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MSU IuAn Affirmative Action/Ecru! Oppommlty Inflation
m1

A COMPARISON OF ABSENTEE/A'I'I'ENDANCE RATES IN HIGH SCHOOLS
WITH AND WITHOUT SCHOOL BASED HEALTH CLINICS

By
Gabrielle Walters

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing
1996

ABSTRACT

A COMPARISON OF ABSENTEE/ATTENDANCE RATES IN HIGH SCHOOLS
WITH AND WITHOUT SCHOOL BASED HEALTH CLINICS

By
Gabrielle Walters

School based health clinics have been developed and implemented throughout the
nation as a method of providing primary health care to adolescents, an underserved
segment of our population. This group is at risk for a variety of behaviors which may be
detrimental to their health and education. One in four adolescents will face consequences of
such high risk behaviors as substance abuse, pregnancy, addiction, contraction of sexually
transmitted diseases, or assault. These behaviors are associated with increased dr0pout
rates, educational failure, and even death. An increase in a student’s absenteeism is in turn
directly related to high risk behaviors.

This thesis hypothesizes that the implementation of school based health clinics will
result in a reduction of absenteeism when compared to schools without school based health
clinics. A retrospective review of attendance rates of four schools in Michigan gives a

preliminary assessment of, and tentative support for, this hypothesis.

ACKNOWLEDGMENTS

The author would like to express her gratitude to her husband, Bill Greenwood, and
her two children, Nathan and Gwendolyn. Without their support, encouragement and
tireless understanding this author would not have been able to fulfill the requirements of the
Master of Science in Nursing.

In addition, the author recognizees the efforts and support of George Allen, thesis
chairperson, committee members Margaret Kingry and Joan Wood, and Patti Peek, the
northern Michigan connection to Michigan State University’s main campus. Their
dedication to teh program and students, not to mention their good humor, help to make it all

worthwhile.

TABLE OF CONTENTS

LIST OF TABLES ................................................................................... v
LIST OF FIGURES ................................................................................ vi
CHAPTER I. INTRODUCTION .................................................................. 1
CHAPTER 11. REVIEW OF LITERATURE .................................................... 3
CHAPTER III. CONCEPTUAL FRAMEWORK .............................................. 6
CHAPTER IV. METHODS ....................................................................... 12
CHAPTER V. RESULTS ........................................................................ 15
Flint Northwest vs. Flint North ......................................................... 16
Port Huron vs. Cadillac .................................................................. 20
CHAPTER IV. DISCUSSION ................................................................... 22
Implications. for Research ................................................................ 23
Implications for Advanced Nursing Practice ........................................... 24

LIST OF TABLES

Table 1 - Mean absentee rates in percent for FN and FNW for 12 years .................... 17
Table 2 - Analysis of variance of Flint schools data ............................................ 19

Table 3 - Yearly mean absenteeism for Port Huron and Cadillac ............................. 20

LIST OF FIGURES

Figure l — Walters’ Modified Health Promotion Model ......................................... 8
Figure 2 - Example of expected outcomes with data prior to SBC opening ................. 13
Figure 3 - Example of expected outcomes without data prior to SBC opening .............. 13
Figure 4 - Mean absentee rates in percent for FN and FNW for 12 years ................... 18

vi

Chapter I
INTRODUCTION

Absenteeism from school in this nation's adolescent population has been receiving
increased attention over the past few years. For example, the Carnegie Council on
Adolescent Development (1989) has examined the incidence of such high risk behaviors
as unprotected sex, substance abuse, and violence, and such consequences as pregnancy,
contraction of sexually transmitted diseases, substance abuse, addiction, assault, and
death. Although there are no definite statistics concerning those adolescents who are at
risk, the Carnegie Council has estimated that 1 in 4 adolescents between the ages of 10-
17 will experience the serious consequences of high risk behaviors plus another 1 in 4 at
moderate risk. These high risk behaviors are tied to increased absenteeism, which in turn
is associated with increased high school drop out rates and educational failure. The
Council estimates that each year's total high school drop outs, over their lifetime, will
cost our nation over $260 billion in lost earnings and tax revenues.

School based clinics (SBCs) offer at least a partial solution to the problems of
absenteeism and high risk behaviors among high school adolescents. A SBC both
increases the likelihood that students will remain healthy and, when illness or injury does
occur, decreases the student’s time away from class.

An increase in attendance for a school system has multiple benefits. Some of
these impact the student directly. The simple reduction of absentee rates reduces the risk
of dropping out since there is a direct correlation between the number of days an
adolescent is absent and the risk of the adolescent in dropping out of school (Klerman,
Weitzman, Alpert, Lamb, Kayne, Geromini, Rose & Cohen, 1987). There is also the
increased capacity of the adolescent to learn and succeed in school with an increased
number days at school and increase in wellness or improved state of health for the days at

school.

Other benefits impact the student’s family. In rural communities there can be
substantial distances between the student’s home, his school, and the health care
providers, making access to health care difficult. Also, students with high absentee rates
are often from families with increased risk for chronic illness, family dysfunction,
poverty, and assorted life stresses. These students and their families could be identified in
the SBC and directed toward appropriate community resources (W eitzman, Klerman,
Lamb, Menary & Alpert, 1982; Kirby, Waszak & Ziegler, 1989).

Finally, there are benefits to the school, itself. Many school systems receive
revenues based upon the number of days children are present in school. If the SBC can
improve attendance rates, schools with SBCs could see an increase in revenues. It is
hypothesized that those schools with school based clinics will see a reduction in absentee

rates with their adolescent populations.

Chapter II
REVIEW OF LITERATURE

Three studies have attempted to reduce absenteeism by direct intervention. A high
poverty school district in San Diego, TX, with high absenteeism and low achievement
was the focus of a plan offering health and nutrition in an intensive fashion (Gordon,
1972). The program, comprehensive through all grade levels, incorporated longer school
days, a summer program, preschool programs, three meals per day, and comprehensive
medical and dental programs. This program resulted in improved nutrition and health
among school students, decreased absence rates, increased numbers of high school
graduates, higher college attendance, greater post graduation job stability, and greater
parent participation.

In a second study, Weitzman, Alpert, Klerman, Kayne, Lamb, Geromini, Kane &
Rose (1986) examined the effects of interventions to reduce absentee rates with
excessively absent students in the Boston, MA , area. An analysis of the health
characteristics of 101 matched pairs of excessively absent students and their mothers and
regular attendees and their mothers showed no significant differences in their use of
health care services, hospitalizations, length of time since last health care visit, length of
time since last dental exam, and number of times an emergency room had been used in
the previous year. Although there were also no significant differences between control
and experimental schools, it was anticipated that these changes were beginning to occur:
experimental schools showed the greater mean increases in attendance rates.

The Weitzman et a1. (1986) study suffered from several limitations. For example,
the school system frequently had inaccurate or missing information with regard to the
excessively absent population. Furthermore, the intervention program had been in
operation for only three and one half years, with absentee follow-up data limited to one

year for each child. The authors discuss the possibility of an earlier intervention program

which would target the student population before the excessive absenteeism was so
ingrained.

Finally, Long, Whitman, J ohansson, Williams & Tuthill (1975) studied
elementary students with high absentee rates. Six schools were targeted for experimental
intervention and two schools, matched for attendance rates and socioeconomic status,
were used for controls. Nursing services in the SBC, focused on students with high
absence and their families, included student assessments and development of action
plans, home visits, family assessments, conferences involving the student, teachers,
principal and SBC staff to help address issues concerning absenteeism, and phone calls to
keep communication lines open. Absentee rates for the intervention group averaged 1.98
days less than for the control group. Not only was this difference statistically significant,
but it proved to be worthwhile from a practical point of view as well.

Additional research has studies the effects of SBCs on a variety of health care
measures. The Middletown (DE) Adolescent Health Project (MAHP, Siegel and Krieble,
1987) established a SBC in a rural community school. When insured student health care
costs were compared between students accessing MAHP and students who did not,
MAHP was found to be consistently less expensive. The savings were even more
dramatic when the time lost from school and work to access primary health care were
factored into the equation. However, attendance rates did not differ significantly between
the two groups over the short period of the study. Another study (Kirby, Waszak and
Ziegler, 1989) examined six SBCs providing low income populations with primary health
care daily during school hours. Perhaps because of wide differences among the clinics in
their ages, sizes, and numbers of clients seen per year, goals, and objectives, this study
also did not show statistical significance on any of its measures. In an indirect study,
Lavin, Shapiro and Weill (1992) reviewed 25 selected reports, published between 1989
and 1991, relating health status to education. They found evidence that health status does

in fact effect education: learning is apparently easier for the healthy child. Physical and

mental health problems put the child in a position of potentially missing school, thus
missing instruction, and further jeopardizing his ability to succeed. Statistically non-
significant trends supporting these claims were found by Feroli, Hobson, Miola, Scott, &
Waterfield (1992).

In spite of the lack of universally significant findings in the studies reviewed, the
trends agree that SBCs are likely to have not just the clearly established positive
economic impact on students, their schools, and their families, but also a supportive

effect on students’ learning and eventual school success.

Chapter III
CONCEPTUAL FRAMEWORK

Pender (1987) emphasizes the great potential adolescents have as they develop
and thus views this population as an important target group for well planned health
promotion programs. “The rapidity of change during adolescent years makes anticipatory
guidance and peer support for healthy lifestyles especially critical during this period of
development. It is interesting to note that positive health behaviors developed during
adolescence are resistant to change and can persist over time” (p. 6). The National
Commission on Children (1991) agrees that lifestyles developed in childhood and early
adolescence can last over a lifetime.

Health promoting behaviors are an integral part of one's life style and are part of
everyday behaviors. If a negative pattern of behavior has been established it is necessary
to remove it and releam a new pattern of behavior to enhance health and well being.
Pender (1987) suggests that "health promoting behaviors represent man acting on his
environment as he moves toward higher levels of health rather than reacting to external
influences or threats posed by the environment" (p. 60). A positive response to health
promotion thus increases the likelihood of enhanced health and well being.

Pender's Health Promotion Model (1987) is categorized into cognitive-perceptual
factors, modifying factors and cues to action. The cognitive-perceptual factors affect the
predispositions towards engaging in health promoting behaviors. The modifying factors
indirectly influence health promoting behaviors through the cognitive-perceptual factors.
Cues to action are the activating cues, originating both internally and externally, which
affect the likelihood to health promoting behavior. The individual’s level of readiness to
this likelihood determines the intensity these cues need to activate change.

Cognitive-perceptual factors are the primary motivational factors which direct an
individual towards health promoting behaviors. They directly influence the likelihood of

health promoting behaviors. Seven factors have been identified within this group,

namely: importance of health, perceived control of health, perceived self-efficacy,
definition of health, perceived health status, perceived benefits of health-promoting
behavior, and perceived barriers to health-promoting behaviors.

Modifying factors are a dynamic group of external factors which influence the
cognitive-perceptual factors both positively and negatively. They include: demographic
factors, biological characteristics, interpersonal influences, situational factors, and
behavioral factors.

Figure 1 illustrates the influences which modifying factors have on the cognitive-
perceptual factors of an adolescent.

SBCs can create an environment which will supply external cues to action,
thereby enhancing positive modifying factors. For example, a SBC might initially consist
of staff which includes an Advanced Practice Nurse (APN), a medical assistant or
Licensed Practical Nurse, a social worker, a dietitian, a psychologist, clerical staff, and a
collaborating physician. During the establishment phase there would be drives which
focus on obtaining parental consent for children's treatment at the clinic. The APN and
support staff would make impromptu visits to classrooms informing students of the
services offered. Educational opportunities would arise and school faculty would consult
with the APN for additional information. As the school year progressed the adolescents in
need of sports physicals would begin to make their way into the clinic. A questionnaire
developed by the SBC staff could be circulated to students to determine what students
consider to be important health issues. These events are all cues to action that initiate the
building of trust. Modifying factors are influenced by such cues. Some cues are more
direct than others. The need for a sports physical directly influences modifying factors.
Student are required to have the sports physical in order to play any school sponsored
sports. This requirement changes the cognitive-perceptual factor of perceived benefit of

health promoting behaviors. The student gets to play the desired sport by participating in

 

Figure l - Walters' modified health promotion model

 

I-..»

 

 

Influences on

Modifying Factors
Consent sought
Students informed of service
Sports physicals offered
Student survey to identify
health issues

Peer influence/peer

pressure

4-

[Cues to Action I

 

 

 

  

v

Modifying Factors

 

 
   
 

D - nographic
U = acteristics

@ical CharacteristicD

 

@tsonal Influences >

 

Situational
F ctor
a s @vioral Factors

 

l

 

 

 

 

 

 

 

 

 

 

 

 

 

     
     
     
  

 

Health

 

 

 

human“ I Cognitive-Perceptual Factors
of Health _ ,
’ Perceived Perceived Defimton l
Self-Efficacy Health Status of Health
Perceived Perceived Barriers to
Control Of Perceived Benefits Health promoting _
Behaviors

 

 

of Health
Promoting Behaviors

 

 

 

 

 

Likelihood of Engaging
. in Health Promoting
Behaviors

 

 

"' Development

 

 

 

er I
* Other students use ciuuc

* Additional questionaires

"‘ Increased understanding of student
. health & perceived health status

* Assess family needs

 

of peer support groups

 

 

the health promoting behavior of an annual physical. Thus modifying and cognitive-
perceptual factors can be influenced in a positive way.

The health status and needs of both individual and family can be addressed. The
SBC staff would have the ability to access the appropriate team members within the
health care system to help clients and their families cope with stressors in their lives.
Wietzman et al. (1982) report that the chronically absent student had up to twice the level
of chronic family illness and problems relating to family dysfunction as students in low
absence groups.

As a result of stimuli from the SBC, students might begin peer support groups,
ranging from alcohol- or substance-abuse recovery groups to homosexual support groups.
Such support groups could be mediated by the SBC, but run by the students themselves.
Modifying factors would thus be influenced through peer influence and peer pressure,
generally in positive directions. The Health Promotion Model reflects guidelines by
which many young adolescents lead their lives. Perceived barriers are reduced as
perceived benefits are experienced. Students who see positive results from their own
health promoting behaviors are likely to continue to do such behaviors.

A hypothetical example of this theory in action follows. Chuck and Andy attend
school. Chuck goes to the SBC for his sports physical. While Chuck is there he develops
an initial relationship with the APN. Through the assessment process, the APN shares
with him educational information about weight training and nutrition. Chuck comes away
from the SBC with a positive view of his initial experience with the APN and the SBC.
He has the required physical and additional information which he can apply to his life.
This interpersonal influence positively affects his cognitive-perceptual factors, increasing
in turn the likelihood of his engaging in additional health promoting behaviors. Later, the
APN sees Chuck in the hall and inquires as to the success of his weight training, further

reinforcing the interpersonal relationship which had begun to be developed during the

10

first visit. Once again the modifying factors are positively influenced. Changed
behaviors, such as weight training, and continued interpersonal influences including the
APN’s inquiry about the new health promoting behavior, affect Chuck's cognitive-
perceptual factors. In this instance all of the cognitive-perceptual factors are influenced
and positive health promoting behaviors are further reinforced.

Chuck talks to Andy about his experience. Andy has been very negative in his
attitudes about the SBC, but his good friend has a different perception of the SBC. Chuck
encourages Andy to use the clinic for a cough which he has had for a couple weeks.
Andy drops by the clinic and finds to his surprise that he will be seen that day. Once he is
evaluated, the APN prescribes an antibiotic and further finds that two siblings and his
mother are ill as well. The APN is able to activate the appropriate health care providers
for the family members (in many cases that could be the SBC). Andy is able to get the
needed antibiotics before he leaves school that day. His perception of health and
perceived control of health have been influenced and the perceived barrier has been
lowered as a result of a positive encounter with the APN.

One measure of the positive effect of the SBC is attendance rates. The student
who has an established trusting relationship with the APN in their SBC has made the first
step towards initiating health promoting behavior. Ease of access to heath care with
minimal expenditure of time results in the student feeling better faster and with less time
expended. The result is a reduction in the days absent from school.

This example can be used for teenage pregnancy as well. Wietzman et al. (1982)
report that intervention programs specialized for the pregnant teen have been successful
in keeping females in the educational setting during prenatal care and after the delivery of
their children. Reducing days absent and preventing school drop outs demonstrates
students’ health promoting behaviors which are directly influenced by the actions which

occurred at the SBC.

11

Health promoting concepts and life styles are best achieved by collaborative
efforts which encompass the individual, family, health professional, community and
school. Healthier choices will result in less illness, increased attendance, more days at
school, higher levels of learning, increased self esteem, lower needs for risk taking
behaviors such as drugs and alcohol abuse, higher probabilities for achievement, and

reinforcement of the positive attributes of health promoting behaviors.

Chapter IV
METHODS

The impact of the SBC on attendance was evaluated by a retrospective review of
high school attendance records. Michigan currently has approximately 27 SBCs, of two
types. The school linked clinic is one which is located near a school, but not on the
school’s campus. The student must leave the school campus to access it. The school
based clinic is a primary health care clinic located directly on campus, although it may be
located on the grounds rather than within the actual building.

After IRB approval was obtained for the study, schools were selected from the list
of SBCs supplied by the State of Michigan Division of Child and Adolescent Health,
Michigan Department of Public Health (1994), for their ability to supply the requisite
attendance data and for their district's willingness to participate in the study. In Michigan,
SBCs are managed both by the Department of Public Health and by hospitals with
collaborative agreements with APNs and physician assistants. These persons are the
primary health care providers in many of these clinics. The SBCs in this study were
headed by APNs sponsored by the Michigan Department of Public Health and fit the
definition of school based clinics.

Schools without SBCs were matched to participating SBC school on the basis of
demographics and school classification. Matched schools from the same basic geographic
areas would have a likelihood of sharing similar regional cultural attitudes, social mores,
influences on adolescent behaviors, and epidemics, thus helping to control for some
variability in attendance rates.

Attendance rates in these schools were compared in either of two ways. If data
were available prior to the SBC’s opening, rates of attendance were compared both before
and after the time of SBC opening in the two schools. In the SBC school a relatively
stable trend in attendance for the first two years and then a gradual increase in attendance

over the next two years, after the point which the SBC has been opened, was anticipated.

12

13

No significant difference in the attendance rates before and after the time of SBC Opening
was anticipated for the control school. This outcome is diagrammed in Figure 2.
If data prior to the SBC’s opening were not available, then at least the last four

years of attendance data were compared between the two schools of the pair. It was

Figure 2 - Expected Outcomes With Data Prior to SBC Opening

 

 

 

 

 

 

 

 

 

 

X X
SBC opening
y Y
x= attendance % y= years x=attendance % y= years
Control School Experimental School
Figure 3 - Expected Outcomes Without Data Prior to SBC Opening
X X
y Y
x= attendance % y= years x= attendance % y= years

Control School Experimental School

14

expected that the experimental school would have an overall increase or an increasing
trend in their attendance rates when compared to the control school. (cf., Figure 3.)

Each school system providing data for the study was asked to provide at a
minimum the yearly attendance total by grade, thus permitting estimates of variability.
School districts were also asked to provide information regarding any particular
epidemics of viruses which might have affected attendance rates for that school.

The research design is a causal-comparative type, with the independent variable
being the presence vs. absence of a SBC. The dependent variable is attendance rate,
defined here as the total number of students present within a school in a given month,
grade, and/or year. The SBCs studied all fit the description given on page 12 of this
thesis, and all were headed by APNs.

Chapter V
RESULTS

Although the State of Michigan requires schools to maintain attendance records
for a minimum of five years, in practice school districts seem to be overwhelmed with the
amount of record keeping required and the limited funding with which to accomplish this
enormous task. As a result, many schools which had initially agreed to participate in this
study were unable to provide the necessary data. Some schools had recently transferred
their records from a manual system to a computerized database and in the process had
purged much of their data. Another school district had experienced a change in personnel
and had no idea what had been done with their previous records.

In the end, two schools were found with SBCs and data going back a minimum of
five years. Flint community schools had excellent records for every school in their district
back into the 19705. Data were obtained from September, 1982, two years prior to the
opening of the SBC at Flint Northwestern High School, to June 1994. Flint Northern
High School was chosen as the comparison school (without SBC).

The second school with a SBC was Port Huron High School, in St. Clair County.
Initially, it was planned to the other Port Huron high school for comparison, but the
control school’s records were inadequate. After an extensive search of public school
districts in Michigan for a comparison control school with similar demographics to Port
Huron, Cadillac High School was selected. Wexford County has demographics similar to
St. Clair County, although the population and school size are smaller.

Even though the experimental and control groups were thus small (2 each), a
representation of urban and suburban/rural was obtained. According to the 1990 Census,
the Flint Community School represents the urban community of the City of Flint with a
total population of 140,761. The school age population of 5-18 years encompasses 22.8%
of the total population. Racially the population in the City of Flint breaks down to White:

15

16

46.9%, African American: 47.9% , Hispanic: 2.7%, American Indian: 0.5%, Asian: 0.5%.
and all others: 1.4%. Financially, the City of Flint has an average of 30.6% living below
poverty level.

St. Clair County has a total population of 145,607, 22% of whom are 5-18 years
old; Wexford County's total population is 26,360, again with 22% between 5 and 18 years
of age. The racial and income demographics are also very similar. St. Clair County has a
race distribution of White: 96.5%, African American: 2%, American Indian: 0.5%, Asian:
0.3%, Other: 0.7%. Wexford County's racial population distribution is White: 98.6%,
African American: 2%, American Indian: 0.8%, Asian: 0.3%, and Other: 0.04%. The
median family income in St. Clair County was $35,678 compared to Wexford County’s
$27,328. St. Clair County has an average of 10.9% of all persons living below poverty
level as compared to Wexford County's 14.6%.

In summary, the matching of the schools in this study is as follows: Flint
Northwestern High School (SBC established 1985) compared with Flint Northern High
School (non-SBC); and Port Huron High School (SBC established 1985) compared with
Cadillac High School (non-SBC). Henceforth the schools will be referred to as FNW,
FN, PH and Cad, respectively.

FNW vs. FN

Because of the completeness of the data from the two Flint schools, in comparison
to the other pair studied, detailed examination of absentee rates began with the Flint data.
The PH/Cad comparison was then used to confirm or disconfirm hypothesis generated by
the Flint data.

Table 1 shows the mean absentee rates for FNW and FN for the 12 years
examined. Fig. 4 shows these same data in graphical form. As may be seen, FNW has a
lower mean absentee rate than FN in 9 of these 12 years. Beginning in 1990, there was a
gradual decrease in absenteeism at FNW, while FN experienced an increase over the

same period. However, because of the great variability in mean absentee rates over the

17

Table l - Mean Absentee Rates in Percent for FN and FNW for 12 Years

Mean Percent Absenteeism

Year FN FNW
1982 13.6 11.8
1983 11.4 10.6
1984 13.4 11.1
1985 9.6 11.3
1986 10.0 8.0
1987 14.4 11.3
1988 12.6 14.4
1989 14.0 10.7
1990 12.1 13.6
1991 14.2 12.6
1992 12.8 11.8
1993 15.85 9.8
All Years 12.8 11.4

period shown, it is impossible to say without further analysis whether this trend is
statistically significant. To answer this question, analysis of variance (ANOVA) of the
Flint data was performed.

Prior to AN OVA, the data were examined for homogeneity of variance. This
analysis showed that the data for June were significantly more variable, across schools,
grades and years, than data for other months. Seniors had the greatest amount of
absenteeism in the month of June with frequently more than 50 percent of the class
missing. (This is explained by what teachers call “senioritis,” a phenomenon of skipping
class the last few weeks of school, common to all schools.) Hence the June data were
omitted from the ANOVA.

The ANOVA examined absenteeism as a function of four factors: SCHOOL
(FNW vs. FN), GRADE (9 through 12), YEAR (1982 through 1993), and MONTH
(September through May). The results of this ANOVA are shown in Table 2. As can be
seen in this table, all main effects and several interactions were statistically significant.
The interaction of interest to this study, namely SCHOOL by YEAR, was in fact

significant; moreover, since the greatest mean difference between the two schools was for

18

Figure 4 - Mean absentee rates in percent for FN and FNW for 12 years

3mm;

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1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993
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19

the last year studied, the evolving trend of reduced absenteeism in the school with the
SBC is supported. However, this support is not strong since the second greatest difference
appeared in 1987, just two years after the SBC was created, immediately after which (in

1988) the absenteeism rates in the schools were reversed.

Table 2. Analysis of Variance of Flint Schools Data

Source SS DF MS F-ratio Signif.
Main Effects 7074 23 308. 21. .001
SCHOOL 438 1 438. 29. .001
GRADE 2714 3 905. 60. .001
YEAR 1413 11 128. 8.6 .001
MONTH 2523 8 315. 21. .001
2-Way Interactions 9480 167 56.8 3.8 .001
SCHOOL GRADE 346 3 115. 7.7 .001
SCHOOL YEAR 1031 11 93.8 6.2 .001
SCHOOL MONTH 961 8 120. 8.0 .001
GRADE YEAR 955 33 28.9 1.9 .003
GRADE MONTH 460 24 19.2 1.3 .177
YEAR MONTH 5794 88 65.8 4.4 .001
3—Way Interactions 7907 409 19.3 1.3 .013
SCHOOL GRADE YEAR 1056 33 32.0 2.1 .001
SCHOOL GRADE MONTH 326 24 13.6 0.9 NS
SCHOOL YEAR MONTH 3073 88 34.9 2.3 .001
GRADE YEAR MONTH 3438 264 13.0 0.9 NS
Explained 24595 599 41.1 2.7 .001
Residual 3930 262 15.0
Total 28525 861 33.1

Further weakening the strength of the observed trend is the even greater
interaction between SCHOOL and MONTH (cf. Fig. 4A). The generally expected
pattern of low absenteeism early in the year is shown by both schools, but FN shows
large increases in the winter months as well as at the end of the year, while FNW’s
absenteeism rates are steadier across the year. This variability in absenteeism between
schools across the year makes it difficult to draw firm conclusions as to the source of the

trends from year to year.

20

According to the hypothesis, the SCHOOL-by-YEAR data should show a gradual
divergence between the two schools' absentee rates, beginning with the year the SBC was
established. This divergence was not seen until the 1991 school year.

PH vs. Cad

Table 3 shows the yearly mean absentee rates for both PH and Cad. PH had a
mean absentee rate over a four period from 1991 to 1994 of 3.9 while Cadillac showed a
mean absentee rate of 13.8 for the same period. This difference is highly significant (p <
.001). In 1992 Cadillac exhibited a dramatic increase in absenteeism. It is noted that the

region experienced an influenza epidemic that year.

Table 3 - Yearly Mean Absenteeism for Port Huron (PH) and Cadillac (Cad)

Yearly Mean
Year PH Cad
1991 3.9 14.4
1992 3.8 19.8
1993 4.6 10.9
1994 3.3 9.4

PH’s average monthly attendance rates were calculated throughout the year using
the 5th Friday attendance figures, whereas the other three schools in the study calculated
attendance on the actual number of students registered for the period being calculated. If
for any reason throughout the year the school’s total enrollment fluctuated, attendance
rates would be reflected accurately by using the changing enrollment in the calculation of
these rates. When a school district is using the 5th Friday count as an enrollment figure
for an entire year the attendance/absentee rates of the true monthly enrollment figures
cannot be accurately calculated. A difference in true absenteeism of as much as 1% could

have resulted from this phenomenon.

21

Although it was impossible to find pairs of schools with identical demographic
characteristics, policies, and recent histories, small variations in these factors were not

felt to be sufficiently powerful to disguise the influence of SBCs on attendance.

Chapter VI
DISCUSSION

A trend of decreasing absenteeism occurred in the schools with SBCs when
compared to matched schools without SBCs. However, this trend must be interpreted
with great caution because of unexplainable variability in the data. In addition, the sample
size examined was very small, limiting the generalizability of this research. FN and FNW
had very similar absenteeism rates, perhaps because of their many shared similarities. PH
and Cad, on the other hand, had very different mean rates when compared to one another.
PH had a consistently low absenteeism, with very little fluctuation, whereas Cad‘s rates
were more similar to those of FN and FNW, with fluctuations from year to year. The
consistently low absentee rates experienced by PH may indicate that PH has attained
about the best absentee rates that could be expected from a secondary school.

As suggested in the results section, the gradual divergence of the FNW and FN
absentee rates beginning in 1991 may be looked at as a trend. To confirm this potential
trend, continued research must be done with an additional exploration of the interactions
between SCHOOL and MONTH. However, even considering these limiting factors, a
replication of this study with a greater number of paired schools with and without SBCs
may further demonstrate support of the hypothesis.

It is difficult to match schools on all control variables simultaneously. For
example, epidemics or other reasons for abnormally high absenteeism need to be taken
into consideration. It was determined that additional support staff (social worker,
psychologist, crisis support staff) had been added through the SBC to the schools during
the period of the study. There was no concomitant loss of staff members during this
period. Furthermore, although the mainstreaming of handicapped children into the school
systems may indicate an increased level of chronic care, which could effect the
attendance rates, these schools all have had similar mainstreaming policies for similar

lengths of time.

22

23

Implications for Research

Although it was assumed that all school districts would be in compliance with the
state regulations, the data collection process revealed just how difficult this process is. As
a result, both the size of the research project and the quality of the data obtained were
limited. In any case, all four of the schools participating in the project were extremely
helpful in helping to obtain whatever data were available within their district

Current literature has focused on short-tenn effects on absenteeism. On the other
hand, this researcher knows from personal experience how long it takes for significant
change to take place. Future studies should look at longer-term results. Communities
considering establishing SBCs can look at these data and explore with participating
communities what health care programs have worked for them.

As discussed above, the size of this study limits the generality of its results. This
study be replicated as a prospective study, using more schools and encompassing a
minimum of a four year period of time. Every SBC in the state of Michigan which uses
an APN in their collaborative primary care setting may be included in this larger scale
project, with matching control schools accordingly. Monthly attendance data for control
and experimental schools should be collected. Experimental schools should be examined
for attendance target programs currently in use with explanations for the manner in which
the programs were developed and implemented. In addition, careful recordings of any
other influences on attendance should be maintained to help explain any sudden increases
or decreases in absenteeism. Each experimental school should incorporate Pender's
Health Promotion Model into their standards of care within the clinic setting. An
expanded role for SBCs may be realized if they are seen to improve adolescent health and
well being while at the same time decreasing absenteeism.

Another avenue for research in regard to SBC cost effectiveness would be to

compare the use of emergency room and urgent care clinics in communities with and

24

without SBCs. A hypothesis examining health care dollars saved versus school system
dollars spent may prove fruitful.
Implications for Advanced Nursing Practice

Current literature reflects the broad scope of adolescent problems and their
impact. These issues need to be examined from a community perspective. Although we
need to look at the picture as a whole, each individual is a person and a generic recipe for
resolving the issues of adolescents is not going to fit everyone's needs. The SBC is a
community creation, put together as a result of community needs and assessments. Even
though the global picture of adolescent problems and concerns can help guide a
community's focus, it does not replace the energy and focus which a small community
can generate. It is much easier to put forth effort in the development of a SBC when
members of the community realize that it will impact the community's future and well
being.

The presence of a SBC has the potential to impact adolescent health and
perceptions of health, resulting in increased levels of wellness. The clinical setting of the
SBC offers an opportunity for targeting high risk populations. SBCs which do not show a
decrease in absenteeism can evaluate their health promoting programs and adjust them to
target the high risk populations within their school. Personal interactions and continuity
of care are key factors in establishing a trusting relationship with an adolescent. Trust
opens the door to many of the problems which are being experienced by adolescents. As a
result, resolutions of those problems can be worked through by both the APN and the
adolescents.

Although this research project was greatly limited by the number of participating
schools, the author believes that the success of the SBC can be affected by attention to,
and use of, Pender's Health Promotion Model. Astute and careful examination of student
populations using the SBC will guide the programs and methods targeting health issues

specific to that population. As a result, for example, family planning or other clinic

25

services might be extended to all family members of students attending the school. A
willingness of the SBC to serve the complete needs of the adolescent can only increase
attendance in the long run.

The SBC is a conduit for health care members to impact a segment of the
population which has the capacity to make life-long health promoting choices. This
potential is worth exploring and capitalizing on by the ANP in these clinics. Thus the
lives of the adolescents who have made health-promoting choices for their lives may be

positively affected.

List of References

Carnegie Council on Adloescent Development, & Task Force on Education of
Young Adolescents. (1989,.Iune).
gammy. Washington DC: Carnegie Corporation of New York, Carnegie Council on
Adolescent Development.

FeroliK. L. Hobson S. K. MiolaE. S., ScottP. N., &Waterfield, G. D (1992).

School- based clinics: The Baltimore experience. WW (3),
p. 127- 131.

Gordon E (1972). w ‘ ' .
WNational Center for Educational Communication.

 

Kirby D. (1989).
3111303111131, Center for Population Options, Washington D. C.

KirbyD., LovickS., DonovanP., WaszakCS. (1989). Wm
. . . . - -- Center for Population Options,

 

Washington D. C.

Klerman L. V., Weitzman M., Alpert J. 1., Lamb G. A., Kayne H., Gerominini K.
R., Rose L., & Cohen L. (1987). Why adolescents do not attend school: The views of

students and Parents. WWflS). 425-430.

Lavin, A. T., Shapiro, G. R., & Weill,K. W. (1992). Creating an agenda for
school-based health promotion: A review of 25 selected reports. W

W. 212-228.

Long G. V. Whitman C. Johansson M., Williams C. A., & Tuthill R. W. (1975).
Evaluation of a school health program directed to children with a history of high absence.
Ammlanmalafhrbhehealthfi: 388.

National Commission on Children (1991). Wm
AgendmLChfldrenandfauu'lies Washington DC Author

Pender Nola J. (1987). WWW Appleton &
Lange, Second Edition.

Siegal, L. P., Krieble T. A. (1987). Evaluation of school-based, high school
health services. W. 323-325.

26

27

Weitzman M., Klerman L .V. Lamb G., Menary J., & Alpert J. J. ( 1982). School
absence: A problem for the pediatrician. mm), 739-746.

Weitzman M., Alpert J. J., Klerman L., Kayne H., Lamb G. A., Geromini K. R.,
Kane K. T., Rose L. (1986). High-risk youth and health: The case of excessive school

absence. W0). 313-322.

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