Melanie Gold, DO, DABMA, MQT, FAAP, FACOP
Medical Director
School-Based Health Centers
New York - Presbyterian Hospital
Columbia University Medical Center
New York City

School-based health centers (SBHCs) are unique in that they can provide care to adolescents in a setting that is trusted, familiar, immediately accessible, and in their own school. Such centers exist in urban, rural, and suburban communities. They can be found in all but four states: Idaho, Montana, North Dakota, and Wyoming.

School-based health centers provide a wide range of services to students as well as to parents, school faculty, and staff, and sometimes the wider community. According to the 2010-2011 School-Based Health Alliance Census Report, there are 1,930 SBHCs in the United States, 340 more than the previous census report. With expanded funding for these centers provided through the Affordable Care Act (ACA), such centers are likely to expand even further in coming years.1

More than 80% of school-based health centers provide some kind of reproductive health services. However, which specific services are offered vary widely from one center to another, as well as by state and region. The most commonly offered services are counseling on abstinence (82%) and pregnancy testing (81%). Most (69%) also offer diagnosis and treatment for sexually transmitted infections (STIs) and reproductive health services, such as testicular exams for young men (69%), gynecological exams (59%), and contraceptive counseling (64%).1

While contraceptive counseling is reported to be available in two-thirds of centers, dispensing contraceptive methods is less common. In fact, 50% of centers report that they are prohibited from dispensing contraceptives.1

While state laws or regulations prevent contraceptive access for about one-third of SBHCs, a more common barrier is having a restrictive policy at the school or at the district level. School-based health centers in the 2010-2011 census reported having a school district policy that blocked contraceptive dispensing at 76% of centers. Individual school policies also were a barrier in 54% of centers, according to that census report.1

Centers the right venue?

Are school-based health centers the right venue for dispensing contraception?
Adolescents can certainly benefit from access to reproductive healthcare in a variety of settings, and evidence is growing that SBHCs that dispense contraceptives can have a significant impact on increasing the likelihood of students’ using contraception to avoid unintended pregnancy.

A 2011 study of two SBHCs in two demographically similar southwestern U.S. high schools, one that dispensed contraceptives on site and one offering referrals for contraception off site, found a significant impact on teen pregnancy, even among motivated students who requested contraception.2 After 16 months, the school with on-site dispensing found 6% of student who requested contraception became pregnant. At the comparison school, 20% of those referred for contraception became pregnant during the follow-up period.2

More recently, an examination looked at reproductive health behaviors among students at two New York City high schools, of which only one had a school-based health center that dispensed contraception on-site.3 Researchers found students at the school with a school-based health center to be more likely to report using condoms at first intercourse and using hormonal contraception at last intercourse. The students at the school with a health center also were more likely to report receiving education in the classroom on STIs, HIV, and abstinence, as well as higher rates of counseling about contraception and emergency contraception in the last 12 months. However, students at both schools had similar rates of reporting that they ever accessed reproductive health services.3

Additionally, some research indicates SBHCs can have a positive impact on teens who already are pregnant or parenting. Such centers have demonstrated positive effects on pregnant and parenting teens in regard to their educational outcomes, their decisions to use contraception to prevent future unintended pregnancy, as well as in the health and developmental outcomes of their infants.4

Such positive findings have contributed to organizations such as the American Academy of Pediatrics and Society for Adolescent Health and Medicine publishing position statements supporting the school-based health centers model of care and specifically recognizing their role in providing confidential reproductive and sexual health services.5,6

The research to date has not all been positive. In 2011, the “Journal of Adolescent Health” published a study of 12 California high schools, six with school-based health centers.7 Findings indicate that female students at schools with a school-based health center reported higher use of hormonal contraceptive at last intercourse compared to those students at schools without a center. Nevertheless, the group of female students at schools with an SBHC still reported low use (less than one-third) of a hormonal method or condoms at last intercourse. Also, no increase in condom or contraceptive use was found among male students, regardless of school, and students at SBHC and non-SBHC schools reported equal rates of ever accessing reproductive health services.7

Even among schools with school-based health centers where dispensing is available, many students remain at risk of unintended pregnancy. While expansion of SBHCs through ACA funding might positively impact the ability of centers to meet students’ needs for contraception, this is only one of many strategies to help adolescents prevent unintended pregnancies.

REFERENCES

  1. Lofink H, Kuebler J, Juszczak L, et al. 2010-2011 School-Based Health Alliance Census Report. Washington, DC: School-Based Health Alliance; 2013.
  2. Smith P, Novello G, Chacko M. Does immediate access to birth control help prevent pregnancy? A comparison of onsite provision versus off-campus referral for contraception at two school-based clinics. J Adolesc Health 2011; 48(2):S107-S108.
  3. Minguez M, Santelli J, Gibson E, et al. Reproductive health impact of a school health center. J Adolesc Health 2015; 56:338-344.
  4. Strunk JA. The effect of school-based health clinics on teenage pregnancy and parenting outcomes: An integrated literature review. J School Nursing 2008; 24(1):13-20.
  5. American Academy of Pediatrics. Council on School Health. School-based health centers and pediatric practice. Pediatrics 2012; 129(2):387-393.
  6. Society for Adolescent Medicine. School-based health center: Position paper of the Society for Adolescent Medicine. J Adolesc Health 2001; 29:448-450.
  7. Ethier K, Dittus P, DeRosa C, et al. School-based health center access, reproductive health care, and contraceptive use among sexually experienced high school students. J Adolesc Health 2011; (48):562-565.

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