School-based Strategies to Support Adolescent Sexual and Reproductive Health
Schools—including high schools, community colleges, and universities—play a critical role in meeting the health care needs of youth. Currently, a wide range of health care services, including sexual and reproductive health care, are provided in school settings. In some high schools, students receive services on-site through school-based health centers (SBHCs), or through student health clinics on college and university campuses. However, not all school-based health service providers include sexual and reproductive health services, and others provide only a limited set of sexual and reproductive health services. There are also many schools (90% of high schools, 59% of two-year colleges, and 15% of four-year colleges) in which no health care services are available on campus.
This resource provides an overview of strategies that schools and school-based health service providers can use to better meet the sexual and reproductive health care needs of their students. Some of these strategies are already being used in school-based settings, while others could be adopted by schools seeking to expand their health services or those that currently do not provide any on-site health services.
The strategies outlined in this resource include those that improve students’ access to sexual and reproductive health services and those that improve the quality of services being provided—often via youth-friendly approaches that better meet youths’ sexual and reproductive care needs. This resource additionally provides examples of how each strategy has been implemented in a real-world setting and presents considerations for each particular strategy.
The value of any particular strategy will depend on its context. For example, in a school with a health center that already provides prescription contraception on-site, it may be especially beneficial to integrate a mobile app to make contraceptive counseling more engaging and patient-centered. In contrast, schools that are committed to supporting the health care needs of their students but that lack on-site health service providers may benefit more from strategies that provide condoms to students or connect them with local health care clinics. Additionally, the most appropriate strategies will depend on the needs and resources of the populations being served. For example, reliable access to the internet and comfort with health service providers will determine clients’ use of certain strategies.
A note about COVID-19
The strategies highlighted in this resource were identified via a literature scan conducted prior to COVID-19. Many remain relevant during the pandemic. A separate brief highlights some key innovations that schools could adopt to provide sexual and reproductive health care in response to the pandemic.
To view a real-world example of each strategy and for further considerations, click on the text or plus sign where indicated.
Students face multiple barriers to accessing sexual and reproductive health care services, including a lack of transportation or insurance, confidentiality concerns about using their parents’ insurance, and unfamiliarity with navigating the health care system. Schools can use some of the following strategies to promote student access to sexual and reproductive health services.
Many school-based health services—including those at some high schools and community colleges—provide a limited range of prescription birth control methods on-site, including oral contraceptive pills and Depo-Provera. Emergency contraception is also available in school-based settings, and some university student organizations even set up vending machines to dispense emergency contraception. Other schools are expanding their reproductive health services to include long-acting reversible contraceptive methods (LARCs), such as the IUD and implant, as these methods are the most effective reversible methods and are not prone to user error. Providing prescription contraceptive services on-site can reduce some common barriers to contraception for students, including limited awareness of where off-campus health service providers are located, lack of trust in sexual and reproductive health service providers, and lack of time or transportation to get to a clinic.
Example and Considerations
Example: Schools in Seattle launch LARC program
In 2009, an organization of SBHCs in Seattle began to provide LARCs at six sites. The successful integration of services required educating SBHC providers about the appropriateness of LARCs for adolescents and training them in insertion procedures and counseling practices. Additionally, key stakeholders—such as school officials and parents—had to be educated about the program. A proactive and transparent engagement strategy of research-based presentations to school officials and parent, teacher, and student associations developed buy-in before the implementation of LARC services. Ultimately, the Seattle SBHCs were able to provide LARCs confidentially and at no cost to students by enrolling them in Washington state’s Medicaid family planning program.
School-based health service providers seeking to expand the range of prescription contraceptive methods they offer may consider supporting such an initiative and expanding the SBHC’s operational capacity to do so. For example, the aforementioned Seattle program had to overcome some key barriers, including lack of clinician skill and confidence, negative attitudes toward LARCs among providers and stakeholders, lack of training and practice opportunities for clinicians, and challenges related to billing for minors who needed confidential services. Additionally, school-based providers conducting contraceptive counseling with students of color—particularly regarding LARCs—will need to be sensitive to experiences of reproductive coercion among people of color, and prioritize reproductive autonomy and shared decision making with patients. Policies at the school, district, or state levels may also create barriers to providing on-site prescription contraception.
Youth ages 15 to 24 have among the highest rates of sexually transmitted infections (STIs) in the United States; when untreated, STIs can have serious long-term health consequences. Offering or expanding STI screening programs at schools can increase the number of students who receive testing and treatment for STIs by normalizing screening and integrating it into routine care. On-campus testing and treatment can help young people overcome barriers to receiving care, including those linked to transportation, cost, and comfort.
Examples and Considerations
Examples: Operational changes to SBHCs in Delaware and California
SBHCs in Delaware and California successfully implemented changes to their operations and patient interactions to increase STI screening. In Delaware, these changes included training staff in motivational interviewing, adopting same-day testing, and holding STI awareness outreach events. One simple but effective change was to request a urine sample at check-in rather than wait for patients to meet with a provider before drawing a sample, which often resulted in patients not providing the sample because of concerns about getting back to class on time. In California, changes included partnering with Title X clinics for testing, rapid notification of results, and treatment; patient-delivered partner treatment; the development of “opt-out” protocols for chlamydia screening; and standing orders for chlamydia tests during any type of appointment. Over half of all California students who received testing as a result of the increased STI screening were Latinx and the vast majority had not received reproductive health services from another provider in the previous year, indicating that enhanced STI screening in school-based settings has the potential to reach underserved groups.
Offering or maximizing school-based STI screening programs can meaningfully increase access to testing among youth and young adults. However, effective expansion of STI screening in school-based settings may require additional resources and funding for supplies, lab testing, and staffing. Furthermore, staff may require training in STI testing and, as SBHC providers conduct more tests, they may also need expanded capacity to counsel and treat more patients with positive results.1214 Providers may find the National STD Curriculum useful for developing knowledge and comfort around STI testing. In some locations, local health departments may be able to support school-based health services’ STI screening programs.
Condom availability programs in schools and colleges can increase students’ access to condoms by providing them freely and in convenient locations. Although condoms are an effective method for preventing STIs and unplanned pregnancy, adolescents and young adults may be too embarrassed to purchase condoms or lack the money to do so. In practice, condom availability programs may look different depending on the particular school setting.
Examples and Considerations
Examples: Expanding access to free condoms at high schools and universities
A group of high schools in California with high rates of chlamydia and teenage births successfully launched a program to make condoms freely available to students. This program also supported condom distribution staff, who provided prevention counseling and sexual health information, and a program coordinator, who developed procedures for informing parents about the program and allowing them to opt out. In another example, one college in the Midwest noticed that condoms were only available in a campus resource center open only during business hours. To improve access, the college installed vending machines inside residence halls stocked with free condoms, internal condoms, and oral dams (all packaged with lubricant and sexual health resource information).
To be successful, condom availability programs should do more than place a bowl of condoms in a high-traffic location. Although these programs are typically associated with increased acquisition of condoms, it is unclear whether they result in increased use of condoms. Condom availability programs may benefit from being offered in conjunction with skill-building efforts that support students’ ability to effectively and regularly use condoms.
Online contraceptive providers allow users to get a prescription for oral contraceptives, the contraceptive ring, patch, or emergency contraception without having to go to a provider in person. Depending on the service, users can have their contraceptive method delivered directly to their home or pick it up at a pharmacy. This service may be useful for students without on-campus health service providers. Additionally, online consults are often free or low-cost and allow for greater confidentiality, particularly for those living in small, rural communities who may worry about being recognized. Schools can help connect students with online contraception providers.
Example and Considerations
Example: Multiple online services provide contraception with varying levels of patient contact
There are multiple online contraceptive services (e.g., Nurx, Lemonaid Health, Planned Parenthood Direct, Bedsider BCBenefits), all of which operate somewhat uniquely. Some provide new prescriptions and others only refill existing prescriptions. For all services, users first fill out a short questionnaire; beyond that, the level of communication with a provider varies. Some services (e.g., Lemonaid Health) require a video consult, others require audio calls or messaging (e.g., Planned Parenthood Direct), and others offer optional communication through video, calls, or messaging. Most services are available in multiple states.
Online contraception services cannot be used for LARCs, such as IUDs and implants, and the remote nature of the service means that users may have difficulty obtaining their medical records and receiving the same level of support as they would from an in-person provider. Additionally, users may be less likely to receive other important health services, such as Pap smears or screenings for STIs or intimate partner violence, because online services don’t offer holistic care. Users may also experience difficulties accessing follow-up care or continuity of care. Variation in state law affects the availability of online contraceptive services since some states do not allow minors to use these services and not all services accept Medicaid (or only do so in certain states). Online contraception providers that require a video consultation may not be accessible to students who do not have access to high-speed internet or who lack privacy in their homes.
Mobile health clinics are customizable vehicles staffed by providers that travel to communities to provide health care services, including sexual and reproductive health services. They can readily provide condoms and hormonal methods of contraception; with some additional training of staff and resources, these vehicles can also provide LARCs. Mobile clinics can help provide reproductive health services at schools that do not have a health clinic (or that do not provide sexual and reproductive health services) or are located in communities with limited local sexual and reproductive health care providers. Mobile clinics at schools can help some adolescents overcome barriers to accessing care, including lack of time, lack of transportation, cost, stigma, and not knowing where clinics are located.
Example and Considerations
Example: Chicago children’s hospital offers mobile health clinic at high schools
In Chicago, a mobile health clinic, operated by a local children’s hospital and staffed by nurse practitioners and a physician, travels to several local high schools to provide health services to students during school hours. These high schools are located in neighborhoods with relatively high rates of STIs and teen pregnancy. The mobile clinic provides students with sexual and reproductive health care services, including prescriptions for contraception, condoms, and STI testing. At the beginning of the school year, parents provide written permission for their child to use the mobile health clinic’s services. Under Illinois law, students are then entitled to receive contraception confidentially.
To be most effective, schools and mobile health clinics may benefit from being aware of some challenges associated with serving students using this model. For example, pregnancy tests are sometimes required to obtain a prescription for hormonal contraception. However, mobile health clinics are not always equipped with bathrooms to collect the needed urine sample for the test. Providing a prescription for birth control pills without requiring a pregnancy test can limit this challenge and reduce additional confidentiality concerns that might arise if students were asked to use school bathrooms. Another important challenge is that students who use mobile health clinics may have inconsistent follow-up with health care providers, thereby causing disruptions in the continuity of their care.
Telehealth, also referred to as telemedicine, uses technology to offer patients remote medical visits (not inside a physical doctor’s office or hospital), often via a real-time, two-way phone or video conversation. Telehealth may be a useful strategy to reach students at schools that do not provide sexual and reproductive health care services on site, or for students who live in communities with limited health care service providers. Even some students at schools with health service providers may find telehealth more convenient and comfortable. Telehealth has been an essential mode of health care provision during the COVID-19 pandemic.
Example and Considerations
Example: University provides contraceptive counseling via telehealth
One women’s health service provider at a large public university introduced video-based telehealth for contraceptive counseling appointments, which had previously only been offered in person. This well-received and effective model allowed students to enter health information online ahead of time, have a contraceptive counseling appointment over the phone, and obtain a prescription for contraception.
A successful telehealth model requires building trust with patients who may have privacy concerns. Trust-building strategies can include having the provider move their camera around to show patients that they are in a private location, allowing the patient to share information with the provider prior to the appointment, and having the provider use everyday (lacking jargon) language to clearly explain the patient’s HIPAA rights and how they will keep the patient’s information confidential. Insurance coverage for patients is also a potential concern. Prior to the COVID-19 pandemic, Medicaid and other health insurer regulations often limited who could provide telehealth, for what reason, where, and on which technology platform. However, the necessity of using telehealth during the COVID-19 pandemic has led to rapid policy changes that will likely continue after the pandemic. Finally, not all students have access to high-speed internet or the in-home privacy required for telehealth visits. Schools may be able to support telehealth for these students by providing access to devices and internet, and offering private space for those visits.
Partnerships between schools and off-campus sexual and reproductive health service providers who share similar goals is a low-cost strategy to improve youth and young adults’ access to care. Partnerships can vary widely in practice, but common approaches include directly introducing the student to the partnering practitioner, having practitioners from nearby clinics visit schools, and offering a mobile health clinic on school grounds. These partnerships may be particularly useful for schools with resource constraints or those that are otherwise unable to provide services on site.
Example and Considerations
Example: Bronx program facilitates school-clinic connections
The Bronx Teen Connection is a community-wide program that links health centers with youth-serving organizations, including traditional and alternative high schools. The goal of this partnership is to expand contraceptive choice for youth living in the South Bronx, a neighborhood with teen pregnancy rates that are higher than in other areas of the city. Each participating school identified a liaison to coordinate with partnering clinics and promote referrals. The clinics, in turn, designate a staff member to establish a referral system to connect students to the clinic, conduct outreach to school staff to increase awareness of clinic services, give presentations at schools, provide group or individual counseling, and facilitate clinic tours.
Successful school-clinic partnerships may face challenges such as changes in staff and/or leadership, a lack of coordination and structure, and competing priorities across organizations. Strategies to overcome such barriers include sharing community health outcomes and success stories, providing an open line of communication between staff, and ensuring commitment to partnership goals. Furthermore, formal partnerships (e.g., established via a contractual agreement) are ideal for long-term sustainability. However, depending on resources and capabilities, this level of formality may not be feasible for all organizations. Therefore, having partnership agreements with varying levels of commitment may facilitate productive partnerships.
To meet students’ sexual and reproductive health needs, school-based sexual and reproductive health care providers must also consider the quality of their services and ensure that these meet students’ needs. Strategies to enhance the quality of sexual and reproductive health services for students include integrating mobile apps, using text messages to reach students, establishing peer education programs, and tailoring services and service settings to meet the needs of specific populations.
Numerous apps are designed for adolescents and young adults to use in a clinic waiting room, and typically allow users to filter contraceptive options based on their lifestyle and preferences. Contraceptive counseling apps can be tailored for the needs of specific populations. For example, Hi52Hlth from Baylor Teen Health Clinic is tailored for adolescents who have received an HIV diagnosis, while Decide + Be Ready from the University of Southern California and the U.S. Navy is tailored for women in the military. Using an app to review information about contraceptive methods in the waiting room prior to a visit can help students feel more comfortable, prepared, and informed for their appointment. For providers, apps can save time and help overcome any discomfort discussing contraception.
Example and Considerations
Example: Contraceptive app tailors recommendations for adolescents
Health-E You is a contraceptive health app designed for use in SBHCs with Latina adolescents and is available in both Spanish and English. The app asks users to enter information about their needs, experiences, and risk profile before recommending a contraceptive method that might be most suited for them. The app also produces a print-out for the health service provider with a summary of the contraceptive method(s) the user was interested in, the method(s) the app recommended, and any potential contraindications.
Technology limitations, including unreliable internet and health service providers’ inability to troubleshoot technological problems, can pose a challenge to using apps in a school-based setting. Additionally, students may not always have enough time in the waiting room to fully use the app; however, any information gained from the app can still complement in-person counseling.
Text messaging can be used by school-based health service providers to send students reminders about upcoming appointments; texts can also improve the consistency of students’ contraceptive use by reminding them to take their birth control pills daily, change their ring or patch, or come to the clinic for a Depo-Provera shot on time. Additionally, text messaging can enhance health education. Teens may find it difficult to absorb complex information within the time constraints of a short medical consultation; text messaging allows them to ask questions after a clinical visit. Text messaging also allows youth to confidentially seek personalized answers to questions.
Examples and Considerations
Examples: Local and national text interventions can support adolescents’ needs
One experimental intervention, DepoText (not currently publicly available), was tested in a Baltimore clinic for adolescents. DepoText was highly effective for adolescents who used DepoProvera as their contraceptive method. The clinic used the app to send reminders of clinic appointments and annual exams, provide information on condom use and healthy weight management, and send reminders to call the clinic with questions.
The Planned Parenthood Text/IM intervention is a health education texting intervention that aims to answer urgent sexual and reproductive health questions and link young people to services, if needed. It operates as a national sexual and reproductive health hotline, answering users’ concerns about emergency contraception, pregnancy tests, abortion, and STI testing.
Maintaining accurate contact information is critical to effective texting communication. Challenges to keeping students enrolled for text message reminders include cell phone bill nonpayment, phone loss, and cell phone number changes. Some adolescents may have confidentiality concerns about receiving text messages related to sexual and reproductive health services. Uptake of text message reminders may be greater if users have choice over the timing and frequency of reminders. Users are more likely to share and remember text messages if they are short, positive, and witty, and use familiar language.
Peer education programs are commonly used to provide students with the opportunity to receive health education—including sexual and reproductive health information—from peers who share similar backgrounds, based on factors like age, gender, sexual orientation, or race/ethnic identity. Peer education is a youth-friendly approach that delivers information to students in a comfortable, relatable way and helps youth gain a greater ability to ask questions, particularly about sensitive topics such as sexual and reproductive health. Peer educators (also called “peer advocates”) may be recruited and trained by student organizations or by school-based health service staff. Volunteer peer education programs have been used by schools, including some minority-serving institutions, to help address notable disparities in sexual and reproductive health outcomes.
Example and Considerations
Example: A peer training program in a Southern HBCU
In response to the disproportionately high rates of HIV among Black women, one historically Black college or university (HBCU) in the South integrated a volunteer peer education program within its student health services. This program recruited students who received training in sexual health peer education; they then used that training to raise awareness, provide education, and serve as a resource to other students on campus. Peer educators hosted both campus-wide and class-specific presentations. Students reported learning from and valuing the presence of this program.
Many schools have peer education programs that are designed to support the needs of their student bodies. For these efforts to be effective, however, schools may need to be active stakeholders in these health education programs; they should also pay attention to the diverse characteristics of their students (e.g., age, gender, sexual orientation, or race/ethnic identity) and their comprehensive social, physical, and mental health needs. Schools should also consider the demands placed on the program volunteers and help ensure that peer educators can balance program responsibilities with their other demands. Schools may also consider paying students for their work as peer educators.
Improvements to the clinic environment and young people’s health service experiences—including interactions between health service providers and students—can increase the reach and effectiveness of care. This may be especially important for men, students from under-resourced backgrounds, and those who belong to groups that have faced a history of discrimination that has limited their ability to obtain appropriate sexual and reproductive health care in a non-stigmatizing way. For example, many LGBTQ youth have personal experience with LGBTQ-specific discrimination from providers, and school-based health services may not provide a genuinely inclusive environment. Incorporating programmatic and operational changes—like providing incentives for coming to the appointment (incentives could include cash, gift cards, movie tickets, or food), connecting patients to appropriate outside services, using a youth-friendly approach to inquiring about or discussing sexual histories, changing the waiting room area to promote greater inclusivity, conducting targeted outreach, providing staff training, and implementing tailored services—may allow school-based health service providers to better reach and engage with the full diversity of students at their school.
Example and Considerations
To better connect with their male students, a university health service provider integrated a service innovation model to address barriers that men experience in seeking sexual and reproductive health care, including feelings of embarrassment, perceptions of stigma, and distrust of health professionals. his approach included (1) restructuring the clinic environment to provide a more welcoming environment for young men, (2) training clinic staff on providing services for men, and (3) improving promotion of services in the community. Before implementation, the clinic featured stereotypically feminine decor—rooms were painted pink, walls had pictures of flowers, and magazines for women were in waiting rooms. To be more welcoming, the clinic adopted gender-neutral colors and put up signage, posters, and magazines geared toward males. They also hired an additional registered nurse to accommodate male patients and created a separate male reproductive health intake form. Clinic staff participated in trainings focused on male reproductive health and male-sensitive communication. As a result of these changes, the clinic saw an increase in the number of male patients seeking services.
Schools striving to increase their outreach should pay close attention to the diversity of their students’ backgrounds and needs, and should build authentic relationships with those students. To do this, schools must ensure that health service providers have the training and resources to meet needs in an appropriate and inclusive way. This can include training for health service providers. For example, LGBTQ-specific training can reduce instances of misgendering or other forms of microaggressions. Furthermore, school-based health service providers can build a more welcoming and inclusive environment through various strategies, including targeted outreach (e.g., using digital marketing tools to advertise specific services), welcoming signs and literature in waiting rooms, and recruiting staff who reflect the diverse backgrounds of the student body (such as age, gender, sexual orientation, or race/ethnic identity). Encouraging youth engagement and empowerment by including their voices in clinic improvements is essential.
From October 2019 to February 2020, we conducted a literature search to identify the range of strategies being used (or that could be used) to deliver sexual and reproductive health care services in school-based settings—specifically in school-based health centers (SBHCs) and on community college campuses. Within these settings, we searched for some pre-identified domains of innovation (e.g., telehealth, technology, mobile clinics, and partnerships) and for some specific areas of reproductive health care services (e.g., sexual health, LARCs, contraception, Title X). Additionally, we included search terms to identify any additional approaches for reaching and providing services to underserved populations (e.g., hard-to-reach, youth-friendly). For these searches, we included strategies used in four-year historically Black colleges and universities (HBCUs) and Hispanic-serving institutions (HSIs), as well as those used outside of a school-based setting.
In total, we conducted 149 unique searches in Google Scholar and Google. We originally identified 282 resources (219 journal articles and 63 news articles and webpages), although some were added after the original scan was complete (for example, identified in the references of an existing article), bringing the total to 298. Notably, we found substantially more literature on sexual and reproductive health service delivery in high schools than in community colleges. Only a subset of the articles identified described strategies that were implemented (i.e., many articles suggested strategies, but did not describe their implementation). Thus, after concluding our initial search, we abstracted information from 108 resources (80 journal articles and 28 news articles and webpages), including details (when possible) on the specific strategy/innovation used, the population served, the setting, geographic location, evidence of effectiveness, and any barriers to implementation identified.
For this web-based tool, we first identified the most common domains of strategies for providing school-based reproductive health services within our body of literature. In addition to the pre-identified domains, we identified some new domains (e.g., onsite contraceptive services, texting, peer education). We organized the abstracted information by domain and synthesized the information within each domain. Within each domain, we highlighted one “real-world” example from the literature. To select these examples, we prioritized articles on interventions that were conducted in school-based settings (as opposed to those that could be adapted for school-based settings) and included sufficient information to adequately describe the innovation. In some cases, we highlighted two real-world examples within one strategy, either to illustrate the range of examples or to combine information to provide a more robust example.
The authors would like to thank Dr. Jennifer Manlove and Dr. Jenita Parekh for providing feedback on this product throughout its development. The authors would also like to thank Dr. Mindy Scott at Child Trends, Dr. Ana Caskin at MedStar Georgetown University Hospital, Callie Koesters at the Office of Population Affairs, and Emily Baldi and Suzanne Mackey at the School-based Health Alliance for their expert reviews of this product. The authors are also grateful to Anushree Bhatia, Melissa Perez, and Ambika Mathur for their research support, and Catherine Nichols, Stephen Russ, and Brent Franklin for their design and editing work. This publication is funded by grant number 1 FPRPA006065-01-00 from the Office of Population Affairs in the U.S. Department of Health and Human Services. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of OPA or HHS.