Original Research Characteristics of school-based health services associated with students’ mental health Simon Denny 1 , Hamish Howie 2 , Sue Grant 3 , Ross Galbreath 4 , Jennifer Utter 5 , Theresa Fleming 6 and Terryann Clark 7 Abstract Objective: School-based health services (SBHS) have been shown to improve access to mental health services but the evidence of their effectiveness on students’ mental health is lacking. Our objective was to examine associations between variation in the provision of SBHS and students’ mental health. Methods: A cross-sectional analysis of a nationally representative health and well-being survey of 8500 New Zealand high school students conducted in March–November 2012. Students’ mental health is related to data on school health services obtained from clinic leaders and clinicians from 90 participating high schools. Results: After adjustment for socio-demographic differences in students between schools, increasing levels of services were associated with progressively lower levels of student-reported depressive symptoms (p ¼ 0.002), emotional and behavioural difficulties (p ¼ 0.004) and suicidality (p ¼ 0.008). Services with greater levels of nursing hours (p ¼ 0.02) and those that performed routine, comprehensive psychosocial assessments (p ¼ 0.01) were both associated with lower levels of student-reported depressive symptoms. Greater levels of nursing hours and doctor hours were associated with lower self-reported suicidality among students. Conclusions: Although a causal association between school-based health services and students’ mental health cannot be demonstrated, these findings support the benefit of such services and the need for a cluster randomized trial. Keywords adolescence, depression, mental health, school health, suicide Introduction Globally, mental health problems are common and burdensome to children and adolescents. 1–3 One avenue for improving access and support for youths is by school-based health services (SBHS). 4 These pro- vide comprehensive and appropriate care, which aims to be accessible and low-cost. While SBHS have been shown to improve access to mental health services, 5 evidence of its effectiveness in terms of students’ mental health is limited. 6,7 Studies in this field face methodological and ethical challenges. 8 Randomized controlled trials have not been undertaken and would require cluster randomiza- tion. 9 Observational studies face hurdles in matching schools providing health services with control schools to avoid confounding. Those observational studies that have been conducted have ignored variability in the level of health services provided and simply considered 1 Associate Professor, Department of Paediatrics, Child and Youth Health, University of Auckland, New Zealand 2 General Practitioner, Centre for Youth Health, Counties Manukau District Health Board, New Zealand 3 Professional Teaching Fellow, Department of Paediatrics, Child and Youth Health, University of Auckland, New Zealand 4 Research Associate, Department of Paediatrics, Child and Youth Health, University of Auckland, New Zealand 5 Senior Lecturer, School of Population Health, University of Auckland, New Zealand 6 Senior Lecturer, Department of Paediatrics, Child and Youth Health, University of Auckland, New Zealand 7 Senior Lecturer, School of Nursing, University of Auckland, New Zealand Corresponding author: Simon Denny, Department of Paediatrics, Child and Youth Health, School of Population Health, University of Auckland, Private Bag 92019, New Zealand. Email: s.denny@auckland.ac.nz Journal of Health Services Research & Policy 2018, Vol. 23(1) 7–14 ! The Author(s) 2017 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1355819617716196 journals.sagepub.com/home/hsr