Adolescent birth rates in the United States are the highest among industrialized nations.1 At least 80 percent of teenage pregnancies are unintended, and three-fourths of these pregnancies occur to adolescent women who do not use contraception.1 Moreover, unprotected sexual intercourse places adolescents at risk of infection with sexually transmitted diseases (STDs), including HIV. In the United States, about one-fourth of all new STD infections occur among youth ages 15 to 19, and one-fourth of all new HIV infections occur in those under the age of 21.2,3
Young people in the United States may fail to protect themselves during sexual intercourse if they lack 1) accurate information regarding sexuality and contraception and/or 2) access to health care.1 Teens' access to care may be limited by cost, time constraints, lack of transportation, inflexible clinic operating hours, fear that confidentiality will be breached, and apprehension about discussing personal health problems.4
School-based health centers (SBHCs) can deliver accessible, confidential, and comprehensive medical and mental health care specifically designed for and at little cost to teens. Research shows a correlation between students using SBHCs and reduced school absenteeism, improved health knowledge and increased use of health care,5,6 decreased routine use of emergency rooms,6,7 and improvements in sexual health.8,9 Students in schools with SBHCs report neither more sexual activity nor increased frequency of sexual intercourse compared to students in schools without health centers.10
Despite teens' need for contraceptive services, relatively few SBHCs provide these services on site. According to Advocates for Youth's most recent survey, fewer than 25 percent of SBHCs provide contraceptives.11 Nearly 74 percent of SBHCs reported being prohibited from dispensing some or all contraceptives. Respondents reported that school districts restrict providing contraceptives at 79.9 percent of SBHCs, making condoms available at 76.1 percent, and providing contraceptive prescriptions at 70.5 percent. By contrast, state laws restrict providing contraceptive prescriptions at 19.2 percent of SBHCs, providing contraceptives at 20.9 percent, and making condoms available at 20.1 percent.
Nevertheless, some SBHCs successfully provide contraceptive services to teens. To learn more about these successful efforts, Advocates interviewed the staff of three centers. This paper summarizes the lessons learned from these SBHCs in successfully mobilizing community support, designing effective programs, and sustaining program financing.
Case Study Number I. Baltimore, MD
The Baltimore City School-Based Health Center Program is sponsored by the city health department and includes 12 centers offering comprehensive services and making available all contraceptives except Norplant.
Building Support—Surveys of parents and residents demonstrate high levels of community support that enable SBHCs to counter opposition arising mostly from a small group of vocal opponents. Administrators believe that the community's support springs from its belief that SBHCs, like any other health care provider, should meet the community's standards of health service. The SBHCs do not seek media attention for contraceptive services, believing that calling attention to these services would make SBHCs seem different from other health care providers.
Critical Program Components—Components critical to the success of Baltimore's SBHCs in providing family planning services include the following:
- Confidentiality—Guaranteeing confidentiality is vital, and SBHCs work to ensure that teens know their confidentiality is assured. Students may not hang out at the clinics nor work there as part of community service. The program bills no insurer which sends home Explanation of Benefits (EOB) forms, unless staff is absolutely sure parents or guardians already know about the service.
- Youth-Friendly Services—All staff members are trained to work with teens, and aides usually have backgrounds similar to the students'. Staff spends time getting to know the students and discussing family planning decisions. Family planning is provided within the context of decisions young people make about all aspects of life.
- Parental Involvement—Clinic staff encourages teens to involve their parents or other trusted adults in family planning decisions. Most young women (about 95 percent) who use SBHC family planning services involve an adult in their decisions.
- Contraceptive Services—The SBHCs provide all contraceptives except Norplant and find that Depo-Provera is highly popular. Every new patient as well as any student getting condoms for the first time receives family planning counseling, including information about emergency contraception and a condom demonstration. To help teens feel more comfortable in attending an SBHC, the centers advertise a comprehensive package of services rather than just their family planning component.
- Case Mangement—SBHC staff carefully tracks and monitors teens' well-being and adherence to prescription directions.
- Pregnancy Testing—Staff provides pregnancy testing on the same day a student requests it. Staff uses negative pregnancy test results as an opportunity for counseling on family planning. If a student tests positive for pregnancy, staff provides options counseling but does not refer for abortion services.
- Walk-In Appointments—SBHCs respond to adolescents' complex range of needs, and students who come in without appointments are welcomed during certain hours each day. Students with emergencies are always seen.
Impact—Research demonstrates significant results:
- The Health Department attributes Baltimore's reduced STD rates, in part, to the city's SBHCs.
- Users attending SBHCs in Baltimore have greater rates of continuation with Depo-Provera than do those using other sources of care.
- Sexually active young women enrolled in SBHCs report stronger continuation rates for all forms of contraception than do their non-enrolled peers.
Case Study Number 2. St. Paul, MN
The Health Start Program of St. Paul began in 1973 and now operates SBHCs in nine high schools. Three centers also serve junior high schools. Health Start, a private non-profit with a community board, provides comprehensive services to students, including contraceptive prescriptions and, since 1998, directly dispenses contraception.
Building Support—Before SBHCs could dispense contraception, Health Start worked hard to build community support. The following elements were critical to making the case:
- Data Collection and Literature Review—Data provided the most powerful argument for dispensing at SBHCs.
Pick-up Rates— Teens who were referred for contraception never picked up 30 percent of contraceptive prescriptions and 80 percent of condoms.
Literature Review—Research into the impact of directly dispensing contraception showed that dispensing was more effective than referral. Further, research proved that dispensing did not increase sexual activity rates at schools with this service.
Pregnancy and STD Rates—Data revealed that 20 percent of male SBHC users had chlamydial infections and that St. Paul's teen pregnancy rate was second highest in Minnesota.
- Meeting the Community Standard of Care—Health Start argued that providing comprehensive services—including family planning—would bring SBHCs up to the community's standard of care.
- Lobbying the Community—Health Start obtained critical support from the medical and public health communities. Teens played important roles by testifying at hearings, organizing petitions, and mobilizing support among parents and neighborhoods. The opposition presented false data about the success rates of abstinence programs, objected to all SBHC operations, and raised issues of access and minor consent. Health Start overcame these tactics with support from teens and the medical and public health communities.
- Role of Media—Health Start kept its media messages simple, highlighting STD and teen pregnancy rates as well as low contraceptive pick-up rates. Health Start also provided background information that encouraged St. Paul's two major papers to print strong editorials in favor of dispensing and framing the argument as pragmatism versus idealism.
On April 20, 1999, after debate in the press and at public hearings, the school board voted to allow SBHCs to dispense contraceptives.
Critical Program Components—Components critical to the success of Health Start in offering comprehensive services at SBHCs include the following:
- Confidentiality—In 1998, Health Start formed a Confidentiality Committee in cooperation with representatives of four insurers, the Department of Health Services, and adolescent health care providers. The committee's primary concern was insurers' Explanation of Benefits (EOB) forms that could breach teens' confidentiality when mailed to their homes. Each health plan agreed to prepare its own manual on working with SBHCs to assure teens' confidentiality.
- Contraceptive Services—All contraceptive services are now available to teens. Staff expects demand for DepoProvera and emergency contraceptive pills but not for Norplant.
- Outreach—Teens' involvement in the fight to permit SBHCs to dispense contraception has also improved outreach. Health Start plans a youth advisory committee for each center and has hired one staff member who will focus on outreach to males.
Impact—Research demonstrates at least one significant impact:
- Nationally, among adolescent mothers, 25 percent have more than one child. By comparison, 18 percent of Health Starts adolescent mothers have more than one child.
Health Start begins tracking STD and primary pregnancy outcomes in fall 1999 and expects to demonstrate an impact in these areas as well.
Case Study Number 3. Multnomah County, OR
Multnomah County's SBHC program, started in 1985, now has 13 centers, including five serving middle schools. The county's SBHCs provide comprehensive services and have prescribed all forms of contraception since the program's inception. In 1996, staff began dispensing contraception.
Building Support—Several components were critically important to building community support for dispensing contraception in Multnomah County's SBHCs:
- Community Advocates—Important advocates within the community included the following:
Community Health Council—This Council oversees the county's health department and has consistently argued the importance of SBHCs in improving services for teens.
Influential Individuals—The Principal at Roosevelt High School also supported SBHCs, although he did not at first allow contraceptive dispensing on school grounds.
Parents—Community parents, particularly one enthusiastic mother, played a critical role in garnering community support.
Advisory Board—An Advisory Board, established by the first SBHC, actively involved community members, including a minister, whose participation helped maintain community support over time.
- Data Collection and Community Surveys—The program collected multiple types of information to support its request to dispense.
Pick-Up Rates—SBHCs collected data on pick-up rates following referral for contraceptives. Data showed that 50 percent of the female students who were simply given prescriptions did not have them filled; many reported being afraid of seeing someone they knew while others lacked time or transportation to get to the referral site.
Surveys on Condom Availability—Using the opportunity provided by Magic Johnson's HIV diagnosis, SBHCs requested and received permission to dispense condoms at the clinics. In 1994, the SBHC program surveyed parents, students, and staff; results showed a strong majority of support and satisfaction.
- School Board Approval—Supporters took the data to the school board. Strong support from one board member helped staff convince the rest of the school board, which then unanimously approved SBHCs dispensing contraceptives.
Critical Program Components—Components critical to the success of the SBHCs include the following:
- Confidentiality—Implementing a billing system has required that staff adjusts both attitudes and procedures. Now staff sends bills to insurers unless a reason exists for not billing. Concerned that family planning visits may inadvertently be billed to students' homes, staff has identified which services can and which must not be billed. The program works with insurers to reach agreements about EOBs. For example, Blue Cross/Blue Shield has decided that changing its billing and notification system is too expensive and opts instead to pay SBHCs a lump sum that is determined yearly.
- Youth Friendly Services—Staff works to make centers comfortable and welcoming to youth.
Environment—SBHCs have wall decor and reading matter that is appropriate for teens.
Staff training—Staff is specifically trained to work with teens.
Convenience—SBHC locations eliminate barriers of scheduling and travel.
Comprehensive Services—Centers provide many services—not just family planning—thus increasing teens feeling of comfort in visiting SBHCs.
- Family Planning Services—High school SBHCs offer all contraceptives except Norplant and IUDs while middle school SBHCs do not dispense contraception. Many high school students request Depo-Provera, and 25 percent of female students' first visit the clinics when they think they may be pregnant. Parental consent is not required for contraceptive services. Multnomah County's SBHCs provide neither abortion counseling (prohibited by school district policy) nor options counseling.
- Data Collection—Data on utilization and impact are important to health maintenance organizations and other insurers that must meet federal and state patient load requirements and outcome measures. The county demonstrates that teens visit SBHCs rather than primary care physicians, and, thus, that SBHCs help insurers meet government requirements to serve young people.
- Outreach—Direct outreach varies from school to school and may include orientation for new students and feeder middle schools. The SBHCs recognize a need for targeted outreach to male students and are developing a male responsibility video.
- Sustained Financial Support—The Board of County Commissioners allocates funds to the SBHC program that comprise 70 percent of the SBHCs' budget. Recently asked to decrease its dependence on county dollars, the program has begun billing insurers. The program is fortunate in having an infrastructure for billing through the County Health Department.
Impact—Research demonstrates the positive impact of contraceptive services at Multnomah County's SBHCs:
- Sexually active female students who are enrolled in the SBHCs begin using contraception sooner and stay on it longer than other students.
- Among female students who seek family planning services at the SBHCs, 96.2 percent have experienced no pregnancy.
If sexually active female students do not begin contraceptive use in their first few SBHC visits, they do not initiate contraceptive use thereafter. Now staff is focusing on improving services for sexually active female students who are not using contraception.
Overview of Case Study Findings
All three sites demonstrate the importance of the following:
- Data—Good data on SBHCs help build community support as well as strengthen relationships with funding sources. Relevant data may include local rates of teen pregnancy, birth, and STDs, utilization data, pick-up rates for contraceptive prescriptions, data on follow-up care and adherence to instructions or prescription directions, diagnosis data, costs, and trends over time.
- Comprehensive Services— SBHCs must emphasize that comprehensive care is quality care. SBHCs' role as health care providers means that they must provide a full range of services and match the community's standard of care. Failing to provide contraceptive services reduces the quality of SBHCs' care.
- Community Leaders—Community leaders play a critical role in winning and maintaining community support.
- Funding Relationships—Relationships with insurance companies, managed care organizations, and other financial sources are critical to ensuring patient confidentiality, reducing service duplication, and guaranteeing reimbursement.
In summary, success in providing access to contraception at SBHCs requires:
- Building and maintaining community support
- Delivering services that are welcoming to youth, confidential, and affordable
- Financing that does not jeopardize patient confidentiality.
If SBHCs are to improve teens' access to health care, they must truly welcome youth and provide confidential, convenient, comprehensive, and affordable services. Each of these components is critical in SBHCs' efforts to serve teens.
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Written by Kate Fothergill
October 1999 © Advocates for Youth