Toolkit for Improving Family Planning Services in School Settings

Embedding Equity

Hannah Lantos, Lisa Kim, Jenita Parekh, Jennifer Manlove, Katherine Cushing, Andrea Shore, & Donnie Greco

The Robert Wood Johnson Foundation (RWJF) defines health equity with the following two components: 1. “everyone has a fair and just opportunity to be as healthy as possible”; and 2. obstacles to health must be removed to ensure equal opportunity. Obstacles may include “poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.” This two-part definition makes clear that equity has an outcome component (everyone can be healthy) and a process component (removing obstacles). Achieving equity requires paying attention to student outcomes and to how inclusive the processes in your clinic are. Improved clinical processes can impact patient care—and focusing on both is essential for school-based health centers (SBHCs) to impact equity. In this foundational approach on equity, outcomes and processes are highlighted throughout different examples.


Using This Tool

Audience

The equity strategies included in this Foundational Approach focus on steps that individuals who work in school settings can take. These strategies can be helpful to clinic coordinators, directors, and individual practitioners, though many strategies will require buy-in from multiple stakeholders. Some strategies are adaptable for health care organizations and providers outside school-based settings including professionals looking to begin work in schools.

Structure

Each equity strategy in this Foundational Approach includes:

  1. A brief description of the strategy
  2. Case examples of schools, health centers, or organizations that have implemented the strategy
  3. Reflection questions to guide teams and individuals on how to implement a similar strategy

Each of these strategies was identified during interviews and virtual site visits with existing school-based health centers or school-based health initiatives. They come from practitioners in the field.

Adapting equity strategies to your context

Each equity strategy varies in complexity, funding, and scope and is adaptable based on context and resources. You are the expert for your health center or school setting. As you read, think about using these examples as ideas or prompts for brainstorming with your staff.

Before you start, we encourage you to reflect on the following:

  • Your equity goals for sexual health services
  • What equity strategies are currently working well
  • Where there are gaps between your equity practices and your equity goals

Needs Assessment Questions on Current Equity Strategies at Your Site

Consider groups of students missing from those you serve (e.g., students who are truant, have less flexibility to be involved with extracurriculars, are new to the school, have cultural or language barriers, etc.).
  1. What populations of students do you currently reach (if any) with your sexual health services, and what populations are missed?
    1. What populations of students are you missing? Why do you think they are missing?
    2. How can your program ensure that students you are missing are aware of the available sexual health services?
    3. What opportunities exist or can you develop to reach missing populations?
    4. How can you reach the students you are missing and serve them more equitably?
    5. How can you partner with youth to ensure you are fully answering this question?
Consider your organization’s goals for sexual health services and what is working well to ensure that all students are served equitably.
  1. What do equitable services look like in your school or clinic?
    1. How do you define equity?
    2. Is there a common definition among your staff?
    3. What is currently being done in your clinic to ensure that all students have equitable access to services?
    4. What is being done to ensure that structures and systems do not disadvantage certain students?
    5. What kind of data do you collect directly from youth on their experiences in your clinic and on whether services are equitable?
Think about how those providing sexual health services are prepared to meet students’ needs and provide equitable care.
  1. Who in your SBHC or organization is providing sexual health services and/or health education?
    1. Have they received equity training (e.g., implicit bias, history of racism, racism and discrimination, equitable communication, respectful care, or others)? See examples of trainings here, here, and here though this is not a comprehensive list.
    2. What ongoing support do they receive to help them define equitable service delivery and then to assess how equitable their services are?
    3. What voices inform changes to your clinic’s operations and policies? Whose voices are not included that you could benefit from? How can you integrate/further integrate, students’ voices to make the environment more equitable or inclusive?
Consider what barriers may stand in the way of implementing an equity strategy in your clinic or school (e.g., opposition to equitable practices, institutional processes that are cumbersome, needed resources for training or system development, etc.).
  1. What are the barriers to ensuring that all students in your school-based health setting and/or affiliated schools are equitably served or able to access services?
    1. Are there certain groups who might experience more resistance to strategies to connect students with sexual health services?
    2. What resources (e.g., funding, people, space, time) are available to reach all groups of students equitably?

You can view the Needs Assessment questions as a PDF form here.

Strategies to Support Equity in School-Based Health Work

The strategies in this Foundational Approach focus on equity strategies related to improving systems and processes, tracking clinic improvements, and tracking or improving patient outcomes. Many will help your staff ensure that as many students as possible feel welcome, respected, and safe in your clinic and that systematic policies or procedures that create obstacles to advancing equity are removed. While these strategies were defined as relevant for schools with SBHCs, they could be useful for health care organizations that serve adolescents broadly or those looking to enter schools without a clinic to do outreach, education, or service provision. These strategies include approaches such as equitable communication, clinic and patient safety, or staff training.

Prioritize hiring staff who understand the communities you serve and their lived experiences

Hiring staff who consider the lived experience of people in the communities you serve is essential. This can be prioritized by hiring staff with lived experience themselves or by hiring staff who understand the historical and contemporary contexts of the community/ies you serve. Ensuring that your staff can connect with young people’s own lived experiences requires either personal understanding or a depth of reflection and learning about communities other than one’s own. Sometimes people assume that efforts to hire more diverse staff are about lowering standards; however, this is not the goal when prioritizing lived experience or knowledge of it. Specifically, the skills that staff possess that help them effectively connect with young people (e.g., compassion, non-judgmental approaches, ability to neutralize power dynamics, personal approachability) do not always come with degrees/certifications and should be explicitly examined (and valued) in hiring. Additionally, they may come with other non-traditional and less westernized metrics such as restorative justice practices or differing skills to support family and youth engagement. Thinking about the types of skills you need and how to ask questions during the hiring process to assess those skills is an important step.

It is important not to tokenize staff members such that they feel the burden to represent an entire group. Simply because a staff member is a person of color or a certain religion or identifies as LGBTQ should not mean they are expected to connect with all students like them or be hired just to show diversity of staff. Connection is more varied and nuanced than one single demographic dimension. So, while diversifying your staff may increase opportunities for different kinds of connection, expecting the unexpected in terms of who connects with whom is necessary, as is ensuring that staff are recognized for their skills and accomplishments and not simply for their demographic characteristics.  

Case examples

At Ballard High School in Seattle, the SBHC hired a coordinator who had previously attended the school and is Polynesian. The coordinator restarted a club for Polynesian students that had existed when she was a student in the school. A nurse practitioner in the SBHC noted that students in the club began to seek clinic services, because they built a close relationship with the coordinator and enjoyed seeing her at the clinic and spending time with her.

At the Children’s Hospital of Philadelphia’s (CHOP) Health Resource Centers (HRCs), the program director prioritizes hiring coordinators who care about and like working with adolescents and who may have connections to the communities where the HRCs are located. At CHOP, “liking working with adolescents” was typically assessed by identifying staff who already worked with and discussed enjoying working in CHOP’s adolescent clinics. In other settings, asking interviewees questions about their approach to the work, things they love, or why they chose to work with adolescents might also help an interviewer assess this trait. Given that the primary responsibility for coordinators is to reach and engage youth, having coordinators who are familiar with the community and are comfortable with interacting with youth from those communities is essential.

For more information about the CHOP’s HRCs, please see this case study.

One SBHC in Staten Island, New York noted that they have a language line for patients and develop materials, including consent forms, in multiple languages. Furthermore, the SBHC expressed their commitment to having their staff reflect the patients they serve. They add “Spanish-speaking preferred” in their job descriptions and consider job applicants’ backgrounds and lived experiences when hiring. This SBHC has multiple staff who speak different languages and have some staff who attended the high school where they now serve.

Reflection questions

Consider who is currently on your staff and what skills are missing.
  1. How do students currently relate to your staff? How do you assess whether a staff member is good at relating to students?
  2. What questions could you include in interviews to help you identify candidates who may connect or relate to your students effectively?
  3. How could you use role playing or scenarios to ask potential candidates about their skills?
If applicable, identify priorities for any new hiring.
  1. In the hiring process, how can you assess the skills this new staff member needs to provide equitable services?
  2. What are the most important characteristics/qualities for someone filling this role?
  3. What characteristics do students see as the most important?
  4. What skills can you train staff on (e.g., motivational interviewing) versus skills the staff member should have when they start (e.g., liking youth)?
Consider how to prioritize equity during the recruitment and hiring process.
  1. How can these priorities be effectively communicated to the hiring manager or team?
  2. How is equity represented in job postings? Where do you post job openings?
  3. How is equity represented and prioritized in the hiring process?
  4. Is there an opportunity for student voice in the hiring process?

Resources and Citations Referenced in this Section

Create a culture of transparency and openness

Setting up clear and transparent systems or processes to discuss bias or racism can help SBHCs identify systemic issues and support providers and patients in understanding how issues will be addressed. Individuals may find it challenging to share personal experiences of bias or racism, especially if they must disclose who committed the act of bias or racism. Revealing this information can create conflict, which may deter some individuals from sharing their experiences. Setting up anonymous systems for reporting such behavior or creating a more intentional culture where everyone is afforded the opportunity to learn may help SBHCs identify and address these issues. This culture of transparency and openness can also help organizations be accountable to their goals and values.

Systems do not have to be anonymous, but if your clinic prioritizes anonymous systems for feedback, it is important to encourage staff and patients to provide constructive feedback that is specific and is aimed to improve an outcome. Receiving unspecific or negative criticism can feel frustrating and may make it more challenging to address issues. Therefore, thinking about ways to encourage constructive feedback (even when identifiable) is important, when possible.

Case examples

At one SBHC, a nurse practitioner shared that she heard from patients about poor experiences they had with other providers when seeking contraception. For example, patients described feelings of pressure to choose a long-acting reversible contraceptive (LARC) method or shame for choosing other methods (e.g., using condoms instead of a LARC). The provider heard patients say, “They just don’t want black girls to get pregnant” and “I don’t think she would talk to me that way if I was a white girl.” In response, the nurse brought this up with other colleagues, and the SBHC changed the way they approached contraceptive counseling—from focusing on efficacy to centering each student’s contraceptive goals. In instances like this, it is important to have a process for following up on reports of bias or racism and ensuring that patients feel safe and supported. Staff should also create a space for providers themselves to reflect on such comments.

At another SBHC, providers spoke about conducting contraceptive counseling in their SBHC but referring some students to outside clinics for certain contraceptive methods. With some regularity, students would come back with a different method than what they indicated they wanted during their contraceptive counseling session. Providers were then tasked with determining if the patient had changed their mind, and if not, whether they were pressured to choose a different method for some reason. Over time, providers noticed a pattern: it was often their Black patients who returned with a LARC method. This experience led this SBHC to be more careful about how, when they referred patients, they could ensure that their patients knew their preferred method of contraception and how to ask for it in the appointment. They focused on better preparing students to specify what method of contraception they wanted. It also highlighted the importance of having clinics systematically review the variety of outcomes and processes in their data. They would not have identified the pattern mentioned above if they just looked at “receipt of any contraceptive method.” But, by noticing a discrepancy between students’ stated preferred method of contraception and the method of contraception eventually received, the clinic staff were able to identify a concerning pattern.

Reflection questions

Consider how you gain feedback from students regarding their experience receiving sexual health services.
  1. How can students anonymously share feedback?
  2. How do you collect feedback from users and non-users of sexual health services? Non-users may be able to share perceptions of the sexual health services that keep them from engaging.
  3. Who outside the SBHC can students go to if they need to immediately report a problem? How will the SBHC receive this information?
What processes exist for responding to reports of bias or racism?
  1. What is the timeline for reviewing feedback and reports of bias or racism?
  2. Who reviews feedback and reports of bias and racism?
  3. How can you engage your team in conversations to resolve issues relating to bias or racism that arise?
  4. What data would help you identify if there were issues to address like the ones described above? How could you regularly review the data?
  5. What other processes might help your clinic identify challenges relating to bias or racism youth are facing?

Resources and Citations Referenced in this Section

Train on the history of racism and the social determinants of health

Provide trainings to all SBHC staff (clinicians and non-clinicians) on the history of racism in the United States and the importance of social determinants of health or the social and environmental contexts people live in, particularly as it relates to health care and sexual health services. Understanding the systematic constraints that some patients may be navigating or the ways that different social and physical environments can affect health can be transformative for providers because it can help them understand why certain issues repeatedly arise, why patients might be more skeptical or concerned about medical advice, or even why compliance with different treatment regimens is challenging. Trainings can focus on topics such as the history of redlining and its links to opportunities, nutrition, violence, trauma, or other topics. When talking about sexual health, including information about the history of forced sterilization is essential. Overall, understanding how social context impacts patients is key to providing holistic care.

When establishing trainings on racism and the social determinants of health, trainers must 1) help individuals link past inequities to current action, access opportunities to learn more, or identify strategies to combat disparities, 2) think critically about the level of training needed, 3) plan for ongoing support to implement their new skills, and 4) create a space that is empowering and creates time for non-judgmental reflection. Trainings that focus only on the negative or the historical legacy of some practices can leave providers feeling hopeless or stuck. Providers should have space to process feelings of sadness or anger but should also feel empowered to act. Also, all too often, trainings focus on the beginning (or “101”) level, and many clinics need more advanced trainings. Examples of trainings that illustrate these four components are here, here, and here, though this is not a comprehensive list of all high-quality equity trainings.

Case examples

Nationwide Children’s Hospital (NCH) has a robust and active racial justice working group that heads up equity initiatives in their programming/clinics, develops guiding principles for staff to better understand equity issues, and implements frequent provider trainings on topics such as caring for immigrant children and understanding the impact of racism and bias on patient outcomes. The group is voluntary for anyone to join. They also host speakers on topics such as redlining, metropolitan development, and rising real estate costs. This group creates a space for providers to learn about and discuss the history and impact of racism on patient outcomes. NCH tracks participation in trainings and conducts surveys across all staff to evaluate perceptions of their diversity, equity, and inclusion (DEI) work, the impact of the work, and opportunities for improvement. Assessing changes in behavior of or outcomes for youth because of this work would be a logical next step to this work.

In Minneapolis, SBHC staff are intentional about ensuring that their training for new and existing health educators includes a focus on equity. Specifically, the health education manager connects new and existing staff to trainings on topics like LGBTQ+ health, inclusiveness, and racial equity (for a related resource, see On Demand Webinars & E-Learning Modules. They also focus on training staff to respect the cultural and historical experiences of different student populations and the ways in which this respect might impact students’ health An additional step clinics might consider is assessing whether the training leads to changes in staff behaviors.

For more information about the Minneapolis Health Department’s health educator program, please see this case study.

Nurse practitioners working in SBHCs through the King County Public Health Department in the state of Washington participate in groups within the schools and in the greater community to be more intentional in their equity work. They engage with an organization called Washington Building Leaders of Change (WBLOC) to learn more about race, restorative justice, and empowering youth. Additionally, their SBHCs prioritize creating an inviting environment where youth feel they can talk and engage with staff. Youth can come into the clinic for lunch and have shared that they feel ownership over the clinic spaces. Staff also note the importance of having a clinic coordinator, who is a point of contact for students and often is the first face they see at the front desk, to help create this welcoming space and connection with students.

Reflection questions

Consider what training and knowledge staff have received on the history of racism and social determinants of health and how this impacts interactions with students receiving sexual health services.
  1. What do staff know about the history of racism, racism in health care, provision of sexual health services, sexual health research, and informed consent?
  2. What courses or trainings have you and other staff taken as part of professional development offerings or formal education and training?
  3. What aspects of training make it effective for staff to learn and change behavior?
  4. What supports need to be in place after a training to ensure skills can and are consistently applied?
Identify learning opportunities for SBHC staff.
  1. What areas would staff like to learn more about? How can you help your staff (and yourselves) access and receive these trainings?
  2. What topics are particularly relevant for your community? Are there important historical events or policies that have shaped the communities and lived experiences of students?
  3. How can youth be involved in identifying topics staff need to learn more about?
Consider how your understanding of the history of racism and social determinants of health influence practices, policies, and procedures for providing sexual health services?
  1. What practices, policies, and procedures, should be revised to be responsive to community and student backgrounds and provide equitable sexual health serves?

Resources and Citations Referenced in this Section

Train on implicit bias

Train staff to be aware of implicit biases and know how to provide respectful care. The Perception Institute uses the term “implicit bias” to describe “when we have attitudes towards people or associate stereotypes with them without our conscious knowledge.” One example of this in a sexual and reproductive health setting is the belief that Black students need LARCs more than white students because they may not reliably use a daily method. In the medical field, implicit biases have been found to result in worse care for patients of color across a wide range of outcomes. Respectful care focuses on ensuring that patients are seen as whole people, are listened to, and are supported to act on their preferences. Staff should know what implicit biases are and how to create systems that ensure that all patients receive equitable, respectful care.

Providing concrete action steps is also key to resolving implicit biases. If the takeaway message about implicit biases is that we are all biased, and there is nothing we can do, we can feel hopeless or useless. Additionally, we all will carry biases with us because this is the environment in which we live, grow, and practice. The goal should be to minimize the impact of these biases. To do this, staff should identify personal biases, understand how to respond with minimal defensiveness, and assess what processes or systems can be set in place to guard against implicit bias.

Case examples

White health educators in a school-based clinic program in the Midwest formed a discussion group to recognize the history of medical harms done to populations that were historically excluded from high-quality health care. The group then built on this historical understanding to examine how their biases as providers and individuals led to ongoing disparities in health care. The group met regularly and discussed reading material about racism in health care and white supremacy. These exercises focused on identifying biases they may not have been aware of, and together, they came up with strategies to hold themselves accountable to remember and not fall back into the same patterns. They described the group as a safe and vulnerable space for White staff to identify stereotypes (positive and negative) and to ensure that their group remained curious and open to thoughts, fears, and assumptions.

At one SBHC, implicit bias training is incorporated into their staff training. A provider at this clinic spoke about how they hope this training is open and safe, allowing trainees to be honest about the assumptions they have about youth and their patient population. If providers feel able to talk about and name those assumptions, clinic staff can work together to combat them. For example, staff spoke about how providers may feel that LARCs are the best method for patients given their safety and efficacy, but they must cast aside their assumptions and recognize that young people may prefer other methods for a variety of reasons. Promoting LARCs in a way that allows adolescents to make informed and voluntary choices is crucial to providing equitable care.

Reflection questions

Consider what training and knowledge staff have received on implicit biases and how this impacts interactions with students receiving sexual health services.
  1. What do staff know about implicit biases in health care and how implicit biases affect the provision of sexual health services?
  2. What courses or trainings have you and other staff taken as part of professional development or formal education and training?
  3. How do you know an implicit bias training is high quality?
Identify learning opportunities for SBHC staff.
  1. What areas would staff like to learn more about in terms of implicit biases? How can you help your staff (and yourselves) access and receive these trainings?
  2. What topics are particularly relevant for your community in terms of implicit biases? Are there important historical events or policies that have shaped the communities and lived experiences of students?
  3. How can your team create a safe space to reflect on what they learn and their own implicit biases in a constructive way?  How can you help your team apply what they’ve learned day-to-day?
Consider how your understanding of implicit biases influence practices, policies, and procedures for providing sexual health services?
  1. What practices, policies, and procedures, should be revised to be responsive to community and student backgrounds and provide equitable sexual health services?

Resources and Citations Referenced in this Section

Gather patient feedback systematically

Gather feedback systematically to capture the diversity and variations of experiences patients have in your clinic. These variations of experiences occur for a variety of reasons (e.g., individual preferences, norms, or patient factors) but knowing if these variations are related to systematic bias or more negative experiences is important. For example, it might make sense for people with different diagnoses to have different experiences, but it is more problematic if demographic factors (e.g., race/ethnicity, gender, age, sexual orientation, gender identity, etc.) drive positive or negative experiences for certain groups in your clinic. One way to identify these problems is to gather feedback—quantitative (e.g., surveys) and qualitative (e.g., focus groups or feedback from a youth advisory council)—systematically from a variety of patients. Formal and informal feedback is useful but ensuring that the types of patients who provide feedback are varied is of utmost importance. When gathering and analyzing feedback, it is also essential to disaggregate the data on services received in your SBHC across a variety of demographic factors (race/ethnicity, gender, age, sexual orientation, gender identity, etc.). Tracking who receives your services allows you and your team to identify gaps. Just as you might track types of services or upticks in specific diagnoses, tracking services received and, ideally, outcomes for those services, by different demographic groups allows you to be aware of patterns that might be of concern early. Noticing problematic patterns can help you identify systematic disparities and begin to assess whether the disparities are caused by issues in your clinic setting (e.g., coercion or bias) or outside the clinic setting (e.g., messaging received elsewhere).

Collecting a lot of data that do not have a purpose is not useful. Make sure you have reasonable expectations of yourself to review and interpret the data you collect, and do not to collect more data than you can handle. Additionally, when you disaggregate, not all differences indicate a problem. For example, if there are cultural differences to some methods of contraception, observed differences in the data may indicate that your staff are appropriately listening to patients and that there are groups with certain cultural, political, or learned preferences.

Case examples

In one SBHC program, AmeriCorps health educators facilitate a youth advisory council across their SBHCs in high schools. Students who want to share their passion about health care and make a change in their schools are invited to join the council. The main goal of the youth advisory council is for students to connect with their peers and share feedback with SBHC staff about what students need and the types of information and services that best resonate with them. Students may feel more comfortable sharing feedback directly with their peers, so providing an avenue for them to do so may yield more successful results. While not all the topics that come up in a youth advisory council are, or should be, about equity, creating space for youth voice is an age equity issue and encouraging youth to consider how to ensure that diverse voices are on the council can help raise equity issues to the forefront.

One SBHC program developed a LARC doula program where health educators and medical assistants learned to support patients during a LARC procedure. While the program was first implemented in 2019, there was no formal process for patients to provide feedback. Recognizing this gap, SBHC staff developed a patient survey to better understand patients’ experiences with their LARC doula. They hoped to use this data to identify strengths and areas of improvement to improve patients’ experiences during a LARC procedure. By providing this survey to all patients rather than to just the ones who voluntarily speak up, the SBHC helps to ensure that patients who may be most hesitant to share have an opportunity to do so anonymously.

Reflection questions

Consider ways to solicit feedback on sexual health services as you regularly collect other student data.
  1. What is important for you to know about how students perceive and interact with your sexual health services?
  2. How can you consult with youth about the best ways to collect data from them?
  3. Is there a way for youth to share anonymously about things that are going well and areas that need improvement or growth?
  4. Do you collect feedback from users and non-users of sexual health services? Non-users may be able to share perceptions of the sexual health services that keep them from engaging.
Consider what form of data regarding sexual health services would be most helpful to your team and the students you serve and how to help students feel comfortable reporting the data.
  1. How can your team use detailed responses and stories (qualitative data) and frequencies and percentages (quantitative data)?
  2. Are the questions you want to ask about sexual health services sensitive? Will students be more comfortable answering these through an anonymous survey or vocalizing them with SBHC staff or in front of their peers as part of an interview or focus group?
  3. How can you create a safe environment for students? Should SBHC staff lead the interviews? Can you train a peer to run interviews or focus groups or provide an internship opportunity to an older near-peer who has these skills?
How will your team use the data to improve sexual health service delivery?
  1. Who on your team can analyze the data?
  2. What kinds of additional training would help them analyze more data or different data?
  3. Who will ensure that findings are integrated into sexual health service policies and procedures?

Resources and Citations Referenced in this Section

Validate patient experiences and focus on patient-centered care

Validate patients’ experiences by actively listening, showing empathy, and responding to their experiences or questions appropriately. Receiving validation from someone outside your family, and especially someone with the social standing of a health care provider, can be powerful and moving because it can make experiences less intimidating, scary, or stressful. The Person-Centered Reproductive Health Program at University of California San Francisco (UCSF) emphasizes the importance of autonomy in making decisions and of receiving trust and respect from health care providers and institutions as key components of patient-centered care when it comes to sexual and reproductive health. Validation and patient-centered care are particularly important for many youth of color for two reasons. First, if White is the norm, providers may assume that White experiences are everyone’s experiences and not take the time to understand how other youths’ experiences are different. Second, many youth of color report that they feel pressured to do something they do not want to do in health care settings. Providing patient-centered care is associated with improved health outcomes and patient satisfaction. One way to think about validation is that by recognizing patients as people with lives outside of the clinic who have to navigate complex decisions, you can build trust and positive rapport. Additionally, remembering to ask patients about their lives, not just about the issue that brought them into the clinic, is one way to see them as complete individuals. Existing research also points to a variety of strategies to support patient-centered care especially in a post-COVID-19 world where telehealth is more common. Specifically, centering patients in virtual visits will require more practice and discussion from providers if they are new to this kind of care.

It is important to be authentic when engaging youth about their lives. Ask questions, but more importantly, listen to their answers. Make sure that you actively listen or apologize if you are unable to engage more deeply at certain visits. When patients feel heard and seen, they are more likely to return to the clinic.

Case examples

Health educators in Minneapolis Health Department’s school-based clinic program share resources and create space to reflect on their own experiences supporting students during their health educator staff meetings. In these meetings, health educators learn and discuss ways they support their patients to meet their own goals. For example, one health educator described recently supporting a Latinx student who wanted to prevent pregnancy but had moral concerns related to their familial and cultural beliefs and the use of certain contraceptive methods. The health educator shared with the health education team how she navigated that conversation with empathy and asking open-ended questions to help the student prioritize what was important to them. The goal of this time during staff meetings is to help other team members be better prepared for similar situations.

For more information about the Minneapolis Health Department’s health educator program, please see this case study.

At Every Child Pediatrics in Colorado, providers approach sexual and reproductive health counseling using a framework similar to the PATH Framework. The PATH Framework focuses on Pregnancy Attitudes, Timing, and How important their priorities are. Specifically, providers first ask the patient if they want to become pregnant or would like to ever have children; then they ask when an ideal time would be to have children. Finally, they ask how important those attitudes and timing are. By approaching conversations this way, providers do not assume— based on age, race/ethnicity, partnership, etc.—whether a patient is seeking to avoid pregnancy. It also allows providers to present different contraceptive methods in the context of the patient’s goals and ensures that patients who are seeking a pregnancy now or soon can get pre-conception counseling or prenatal care in a timely manner.

Reflection questions

  1. What opportunities do you have to be present in the school and build relationships with students?
  2. What steps can you take to incorporate a Positive Youth Development approach to sexual health in your SBHC?
  3. How can you ensure that the questions you ask are open ended when possible?
  4. How do you avoid assumptions and stereotypes in your work so that your clinical care is in response to what the patient tells you or how they act rather than what you might expect?
  5. How do you incorporate each individual student’s interests and goals as you work together regarding their sexual health?
  6. What areas of patient-centered care would staff like to learn more about? How can you help your staff (and yourselves) access and receive these trainings?

Resources and Citations Referenced in this Section

Use inclusive, accessible, and plain language

Use inclusive, accessible, and plain language to help patients feel accepted, safe, and included and to help ensure they understand information shared with or asked of them. Using inclusive language is an equity strategy for two reasons. First, at the most basic level, using plain language can ensure that patients understand what providers are saying. They may not understand because they speak another language or because they are not familiar with health care options or processes. Second, using accessible and inclusive language can help patients feel safe and that they are in a trustworthy space. Language holds incredible power to make someone feel included or excluded, judged or accepted, understood or misunderstood. Therefore, it is important to be intentional when choosing words. This intentionality must be there when using the pronouns someone prefers or the words to describe one’s race/ethnicity. It might also mean acknowledging who their partners are or using clear terminology for body parts. Or it might simply mean providing translation. It is important to use inclusive language across race/ethnicity, but also in terms of who one’s sexual partners are, what behaviors one engages in, and where one comes from (e.g., neighborhood or country). This can, in turn, help them share challenges or feel safe when maybe they were apprehensive before, particularly for students who have not interacted with the health care system much or who have heard about bias in the health care system.

Sometimes using more inclusive language can feel awkward at first. For example, many people struggle to say “pregnant patients” instead of “pregnant women,” while others may wonder if they could say something offensive. Ask patients their preferences around language and recognize that this is a crucial way to make people feel welcome in your clinic. Additionally, a genuine apology goes a long way. No one is perfect, but kindness and learning can feel real or forced. Striving for real connection can help when errors are made.

Case examples

In Minneapolis, health educators described using inclusive language when discussing topics related to gender and reproductive health. When introducing themselves, health educators share their gender pronouns and explain that “it doesn’t matter your race, ethnicity, sexual orientation, gender, or immigration status” or whether a student is insured or not—the clinic is “open to everyone.” Furthermore, health educators use non-gendered language when educating on anatomy—for example, saying “people with vaginas” or “people with penises.”

For more information about the Minneapolis Health Department’s health educator program, please see this case study.

At an SBHC in Chelsea, Massachusetts, a provider described partnering with staff leading the Bridge Program, a program dedicated to supporting English language learners. The school has many Spanish-speaking students with a significant population of newly arrived immigrant students. While the school has health classes, they were conducted only in English, and most English language learners would not be enrolled for a year or more after arrival. Recognizing the need to reach their large population of Spanish-speaking students, the provider developed a presentation in Spanish about SBHC services, the importance of confidentiality, and different sexual and reproductive health (SRH)-related topics, including contraceptives. Ensuring that translation of important information was available was one way this site focused on inclusive and accessible language.

Reflection questions

Consider how you communicate verbally with students about their sexual health in an inclusive and accessible way.
  1. What current efforts do you make to use inclusive and accessible language with students when talking about their sexual health?
  2. Is this approach an official part of your SBHC’s policies and procedures?
  3. What efforts can you take to ensure that your verbal communications meet students’ language needs and make them feel safe and included?
Ensure that other sexual health communications are inclusive and accessible.
  1. Do your written and health education materials use inclusive and accessible language and adhere to plain language principles?
  2. Who on your team can review written materials and make revisions?

Resources and Citations Referenced in this Section

Recognize patient autonomy and support their healthy literacy

Help students improve their reproductive autonomy by improving their health literacy. Health literacy means the degree to which people can “find, understand, and use information and services to inform health-related decisions and actions.” In SBHCs, clinicians and other health care providers can support more equitable health care access by focusing on increasing the health literacy of their patients. Focusing on reproductive autonomy and agency can support certain populations that may have less comfort, familiarity, or ease in a health care setting than others. This may be particularly true for students of color, immigrants, LGBTQ+ students, or females. These student groups may be more likely to have had negative experiences in the past or heard about bias or poor health care from those around them. By focusing on patient autonomy, your providers can also help ensure that their patients will be better equipped in future medical contexts. This may mean providing longer appointments for different patients, such as those who have more complex clinical concerns, limited English proficiency, or less support to access care.

Autonomy must not mean a lower quality of care. In ensuring that patients can ask questions and make decisions for themselves, make sure they have all the information and support needed.

Case examples

At one SBHC, a provider shared that a priority for them was to increase the health literacy of their students. To do this, staff developed the peer advocate program where 10 students were selected to learn about different sexual and reproductive health topics and then shared this information with their peers. “Peer advocates” met weekly to learn about and discuss topics, such as different contraceptive methods and confidentiality. Peer advocates also encouraged their peers to visit the SBHC and helped students who feared the health center or meeting a medical provider feel safer and that the clinic was trustworthy. It was particularly important for these peer advocates to look like the students who were part of communities who had systematically had less access to or interaction with the health care system or for whom bias and poor quality or unethical care happened more regularly in the past.

Another SBHC program described the importance of autonomy in contraceptive decision making. When speaking with students about different birth control methods, clinic staff, including health educators and providers, emphasized that patients should choose a birth control method that best fit their lifestyle and that they were most comfortable with. Furthermore, patients were encouraged to express any hesitation they may have and remove a LARC at any time. The LARC doula program is also a testament to the SBHC’s dedication to patient autonomy. The role of LARC doulas is to ensure patient’s sense of control during a LARC procedure. In offering contraceptives, providers shared the importance of “really letting patients be in the driver’s seat and giving them as much information as you can about birth control, and even if you think a method is good for them, let them decide.”

Reflection questions

Consider your students’ health literacy levels and how that influences their interactions with sexual health services.
  1. Are there particular groups in your school who have lower health literacy than others? What groups have low health literacy and what are the reasons for that?
  2. Where do students get most of their information on sexual health?
  3. What opportunities exist to promote health literacy among the students at your school? Is there a student organization or club that you could partner with for a learning initiative?
  4. Are health education materials you distribute appropriate for students’ health literacy levels?
How do you make a commitment to autonomy clear in your SBHC especially in regard to sexual health services?
  1. Do you discuss autonomy with students?
  2. How do you communicate their autonomy and your commitment to working with them to achieve their goals around sexual health?

Resources and Citations Referenced in this Section

Next Steps

Now think about potential next steps to embed equity into sexual health services and set some intentional goals. The following statements can serve as prompts to help you identify next steps.

Reflections on Goal Setting

1. Identify at least one new sexual health equity strategy to implement in your school-based health setting or organization over the next three months.

Think about what you discussed in response to the needs assessment questions and then identify new opportunities for sexual health equity in your SBHC. Ensure that your conversation identifies ways to reach all student populations or that if you narrow to focus on one population, it is intentional. Consider what data can help you identify the strategies on which you should focus.

2. Identify at least one existing sexual health equity strategy in your school-based health setting or organization to improve over the next three months.

Think about what is already happening in your SBHC regarding equity in your sexual health services. Consider what could be done more efficiently or more effectively and what efforts are not having the desired outcomes. Think about smaller changes that you can test and include in SBHC protocols. Ensure that your conversation identifies ways to reach all student populations. Then consider an additional small change. Consider what data can help you identify the strategies on which you should focus.

3. Identify at least one new sexual health equity strategy to implement in the school(s) where you are located over the next three months.

Think about new opportunities for schoolwide equity work related to sexual health services. Ensure that your conversation identifies ways to reach all student populations.

4. Identify at least one existing sexual health equity strategy in the school(s) where you are located to improve over the next three months.

Think about what your SBHC is already doing in the school regarding equity and sexual health that could be done more efficiently or effectively. Think about smaller changes that you can test and include in SBHC protocols. Ensure that your conversation identifies ways to reach all student populations. Then consider an additional small change.

You can view the Next Steps questions as a PDF form here.

General Resources and Further Reading


Suggested Citation

Lantos, H., Kim, L., Parekh, J., Manlove, J, Cushing, K., Shore, A., & Greco, D. (2022). Embedding Equity Approaches into Clinic Processes and Patient Interactions. Child Trends. https://doi.org/10.56417/3031i7003s

This publication is supported by the Office of Population Affairs (OPA) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $2,036,999 with 100 percent funded by OPA/OASH/HHS. The contents reflect the views of the authors and do not necessarily represent the official views of, nor an endorsement by, OPA/OASH/HHS, or the U.S. Government. For more information, please visit https://opa.hhs.gov/.

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