March 26, 2015 —Summary of "Reproductive Health Impact of a School Health Center," Minguez et al., Journal of Adolescent Health, March 2015.
School health centers (SHCs) can help prevent teen pregnancy in several ways by providing access to reproductive health services such as "contraceptive counseling" and "sexuality education," according to a team of researchers led by Mara Minguez of the Mailman School of Public Health at Columbia University.
Prior research has found that there is "high acceptance" of SHCs among parents, students and schools, including "strong" parental support for the centers' reproductive health services and "considerable student utilization" of such services. Moreover, "no studies" have shown SHCs to have "adverse" impacts, such as "increases in sexual activity," the researchers wrote.
Nonetheless, they noted that "evidence remains limited of the impact of SHCs." In this study, the researchers sought to "address this lack of evidence-based research" by comparing experiences of students at a school with an SHC that offered reproductive health services with those of students at a school without an SHC.
The researchers compared New York City high schools with ethnically and socioeconomically similar student bodies. The final sample consisted of 1,365 students from the intervention school and 711 students from the comparison school.
At the intervention school, "services were similar to the self-care model, which combined reproductive health care, counseling in the health center, and classroom education." Specifically, the SHC offered primary care and reproductive health services, with a clinical staff of two or three physicians or nurse practitioners and two fulltime mental health care providers. The intervention school also offered classroom education on pregnancy and sexually transmitted infections/HIV prevention. Meanwhile, the comparison school provided HIV education and a condom availability program, in addition to employing a fulltime nurse who offered referrals to community care and first aid.
Data were collected using a 64-item questionnaire that was "modeled after the 2007 NYC Youth Risk Behavior Survey." Along with the YRBS questions about sexual behaviors, drug use and demographics, the researchers asked about "immigration, general health status, contraceptive use, use of health services, clinical counseling and sexuality education, and willingness to use the SHC."
The researchers used three statistical models to assess data. The primary method -- the "interaction method" -- "examined the statistical significance of school x grade interaction terms, using ninth graders as baseline subjects." The second model -- the "stratification method" -- compared the ninth graders and the older students "between the two schools, controlling for demographic factors," while the third model "compared SHC users and nonusers in the intervention schools to students in the comparison school," the researchers explained.
The analyses focused on four factors:
~ Students' willingness to visit the SHC for reproductive health care;
~ The receipt of health care provider counseling and classroom education;
~ Contraceptive use; and
~ Source of contraception.
Willingness to Use SHC
The researchers found that "similar percentages" of students at both schools were willing to use the SHC at the ninth-grade baseline, "but differences between schools increased sharply by grade." Specifically, 81% of 12th graders at the intervention school were willing to use the SHC, compared with 35% of their peers at the comparison school. Within the intervention school, more than 80% of SHC users said they were willing to use the center for reproductive health services, compared with 57% of students at that school who did not use the SHC and 37% of students at the comparison school.
Receipt of Education, Counseling
As students progressed through the grades, the percentage who reported "that someone other than a teacher talked with them about abstinence, condoms, and HIV/AIDS in class" increased at both schools, although "the increase by grade was greater in the intervention school," the researchers wrote.
Further, students' receipt of provider counseling about birth control and emergency contraception also increased by grade at both schools, "but the increase with grade was greater in the intervention school," the researchers found.
Among sexually experienced female students, the proportion who had ever used hormonal contraception was similar in both schools at ninth-grade baseline. By grade 12, ever-use of hormonal contraception among this population had risen to 71% at the intervention school and 50% at the comparison school.
Meanwhile, among young men, the interaction method and stratification method analyses showed that those at the intervention school were "more likely" than their counterparts at the comparison school "to have ever used condoms." At the comparison school, 52% of male students reported having ever used a condom, compared with 70% of SHC users and 54% of SHC nonusers.
Further, 30% of 10th through 12th graders at the intervention school reported using hormonal contraception at last intercourse, compared with 20% at the comparison school. At the intervention school, 34% of SHC users reported hormonal contraceptive use at last intercourse, compared with 22% of SHC nonusers.
Sources of Contraception
The students reported various sources of contraception, including but not limited to:
~ Clinics and health care providers (60% of respondents);
~ Families, friends and bodegas (16%); and
~ Sources in both categories (6%).
Meanwhile, "29% reported no source of contraceptive supplies."
Among SHC users, 80% of women and 41% of men said it was their "usual source" of contraception.
In summary, the researchers wrote that the "study demonstrates a pattern of improved reproductive health care and education among students in high schools with an SHC providing sexual and reproductive health care compared with students in a school without an SHC."
Specifically, the researchers noted that the SHC was tied to:
~ Better access to classroom health education;
~ More provider and student discussions; and
~ Greater contraceptive use.
The researchers highlighted the "increases in contraceptive use among SHC students as measured by ever use, at the first intercourse, and use at the last intercourse," adding that "[c]ontraception is the most important proximate determinant of teen pregnancy among sexually active youth."
Noting that many restrictions exist on SHCs, the researchers wrote that "[t]o be maximally effective in reducing teen pregnancy, SHCs must be allowed to prescribe and dispense a full range of contraception, including hormonal and long-acting reversible methods." However, ensuring such policies "will mean addressing political and cultural barriers to providing such care," they added.