With the recent resurgence of the Black Lives Matter movement and national calls for racial justice and equity in the United States, many school officials are starting to consider how to implement anti-racist practices into their school environments. As School-Based Health Centers (SBHCs) our mission revolves around creating access to comprehensive, high-quality primary care for all children and youth across the nation. In order to do so, it is important that all SBHCs acknowledge the connection between racially discriminated and health underserved populations. Applying this understanding to our health centers and schools can help our Black, Indigenous & People of Color (BIPOC) students to receive the healthcare and support they need to thrive in their education and home environments.
Racial Disparities Among BIPOC Students in Education
Across the board, BIPOC students are suspended from school at disproportionately higher rates than their white counterparts, perform more poorly on standardized tests (1), experience lower graduation rates, and are less likely to be placed into gifted-education programs by their teachers, even when adjusting for standardized test scores (2). There are many other ways that BIPOC students face discrimination in their school environments, whether it be from their fellow peers, teachers, or school administrators, often in the form of racial bias. It is important now to note that not all students of color experience racism and discrimination at the same level, with Black students often bearing the majority of racial biases in their everyday lives.
A study conducted by Stanford Graduate school for Education used data from U.S. public schools to represent the relationship between racial disparities in school discipline and the achievement gap between Black and white students (1). The study found that the achievement gap and the discipline gap are closely intertwined. Meaning, an increase in either the discipline gap or the academic achievement gap between Black and white students in the United States predicts a jump in the other. Similarly, as one gap narrows, so does the other. Francis Pearman, an assistant professor at Stanford Graduate School of Education and lead author of the study speaks on the importance of these findings, “Prior research has suggested that achievement gaps and discipline gaps may be two sides of the same coin. This is the first study to document this relationship at the national level.”
“Black K–12 students are 3.8 times as likely as their white peers to receive one or more out-of-school suspensions, despite controlling for factors such as achievement, socioeconomic status, self-reported behavior and teacher-reported behavior” -U.S. Department of Education’s Office of Civil Rights
While there are many reasons to explain this disparity between Black and white students, one of the biggest contributors is implicit biases. In many cases, the differential treatment of BIPOC and white students is not intentional or malicious. Implicit biases describe the cultural misunderstandings or unintentional biases that unknowingly affect our thoughts and behaviors (2). This explains why BIPOC students experience poorer education outcomes even when controlling for standardized test scores and socio-economic status. In our society, nearly everyone holds their implicit biases. The question should not be “how do we eliminate these biases,” but rather, “how can we acknowledge them and prevent them from impacting our actions and decision making.” This question is especially important for educators to ask themselves as they enter their classrooms, virtually or in-person, in the upcoming academic year. These racial biases not only influence how teachers teach, but also directly affects how teachers discipline students for misbehavior (or choose not to discipline certain students).
The impact of these racial biases can last with children through adulthood. According to 2013–14 data collected by the U.S. Department of Education’s Office of Civil Rights, “Black K–12 students are 3.8 times as likely as their white peers to receive one or more out-of-school suspensions, despite controlling for factors such as achievement, socioeconomic status, self-reported behavior and teacher-reported behavior” (2). Prior research has documented the impact of discipline on young students as the “school-to-prison pipeline,” noting that students who are suspended are more likely to drop out of school and have run-ins with the juvenile justice system (2). In a study conducted by researchers at the University of North Carolina Chapel Hill, the drivers of racial disparities and school suspension are investigated. According to their findings, the differential treatment/support given to Black students after they enter school is an “important but understudied mechanism in the early criminalization of Black students” (3). With this in mind, it is now imperative to consider how these experiences with racism, discrimination, and criminalzaiton impact the health of BIPOC students in our schools.
Racial Disparities Among BIPOC Students in Health
As highlighted through the COVID-19 pandemic, BIPOC people and communities experience racial disparities in healthcare, leading to higher rates of coronavirus infection and mortality than their white counterparts (4). A recently published study on COVID-19 infections amongst children are showing similar trends, with 30% of Black children and more than 45% of Latinx children testing positive compared to 7% of white children (10). These racial disparities extend beyond the current pandemic and impact the healthcare of BIPOC communities at every level. For BIPOC students, this often means less access to primary and behavioral health services as well as differential treatment from doctors and nurses due to the implicit biases held by health professionals.
“As School-Based Health Centers (SBHCs) our mission revolves around creating access to comprehensive, high-quality primary care for all children and youth across the nation. In order to do so, it is important that all SBHCs acknowledge the connection between racially discriminated and health underserved populations. “
In a study published in the Journal of School Health, ethnic disparities in School-based behavioral health service use was examined for children with psychiatric disorders (5). In the study, researchers identified differences in service use by racial/ethnic groups, both for in-school service use and out-of-school service use. Their main findings revealed that Hispanic students with psychiatric disorders had significantly lower use of in-school services than white students, which can be attributed to cultural differences and language barriers. Furthermore, among children with ADHD, Black students were more likely to receive in-school services and less likely to use out-of-school services than white children with ADHD. This can be explained by previous reports that show how Black students who demonstrate externalizing behavior problems often associated with ADHD are more likely to be referred for in-school services by their teachers and more likely to be misdiagnosed with ADHD. The authors concluded by suggesting the need for culturally appropriate outreach and tailoring of services to improve utilization and health outcomes of BIPOC students (5).
“SBHCs often provide first time exposure to mental health treatment for all students, especially those of BIPOC communities with less access to behavioral and mental health services.”
These observed disparities in use of in-school services have direct implications for improving access to care for BIPOC students. A systematic review published in the American Journal of Preventive Medicine shows that children from racial or ethnic minority populations in the U.S. are less likely to have a conventional source of medical care and more likely to develop chronic health problems than white children (6). Furthermore, they are more likely to experience chronic stress, fatigue, and hunger, and more likely to have impaired vision and hearing—creating obstacles to their educational achievement. When it comes to mental and behavioral health, structural barriers, such as, socioeconomic status, lack of insurance, transportation, and/ or access impeded students from receiving this care (7). School-based health centers have been implemented as a solution to those barriers as I will outline in the following three sections.
“As detailed in a recent webinar from the National School-Based Health Alliance, pursuing excellence through equity requires SBHCs to understand child development, neuroscience, and context “
SBHCs Can Advocate for Racial Health Equity
It is important now to make the distinction between equity and equality. By definition, equality means “the state of being equal, especially in status, rights, and opportunities.” While at first, this may seem like an ideal outcome, when it comes to racial disparities, equality does not address the differential conditions of BIPOC communities in comparison to white communities. In contrast, equity takes a more holistic approach to racial disparities including acknowledging and addressing differences in the needs of students, responding to academic, social and psychological needs that arise from inequality in society (especially now during a pandemic), a commitment to fairness in treatment, and a willingness to speak out when faced with injustices against BIPOC students. Therefore, it is imperative to center on equity as opposed to equality. When it comes to students, equity means giving each student exactly what they need to be successful, even if it means giving some students more resources and attention than others.
As detailed in a recent webinar from the National School-Based Health Alliance, pursuing excellence through equity requires SBHCs to understand child development, neuroscience, and context (8). Child development entails adopting a holistic approach to education and giving differentiated support to students based on their individual needs. Neuroscience signifies the elasticity of each child’s brain determines how they learn and understanding this ensures that all students have access to deeper learning that suits their needs. Finally, context is important in understanding and responding to the ways in which students are influenced by their environments, whether that be their neighborhood, their homes, or their schools. With this in mind, the advancement of equity in schools can be supported and encouraged by the work of SBHCs in addressing the achievement and discipline gaps between BIPOC and white students.
“Through increasing access to behavioral health services and coaching for both students and teachers, SBHCs can help to address the achievement and discipline gaps that impact the academic performance and lifetime wellbeing of BIPOC students. “
SBHCs Can Address the Achievement and Discipline Gap
One important way to improve access and reduce racial disparities in health and educational outcomes is to provide behavioral health services in schools. SBHCs often provide first time exposure to mental health treatment for all students, especially those of BIPOC communities with less access to behavioral and mental health services. Research shows that many minority youth with psychiatric disorders do not receive needed behavioral health services, which can be explained by their own and their families’ interpretation of symptoms, cultural beliefs and stigmas around mental health treatment, and poorer access to specialty care (5). Furthermore, the prevalence of mental illness is higher in communities that face multiple prejudices and disadvantages within society (8). These communities often face trauma, racism, and adverse social circumstances. For SBHCs, understanding how disparities in school-based behavioral health service use differ across race/ethnicity and psychiatric disorders can point to the ways in which schools may differentiate care to address unmet behavioral health needs and advance health equity within schools.
Furthermore, improving access to behavioral health services is important not only for students, but for teachers as well. Research shows that teachers who had regular relationships with a behavioral consultant had lower expulsion rates than teachers who did not have this behavioral health support (2). Another solution for teachers is to implement programs that pair teachers with coaches who review their classroom interactions and make specific suggestions to help teachers better engage with and motivate their students. In coaching classrooms, researchers found there was no difference in discipline referral rates between Black, Asian, Latinx and white students (2). Through increasing access to behavioral health services and coaching for both students and teachers, SBHCs can help to address the achievement and discipline gaps that impact the academic performance and lifetime wellbeing of BIPOC students.
“If SBHCs can overcome educational obstacles and increase receipt of needed medical services in disadvantaged populations, they can greatly help to advance health equity.”
SBHCs Can Help to Educate
SBHCs have an important role in educating students, faculty and staff, and parents/guardians of students. The common thread in many health outcomes amongst BIPOC students is lack of knowledge of their symptoms and available health services. Therefore, SBHCs can evaluate the barriers in their own school that prevent BIPOC students from accessing care and implement solutions and strategies to improve usage on SBHCs and services. In a study on School-Based Health Centers and Adolescent Substance Use in the Journal of School Health, findings revealed that SBHC exposure was inversely associated with past 30-day alcohol use, binge drinking, and cigarette and e-cigarette use among Black youth. Furthermore, they also found a significant interaction between SBHC exposure and parent education for past 30-day alcohol use and binge drinking (9).
Parent education is an important step in achieving health equity. Parents’ perceptions of health and behavior often greatly impact the students perception of their own health and behavior. Lastly, educating faculty and staff education on implicit biases and their impact on student health is incredibly important in starting to overcome the disparities BIPOC students face in school. This education should be supplemented by support from SBHCs in creating relationships between teachers and behavioral support specialists and other racial bias counsellors. If SBHCs can overcome educational obstacles and increase receipt of needed medical services in disadvantaged populations, they can greatly help to advance health equity.
For resources related to BIPOC student health, visit our new Students of Color Resource Page. For more information on SBHCs, visit the New York School-Based Health Alliance or the New York School-Based Health Foundation.