Background: School-Based Health Centers (SBHCs) are designed to provide youth-friendly services and to reduce barriers associated with accessing services. SBHCs serving teens provide varying ranges of sexual and reproductive health services. Most provide abstinence and contraceptive counseling, pregnancy testing, vaccinations against human papillomavirus (HPV), and on-site diagnosis and treatment for STIs. However, the evidence on the impact of SBHCs on adolescent sexual and reproductive health remains limited.

Methods: The current scoping review focuses on identifying broad patterns and mapping approaches of promoting SBHC health services in order to offer recommendations for advancing sexual and reproductive health services in SBHCs along with directions for future research.

Results: Among the 18 studies meeting the inclusion criteria, 13 reported significant positive changes in adolescents’ sexual and reproductive health based on services provided by SBHCs.

Conclusion: SBHCs that are motivated to address the sexual and reproductive health needs of the students they serve may need to look to the experiences of more mature centers for a way forward. The older an SBHC is, the more likely it is to offer contraceptive services on-site. The challenges that have had an impact on the provision of a full array of sexual and reproductive health services at SBHCs are related to politics and funding.

Keywords: School-based health centers, Sexual and reproductive health, Prevention services, Child and adolescent health

INTRODUCTION

Since the founding of the first school-based health centers (SBHCs) over 50 years ago, researchers have attempted to measure their impact on child and adolescent physical and mental health and academic outcomes [1,2]. SBHCs are defined as health centers located in schools or on school grounds that provide acute, primary, and preventive health care [1,3]. Depending on a variety of factors, SBHCs generally provide immunizations; testing and treatment of sexually transmitted infections; contraception, pregnancy testing, prenatal care; mental health assessment and treatment; crisis intervention and referrals; substance abuse counseling; health education; and dental care [1]. Services are often provided by a multidisciplinary team that may include physicians, nurse practitioners, physician assistants, school nurses, health educators, dentists, and mental health providers. SBHCs also vary significantly in their hours of operation, with some open a few hours a week and others open for the full school day, weekends, and/or through the summer [1,3].

There has been tremendous growth in the establishment of SBHCs across the USA, with an increase in the number of SBHCs in the past 25 years, from 150 in 1989 to 2,584 in 2016 [4]. Starting in 2014, more than 90% of SBHCs were traditional, but the distribution shifted in 2017 with the growth of telehealth exclusive SBHCs [4]. Twenty percent of SBHCs now have at least one provider available through telehealth [4]. SBHCs are distributed widely but unevenly in 48 of the 50 states, including 201 in Texas, 199 in California, 196 in New York, and 115 in Florida while almost half (46%) of SBHCs serve communities in urban areas, 36% are in rural areas, and 18% are located in suburban areas [4].

SBHCs potentially can improve physical and mental health as well as academic outcomes. Embedded within schools, SBHCs have the ability to provide services to most children and adolescents [1]. SBHCs are designed to provide youth-friendly services and to reduce barriers associated with accessing services (e.g., finances, inconvenient hours, transportation) [1,5]. They also have the capacity to teach young people when and how to access health care and to modify attitudes and behaviors [1,6] While the SBHC model has not yet received widespread recognition and support [5,7] there is evidence that delivery of health care within schools may reduce more expensive types of care, such as emergency room use and inpatient hospital care [1]. This may be a function of increased preventive care including the likelihood of having at least one physician visit and an annual dental examination [5].

Prior research has confirmed the potential benefits of well-integrated and adequately funded SBHCs, including improving health care access, reducing absenteeism, facilitating management of chronic disease, and preventing risky behaviors among students [8-10]. The American Academy of Pediatrics has argued that SBHCs facilitate better management and control of behavioral problems that affect student performance and disrupt the school environment and that the benefits extend beyond physical and mental health to include decreased dropouts and improved academic success [9-12].

Sexual and Reproductive Health Services

SBHCs serving teens provide varying ranges of sexual and reproductive health services. Most provide abstinence and contraceptive counseling, pregnancy testing, vaccinations against human papillomavirus (HPV), and on-site diagnosis and treatment for STIs [4,13]. Many SBHCs offer programs on sexual orientation and gender identity, sexual assault, rape prevention and counseling, and intimate partner violence [13]. More than half of SBHCs report providing HIV counseling and testing, although a significant proportion (19%) have policies that prohibit HIV testing [13].

The evidence on the impact of SBHCs on adolescent sexual and reproductive health remains limited [13,14]. Offering reproductive health care at SBHCs is associated with youth’s delayed initiation of sexual intercourse, decreased number of sexual partners and increased contraceptive use [13]. Nevertheless, few studies have found significant relationships between SBHCs and adolescent sexual and reproductive health [13-15]. With the goal of providing a foundation for strengthening services in SBHCs nationwide, this scoping review examines studies evaluating interventions that may be designed to focus on sexual and reproductive health services. Specifically, the evidence of the effects of SBHCs on adolescent sexual and reproductive health are examined in this review. The research question guiding this review was: How effective are SBHCs in improving the sexual and reproductive health outcomes of adolescent students?

METHODS

A scoping review was fitting because of the exploratory nature of the research question. Scoping reviews facilitate the summary of research findings drawn from existing literature with a goal of making recommendations and identifying research gaps [16,17]. The current scoping review focused on identifying broad patterns and mapping approaches of promoting SBHC health services in order to offer recommendations for advancing sexual health services in SBHCs along with directions for future research. Although reporting guidelines do not currently exist for scoping reviews [18], a systematic search of the literature for interventions that promote sexual and reproductive health services in SBHCs was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines as closely as possible. Following Arksey & O’Malley’s 2005 framework for scoping reviews, the present scoping review followed five stages: (a) identifying the research question, (b) identifying studies, (c) selecting studies, (d) extracting and charting the data, and (e) collating/summarizing the results [19].

In order to be included in this review, studies had to evaluate an intervention or program that included sexual and reproductive health services through an SBHC. In addition, studies had to include process outcomes (i.e. contraception use by adolescents) and any sexual behavior measures (e.g. sexual activity, condom use during sexual intercourse, number of sexual partners), as defined by each study, to be eligible.

 The databases Google Scholar, PubMed, and Web of Science were searched using the keywords “school-based health centers” and “sex*” for articles published between 2010 and 2020. The initial general Google Scholar search used the words “school-based health centers sex” altogether and produced 17,900 items. The next Google Scholar search was advanced in order to filter the results. The key words used were “allintitle: school-based health centers AND sexual”, which produced nine items, two of which met criteria. The next search was a PubMed advanced search of keywords “sbhcs AND sex*” which produced 29 items, of which 11 met criteria. The next search was a Web of Science advanced search of “sbhcs AND sex*” which produced 222 items in which 12 met criteria. Title and abstracts were screened to identify articles that potentially met the inclusion criteria. In total, 237 articles were identified for further assessment, and the full texts of these articles were reviewed. After excluding articles that did not meet the inclusion criteria 18 articles were identified for inclusion. Relevant information from each study, including year, location, sample, method, and main findings was extracted. Table 1 includes a summary of all included articles.

RESULTS

Of the 18 studies included in this review, 12 were quantitative, 5 were qualitative and 1 included both quantitative and qualitative study designs. Studies were conducted in a number of locations in the U.S, including California (n = 2), New York (n = 5), Washington State (n = 2), Alabama, Arkansas, Louisiana, Oklahoma, and Texas (n = 1), Colorado (n = 1), Michigan (n = 1), Oregon (n = 1), Midwest Region of U.S. (n = 1), the countries of U.S (n = 3), and New Zealand (n = 1). In the majority of studies (n = 11) researchers evaluated services that were offered to all high school students, and 7 studies had female-only samples. The primary outcome of interest in the current review was the promotion of sexual and reproductive health services in SBHCs. Among the 18 studies meeting the inclusion criteria, 13 reported significant positive changes in adolescents’ sexual and reproductive health based on services provided by SBHCs. Detailed explanations of findings in the 18 studies can be found in Table 1.

CONCLUSION

The major findings of this literature review suggest that communities should garner support for offering sexual and reproductive health services through SBHCs. The findings in this review may assist other communities interested in implementing similar clinics. Such services have potential for positively impacting the sexual and reproductive health of youth.

The challenges that have had an impact on the provision of a full array of sexual and reproductive health services at SBHCs are two-fold. The first involves the politics of adolescents and sex. Critics of SBHCs have argued that by offering contraceptives, SBHCs undermine parental rights. However, to promote parental support for their programs around contraception and other services, most SBHCs go out of their way to involve parents. All SBHCs require parental consent for primary care, and six in 10 allow parents to restrict children’s access to specific services [13] Critics also argue that if SBHCs dispense contraceptives the rates of teen sexual activity will increase. However, there is no evidence that providing teens with contraceptive information, education and services results in increased sexual risk-taking behaviors [13,20].

The second challenge that has had a major impact on the provision of contraceptive services at SBHCs involves funding. Because SBHCs rely on a diverse funding portfolio, careful planning is required to generate enough revenue to match expenses and finding adequate and consistent resources remains a challenge [13]. This can affect many of the services that SBHCs provide, not just contraceptive services, but lack of consistent funding may make expanding the range of reproductive health services even more difficult [13] Also, because SBHCs are guided by policies at multiple levels—from state laws to local school district guidelines to health center policies—political and societal leadership is needed at each level to support the provision of contraceptive services [13].

SBHCs that are motivated to address the sexual and reproductive health needs of the students they serve may need to look to the experiences of more mature centers for a way forward. Interestingly, the older an SBHC is, the more likely it is to offer contraceptive services on-site. About 60% of SBHCs that have been in operation for more than 10 years dispense contraceptives, compared with only 40% of newer centers [4,13]. Public health and children’s advocates must recognize that SBHCs are a critical access point to care for adolescents who are most at risk of unintended pregnancy and STIs, and that more must be done to ensure that students’ sexual and reproductive health needs are met at SBHCs [13].

IMPLICATIONS FOR SCHOOL HEALTH

SBHCs are typically viewed as a promising way to address teen pregnancy and reach students most at risk of HIV and other STIs. Nationwide, nearly half of high school students have had sex [13,21]. These students require information and services to avoid the negative consequences of sex. From a public health standpoint, students should be given information about and access to contraceptive and STI services before they begin to have sex, so that they are more likely to use protection when they do have sex. Although few younger teens have ever had sex, 20.4% of ninth graders and 57.3% of twelfth graders have had sex in the United States [22].

Over the last several decades, teen pregnancy, birth and abortion rates have declined dramatically in the United States [13,23]. In 2010, the pregnancy rate reached [23] per 1,000 women aged 15-19 [23], its lowest level in approximately 40 years. This is generally due to improved contraceptive use and use of more effective methods [13] even with these trends, however, teen pregnancy still remains a serious public health concern. Each year, nearly 615,000 U.S. women aged 15-19 become pregnant, and 82% report that their pregnancy was unplanned [24]. Furthermore, rates of reported cases of chlamydia are highest among adolescents and young adults aged 15-24 years [25].

SBHCs provide a range of sexual and reproductive health services. However, since the inception of these centers, debates have erupted in communities across the country over whether they should provide contraceptives on-site. At the same time, a number of SBHCs that are committed to sexual and reproductive health are working within their communities to overcome opposition and provide contraceptive care [13].

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