During the last decade, a number of reports have documented the significant health problems of American youth. In Code Blue: Uniting for a Healthier Youth, the National Association of State Boards of Education and the American Medical Association reported that "never before has one generation of American adolescents been less healthy, less cared for, or less prepared for life than their parents were at the same age."¹

The Carnegie Council on Adolescent Development also described the problem in urgent terms: "In the 1990s, the state of adolescent health in America reached crisis proportions: large numbers of ten- to fifteen-year-olds suffer from depression that may lead to suicide; they jeopardize their future by abusing illegal drugs and alcohol, and by smoking; they engage in premature, unprotected sexual activity; they are victims or perpetrators of violence; they lack proper nutrition and exercise. Their glaring need for health services is largely ignored."²

Despite these problems among adolescents, data indicate that teens underutilize the health care system, largely because of access barriers, including a lack of insurance coverage, transportation problems, and a shortage of age-appropriate services. The National Research Council reported: "Adolescents—and especially adolescents who engage in high-risk behavior—have no apparent home in the U.S. medical system. They have relatively low visit rates in office-based practices, and their problems are poorly represented in standard medical data."³ The fragmentation of the current system makes it especially difficult for adolescents to access services for their diverse needs. As a result, teenagers do not seek health care and their problems often go undetected and untreated.

School-Based and School-Linked Health Centers

In response to this need for adolescent-oriented health services, a number of communities have established school-based health centers (SBHCs) and school-linked health centers (SLHCs). The more than 1,000 SBHCs nationwide are popular as providers of affordable, convenient, confidential, and comprehensive services at the school. Although SBHCs are praised for their delivery of comprehensive services, they often are pressured to omit reproductive health care, mental health, and substance abuse services because of community or state opposition.

"Many states prohibit the provision of contraception on school sites. Even in states with no restrictions, most school health centers do not provide comprehensive family planning services to students."⁴ In the past year, many states considered or enacted more restrictive legislation, and many school boards tightened policies regarding contraceptives.

For those communities wanting to provide reproductive health care and mental health service, the school-linked health center model is a viable option. School-linked health centers maintain the advantage of accessing school populations, but are less restricted than school-based health centers.

To date, very little is known about SLHCs and their effectiveness. In 1986, researchers demonstrated a 30 percent reduction in teenage pregnancy within three years of implementing a multi-modal teen pregnancy prevention program through a nearby school-linked health center. Schools without SLHCs showed a 58 percent increase in teenage pregnancy during the same three years. The study further found that the program helped delay sexual initiation for younger clients by seven months and increased the use of contraceptives among sexually active teens.⁵

To learn more about the SLHC model, the Support Center for School-Based and School-Linked Health Care at Advocates for Youth conducted an informal study of 21 SLHCs. Descriptive and statistical information from a written survey was followed up with telephone interviews and site visits. Findings indicate that although the history and design of each SLHC is unique, there are a number of shared characteristics that make this delivery vehicle an attractive option for communities attempting to meet the health care needs of their adolescents.

Age-Appropriate, Comprehensive Care

SLHCs appeal to young people because they respond to adolescent health and development issues and the providers are experienced in serving this population. Most SLHCs provide a wide array of general medical services, counseling services, reproductive health care, and social services designed for adolescents. By offering comprehensive services, SLHCs can respond to multiple problems at one time, and adolescents have one central place to go for all needs. In addition to offering a breadth of services, most SLHCs staff employ specific procedures to facilitate and encourage adolescent use of services, such as calling to remind them of appointments and to conduct follow-up.

Linkage with Schools

SLHCs' special relationships with schools gives them a distinct advantage over other community-based models of care. SLHCs reported various types of formal and informal linkages with schools. Regardless of the degree of interaction, the school provides the health center with a natural audience for outreach and education. The relationships with school staff facilitates two-way referrals and consultations, improving overall quality and continuity of care.

Ability to Reach High-Risk Youth

School-linked health centers typically reach beyond school populations and serve dropouts, homeless youth, runaways, and youth in detention centers, shelters, and other social service programs. A significant strength of the SLHC model is that it allows communities to reach those at high risk of unwanted pregnancies, HIV infection, drug abuse, violence, and the other morbidities.

Versatility in Service Design

One distinct advantage of school-linked over school-based health centers is that they have more autonomy to decide their scope of services. According to the Support Center's survey of SBHCs in 1993, 74.4 percent of the responding centers reported that provision of contraceptives was restricted. These restrictions were by state policy (11.7 percent), school district policy (81.4 percent), policies of sponsoring agencies (20.7 percent), and by health center choice (17.9 percent).

For communities attempting to prevent and reduce adolescent pregnancies as well as HIV and other STD infections, providing reproductive health care to teens is critical. SLHCs usually do not face as many barriers, and they typically operate with strong community support. The SLHC model's ability to provide confidential, age-appropriate, reproductive health services is one of its major strengths.

Ability to Serve More than One School

One clear benefit of the SLHC model is that it serves students from more than one school. The programs are located on sites convenient to a number of schools and neighborhoods. This not only improves adolescents' access to services but is less expensive than establishing a health center at each school. When a SLHC serves both junior and senior high schools, it can offer continuity of care throughout the adolescent years.

Extensive Hours

Unlike SBHCs, whose schedules are determined by the school, SLHCs provide services in the evenings, during school vacations, and in the summer. A few SLHCs offer services on Saturday. Extended hours are a distinct advantage for adolescents who require scheduling flexibility.

Financing

Most SLHCs charge a fee, even if minimal, for each service. Sliding fee scales and innovative billing systems allows SLHCs to recover some of their costs. Since they are community-based health care providers with a history of communicating with other providers and billing clients for services, SLHCs are better positioned to negotiate with managed care plans. SBHCs are not independent health centers, have limited experience billing clients, and are less likely to meet the stringent criteria imposed by the managed care plans (e.g., hours of service, composition of staff, record/information exchange, and billing procedures).

Potential Disadvantages

Despite the models many strengths, there are a few drawbacks to consider. Although the SLHC serves multiple schools and out-of-school youth, its location off school grounds can be a barrier for some adolescents. Some teens do not have the time or will not make the effort to get to a community-based health center. Some cannot afford the cost of transportation. Others are intimidated by the notion of going to a community health center. For some, even the minimal cost of a visit is prohibitive. Further, it is more difficult to follow-up with clients at SLHCs than SBHCs where providers can access students in the classrooms. As a result, utilization per student is usually lower at SLHCs than at SBHCs. Finally, rent and overhead add to the costs of running SLHCs.

Conclusion

For those planning community health care programs or policies for adolescents, SLHCs are a promising model for providing affordable, age-appropriate, confidential, convenient services to a traditionally hard-to-reach population. The SLHC's ability to provide reproductive health care to adolescents is a particularly significant strength of the model. Further research is needed to determine the impact of SLHC programs, the viability of negotiating with managed care organizations, and methods to reduce barriers to accessing SLHC services.

Written by: Kate Fothergill, MPH, Director, and Beth Orlick, Program Associate, Support Center for School-Based & School-Linked Health Care, June 1997

References

1. The National Commission on the Role of the School and Community in Improving Adolescent Health, National Association of State Boards of Education, American Medical Association. Code Blue: Uniting for Healthier Youth. Alexandria, VA: National Association of State Boards of Education, 1990.
2. Hechinger F. Fateful Choices: Healthy Youth for the 21st Century. New York: Carnegie Council on Adolescent Development, 1992.
3. National Research Council. Losing Generations: Adolescents in High-Risk Settings. Washington, D.C: National Academy Press, 1993.
4. Dryfoos J. Full Service Schools. San Francisco: Jossey-Bass, 1994.
5. Zabin LS, Hirsch MB, Smith EAet al. Evaluation of a pregnancy prevention program for urban teenagers. Fam Plann Perspect 1986;18:119-126.

School-Linked Health Centers: Facts From Advocates for Youth's 1995 Survey