Toolkit for Improving Family Planning Services in School Settings

Leveraging Partnerships

Isabel Griffith, Samantha Ciaravino, Jennifer Manlove, Jenita Parekh, Katherine Cushing, Andrea Shore, & Donnie Greco

Connecting students to family planning services, both in and outside of schools, can reduce rates of unintended pregnancies and sexually transmitted infections (STIs), improve students’ access to services, and dispel misconceptions and stigma around contraceptive use. However, there may be significant barriers to accomplishing these goals, such as pushback from school administrators or community members, or insufficient resources. Leveraging Partnerships is one way for schools—regardless of whether they have school-based health centers (SBHCs)—to overcome hurdles to connecting students to family planning services. As such, we consider it to be one of four foundational approaches to school-based sexual health services highlighted in this toolkit.

This section of the toolkit highlights partnership strategies that have benefitted practitioners in two school contexts: schools that currently have an SBHC and schools that do not. The strategies are based on interviews with service providers and administrators from SBHCs, high schools, and community colleges across the United States.


Using This Tool

Audience

The partnership strategies described below are targeted to individuals working in school settings who are interested in offering or enhancing sexual health services through partnerships. This can include SBHC coordinators, directors, and individual practitioners, as well as school staff. These strategies may also be applicable to health care or nonprofit organizations looking to partner with schools to provide sexual health education and/or services to students.

Structure

Each partnership strategy listed below includes:

  1. A brief description of the strategy
  2. Case examples of schools that have implemented the strategy
  3. Reflection questions to guide your team on how to implement a similar strategy

Adapting partnership strategies to your context

Each partnership strategy varies in complexity, funding, and scope and is adaptable based on context and resources. You may find that some strategies are more feasible for your setting than others, but we hope that all strategies can spark ideas for potential partnerships to enhance or expand sexual health services/programming in your unique setting.

Before getting started, we encourage you to reflect on any areas in which your sexual health services or programming could be improved and whether there are specific partnerships that could fill gaps or enhance services. To aid in this reflection, we provide a set of needs assessment questions to guide your thinking about existing partnership efforts. After you’ve read the partnership strategies, we provide a series of prompts at the end of this tool that can guide your thinking and set intentions about next steps.

Needs Assessment Questions on Current Partnership Strategies at Your Site

Consider your organization’s goals for sexual health services and determine what is working well within your setting to engage students in these services.
  1. What partnerships, if any, do you currently use to facilitate sexual health education and/or services?
    1. Which of these are successful?
    2. Where is there room to improve?
Think about who is already doing sexual health work in your school (e.g., health educators, health teachers, coaches, etc.) and consider gaps and opportunities for partnerships.
  1. Who in the school can help fill these gaps?
Consider what resources are present in the school or community that could help create or expand sexual health services in your school.
  1. Who in the community can you engage to supplement current sexual health education and/or services? Potential partners can exist both within the school (teachers, coaches, administrators, etc.) and externally in the larger community (such as community-based, nonprofit, and health care-providing organizations).
Consider barriers for developing or expanding partnerships for sexual health services in your setting or school.
  1. What are the barriers to effectively reaching students in your schools?
    1. Who may be resistant to new partnerships for adolescent sexual health services?
    2. What existing or potential partnerships can help you overcome some of these barriers?

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

Partnership Strategies for Schools Without School-Based Health Centers

Even when it is infeasible for a school 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. The strategies in this section focus on leveraging partnerships to connect students to family planning services, either on-site or within the community.

Partner with community organizations to provide sexual health education

Partnering with community organizations—including local health departments, hospital systems, or nonprofit organizations—is one way to offer reproductive health and family planning education to students in schools without SBHCs. Most commonly, this health education is provided by health educators or coordinators employed by 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.

Schools interested in creating these partnerships should consider using a team approach, between school staff and nurses and the partner organization, to refer students to family planning services and maximize the number of youth served. School staff and their partner organization 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. Health educators can raise students’ awareness of available services and prepare students for their appointments.

Case example

In response to high rates of unintended teen pregnancies among youth in Columbus, OH, the Columbus City Mayor’s office convened four Ohio-based health care-providing organizations—Nationwide Children’s Hospital, Planned Parenthood of Greater Ohio, Columbus Public Health, and Ohio Health—to establish the Sexual Health Education Partnership (SHEP). Through this partnership, each of the four organizations employs health educators who deliver an evidence-based sexual health curriculum in 19 Columbus City middle schools and connect students to family planning services through SBHCs, mobile units, and community health care providers.

For more information about the SHEP, please see this case study.

Reflection questions

Consider how student sexual health needs could be met via partnerships with off-campus organizations to provide sexual health education.
  1. Which community organizations—including local health departments, hospital systems, federally qualified health centers, or other nonprofit organizations—are potential partners?
  2. How can sexual health education be incorporated in your schools?
    1. Would it be feasible to use health educators to provide this education?
    2. If health educators are part of this work, who will employ the health educators?
  3. How can you and/or your partners link students to family planning services after receiving sexual health education?
  4. What gaps exist in students’ sexual health needs and services that specific partners can fill?

Develop partnerships to refer students to local family planning clinics

Providing referrals to local clinics and health care systems for family planning services can be an important way to link students to care in schools that do not have SBHCs. Schools can provide students with referrals in a variety of ways. For example, in some cases, school staff may invite staff from local clinics into classrooms to get to know students and provide information on the types of services they offer. Alternatively, if schools are already partnered with local nonprofit organizations and have health educators coming to school campuses to provide sexual health education to students, these health educators can also provide referrals to local services.

Students may have reservations about seeking family planning services, so it is important for providers and health educators to provide information on what will happen during clinic visits and answer any questions. Health educators can also help students make appointments. 

Case examples

As one part of a larger initiative called BAE-B-SAFE, campus-based health educators employed by Health Futures of Texas created a “critical referral system” for students on college campuses without health centers. In this system, health educators identify and vet local certified adolescent-friendly clinics and local hospital-affiliated health centers. These clinics and health centers are also often funded through the state or Title X to ensure that students can access low- or no-cost health care services. Health educators visit classes and refer students to these clinics while also answering questions about what clinic visits may entail, confidentiality requirements, and how students can pay for services. The health educators also have offices on campus where students may visit to request referrals. Using this approach may increase students’ level of comfort in seeking services, especially if they know the clinics have been vetted by health educators.

A nonprofit organization in Philadelphia, PA, AccessMatters, has partnered with several city schools and developed health resource centers (HRC) in each school. Each HRC is staffed with a coordinator who is responsible for helping students learn more about sexual health, providing basic family planning services on site (e.g., pregnancy and STI testing), and referring students to local clinics for ongoing or more complex services (e.g., dispensing contraception). The coordinators provide warm, supportive handoffs to neighborhood Title X clinics at which coordinators have established working relationships with providers. HRC coordinators also frequently follow up with students regarding their experiences after their appointments.

For more information about the AccessMatters HRCs, please see this case study.

Reflection questions

Consider how student sexual health needs could be met by partnering with an off-campus service provider.
  1. Which community organizations—including local health departments, hospital systems, federally qualified health centers, or other nonprofit organizations—are potential partners?
  2. What gaps exist in students’ sexual health needs and services that the specific partners can fill?
    1. How can partnerships be used to connect students to services locally?

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

Providers from partner community organizations can provide limited family planning services on or near the school campus. Providers can either visit school regularly to offer family planning services to students within the school or offer services outside the school building using a mobile unit. Both approaches can be implemented in schools without SBHCs, thus removing transportation barriers that may make it difficult for students to seek care at community family planning clinics. In these cases, visiting health providers and mobile clinics are often used to supplement existing health education and referral systems within schools.

Students may have fears about accessing services with outside providers. Health educators can introduce students to providers and talk them through what will happen during their visit, either on-site or at a visiting mobile clinic. 

Case examples

A health department in New York operates a program in which school nurses are trained to provide limited family planning services (such as distributing condoms and administering pregnancy tests). Additionally, medical providers employed by the health department visit schools regularly to offer additional services, such as dispensing oral contraceptives or administering Depo-Provera. Trained health educators visit classes to ensure that students are aware of these services and link students to care by providing referrals to the school nurse or helping students schedule appointments with the visiting medical provider.

One school in Washington state partnered with a local hospital system that sponsors several SBHCs. Although this school does not have an SBHC, a nurse practitioner staffed at one of the hospital’s nearby SBHCs visits the school every other week to answer students’ questions and provide services. The visiting clinician provides services, including family planning services, to students in school nurses’ offices, but often sits in the lobby when not providing services to increase visibility and answer students’ broad health-related questions.

Reflection questions

Consider whether students’ sexual health needs could be met by partnering with an off-campus provider through a school-linked, mobile model, or through a limited on-campus presence.
  1. Which community organizations—including local health departments, hospital systems, federally qualified health centers, or other nonprofit organizations—are potential partners?
  2. What gaps exist in students’ sexual health needs and services that specific partners can fill?
    1. What services, if any, can be offered on the school campus?
    2. What barriers exist to students accessing sexual health services provided off campus?
    3. Where could a mobile van park to conveniently provide services to students?

Partnership Strategies for Schools with School-Based Health Centers

In schools with SBHCs, partnerships can establish family planning services at SBHCs that did not previously offer these services, or enhance family planning services that an SBHC already provides. In this section, we describe strategies that practitioners have used to establish and improve family planning services at schools with SBHCs.

Establish community partnerships to provide long-acting reversible contraceptives

Partnering with off-campus health care providers can be an effective strategy for expanding family planning services within SBHCs, especially when considering offering long-acting reversible contraceptives (LARCs). 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 can engage specialized family planning staff from their sponsor organization, or partner with practitioners from other organizations (e.g., a medical school or local family planning clinic) who can visit schools to assist with these procedures.

Because off-campus providers are not able to be on site at schools every day, it is important to make the most efficient use of visiting providers’ time in schools. For example, SBHCs can ask staff to complete all pre-insertion requirements (pregnancy, STI testing, etc.) with students prior to the day of the insertion so the visiting provider can focus exclusively on procedures. SBHCs can also send frequent reminders to students to reduce the likelihood they miss their scheduled appointment with the visiting provider.

Case examples

Two SBHCs in Washington, DC established an ongoing partnership with a midwifery program from a local hospital system, MedStar Washington Hospital Center. Because midwives have specialized training in sexual and reproductive health, they can deliver services on which pediatricians and pediatric nurse practitioners may not be trained. Partnering with a midwife allowed the SBHCs 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. The midwife visits the SBHC every other week to provide these services to students.

An SBHC located in Washington state partners with family nurse practitioners (FNPs) from their sponsor organization to perform IUD insertions at the SBHC several times a year. SBHC providers help complete all pre-insertion requirements—including pregnancy and STI testing—on site with students prior to the day of the insertions to ensure a smooth and efficient use of FNPs’ time.

Reflection questions

Consider what partnerships are needed to strengthen or expand sexual health service offerings.
  1. What is the ideal number of staff needed to provide or expand specialized sexual health services?
    1. If you need to expand your care team, consider who might be a good fit (midwife, nurse practitioner, etc.).
  2. What sources for additional staff or partners exist?
    1. Would your sponsoring organization support engaging staff from another service site? How would staffing these services support the sponsoring organization and the community at large?
    2. If you need to look beyond your sponsor organization for staff, who else in the community shares a similar mission and values? Do they have staff who meet your needs? How can this partnership be mutually beneficial? What benefits would this partnership bring for them?

Partner with local health departments to provide STI testing and treatment

SBHCs can meet high demand for STI testing by collaborating with local health departments. Conducting STI testing and providing treatment may be cost-prohibitive for some SBHCs. One option to mitigate costs accrued to the SBHC or sponsor organization is to partner with a local health department to establish the SBHC as a formal county testing site. This allows all students—even those who do not have permission to seek services in the SBHC—to access STI testing on site.

When utilizing this approach, it is important to let students know that services are available and can be accessed even by students who may not otherwise have permission to receive services within the SBHC. Additionally, it can be time intensive for SBHC staff to develop these collaborations and embed the testing site within the SBHC.

Case example

An SBHC located in Florida collaborated with the local health department to provide free, confidential HIV, syphilis, gonorrhea, chlamydia, and hepatitis testing to youth in SBHCs. Through this collaboration, SBHCs are considered formal testing sites, which means all students can come in for this service any time during SBHC hours—even those who do not have parental consent to be seen at the SBHCs. Most times, SBHC providers also use this as an opportunity to discuss contraception options with students.

Reflection questions

Consider whether a local health department can help meet the needs of students and the SBHC and complies with local and state policies around sexual health services.
  1. Think about whether a local health department could partner with your SBHC.
    1. If so, do they have the staffing capacity and resources available to establish an STI testing site within the SBHC?

Partner with pharmacies to expand access to contraceptives

SBHCs can expand students’ access to contraceptives by partnering with local pharmacies to deliver prescriptions to students and facilitate access to contraception, even when schools or SBHCs are closed. These partnerships may be particularly helpful for students who are uncomfortable with traveling—or unable to travel—to pharmacies to pick up their contraception. By partnering with pharmacies to send prescriptions to a more convenient location for students, SBHCs can eliminate barriers that may otherwise prevent them from receiving contraception.

Some pharmacies may only offer certain types of contraception or deliver within a specific area, so it can be beneficial to partner with more than one pharmacy to ensure that your students’ needs are met. When choosing pharmacies with which to partner, SBHCs can account for pharmacies’ delivery ranges, the types of contraceptives carried, and whether they accept all types of insurance plans, including Medicaid.

Case examples

Several of the 13 SBHCs operated by Nationwide Children’s Hospital in Columbus, OH partner with five local pharmacies to deliver a wide range of contraceptive options to SBHCs and directly to students’ homes. Because SBHCs in this region are unable to dispense contraceptives on site and prescriptions are called in to off-site pharmacies, students (and their parents) were often unable to pick up the medications, leading to concerns that students might miss doses. Therefore, SBHC staff began reaching out to local pharmacy directors to ask whether they would deliver medications. Staff then selected several pharmacies to partner with based on the range of contraceptive options provided and delivery area.

An SBHC located in Massachusetts partnered with a pharmacy within its sponsor organization to deliver prescriptions directly to the SBHC. SBHC staff initially sent prescriptions to a pharmacy across the street from the school, but students were often unable to pick up their medications, so this change was made to increase compliance with medications.

Reflection questions

Consider whether an off-site pharmacy will meet the needs of students and the SBHC, and whether such a partnership would comply with local and state policies around sexual health services.
  1. Think about whether a nearby pharmacy (or multiple pharmacies) could partner with your SBHC.
    1. If so, do they carry the range of medications prescribed to SBHC users, or would you need to partner with multiple pharmacies to meet students’ needs?
    2. Do the pharmacies accept insurances that are common among SBHC users?
    3. Do the pharmacies deliver, or would students have to travel to pick up prescriptions?
    4. How can the SBHC ensure that deliveries reach the student smoothly and maintain student privacy?

Strengthen collaborations between SBHC providers and school staff

Establishing and maintaining close collaborations between SBHC providers and school staff can mitigate barriers to providing family planning services in schools. For example, in some cases, SBHCs are constrained by school or district policies that may prohibit or restrict the provision of family planning services, and all changes to existing services must be approved by key administrators and district board members. Building relationships with SBHC providers and school staff can provide important opportunities to convince stakeholders of the benefits of providing family planning services.

Fostering relationships with school staff to create or expand sexual health services in schools is often a lengthy process. SBHC staff looking to use this approach should remain patient, involve various stakeholders in the process, and utilize data to facilitate buy-in from school staff. Several SBHC staff noted that presenting data on local teen birth and STI rates to key school staff was particularly effective, as was presenting information about the association between poor sexual health outcomes and lower graduation and educational attainment rates.

Case examples

SBHCs in a school district in New Haven, CT were unable to provide contraception (except condoms) for many years due to hesitancy from school district staff members. Misconceptions among school administrators that the school nurse would be “giving [contraceptive pills] out in bowls in the [SBHC] waiting room” indicated a need to educate district officials and gain their support for providing family planning services. Eventually the Mayor’s Office convened “a committed group of people who understand adolescents’ rights” to advocate to the schools’ superintendent. This group used data and provided scenario-based examples of processes for providing family planning services to dispel any misconceptions held by school staff and community members (more detailed information on this process can be found in the article “Contraceptive Services in SBHCs: A Community Experience in Creating Change”). Eventually, after four years of advocacy, the SBHC received permission to offer family planning services, including prescribing contraception.

A health care system in Delaware that operates several SBHCs throughout the state collaborated closely with SBHC staff, community partners, medical experts, parent advocacy groups, and school board members to gain approval for providing reproductive health care services in schools. For example, SBHC staff invited medical experts to present to school staff and parents on the importance of providing family planning services in school settings. As more school staff and community members invested in these services, they joined SBHC staff in advocating to the school board. Ultimately, the school board approved changes incrementally, in which the SBHC could first provide condoms and pregnancy testing to students and later offer oral contraceptives, Depo-Provera, and the NuvaRing.

One SBHC in New Mexico collected annual data to present to school staff on the number of students receiving family planning services and the rates of STIs and unintended pregnancies. SBHC staff presented regularly to school staff on the importance of young people having access to high-quality family planning services. During these presentations, SBHC staff highlight data from their own students to underscore the importance of providing these services on site to increase the number of school staff referring students to services offered within the SBHC.

Reflection questions

Consider what barriers might exist for schools to support sexual health services.
  1. Are there community champions who are trusted by the school and with whom you could partner to gain the school’s support for sexual health services?
  2. What sexual health services would you like to add?
    1. What would make it possible to get key decision makers’ approval to do so?
  3. What data would help you advocate for the sexual health services you are interested in providing?
    1. Are the aforementioned data available and accessible?
    2. How can you go about obtaining these data?

Next Steps

Now think about next steps to increase partnerships around sexual health services and set some intentions. The following statements serve as prompts to help you identify your next steps.

Reflections on Goal Setting

1. Identify at least one new potential partnership that would benefit sexual health services provision within your school-based health setting over the next three months.

Think about new opportunities for partnership development related to sexual health service delivery in your SBHC. Ensure that your conversation identifies ways to reach all student populations.

2. Identify at least one existing partnership that could further improve sexual health services within your school-based health setting over the next three months.

Think about what is already happening within your SBHC around sexual health services partnerships engagement. Consider how an improved partner relationship could make services more efficient or more effective. What small change do you think would improve a key relationship? Test the idea. Then consider an additional small change.

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

This section of the toolkit is based on findings and content from the following brief: Ciaravino, S., Manlove, J., Parekh, J., Barnett, H., Kim, L., & Vazzano, A.  (2021). Family Planning Practitioner Perspectives on Developing Partnerships to Provide Services in Schools. Child Trends. Available here.


Suggested Citation

Griffith, I., Ciaravino, S., Manlove, J., Parekh, J., Cushing, K., Shore, A., & Greco, D. (2022). Leveraging partnerships. Child Trends. https://doi.org/10.56417/5723e7986d

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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