicate statistical significance (p<5%).

Models control for age, sex, household vulnerability, economic vulnerability, year, and random effects at student and school district levels. Bonferroni correction is used to adjust for multiple testing.

SBHC, school-based health center.

Table 3 shows that students with SBHC access had more overall office visits (0.76; 95% CI=0.70, 0.81) and had a higher probability of a well-child visit (0.01; 95% CI=0.004, 0.03), an immunization visit (0.11; 95% CI=0.10, 0.12), or a chronic-condition visit (0.01; 95% CI=0.004, 0.02) than students with no SBHC access. Results differed within SBHC-access categories. Hybrid users had about 2 more visits (95% CI=2.28, 2.48) and a higher probability of a well-child visit (0.13; 95% CI=0.11, 0.14), an immunization visit (0.21; 95% CI=0.20, 0.23), or a chronic-condition visit (0.07; 95% CI=0.06, 0.09). SBHC-only users also had more visits (0.61; 95% CI=0.55, 0.66) and had a 14% increase in the probability of an immunization visit (95% CI=0.13, 0.15) but not a well-child visit (−0.02; 95% CI= −0.03, −0.01). SBHC nonusers had fewer overall visits (−0.15; 95% CI= −0.21, −0.09) and a lower probability of a well-child (−0.02; 95% CI= −0.04, −0.005) or immunization visit (−0.02; 95% CI= −0.04, −0.01).

Table 4 shows that overall, hybrid users had more office visits at SBHCs than at other primary care clinics. Hybrid users also had a higher probability of using SBHCs for immunization visits (0.29; 95% CI=0.28, 0.31) but a lower probability of using SBHCs for well-child visits (−0.07; 95% CI= −0.08, −0.05) and chronic-condition visits (−0.03; 95% CI= −0.04, −0.02).

Interaction effects between SBHC access and covariates are presented in Appendix 5 (available online) and are reported as incidence rate ratios for the number of office visits and ORs for well-child, immunization, and chronic-condition visits. Although SBHC access was associated with lower odds of a well-child visit, the interaction terms indicated that older students with SBHC access, including both SBHC-only users and hybrid users, had higher odds of a well-child visit and a higher incidence rate ratio of office visits. Among hybrid users, older students had higher odds of using SBHCs for well-child visits. The odds of well-child, immunization, and chronic-condition visits increased with age for students with SBHC access. However, students in areas with greater socioeconomic vulnerability were less likely to use primary care, even if they had access to SBHCs.

DISCUSSION

In this study, SBHCs played an important role in primary care services for children in this rural area: among students using primary care, SBHC users had more overall office visits and a higher likelihood of well-care, immunization, and chronic-conditions visits. This baseline finding adds new evidence that supports the efficacy and importance of rural SBHCs^{10,11,26–28} because improving access to primary care may reduce health disparities among rural children.^29,30

Hybrid users in this study (those who used SBHCs in addition to other primary care providers) had the highest primary care utilization rates, suggesting that SBHCs provided more options for students who were used to navigating the healthcare system. Students who exclusively used the SBHC (SBHC-only users) also had higher utilization rates than students with no SBHC access and students with access but no visits to SBHCs (SBHC non-users), suggesting that SBHCs are crucial to facilitating access to care for those with more limited options.

SBHCs were an important access point for immunization visits.^31,32 Both hybrid users and SBHC-only users had higher rates of immunization visits than students with no SBHC access and SBHC nonusers. Hybrid users were much more likely to receive immunizations at SBHCs than at other primary care clinics (42% and 12%, respectively). SBHC nonusers had the lowest immunization visit rates and were less likely to have had an immunization visit than all the other groups despite using providers within the healthcare network.

Relative utilization patterns indicated by the interaction between SBHC access and age suggested that SBHCs could help build better consumers of health care. Research shows that older adolescents tend to fall short in using health care relative to younger children³³ but are more likely to use SBHCs as their usual source of care.³⁴ This study showed that, overall, office visits and well-child visits increased with age among SBHC users, whereas for SBHC nonusers and students with no SBHC access, well-child visits decreased with age.

This study reveals some challenges faced by SBHCs in rural communities. Among school districts with SBHCs, approximately one fourth of students using network providers did not use SBHC services, and these SBHC nonusers had the lowest rates of primary care utilization. This suggests challenges with SBHC enrollment, despite its importance in increasing primary care utilization. Interaction effects between SBHC access and socioeconomic vulnerability also indicate that even when an SBHC is available, students living in areas of greater socioeconomic vulnerability had fewer office visits and were less likely to have a well-child visit. These findings highlight the need for SBHCs to proactively engage and support students who are most in need of preventive care.

Among students who used primary care, SBHCs played an important role in access to care among SBHC-only users. Those students showed an increase in frequency of office visits and immunization visits. The frequency of well-child visits also increased with age. Importantly, the loss of SBHC access after graduation could pose access challenges for these students who formerly relied solely on SBHCs. Educating students on healthcare resources is important to facilitate a smooth transition and encourage the continuity of positive health behaviors.³⁵

Limitations

This study strengthened evidence that SBHCs increased access to care by analyzing patient encounters within a large healthcare network that was the predominant healthcare provider and the only SBHC provider in a 4-county rural region. However, the data set had several limitations because it did not include visits to non-network providers such as access to vaccination through public health departments or students who were not patients of the network. Students were included in the analysis data set only if they had at least 1 primary care encounter within the network in a year. Additional limitations are that comparisons were limited to the use of primary health care, and these findings may only be generalized to rural communities with limited primary healthcare providers.

Two SBHCs that opened during the study period were excluded from the analysis for comparability reasons. Future research on pre-SBHC versus post-SBHC opening could provide additional insights into how SBHCs affect care utilization. The data set extended only through 2017, which could limit generalization of the findings to the current healthcare environment. Future research on the post-coronavirus disease 2019 (COVID-19) period (2020+) would allow for examination of COVID-19 disruptions and changes in service models and healthcare utilization in rural areas.

CONCLUSIONS

SBHC access was associated with an increase in rural students’ use of primary care services. In this study, among students with primary care encounters, 76% of students who lived in school districts with SBHCs had at least 1 primary care visit to the SBHC in a year, and 52% of students who utilized SBHCs received care exclusively from the SBHC. For 24% of students, the SBHC increased options for care.

Among students who used primary care, SBHCs were associated with increased overall office visits and the probability of well-child visits, immunization visits, and chronic-condition visits. However, study results suggested that providing SBHCs is not sufficient because students living in districts with SBHCs but not utilizing these services showed lower utilization of primary care. It is crucial not only to expand the availability of SBHCs but also to encourage students’ enrollment and use. Students using both SBHCs and other primary care providers showed the greatest use of primary care. Students relying only on SBHCs also had more total office visits and were more likely to have immunization visits. Those students were also more likely to have well-child visits at an older age. This suggests that the SBHCs fostered a culture of health and encouraged older children to become more regular and better consumers of health care.

Supplementary Material

Supplemental materials associated with this article can be found in the online version at https://doi.org/10.1016/j.amepre.2025.107962.