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Break down teen barriers with direct provision
Switch from voucher system works in school clinics
Direct distribution of birth control may be an effective strategy for school-based clinics wishing to remove barriers to contraceptive access, according to research findings from Minnesota public health officials.1
The Minneapolis Department of Health and Family Support operates comprehensive school-based clinics in five traditional high schools. Prior to 1998, its clinics issued vouchers redeemable for free birth control at community clinics. The voucher system proved less than effective, however; just 41% of students received all of the contraceptives they requested during the last year of voucher issuance. By switching to direct distribution, that number increased to 99% by 2000.1
School-based health centers are on the rise; their numbers have increased by 9% over the past two years, according to statistics from the Washington, DC-based Center for Health and Health Care in Schools.2 According to a 2002 survey conducted by the organization, there are 1,498 such centers across the country; 36% are located in high schools.2 Forty-three states plus the District of Columbia operate school-based health centers; seven states (Arkansas, Hawaii, Idaho, Montana, North Dakota, South Dakota, and Wyoming) do not have such facilities.2
Despite the growing numbers of school-based clinics, many are restricted from providing contraceptives, usually due to school district policy.3 A recent national survey of high school clinics found just 18% directly dispensing oral contraceptives and 28% distributing condoms.3
Controversy over providing family planning services to students has limited many clinics in their ability to meet the needs of sexually active teens by dispensing contraceptives on-site.4
"Our findings suggest that school-based clinics could go a step further in reducing adolescents’ barriers to accessing contraceptives by adopting an on-site direct delivery system," says Abbey Sidebottom, MPH, an epidemiologist with the Minneapolis Department of Health and Family Support and lead author of the Minneapolis study.
To receive care from the Minneapolis school-based clinics, parents are requested to sign a form to allow their child to receive one of the following options: all clinic services, all services except contraceptive counseling and birth control services, or no services, explains Donna Amidon, RN, CNP, MPH, manager of school health services for the Minneapolis Department of Health and Family Support.
Under the voucher system, students were issued vouchers for free birth control, good for two weeks, and redeemable at participating community clinics, following contraceptive counseling at the school clinics. The logistics involved in obtaining the contraceptives proved problematic for many teens, she notes. Students often were unable to get to community clinics during operating hours, and even if Saturday hours were available, many teens were reluctant to go, Amidon states.
"You are dealing with teen-agers who are already scared to talk to an adult about something so personal as contraception," she says. "It is hard enough for them to walk into a school-based clinic, with very teen-friendly people, then to have to go to yet another clinic, face another adult, whom they don’t know. For some, they don’t want to do that."
With the addition of Depo-Provera (depot medroxyprogesterone acetate or DMPA, Pfizer, New York City) to the list of school clinic contraceptive options, further flaws arose with the voucher system, states Amidon. Adolescents who chose DMPA would undergo counseling and examination at the school clinics and then would travel to a community clinic for their injections. Going off-site to get injections raised potential liability questions, since the students were not clients of the community clinics, explains Amidon. Timing issues in initiating and maintaining DMPA injection schedules also were of concern.
In 1997, pregnancy rates among Minneapolis 15- to 17-year-olds were 79.4 per 1,000, compared to state and national levels of 32.0 and 57.1, respectively.5 School and public health officials then moved to change the voucher system to a direct distribution method in an effort to be more effective in combating teen pregnancy rates.
Did teens seek care?
To perform the Minneapolis study, researchers performed chart audits of students requesting contraceptives. Charts were divided into two groups based on the students’ year of graduation. The first group consisted of students from the class of 1998 who requested contraceptives under the voucher system, and the second group was comprised of students from the class of 2000 who requested birth control during the first two years of the direct distribution system.1
Did more teens come to the school-based clinics for contraceptives following the switch to direct distribution? Study results indicate that numbers stayed steady; 11% of students sought birth control at the facilities during the two time periods analyzed in the investigation.1
Change not widely publicized
Overall demand might have increased if the change had been more widely publicized; the staff informed current patients and school administrators, says Amidon. While contraceptive services are mentioned in classroom presentations about the school-based clinics, they are listed as just one of the total health services made available through the facilities, she notes.
Critics of school-based health centers have argued that by offering contraceptives, school-based health centers increase rates of sexual activity among teens.4
"Previous research with adolescents has indicated that making contraceptives accessible does not increase sexual activity among adolescents who weren’t previously sexually active,"6 Sidebottom says. "The fact that we did not see an increase in demand for contraceptives among the student population at these schools seems to agree with these findings."