School Based Health Care: A Model for Improving Educational Achievement for Children in Inner City Schools

• ClinicalTrials.gov Identifier: NCT04540003
• Recruitment Status: Completed
• First Posted: September 7, 2020
• Last Update Posted: February 16, 2022
• Sponsor: Unity Health Toronto
• Collaborator: Toronto District School Board
• Information provided by (Responsible Party): Unity Health Toronto

Study Description

Brief Summary:

Developmental problems have tremendous impact on children, affecting academic achievement and mental health later in life.The process of receiving a developmental assessment is long and arduous, and may require multiple physician visits taking over one year. Although a relatively new concept in Canada, School-Based Health Centres (SBHCs) have been successfully implemented in over 1900 schools in the United States.The first SBHC in Ontario, and Canada as a whole, was established through the Model Schools Pediatric Health Initiative (MSPHI) and is dedicated to reducing health inequities for inner city children by reducing barriers and providing accessible clinical care. To provide more conclusive evidence on the relative benefits of SBHCs as compared to traditional health care access, this study will use a cluster randomized control trial (RCT) design to compare differences in educational achievement for developmental assessments in the SBHC model relative to standard care. As per standard of care, students having difficulty in school are identified by the Toronto District School Board (TDSB) internal research staff and are presented to the monthly School Support team (SST) meetings. Historically physicians do not attend SST meetings, however, as a part of the SBHC program, pediatricians will participate in monthly SST meetings. Schools assigned to the intervention group will have SBHC physicians attend SST meetings, while schools assigned to the control group will not.

The overall objective of this study is to examine educational achievement, as defined by standardized test scores and report cards in students who use an inner city SBHCs for developmental concerns relative to those who do not. We hypothesize students attending schools in which SST meetings have a pediatrician present, that are referred to a SBHC, will score higher and show a greater increase in standardized test scores and report cards (from baseline to follow-up) than students attending schools in which SST meetings do not have a pediatrician present and access services through traditional means in the community (standard of care).The secondary objectives are: a) to examine socio-demographic data for these students and its relationship to educational achievement and b) to determine wait times to developmental assessment for students in the intervention group who attend the SBHCs using retrospective chart review.

Condition or disease	Intervention/treatment	Phase
Educational Achievement	Other: Access to School Based Health Centre	Not Applicable

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 147 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Intervention Model Description: This project will be a cluster RCT design to compare the benefits of using SBHCs as opposed to the traditional health care by evaluating educational achievements. The study period includes September 2017-June 2018 and September 2018-June 2019. Of 16 inner city schools not previously exposed to the SBHC in the TDSB, some schools (n=8) will be in the control arm following the standard of care while others (n=8) will have access to SBHC. Students presented to SST meetings whose outcomes include the need for a developmental/pediatric assessment at the 16 schools will be identified by TDSB internal research staff. To conduct our primary analysis, standardized test scores and numeric data from report cards will be analyzed using a linear mixed effect model where the schools are the random effects and the baseline test scores and report cards are adjusted for by including it as a covariate.
• Masking: None (Open Label)
• Masking Description: It is not feasible to blind students or their families or SST members as there are obvious differences in care procedures between the two groups.
• Primary Purpose: Health Services Research
• Official Title: School Based Health Care: A Model for Improving Educational Achievement for Children in Inner City Schools
• Actual Study Start Date: September 1, 2016
• Actual Primary Completion Date: January 20, 2022
• Actual Study Completion Date: January 20, 2022

Arms and Interventions

Arm	Intervention/treatment
Experimental: Access to School Based Health Centre; Of the eight school in the intervention arm, four schools will be linked to a school based health center (SBHC) at Sprucecourt or Nelson Mandela Park Public Schools (established in partnership with the department of Pediatrics at St. Michael's hospital) and four schools will be linked to a SBHC at Parkdale Public School (established in partnership with St. Joseph's Health Centre). SBHC pediatricians will attend School Support Team (SST) meetings at all intervention schools and students with developmental concerns identified at the SST meetings will be referred to the SBHC.	Other: Access to School Based Health Centre; The SBHC will be staffed by a family physician, two pediatricians and a developmental pediatrician, each with at least one half-day of clinic time per week from September through June. The SBHC is also staffed by a clinic coordinator who is responsible for booking appointments on a first-referral, first-serve basis.
No Intervention: Control Arm: Standard of care; Of the eight schools assigned to the control condition, four will be in the South East area of the city closer to Nelson Mandela Park PS and four will be in the South West area of the city closer to St. Josephs Health Center. The eight schools will be subject to standard of care which is: when a child is identified by the SST (no pediatrician present), students identified with developmental concerns are advised to access a pediatric/developmental assessment in the community.

Outcome Measures

Primary Outcome Measures :

1. Educational achievement as assessed by numeric data from report cards. [ Time Frame: Change from baseline to 18 months after identification at SST ]

   For each student attending the schools enrolled in this study, the report cords have the student's grade for all the core subjects reported as a percentage (0-100%). The higher the grade the better the academic performance. There is also the class median reported as a percentage so that the student's academic performance in that particular subject can be compared to that of their class's average performance for that same subject.

   Numeric data from report cards will be analyzed using a linear mixed effect model where the schools are the random effects and the baseline report cards are adjusted for by including it as a covariate. Baseline report cards will be determined as those that have occurred most proximal to the SST date. The treatment effect will be expressed as the mean adjusted difference in standardized test scores with 95% confidence interval.

2. Educational achievement as assessed by Canadian Achievement Test 4 (CAT4) scores. [ Time Frame: Change from baseline to 18 months after identification at SST ]

   The Canadian Achievement Test 4 (CAT4) is a standardized test administered to students in grades 1-6 across Canada to assess basic skill areas: reading, writing, and mathematics. Higher scores mean better outcome. The raw score (0-100%) on each test section is converted to a national stanine range (1-9), where scores in the range of 1-3 is considered below-average (i.e. Low (L)), scores in the range of 4-6 are considered average (i.e. Competent (C)) and scores 7-9 are considered above average (i.e. Proficient (P)) performence.

   Standardized test scores will be analyzed using a linear mixed effect model where the schools are the random effects and the baseline test scores are adjusted for by including it as a covariate. Baseline test scores will be determined as those that have occurred most proximal to the SST date.The treatment effect will be expressed as the mean adjusted difference in standardized test scores with 95% confidence interval.

3. Education achievement as assessed by Education Quality and Accountability Office (EQAO) scores [ Time Frame: Change from baseline to 18 months after identification at SST ]

   Toronto District School Board (TDSB) Standardized tests include the Education Quality and Accountability Office (EQAO) test. The EQAO is a test that assesses literacy and math skills and is administered to students in grades 3 and 6. Based on the student's performance on the EQAO, the student's raw score is converted into a score on a scale from 200 (level 2) to 400 points (level 4). A score of 300 (level 3) (i.e. average student score) is required to be successful. A score above 300 (i.e. level 4 (400 points)) is considered above average.

   Standardized test scores will be analyzed using a linear mixed effect model where the schools are the random effects and the baseline test scores are adjusted for by including it as a covariate. Baseline test scores will be determined as those that have occurred most proximal to the SST date.The treatment effect will be expressed as the mean adjusted difference in standardized test scores with 95% confidence interval.

Secondary Outcome Measures :

1. Socio-demographic data and relationships to educational achievement [ Time Frame: change from baseline to 18 months after identification at SST ]
   Children from inner city schools may face additional difficulties accessing healthcare to address developmental and mental health concerns, particularly when they come from families with socioeconomic challenges, language barriers and limited means of transportation. Data collection will entail the collection of in-depth, in-person interviews with each participant 18 months after the SST meeting in both arms. During baseline interviews, participants will be asked questions regarding their current experiences (and contexts) at the outset of the trial. At the end of the trial, participants will be asked to reflect on their experiences before the trial began, how their experiences and perspectives changed as a result of the trial, and their reflections on trial implementation. Interviews will be conducted by experienced qualitative research personnel, audio taped and transcribed verbatim.
2. Wait time data will be determined retrospectively from chart review for the intervention group [ Time Frame: date of SST meeting to date of developmental assessment ]
   Charts of students attending the SBHC from the schools in the intervention arm will assessed for the following only: date of SST meeting, date of first visit to SBHC, date of developmental assessment. This will be used to determine the wait time. Wait times will be reported as a mean and standard deviation. Since data from the TDSB is de-identified, we will not be linking wait time data with outcomes or any other data provided by the TDSB.

Eligibility Criteria

• Ages Eligible for Study: 4 Years to 13 Years (Child)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria:

• All students identified at the SST meetings requiring a developmental assessment could be included in the cluster RCT.

Exclusion Criteria:

• Students without a developmental concern and not identified at the SST meeting will be excluded from the cluster RCT component of the study. No other specific exclusion criteria will be applied.

Contacts and Locations

Locations

Canada, Ontario

Unity Health Toronto

Toronto, Ontario, Canada, M5B 1W8

Sponsors and Collaborators

Unity Health Toronto

Toronto District School Board

Investigators

• Principal Investigator: Sloane Freeman, MSc,MD,FRCPC; Unity Health Toronto

More Information

Additional Information:

Related Info 

Publications:

Breslau J, Miller E, Breslau N, Bohnert K, Lucia V, Schweitzer J. The impact of early behavior disturbances on academic achievement in high school. Pediatrics. 2009 Jun;123(6):1472-6. doi: 10.1542/peds.2008-1406.

Reynolds AJ, Temple JA, Ou SR, Robertson DL, Mersky JP, Topitzes JW, Niles MD. Effects of a school-based, early childhood intervention on adult health and well-being: a 19-year follow-up of low-income families. Arch Pediatr Adolesc Med. 2007 Aug;161(8):730-9.

Shevell MI, Majnemer A, Rosenbaum P, Abrahamowicz M. Profile of referrals for early childhood developmental delay to ambulatory subspecialty clinics. J Child Neurol. 2001 Sep;16(9):645-50.

• Responsible Party: Unity Health Toronto
• ClinicalTrials.gov Identifier: NCT04540003
• Other Study ID Numbers: 13-341
• First Posted: September 7, 2020
• Last Update Posted: February 16, 2022
• Last Verified: February 2022

Individual Participant Data (IPD) Sharing Statement:

• Plan to Share IPD: Undecided

• Studies a U.S. FDA-regulated Drug Product: No
• Studies a U.S. FDA-regulated Device Product: No

Keywords provided by Unity Health Toronto:

school-based health centre; SBHC; School Support Team; SST; academic; inner city schools; standardized test scores; developmental pediatrics; education; achievement