School-based health centers increasingly are becoming part of mainstream health care, providing an important source of primary and preventive medical services to young people in the United States. Research shows that while adolescents have significant unmet health needs, those with access to a school-based health center are more likely than their peers who do not to obtain needed services. Since their inception, however, the question of whether school-based health centers should provide family planning services has sparked heated debates in many communities across the nation. With the number of school-based health centers on the rise, this controversy is likely to spread as parents, educators and health care professionals grapple with the appropriate role of school-based health centers in meeting the family planning needs of sexually active teenagers.

Profiling the Centers

According to a 1998-1999 survey conducted by the National Assembly on School-Based Health Care (NASBHC), there are currently 1,135 school-based health centers across the country, up from only 200 in 1990. Much of this growth is recent: Six in 10 of the centers have been in operation for four years or less (see chart). The centers are located in 45 states—all but Idaho, Nevada, North Dakota, South Dakota and Wyoming—and the District of Columbia and can be found in urban, rural and suburban areas where children have significant unmet health care needs because they are low-income or uninsured. Three in 10 are located on-site at elementary schools, and the rest in middle schools and high schools. By and large, they are sponsored by a larger health agency, such as a hospital, health department or community health center (see chart).

CENTERS AT A GLANCE
Most school-based health centers were established recently...	...and are sponsored by a larger health agency
Number of years established	Type of agency
Years:  Fewer than 2  2-4  5-9  10 or more	Sponsor:  Hospital or university/medical school  Local health department  Community health center  School system  Other
Note: Based on 1998-1999 school year. Source: National Assembly on School-Based Health Care (NASBHC), Creating Access to Care for Children and Youth: School-Based Health Center Census 1998-1999, NASBHC: Washington DC, 2000.

States are the largest source of funding for school-based health centers, contributing almost $30 million in general revenues during the 1997-1998 school year, reports Making the Grade, a national grant program of the Robert Wood Johnson Foundation that assists states in developing the long-term financing policies necessary to sustain school-based health centers. Historically, federal support for school-based health centers came primarily from the maternal and child health block grant and the Healthy Schools/Healthy Communities program (providing $9 million and $8 million, respectively). However, with school-based health centers increasingly seeking third-party reimbursement, Medicaid has also become an important source of support, contributing almost $9 million in 1997-1998.

According to NASBHC, school-based health centers provide a broad range of primary and preventive health services on-site to almost one million students, often at no cost to the students or their families. In accordance with state law, local communities determine what services a center will offer and under what terms. Generally, these services include treatment for chronic and acute illnesses; prescription services; lab tests; sports physicals and general health assessments; vision and hearing screenings; and mental health services. School-based health centers also typically offer education and health promotion services focusing on the prevention of tobacco, drug and alcohol use; sexually transmitted disease (STD), including HIV, infection; pregnancy; injuries; and violence. More than nine in 10 school-based health centers require parental consent for services when students enroll in the school, and almost two-thirds allow parents to give consent but restrict their children's access to specific services.

Reproductive Health Services

According to NASBHC, centers located in middle or high schools typically provide a range of reproductive health services on-site (see chart). Almost nine in 10 of these school-based health centers provide pregnancy testing; seven in 10 offer testing and treatment for STDs, gynecologic exams and Pap smears; almost six in 10 provide HIV testing; and two in 10 offer prenatal care. These services, moreover, are in demand: Studies show that when reproductive health services are available, they account for anywhere between 10% and 17% of health center visits.

CENTERS AND REPRODUCTIVE HEALTH CARE

Centers in middle and high schools provide a range of reproductive health services, but few dispense contraceptives on-site.

Source: See previous chart

Contraceptive services, however, are often treated differently from other reproductive health services. In fact, three out of four (77%) school-based health centers located in middle or high schools are prohibited from dispensing contraceptives on-site (although not all of those prohibitions include condoms). Only 4% of health centers that do not dispense contraceptives adopted the policy voluntarily; in most cases, the policy was set by the school district (73%), the school (29%) or the state (12%). The most common methods dispensed in school-based health centers are condoms (30%) and oral contraceptives (25%); emergency contracptives are dispensed in only 15% of centers.

John Schlitt, NASBHC's executive director, notes that while relatively few school-based health centers are allowed to actually dispense contraceptives directly to students, seven in 10 provide birth control counseling, and most provide referrals for services off-site. Still, Schlitt acknowledges that this situation is less than ideal from a public health perspective—particularly given the high rates of sexual activity and unintended pregnancy among teenagers in this country. Referrals alone are often inadequate, he says. Students frequently do not follow through, because they either lack transportation, have concerns about confidentiality or simply may not regard doing so as an urgent priority.

Navigating the Waters

Since the early 1970s, when the first school-based health centers were established, critics have charged that they exist primarily to provide birth control. Other health services, they contend, are provided only to lure students into the centers and to provide a front for the centers' reproductive health activities. And despite research to the contrary, critics argue that by offering contraceptives, school-based health centers increase rates of sexual activity among teens.

In 1994, a report by the General Accounting Office (GAO) concluded that the controversy over family planning services constrained the ability of school-based health centers to meet some adolescents' health needs. According to GAO, "opposition to some reproductive health services expressed by groups of citizens, elected officials and religious leaders has led some centers to limit or eliminate family planning services, move their operations off the school campus, or not open. Other sites have had their funding withheld."

The GAO report also noted, however, that some school-based health centers were taking steps to mitigate the potential effects of opposition and controversy. NASBHC's Schlitt agrees, pointing out that the older a school-based health center is, the more likely it is to offer contraceptive services on-site (see chart). In fact, 41% of school-based health centers that have been in operation for more than 10 years dispense contraceptives, compared with only 21% of newer centers. This has to do, he says, not with the fact that older health centers were more likely to offer family planning services from the start, but with the "evolutionary quality" of school-based health centers. "As these centers become more established, they gain community support and a buy-in from parents. At the same time, the needs of students become better known. This places centers in a much better position to advocate for birth control services."

Julia Graham Lear, program director of Making the Grade, adds that HIV/AIDS has played a major role in changing the views of parents and residents in some communities. According to Lear, "In the early days of school-based health centers—back in the 1970s and early 1980s—the idea of providing family planning services on-site was extremely controversial. The headlines in the paper would read, 'The Pill Goes to School.'" Lear continues, "While echoes of that still linger on in the minds of some people today—largely those who aren't very familiar with school-based health centers or the communities they serve—HIV/AIDS significantly altered the equation." Lear explains, "The price was too high in many communities for parents and educators to ignore the changing norms. More students were becoming sexually active, and it became apparent that there was an increasing need to bring reproductive health services to high school students in a way that addressed their very real problems."

In spite of these changing norms, Schlitt acknowledges that acceptance of family planning in school-based health centers remains the exception, not the rule. Says Schlitt, "Yes, prohibitions compromise the health centers' scope of service, but for many, the center simply could not operate under any other condition." Schlitt hastens to add that those prohibitions are not always permanent. "School and parental attitudes have been known to shift over time, particularly as the school-based health center builds trust, comfort and familiarity, as well as the data" underscoring the need for such services (see box). Schlitt continues, "These providers are committed to meeting all the various health care needs of the students they serve. And it often doesn't take long for a school or community to realize that school-based health centers play an enormous role in meeting students' health care needs and for the providers to say we can do even more."

POWER OF AGE

Long-established centers are more likely than newer ones to provide countraceptives on-site.

Source: Unpublished data from NASBHC, school year 1998-1999.