Teens and young adults have the highest rates of unintended pregnancies and sexually transmitted infections (STIs) in the United States, yet many cannot access or utilize family planning care. For example, one quarter of sexually experienced females and one third of sexually experienced males ages 15 to 19 did not receive family planning services in the past year. Further, these rates are even lower among young people from historically underserved groups—for example, Black or Hispanic or LBGTQ teens. These low rates of utilization are often due to a lack of knowledge of how to access or use family planning services, as well as limited availability of conveniently located services.
High schools and community colleges are promising entry points for offering sexual health services to adolescents and young adults, especially those from underserved groups. For example, the United States has a network of school-based health centers (SBHCs) operated by local sponsor organizations (e.g., hospital systems or health departments) that provide comprehensive health services to students in under-resourced communities. SBHCs, which are primarily located in schools eligible for Title 1 services for low-income student populations, are an ideal setting for delivering family planning services, including pregnancy and STI testing, contraceptive counseling, and contraceptive provision.
Practitioners working in SBHCs and other school settings are often highly motivated to connect students to family planning services to reduce high rates of unintended pregnancies and STIs, improve access to services for students, and dispel misconceptions and stigma around contraceptive use. However, there can be significant barriers to accomplishing these goals, such as pushback from school administrators or community members, or insufficient resources. Consequently, few SBHCs or community colleges offer comprehensive family planning services on-site or provide referrals to local clinics. For example, only about one third of SBHCs dispense contraceptives on-site and only a small number of community colleges have a referral network in place for students.
In this brief, we explore how schools and SBHCs are using partnerships to overcome hurdles to offering or connecting students to family planning services. We highlight specific examples of partnerships that have benefitted practitioners in two school contexts: Schools that currently have an SBHC and schools that do not. We also provide recommendations for schools and SBHCs interested in implementing similar partnership approaches.
This brief highlights findings and recommendations from interviews with 23 medical providers and administrators from SBHCs, high schools, and community colleges in the United States. Child Trends conducted these interviews from February 2020 to February 2021 as part of the OPA-funded Innovations in Family Planning Clinical Service Delivery for Underserved School-Based Populations project. This project aimed to identify, evaluate, and disseminate successful strategies for providing family planning services to adolescents in school-based settings.
In total, the interviewees for this brief represented 19 organizations in 11 states and the District of Columbia. Of these organizations, 12 operated in urban areas, two operated in suburban settings, one operated in a rural area, and four operated in both urban and rural settings. All organizations reported serving one or more of the following underserved populations: people of color, including members of American Indian Tribes; people with limited English proficiency; people who have immigrated to the United States; people experiencing or at risk of experiencing homelessness; and rural communities and communities that do not have accessible family planning clinics.
For more information on the study background, full study sample, and methodology, please see the methodology brief.
In schools with SBHCs, partnerships can be critical to ensuring that students have access to high-quality family planning. In some cases, partnerships can help establish family planning service provision at SBHCs that did not previously offer these services. In other cases, partnerships can enhance family planning services that an SBHC already provides. In this section, we describe three partnership strategies that practitioners have used to establish and improve family planning services at schools with SBHCs, along with their recommendations for maximizing the success of these strategies.
SBHCs are often constrained by school or district policies that may prohibit or restrict the provision of family planning services. Before adding or making changes to existing family planning services, SBHC staff must seek approval from key administrators and district board members. However, obtaining this approval can be very challenging for a variety of reasons. In some cases, school district members themselves are opposed to offering any family planning services. One SBHC practitioner shared, reflecting on the process of obtaining this approval, “… one superintendent … would lay his hands on his Bible on the desk and say, ‘There’s no way that this is going to happen in my district.’” In other cases, key school staff may be more worried about backlash from parents or complaints from community members. For example, one practitioner described administrators fearing that parents may want to close the SBHC altogether if they were to add family planning services: “[Administrators] were afraid that the parents would be angry [if the SBHC offered contraceptives] and would not want the school-based clinics anymore, undoing all these years of great things that we’ve done.”
SBHCs require written consent from parents or caregivers prior to providing any services to youth (under age 18). Once consent is obtained, the young person can access any health care services, including family planning, offered by the SBHC. SBHCs must adhere to state and federal laws around the confidentiality of patient information. All SBHCS are required to have accessible documentation of their policies related to confidentiality (e.g., who will have access to medical record information, when confidentiality must be broken to protect patient safety, etc.).
Establishing and maintaining close collaborations between SBHC provider staff and school staff can mitigate some of the barriers posed by existing school or district policies. These relationships provide important opportunities to convince key stakeholders of the benefits of providing family planning services.
An SBHC in a suburban area of the Northeast was unable to provide family planning services for many years due to hesitancy from school district staff members. The practitioner we spoke to from that SBHC described learning of a misconception among school administrators that the school nurse would be “giving [contraceptive pills] out in bowls in the [SBHC] waiting room.” At that point, she realized how essential it would be to provide education to district officials to gain their support for family planning services. The SBHC convened “a committed group of people who understand adolescents’ rights” to help advocate to the school board. Eventually, after four years of advocacy, the SBHC received permission to begin offering family planning services, including prescribing contraception.
Staff from SBHCs described several ways in which they successfully developed and cultivated relationships with the school district and board members to gain support for family planning services. These recommendations for SBHCs include the following:
Partnering with outside providers can be an effective strategy for expanding family planning services, especially when considering offering LARCs in schools. While many SBHCs recognize the importance of offering LARCs as contraceptive options for adolescents, adding LARC insertions and removals can be difficult. SBHCs often struggle to offer LARCs to students because of time constraints, barriers to obtaining training, or lack of comfort with the procedures among existing SBHC staff. To overcome these barriers, SBHCs could engage specialized family planning staff from their sponsor organization, or partner with practitioners from another organization (e.g., a medical school or local family planning clinic) who can visit schools to assist with implant and IUD insertions and removals.
One SBHC, located in an urban area in the South, established an ongoing partnership with a midwife from a local hospital system. The decision to partner with a midwife was intentional: Midwives have specialized training in sexual and reproductive health, enabling them to deliver services that pediatricians and pediatric nurse practitioners may not be trained in. For example, one practitioner explained that, sometimes, “pediatricians [can] put in a Nexplanon, but they won’t take it out because they don’t feel that they have the skills … to be able to take them out.” The practitioner explained that partnering with a midwife allowed the SBHC to provide services that they would otherwise be unable to offer, including LARC insertions and removals, abortion follow-up care, and prenatal and postpartum care.
Although these partnerships are valuable for expanding student access to IUDs and/or implants within SBHCs, they often pose challenges—especially because these providers are not on-site every day. Below, we provide practitioner recommendations for making these partnerships as effective as possible:
Some SBHCs prescribe contraception but do not dispense contraceptives (such as pills, the patch, and the ring) on-site due to logistical and/or capacity constraints. For example, some SBHCs may not have the space to store the medications; others may not have the staff capacity to manage an on-site pharmacy. In these instances, health centers can expand students’ access to contraceptives by partnering with pharmacies that will deliver medications.
We spoke with several SBHCs that created partnerships with pharmacies during the COVID-19 pandemic. These partnerships allowed students to access their medications even when schools or SBHCs were closed. SBHCs could call in prescriptions to pharmacies, which would then deliver medications to students’ homes or locations that were convenient for them.
These partnerships may be particularly helpful for students who are uncomfortable with traveling, or unable to travel, to pharmacies to pick up their contraception. Although many pharmacies deliver prescriptions directly to SBHCs, some clinics may direct pharmacies to send prescriptions to students’ homes if the students cannot pick them up at the SBHC (and if the student agrees to this approach). By partnering with pharmacies to send prescriptions to a more convenient location for students, SBHCs can eliminate barriers that may otherwise prevent students from receiving contraception.
At one point, the SBHCs operated by a large health care system operating in rural and urban areas in the Midwest were unable to dispense contraceptives on-site. Although practitioners were allowed to prescribe contraceptives, the SBHCs were not equipped with a pharmacy on-site. And because prescriptions were called in to pharmacies away from the school, students (and their parents) were often unable to pick up the medications, creating concern that these students might miss doses. Therefore, the SBHC staff began reaching out to local pharmacy directors to ask whether they would deliver medications. SBHC staff then decided which pharmacies to partner with based on the contraceptive options provided and the delivery area of each pharmacy. Ultimately, these SBHCs have established partnerships with five local pharmacies that deliver a wide range of contraceptive options to the health centers and directly to students’ homes.
Staff from SBHCs and their partner organizations provided several considerations for SBHCs looking to establish a partnership with a pharmacy. The following are recommendations for SBHCs looking to partner with pharmacies:
While SBHCs offer important benefits—such as improving access to and utilization of any in-school family planning services—many schools do not have the resources and capacity needed to operate an SBHC. Even when it is not feasible to establish an SBHC, schools are still a critical access point to family planning for young people. Partnering with community health care providers can facilitate linkages to care. In this section, we describe two partnership strategies that schools without SBHCs have used to connect students to family planning services, either on-site or within the community.
Our interviews identified schools that had established community partnerships (with local health departments, hospital systems, or nonprofit organizations) to offer reproductive health and family planning education to students. Most commonly, this health education is provided by health educators or coordinators employed by the partner organizations. These partnerships and the presence of on-site health educators within schools create opportunities—not only for students to learn about family planning and ask important questions about their family planning needs, but also for health educators to link students to these important services. For example, health educators can provide students with referrals to local family planning clinics, including clinics where those educators are based.
To connect students to care in their community, one nonprofit organization established several nonclinical “wellness centers” in several schools in a major city in the West. A health educator working in one wellness center explained that each center is staffed with a part-time health educator to provide family planning education to students, counsel students on reproductive health needs, and provide students with referrals to family planning clinics within the community. The health educators assist students in scheduling appointments at these clinics and follow up with students after their appointments to answer any questions.
School and partner organization staff offered several recommendations for schools without SBHCs to foster successful partnerships and connect students to care:
Community partnerships can also be used to provide limited family planning services on or near the school campus. Providers from the partner organization can visit schools regularly (e.g., once or twice a month) to offer family planning services to students within the school. Alternatively, partner health providers can offer services outside of the school building using a mobile unit. Both approaches remove any transportation barriers that may make it difficult for students to seek care at community family planning clinics and can be implemented in schools without SBHCs. In these cases, visiting health providers and mobile clinics are often used to supplement the existing health education and referral systems within schools.
To increase access to family planning services in schools without SBHCs, a health department in a major Northeastern metropolitan area created a program to connect students to comprehensive health care, including family planning services. The program is implemented through a partnership between the health department and the city’s public schools and uses trained health educators to provide reproductive health information to students. Further, as part of the program, school nurses are trained to provide limited family planning services (such as distributing condoms and administering pregnancy tests) and medical providers visit schools regularly to offer additional services (e.g., dispensing oral contraceptives or administering Depo-Provera). Additionally, health educators link students to care by providing referrals to the school nurse or helping students schedule appointments with the visiting medical provider. Health educators can also provide students with referrals to local family planning clinics if they need to see a provider quickly or if a student needs services not provided within the school.
School and partner organization staff offered several recommendations for schools looking to provide family planning services using visiting providers or mobile units:
Offering family planning services in school settings benefits students, schools, and their communities. School-based family planning services can increase students’ access to those services, reduce student dropout due to pregnancy or STIs, and subsequently reduce public costs associated with unintended pregnancy and STIs. This is especially true for schools serving populations with limited family planning resources. Despite these benefits, schools and SBHCS face significant barriers to offering these services, including limited funding and staff training, and prohibitive state, local, or school district policies. Creating and fostering partnerships is often an effective strategy in overcoming these hurdles.
One key benefit of offering family planning services through partnerships is the versatility of partnership approaches: Many practitioners described partnership strategies that were uniquely tailored to address specific barriers faced within their schools or SBHCS. For example, some SBHCs in our sample were limited by school regulations—often district-wide policies prohibiting the provision of contraceptives on school grounds—so decided to strengthen the partnership between the school and SBHC in order to change the policy. While this approach is often time-consuming, the SBHCs eventually received approval to offer family planning services directly on-site. In other instances, state policies (e.g., restrictions on the use of state funding) or limited resources led schools to create partnerships to connect students to family planning services in the community. These partnerships are often relatively easy to implement and several models exist for schools to emulate, such as Project Connect or Single Stop. However, students will still need to seek care in the community and may face barriers to doing so, such as lack of reliable transportation. Ultimately, schools and SBHCs should decide on a partnership strategy that will be effective based on their unique needs and resources.
The partnership strategies highlighted throughout this brief have been implemented in a diverse range of schools and SBHCS with varying levels of resources and support for family planning services. Therefore, the recommendations provided should support successful implementation of these partnership strategies in a wide range of school settings. However, in many instances, the depth and scope of our interviews did not provide information on how to create these partnerships. For schools and SBHCs interested in using partnerships to expand family planning services, please see Establishing Organizational Partnerships to Increase Student Access to Sexual Health Services for more information on identifying partners, assessing organizational readiness, and establishing formal partnerships. Ultimately, despite this limitation, it is our hope that the examples and recommendations provided in this brief spark ideas for innovative and creative ways to leverage partnerships to improve young people’s access to family planning services. Future work will include a toolkit designed for practitioners providing (or considering providing) these services that offers additional information and resources related to partnerships.
The authors extend their gratitude to the Office of Population Affairs for supporting this research under grant FPRPA006065. We would especially like to thank our project officer, Callie Koesters, for her leadership. The authors also thank the School Based Health Alliance for their partnership on the project, and especially for their assistance connecting us to practitioners to interview. Further, we thank Andrea Shore and Katherine Cushing of the Alliance for their review of the brief.
This brief would not have been possible without the assistance of many colleagues at Child Trends who contributed to the interviews and analyses, including Elizabeth Cook, Hannah Lantos, Elizabeth Wildsmith, Sydney Briggs, Anushree Bhatia, and Huda Tauseef. We additionally thank Brent Franklin, Jody Franklin, Tina Plaza-Whoriskey, and Kristin Harper for their reviews; Catherine Nichols for her design work; and Zabryna Balén for her fact check. Finally, the authors are deeply grateful to the practitioners who offered their time and critical perspectives to this research.
© Copyright 2023 ChildTrendsPrivacy StatementNewsletter SignupLinkedInThreadsYouTube