School-based health centers offer U.S. adolescents a wide range of reproductive health counseling, testing and treatment services, both on-site and through referrals. The centers face important barriers in providing these services, however: Reproductive health services are significantly less likely to be available in rural centers and in centers serving younger students than in urban centers and those serving high school students, according to a national survey of centers conducted in 1998- 1999.1 Overall, only about one-quarter of centers offer contraception on-site; 55-82% offer other reproductive health services, such as counseling or testing on-site. Seventy-seven percent of centers prohibit the provision of contraceptive methods to adolescent students.
The data come from 551 programs that responded to the Census of School-Based Health Centers and were located in schools with middle or high school students (i.e., schools with at least one grade between seven and 12). The survey asked whether 16 reproductive health care services (including various types of exams, screening and counseling, as well as contraceptive method provision) were available during the 1998-1999 school year on-site or through referrals. The researchers used logistic regression to assess which characteristics of health centers were associated with services they offered and their policies.
Fifty-seven percent of the responding centers were in high schools, 18% in middle schools and the remaining 25% in schools that included elementary, middle and high school grades. A majority of centers operated out of the main school building (90%), stayed open throughout the school day (76%) and were located in urban areas (55%). Fourteen percent were less than two years old, and 24% had been established for 10 or more years.
Most centers (80% or more) offered every reproductive health service, either on-site or through referrals, except emergency contraception and implant insertions. On-site provision of reproductive health testing, counseling and treatment was available at 55-82% of centers. Contraceptives were not widely available on-site: The methods most commonly offered were the condom (28%), the pill (24%) and the injectable (20%); the implant was available at a negligible proportion of sites (3%). In addition, 15% of school-based centers provided emergency contraception. Despite the relatively low proportions of centers that dispensed methods, 69% offered contraceptive counseling and 58% provided contraceptive follow-up.
School-based health centers also provided a variety of educational services, in the health center itself and in the classroom. Overall, 71% each offered HIV education and pregnancy prevention education in the center itself, whereas 52-59% offered these services in the classroom. The proportions providing prevention education were 45-65% among middle school centers and 58-81% among high school centers.
Although school-based health centers generally required minors to obtain parental permission to use the center, 48% allowed students to obtain treatment for sexually transmitted diseases (STDs) independently, in accordance with state minor consent laws. Forty percent had policies allowing adolescents independent access to family planning services. Overall, 77% of school-based health centers prohibited on-site dispensing of contraception.
Centers located in rural (rather than urban) areas and those serving elementary and middle school students (rather than high school students) had a significantly reduced likelihood of offering the majority of the 16 reproductive health services, according to the logistic regression results; this lower likelihood of reproductive services provision adds to the barriers to care that rural and younger students already face (for example, inadequate transportation). For the majority of reproductive health services offered, centers that provided them on-site were staffed significantly more hours per week than centers that did not offer such services (means of 25-32 hours vs. 11-15). Centers that had been open for 10 or more years were more likely than ones open for fewer than two years to offer contraceptive counseling, condoms, the injectable or emergency contraception.
Middle school centers were significantly less likely than high school centers to conduct both HIV and pregnancy prevention education in the center itself. Centers' years of operation and the number of hours they were open per week were significantly and positively associated with HIV and pregnancy prevention education in both the center and the classroom. Middle school centers and rural centers were significantly less likely than high school centers and urban ones to allow adolescents independent access to family planning services; centers that had been open for at least 10 years were significantly more likely than recently established ones to provide contraceptives without parental consent. Further, the longer that a center had been open, the more likely it was to allow students to receive STD services without parental permission.
Rural centers were significantly more likely than urban centers to prohibit contraceptive provision. Finally, the mean number of weekly provider staffing hours was significantly lower among centers that prohibited contraceptive provision than among centers that did not (22 hours vs. 29 hours).
The data indicate that the majority of U.S. school-based health centers do not allow contraceptives to be provided on-site; the researchers observe that this prohibition stems more from local community and school policies than from restrictive state laws. Despite the widespread prohibitions on dispensing contraceptives, most centers can still refer their clients off-site for these services and are able to provide other reproductive health services on-site, although many face logistic barriers (i.e., limited staffing) in doing so. The researchers conclude that "more community and resource development" is needed for centers to realize their potential as an entry point into reproductive health care for adolescents and as "an important tool in a portfolio of other comprehensive approaches to improve access and to reduce poor health outcomes."--L. Remez
1. Santelli JS et al., Reproductive health in school-based health centers: findings from the 1998-99 Census of School-Based Health Centers, Journal of Adolescent Health, 2003, 32(6):443-451.