Widespread school closures and additional safety concerns related to COVID-19 have restricted students’ ability to access reproductive health care, especially through school-based health centers (SBHCs). Young adults (ages 15 to 24) have the highest rates of unintended pregnancy and sexually transmitted infections (STIs) of any age group, which means that their access to sexual and reproductive health care through SBHCs is especially important. Despite school closures, though, SBHCs can use innovative strategies to reach students remotely and maintain their access to reproductive care.
SBHCs are critical sources of primary health care for students at over 10,000 schools in the United States, especially for adolescents from low-income, rural, and racial or ethnic minority populations. Many SBHCs are located on school grounds and may typically rely on in-person communication with students to provide various family planning services. As a result, SBHCs that operate at schools that are closed or have adopted a hybrid model (some online and some in-person classes) for the upcoming academic year will need to use innovative strategies to maintain students’ access to their primary source of family planning services.
SBHCs can use the following six innovative strategies to reach students and administer family planning services remotely.
One of the biggest challenges to providing remote school-based family planning services is to ensure that students, especially new students, know that family planning services and providers are available to them. SBHCs may commonly rely on foot traffic and casual interactions to connect with students and advertise their services. With school closures eliminating personal interactions in hallways and classes, clinics can feature their services prominently on school webpages or online portals. Clinics can also provide contact information for clinical staff on their social media accounts and post about remote and in-person services.
Students in rural areas and low-income families may have limited access to high-speed internet or data plans that enable them to learn about or access these resources via social media outreach; however.
Providers can also make phone calls to inform students about family planning services. Clinics can schedule phone outreach during evenings, when adolescents are more likely to be alone in their rooms and can talk more freely about family planning services. Additionally, adolescents are more likely to stay up late at night and sleep longer in the morning, so the timing of calls should be an important consideration for clinics. One clinic found that youth were less likely to answer calls during the day than in the evening. Clinics can also use phone calls to check in with students to ask how they are doing and build rapport.
Adolescents are often curious about contraceptive options but may not always be comfortable having clinics reach out to them. In particular, many adolescents are unlikely to be comfortable talking to clinic staff when they are with their parents or when their parents can hear them. Further, because parent-child communication about sexual health is often shaped by families’ racial and ethnic backgrounds, adolescents from some racial or ethnic groups may have less open communication with their parents about sexual and reproductive health. Therefore, during school closures, some adolescents might have concerns about clinics calling them while they are with their parents, and may be uncomfortable talking about sexual and reproductive health in a non-clinic setting.
Instead, clinics can set up hotlines using a shared phone line (like Google Voice) to allow students to reach clinic staff at their convenience. Unlike a traditional phone number, the hotline allows multiple clinic staff to be on call on a rotational basis. Providing a hot-line phone line can encourage students to call, in real time, to discuss any non-emergency health concerns and receive the information they need.
Clinics can create or share videos about reproductive health topics and upload them to social media platforms to provide ongoing health education to students. Patient education videos may be especially effective and relatable if they involve the target audience in the content creation process. One way to accomplish this is through the use of a human-centered design approach to create videos, bearing in mind the characteristics and needs of the local student community. Certain adolescent populations, like Asian American teens, are less likely to talk to providers about sexual and reproductive health, and have been traditionally underrepresented in sexual and reproductive health education materials. Representation in videos might make these groups feel more comfortable with clinical staff. In addition to posting on social media, clinics can also email or text video links to their students.
During the COVID-19 pandemic, the U.S. Department of Health and Human Services has encouraged health care providers to adopt and use telehealth as a safe way to provide care. Adolescent telehealth users may have concerns about audio-visual privacy and the risk of their personal health information being shared without their consent. Patients in rural areas may be especially concerned about exchanging personal information virtually, and may mistrust the health care system or providers. HIPAA-compliant videoconferencing platforms that offer end-to-end encryption, like doxy.me and RingCentral for Healthcare, represent confidential options to provide counseling. Clinics can implement a proxy server to protect their online medical records. Under the proxy server, only select individuals—in addition to the student and their provider—will have access to students’ personal medical records. Additionally, parents and guardians will only have limited access to clinical notes once the student reaches age 12. These practices help ensure confidentiality for sensitive services, such as STI testing or contraceptive counseling, and could increase students’ trust in clinic staff.
Providing contraceptive counseling is an essential first step in helping youth select the most suitable contraceptive option. Students may be nervous about seeking contraceptive counseling due to the stigma surrounding contraceptive use, especially in certain immigrant populations. Using online patient-facing tools, such as Bedsider.org, can increase students’ familiarity and comfort with a wider range of contraceptive options. Clinics can also incorporate contraceptive counseling apps, such as Health-E-You and Decide + Be Ready. These apps provide students with information on different contraceptive options and ask screening questions to provide recommended options while students are in the virtual waiting room. Students’ familiarity with contraceptive options prior to their telehealth appointment may improve the quality and efficiency of contraceptive counseling.
Family planning providers can also use special tools—such as a virtual patient waiting room, secure file sharing, and client self-scheduling—to mimic an in-person visit. Some platforms, like Thera-LINK, offer an automatic text message reminder service for telehealth appointments. Text message reminders for virtual visits are easy to use and relatively inexpensive. In studies, clinics that implemented texting also witnessed a lower no-show rate. Adopting such practices will result in a smoother telehealth appointment.
SBHCs need to ensure that patients can access their preferred contraceptive method. According to the 2013-14 National School-Based Health Care Census, 50 percent of SBHCs offer contraceptive counseling, but only 32 percent dispense contraceptives onsite. Clinics that prescribe and dispense contraceptives onsite can offer contraceptive counseling remotely but distribute birth control in alternate school spaces, such as the school parking lot. Clinicians can also develop relationships with local pharmacies that offer delivery to facilitate access to students.
Clinic staff at SBHCs that do not prescribe contraceptives can connect students with other providers. Several online platforms, such as LemonAid, Pill Club, and Virtuwell, allow patients to answer intake questions, after which a nurse practitioner can virtually prescribe hormonal contraceptives.
Note on methodology
The authors identified the six strategies discussed above primarily through interviews conducted in Spring and Summer 2020 with representatives from more than 20 SBHCs across the country. In these interviews, we discussed innovations in the field of school-based reproductive health care, as well as adaptations made in response to COVID-19. We also identified strategies through a literature scan conducted in early 2020. In the scan, we reviewed over 100 journal articles, news articles, and webpages for innovations related to family planning delivery.
The SBHCs we interviewed were implementing many of these innovative strategies before the COVID-19 pandemic, and further groundwork may be needed for clinics seeking to implement these strategies for the first time. Clinics and practitioners seeking to implement any of the strategies described in this brief should also consider inequities in access to high-speed internet and difficulties finding a safe space for private conversations among different groups of adolescents. For example, students who are experiencing poverty, or those living in rural communities, may not have internet access or their own bedrooms and may experience greater barriers to privacy. Lastly, while some of these strategies have not been tested in the COVID climate, they may nonetheless prove beneficial as SBHCS search for new ways to reach and successfully deliver family planning services to youth remotely.
The authors would like to commend the additional contributors to this brief, including Samantha Ciaravino and Lisa Kim. Special thanks goes to Sara Anderson for her expert review. This project is part of a collaborative effort with School-Based Health Alliance. School-Based Health Alliance analyzed the 2013-14 National School-Based Health Care Census to identify the proportion of SBHCs that offer reproductive health care.
 Love, H., Schelar, E., Schlitt, J., & Even, M. (Unpublished data). 2013-14 National School-Based Health Care Census. Washington, DC: School-Based Health Alliance.
This project is supported by Grant Number 1 FPRPA006065-01-00 from the Department of Health and Human Services Office of Population Affairs. Contents are solely the responsibility of the authors and do not necessarily represent the official views of the Department of Health and Human Services or the Office of Population Affairs.
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