July 29, 2015 —Summary of "The Role of Federally Qualified Health Centers in Delivering Family Planning Services to Adolescents," Katherine Mead et al., Journal of Adolescent Health, July 2015.
Adolescents "in many parts of the country ... report a range of barriers" to accessing "[h]igh quality family planning services," such as cost concerns, inability to use parental coverage and a lack of awareness, according to Katherine Mead of the Milken Institute School of Public Health at George Washington University and colleagues.
Meanwhile, "[c]ommunity health centers (CHCs) are the most widely utilized safety net provider for medically underserved patients " and "are mandated by both mission and legislative action to target care to vulnerable populations," the authors noted. The authors wrote, "Given this position, health centers should serve as an important source of family planning services for underserved adolescents; however, no studies have examined the capacity of CHCs to provide high-quality family planning care to this population."
In their study, the authors aimed "to provide the first ever national examination of the role of CHCs in providing comprehensive family planning services to adolescents." Specifically, they shared "findings on the services that the health centers most frequently offer adolescents"; presented "the factors that influence health centers' ability to provide certain adolescent family planning services"; and discussed how CHCs "could address some of the persistent barriers to quality reproductive care for adolescents."
According to the authors, the article "is part of a larger national study examining the organization and delivery of family planning care in CHCs for underserved women." The study involved a national survey distributed to the chief medical officers and CEOs of CHC organizations, "followed by in-depth case studies in six communities."
The survey addressed CHCs' use of "nine services that have been shown to have implications for the provision and use of family planning among adolescents," including:
~ Alternative entrance and/or exit;
~ Collaboration with other organizations for outreach efforts;
~ Contraceptive services available onsite and offsite that are tailored to adolescents;
~ Drop-in centers;
~ Keeping adolescent family planning medical records private;
~ School-based education;
~ School-based treatment;
~ Staff training in adolescent family planning; and
~ Walk-in appointments.
The authors then "created an adolescent services index" by weighing each of the services to assess "the range of services delivered" among participating CHCs. Meanwhile, the researchers selected case study sites based on patient volume, regional distribution, receipt of Title X funding, range of available contraceptive methods, and variation in state's Medicaid and family planning policies.
Four hundred twenty-three CHCs (44%) responded to the survey, providing care for roughly 1.25 million adolescents in 2011, or 13.8% of the CHCs' patient population. Overall, the surveyed CHCs had a mean score of 6.33 out of 13 on the adolescent family planning services index. Specifically, of the CHCs that responded:
~ 82% reported making "efforts to protect privacy and confidentiality of adolescent family planning information by limiting access to the patient's medical record to the patient or a formally designated individual";
~ 78% "reported providing walk-in appointments for adolescents";
~ 66% "reported staff members receive training in adolescent family planning";
~ 52% reported "that they collaborate with other entities in family planning outreach to adolescents";
~ 47% "reported providing either on-site or off-site contraceptive services specifically for adolescents";
~ 45% of CHCs "indicated they provide school-based family planning education";
~ 29% "offered school-based family planning treatment";
~ 15% "had drop-in centers"; and
~ 11% had "an alternative entrance and exit for adolescents."
Role of Title X Funding
The researchers also found that about 26% of surveyed CHCs received federal Title X family planning funding and that CHCs with such funding scored higher on the adolescent family planning index (8.13) than health centers that did not receive such funding (5.33). Overall, the researchers found that:
~ 87% of Title X-funding CHCs had training in adolescent family planning needs, compared with 57% of CHCs without such funding;
~ 76% of Title X-funded CHCs collaborated with other organizations for outreach, compared with 44% of CHCs without such funding;
~69% of Title X-funded CHCs offered contraceptive services tailored to adolescent patients, compared with 38% of CHCs without such funding;
~63% of Title X-funded CHCs provided school-based education, compared with 38% of CHCs without such funding;
~41% of Title X-funded CHCs provided school-based treatment, compared with 24% of CHCs without such funding;
~26% of Title X-funded CHCs had drop-in centers, compared with 11% of CHCs without such funding; and
~19% of Title X-funded CHCs had an alternative entrance/exit for adolescents, compared with 8% of CHCs without such funding.
Location and Size of CHCs
Further, the authors found that medium-to-large CHCs scored higher on average on the adolescent family planning index (6.55) than small CHCs (5.58). According to the study:
~ 35% of medium-to-large CHCs offered school-based treatment, compared with 21% of small CHCs;
~ 54% of medium-to-large CHCs provided contraceptive services tailored to adolescents, compared with 38% of small centers; and
~ 57% of medium-to-large CHCs worked with other organizations on outreach to adolescents, compared with 47% of small centers.
Meanwhile, the researchers found that "a significantly higher proportion of rural health centers offered a drop-in center for adolescents compared with health centers in urban/suburban settings (27% vs. 13%), and 95% of rural health centers employed policies to limit access to adolescents' family planning records compared with 83% of urban/suburban health centers."
Role of Policy Climate
The authors also found that health centers located in "favorable/neutral policy climates" had a higher index score (6.33) than those located in less favorable climates (5.48). According to the researchers, 57% of health centers in favorable or neutral climates collaborated with other entities in adolescent family planning, compared with 42% of CHCs in less favorable political climates. The centers in the more favorable climates "also had more facility supports for adolescent services such having a drop-in center (18% vs. 7%) and offering walk-in appointments (81% vs. 73%)."
Factors Associated With Higher Index Scores
The authors found that "receipt [of] Title X funding," "the number of health center sites that provide family planning per health center organization," having a "family planning educator on staff ... and being located in a favorable policy state" all were factors associated with a higher index score. Further, the researchers found "a positive correlation between the proportion of adolescents among the total patient population and higher index scores."
Barriers to Adolescent Family Planning Funding
Looking at the case studies, the authors found that while "providing accessible and confidential family planning services to adolescents is a priority ... study sites faced challenges doing so," such as "inadequate funding, underutilization due to lack of knowledge of services, access barriers due to restrictive school policies, and the absence of confidentiality protocols for adolescents who seek family planning services."
According to the authors a "[l]ack of funding was the most substantial challenge to the provision of adolescent family planning" among the case study sites. The study found that every CHC "reported the reduction of funding for some aspect of their family planning services for teens," with some having "to eliminate entire programs for teens" and others curbing their outreach efforts.
In addition, the "[s]tudy sites also reported that a lack of knowledge about the availability and confidentiality of services may lead to underutilization among teens," the authors wrote. According to the study, one CHC provider noted that "underutilization of teen-targeted programs feeds into the cycle of funding cuts," wherein the center "cannot justify" certain services because they "are not being used."
The study also found that while several CHCs said school partnerships were "critical to serving the adolescent population" and to boosting adolescents' use of CHC services, "there are substantial barriers to fully leveraging school partnerships, including funding and push back from the community and parents." For example, one CHC "felt strongly that their inability to dispense birth control at the school clinic dramatically impeded their ability to provide needed care" and another CHC that offered care in schools called the inability to provide contraceptives in school clinics "a huge 'missed opportunity.'"
The case study CHCs also expressed concern about "the lack of protocols or enforcement of protocols to protect adolescent's privacy and confidentiality." One CHC said the providers at their site "often defer to the parents' wishes on confidentiality," and CHCs also "reported the absence of policies related to separate billing for adolescent family planning services."
"Survey results found substantial variation in both the range and type of family planning services provided to adolescents in CHC settings, and the case studies suggest that there are substantial funding and organizational barriers that make provision and utilization of family planning for teens challenging," the authors wrote.
According to the authors, "Many health centers incorporate key elements of quality adolescent family planning care as outlined by the CDC/[Office of Population Affairs] guidance, such as confidential care and youth-friendly services." In addition, most of the "health centers also train their staff on adolescent needs and collaborate with other organizations to target teen family planning needs." The researchers wrote, "In these ways, health centers are filling a critical gap -- they address many of the access barriers that impede teens' use of preventive services generally, and family planning care in particular, and provide services recommended by the CDC/OPA guidance."
Nonetheless, "CHCs still face substantial challenges in providing care to this population," the authors wrote. They noted that "few health centers have special access points for adolescents" and fewer than 50% "offer family planning education or treatment through school-based health centers."
According to the authors, the case studies give "further insight into why these gaps are so prevalent." Specifically, they noted that that a "[l]ack of funding impedes health centers['] ability to provide targeted programs, to effectively partner with schools and other organizations" in outreach efforts and "to build infrastructure that could protect privacy and provide adolescent-specific services." The authors added that because teenagers likely are more familiar with Planned Parenthood than with family planning services offered through CHCs, Planned Parenthood clinics might be "better positioned to meet their unique needs."
The authors also cited findings about how Title X funding, favorable political climates, multiple site locations and having family planning educators on staff were associated with higher scores on the adolescent services index. According to the authors, those "findings suggest that there are mutable factors that influence the provision of a greater number of adolescent family planning services and ways in which health centers can better leverage their services for adolescent family planning care."
"CHCs have the opportunity to play a significant role in providing quality family planning care to adolescents who are disproportionately low-income, from racial and ethnic backgrounds, and medically underserved," the authors wrote. Still, they added that "gaps exist and much can be done to improve care for this special population."
The authors urged CHCs to "explore using ... new funding" available through the Affordable Care Act "to support services targeted to family planning for teens, especially when Title X funding is not available." The authors also noted that insurance expansion under the ACA "will increase adolescents' access to preventive care," while delivery reform backed under the ACA might "also spur innovative programs that target teens' family planning needs." Moreover, the ACA's resources as well as the OPA/CDC guidelines could "serve to stimulate outreach and education efforts focused on adolescents."
The authors called for "additional research examining the relationships and referral networks between CHCs and other family planning providers within a community."