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.

Key findings

  • Partnerships between SBHCs (and other school-based health services), school and district officials, and community organizations are often critical in improving access to family planning services within school-based settings.
  • Intentional efforts by SBHC staff to cultivate relationships with school administrators and board members can be instrumental in obtaining their approval to add or expand family planning services.
  • SBHCs can integrate family planning services provided by the SBHC’s sponsor organization or another local health care system to offer services they may not be able to provide otherwise, such as long-acting reversible contraceptive (LARC) insertions and removals.
  • SBHCs can partner with pharmacies—which are experienced in handling logistics of partnerships and accept a variety of insurance plans—to provide contraception to students in school or at home.
  • While it be may be more challenging for schools without SBHCs to offer family planning services, creating partnerships with community organizations to provide sexual and reproductive health education on-site creates opportunities to refer students to local family planning clinics. These community partnerships can often be expanded to provide limited family planning services on-site, even when establishing a formal SBHC is not feasible.

Background and Sample

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.


Partnership Strategies for Schools With School-Based Health Centers

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.

Strengthen partnerships with school administration and school districts to begin offering family planning services in SBHCs

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.”

Parental Consent for SBHC Services and Confidentiality

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.

Case example: Convening family planning advocates for policy change

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:

  • Prioritize transparency. SBHCs should be clear early on with school district staff and board members about their expectations for the partnership. Initiating these conversations can minimize misunderstandings or confusion from either party. One provider worked collaboratively with a school district to create a “blueprint of what we expect from the schools, what they should expect from us.”
  • Convene a group of community experts. SBHCs should consider a committee of community groups that are supportive of providing family planning in SBHCs to help get approval from school district staff. For example, one SBHC convened representatives from multiple sectors that serve youth, including different city agencies, hospitals, and schools. They also included social workers, physicians, and nurse practitioners, as well as providers in other youth-serving community organizations.
  • Identify an ally within the school. Find a key person within the school, such as a school nurse or principal, who is motivated to ensure that students have access to family planning services within the SBHC. This ally may be able to provide insight into the best approach for gaining the support of key school district staff who may be more reluctant or hesitant.
  • Use presentations to school administrators and board members as an opportunity to provide education. According to SBHC providers, these presentations could:
    • Address the specific misconceptions around, and need for, contraceptive services in the community.
    • Be tailored for specific audiences. For example, some board members may respond favorably to a data-driven presentation while others may be more swayed by personal stories.
    • Be supplemented with one-pagers that answer commonly asked questions and address community concerns.
  • Implement an incremental approach. In some cases, it may be most effective to introduce family planning services slowly over time. For example, some providers noted that—for SBHCs seeking approval to provide family planning services—asking permission to provide all forms of contraception at once may be “too big an ask.” SBHC staff should consider first seeking approval to provide basic family planning services (e.g., pregnancy testing and condoms) and then incrementally adding services as school district staff and community members have time to acclimate to these basic services.
  • Hire a center liaison or outreach director. If resources allow, SBHCs should consider hiring a center liaison or outreach director. While the role of the outreach director would likely be to increase general awareness of the SBHC, this individual would also work closely with school district staff to address concerns and sustain positive relations.
  • Be patient. The process of adding family planning services can often take several years, so it is important for SBHC staff to remain patient and consistent in their efforts to strengthen relationships with, and gain buy-in from, school district staff.

Establish community partnerships to expand family planning services

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.

Case example: Working with a midwife to offer comprehensive family planning services

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:

  • To the extent possible, integrate visiting providers into the SBHC. To increase students’ comfort with visiting providers, SBHCs should integrate visiting providers into the SBHC as much as possible. Examples for integrating these providers include the following:
    • Introduce all students who visit the SBHC to the visiting provider, even if the student is not there for an appointment with that provider.
    • Add a picture and an introduction of the visiting provider to an SBHC bulletin board to increase student familiarity.
  • Preempt challenges that may occur when same-day appointments are not possible. Because same-day LARC insertions/removals are rarely feasible, SBHCs could:
    • Send frequent appointment reminders to students to reduce the likelihood that they will miss their appointment when the visiting provider is on-site.
    • Discuss alternate contraceptive methods, such as pills or the vaginal ring, that students can use in the interim.
  • Make the most of provider visits. To make the most efficient use of visiting providers’ time on-site, SBHCs could:
    • Ask staff to complete all pre-insertion requirements (pregnancy and STI testing, education, etc.) with students prior to the day of insertion so that the visiting provider can focus on procedures only.

Partner with pharmacies to allow greater access to contraceptives

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.

Partnering with Pharmacies During the COVID-19 Pandemic

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.

Case example: Creating pharmacy partnerships to provide contraceptives on-site

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:

  • Create partnerships with more than one pharmacy. Pharmacies may only offer certain types of contraception or deliver within a specific area. Multiple partnerships may help SBHCs better address their students’ range of geographic and prescription needs.
  • Factor in the pharmacy’s organizational capabilities as well as their own. When choosing pharmacies with which to partner, SBHCs should account for pharmacies’ delivery ranges and the types of contraceptives carried. Moreover, SBHCs should consider their own capacity to handle multiple partnerships and to address logistical challenges that may arise, such as determining the time that a student will be home to receive a prescription or troubleshooting when a student does not receive their medicine as scheduled.
  • Consider the needs of the student population. Some pharmacies only offer delivery services to patients with private insurance. SBHCs should make sure to partner with pharmacies who accept all types of insurance plans, including Medicaid.

Partnership Strategies for Schools Without School-Based Health Centers

Case example: Using health educators to connect students to community-based family planning services

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:

  • Establish a designated space for health educators. Some health educators may not have a designated space in the school to provide services. School staff and their partner organizations should work together to establish a fixed, private location in the school, preferably near the school nurse, that students know is a safe space to access services.
  • Find unique ways to reach students. Health educators should try different approaches to raising students’ awareness of available services and resources, such as speaking to students during gym or health classes, at after-school sports practices, or at school health fairs.
  • Use a team approach. A strong relationship between school staff and their partner organization can help maximize the number of young people served. For example, the school nurse can refer students to the health educator, and vice versa, based on students’ individual needs. As they are often the first person to receive a student, school nurses are essential for establishing intentional connections between health educators and the students who may benefit from their services.
  • Consider offering additional family planning services. In addition to sexual health education and referrals, health educators should consider offering other services, such as pregnancy and STI tests. These additional services may not only increase the number of students accessing services, but may also let health educators more effectively serve students’ needs.
  • Maximize utilization of family planning services through referrals. Health educators can improve the likelihood that students will receive the services to which they are referred by helping students prepare for their appointment. For example, health educators help students schedule appointments and make a plan for getting to the appointment.

Expand community partnerships to offer family planning services on or near school campus

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.

Case example: Partnering to provide family planning services in schools without SBHCs

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:

  • Create and maintain strong relationships with school administrators and staff. The ability to offer family planning services on-site is often dependent on permission from school administrators and board members. Take steps to create strong working relationships with key individuals to gain this approval. For additional recommendations, see “Strengthening partnerships with school administration and school districts to begin offering family planning services in SBHCs” above.
  • Connect students to local family planning clinics if they require services quickly. Because visiting providers are not on-site every day, it is important to provide students referrals to local family planning clinics when they need to be seen immediately.
  • Ask health educators to connect students with visiting providers. Students may have fears or anxieties about accessing services, especially with a new provider. To alleviate stress, health educators should introduce students to visiting providers (on-site or in visiting mobile clinics) and talk through what will happen during the visit.
  • Consider using mobile clinics when local or state policies prohibit family planning service provision in schools. Local or state policies often prevent schools from providing certain family planning services on-site—especially dispensing contraceptive to students. In these instances, schools can consider using mobile clinics to offer services close to schools (but not on school grounds). Mobile clinics can help remove transportation barriers students may face in seeking services in the community.

Conclusion

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.

Acknowledgements

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.