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Partnership Strategies for Schools With School-Based Health Centers

In schools with SBHCs, partnerships can be critical to ensuring that students have access to high-quality family planning. In some cases, partnerships can help establish family planning service provision at SBHCs that did not previously offer these services. In other cases, partnerships can enhance family planning services that an SBHC already provides. In this section, we describe three partnership strategies that practitioners have used to establish and improve family planning services at schools with SBHCs, along with their recommendations for maximizing the success of these strategies.

Strengthen partnerships with school administration and school districts to begin offering family planning services in SBHCs

SBHCs are often constrained by school or district policies that may prohibit or restrict the provision of family planning services. Before adding or making changes to existing family planning services, SBHC staff must seek approval from key administrators and district board members. However, obtaining this approval can be very challenging for a variety of reasons. In some cases, school district members themselves are opposed to offering any family planning services. One SBHC practitioner shared, reflecting on the process of obtaining this approval, “… one superintendent … would lay his hands on his Bible on the desk and say, ‘There’s no way that this is going to happen in my district.’” In other cases, key school staff may be more worried about backlash from parents or complaints from community members. For example, one practitioner described administrators fearing that parents may want to close the SBHC altogether if they were to add family planning services: “[Administrators] were afraid that the parents would be angry [if the SBHC offered contraceptives] and would not want the school-based clinics anymore, undoing all these years of great things that we’ve done.”

Establishing and maintaining close collaborations between SBHC provider staff and school staff can mitigate some of the barriers posed by existing school or district policies. These relationships provide important opportunities to convince key stakeholders of the benefits of providing family planning services.

Staff from SBHCs described several ways in which they successfully developed and cultivated relationships with the school district and board members to gain support for family planning services. These recommendations for SBHCs include the following:

• Prioritize transparency. SBHCs should be clear early on with school district staff and board members about their expectations for the partnership. Initiating these conversations can minimize misunderstandings or confusion from either party. One provider worked collaboratively with a school district to create a “blueprint of what we expect from the schools, what they should expect from us.”
• Convene a group of community experts. SBHCs should consider a committee of community groups that are supportive of providing family planning in SBHCs to help get approval from school district staff. For example, one SBHC convened representatives from multiple sectors that serve youth, including different city agencies, hospitals, and schools. They also included social workers, physicians, and nurse practitioners, as well as providers in other youth-serving community organizations.
• Identify an ally within the school. Find a key person within the school, such as a school nurse or principal, who is motivated to ensure that students have access to family planning services within the SBHC. This ally may be able to provide insight into the best approach for gaining the support of key school district staff who may be more reluctant or hesitant.
• Use presentations to school administrators and board members as an opportunity to provide education. According to SBHC providers, these presentations could:
  • Address the specific misconceptions around, and need for, contraceptive services in the community.
  • Be tailored for specific audiences. For example, some board members may respond favorably to a data-driven presentation while others may be more swayed by personal stories.
  • Be supplemented with one-pagers that answer commonly asked questions and address community concerns.
• Implement an incremental approach. In some cases, it may be most effective to introduce family planning services slowly over time. For example, some providers noted that—for SBHCs seeking approval to provide family planning services—asking permission to provide all forms of contraception at once may be “too big an ask.” SBHC staff should consider first seeking approval to provide basic family planning services (e.g., pregnancy testing and condoms) and then incrementally adding services as school district staff and community members have time to acclimate to these basic services.
• Hire a center liaison or outreach director. If resources allow, SBHCs should consider hiring a center liaison or outreach director. While the role of the outreach director would likely be to increase general awareness of the SBHC, this individual would also work closely with school district staff to address concerns and sustain positive relations.
• Be patient. The process of adding family planning services can often take several years, so it is important for SBHC staff to remain patient and consistent in their efforts to strengthen relationships with, and gain buy-in from, school district staff.

Establish community partnerships to expand family planning services

Partnering with outside providers can be an effective strategy for expanding family planning services, especially when considering offering LARCs in schools. While many SBHCs recognize the importance of offering LARCs as contraceptive options for adolescents, adding LARC insertions and removals can be difficult. 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 could engage specialized family planning staff from their sponsor organization, or partner with practitioners from another organization (e.g., a medical school or local family planning clinic) who can visit schools to assist with implant and IUD insertions and removals.

Although these partnerships are valuable for expanding student access to IUDs and/or implants within SBHCs, they often pose challenges—especially because these providers are not on-site every day. Below, we provide practitioner recommendations for making these partnerships as effective as possible:

• To the extent possible, integrate visiting providers into the SBHC. To increase students’ comfort with visiting providers, SBHCs should integrate visiting providers into the SBHC as much as possible. Examples for integrating these providers include the following:
  • Introduce all students who visit the SBHC to the visiting provider, even if the student is not there for an appointment with that provider.
  • Add a picture and an introduction of the visiting provider to an SBHC bulletin board to increase student familiarity.
• Preempt challenges that may occur when same-day appointments are not possible. Because same-day LARC insertions/removals are rarely feasible, SBHCs could:
  • Send frequent appointment reminders to students to reduce the likelihood that they will miss their appointment when the visiting provider is on-site.
  • Discuss alternate contraceptive methods, such as pills or the vaginal ring, that students can use in the interim.
• Make the most of provider visits. To make the most efficient use of visiting providers’ time on-site, SBHCs could:
  • Ask staff to complete all pre-insertion requirements (pregnancy and STI testing, education, etc.) with students prior to the day of insertion so that the visiting provider can focus on procedures only.

Partner with pharmacies to allow greater access to contraceptives

Some SBHCs prescribe contraception but do not dispense contraceptives (such as pills, the patch, and the ring) on-site due to logistical and/or capacity constraints. For example, some SBHCs may not have the space to store the medications; others may not have the staff capacity to manage an on-site pharmacy. In these instances, health centers can expand students’ access to contraceptives by partnering with pharmacies that will deliver medications.

These partnerships may be particularly helpful for students who are uncomfortable with traveling, or unable to travel, to pharmacies to pick up their contraception. Although many pharmacies deliver prescriptions directly to SBHCs, some clinics may direct pharmacies to send prescriptions to students’ homes if the students cannot pick them up at the SBHC (and if the student agrees to this approach). By partnering with pharmacies to send prescriptions to a more convenient location for students, SBHCs can eliminate barriers that may otherwise prevent students from receiving contraception.

Staff from SBHCs and their partner organizations provided several considerations for SBHCs looking to establish a partnership with a pharmacy. The following are recommendations for SBHCs looking to partner with pharmacies:

• Create partnerships with more than one pharmacy. Pharmacies may only offer certain types of contraception or deliver within a specific area. Multiple partnerships may help SBHCs better address their students’ range of geographic and prescription needs.
• Factor in the pharmacy’s organizational capabilities as well as their own. When choosing pharmacies with which to partner, SBHCs should account for pharmacies’ delivery ranges and the types of contraceptives carried. Moreover, SBHCs should consider their own capacity to handle multiple partnerships and to address logistical challenges that may arise, such as determining the time that a student will be home to receive a prescription or troubleshooting when a student does not receive their medicine as scheduled.
• Consider the needs of the student population. Some pharmacies only offer delivery services to patients with private insurance. SBHCs should make sure to partner with pharmacies who accept all types of insurance plans, including Medicaid.

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Partnership Strategies for Schools Without School-Based Health Centers

While SBHCs offer important benefits—such as improving access to and utilization of any in-school family planning services—many schools do not have the resources and capacity needed to operate an SBHC. Even when it is not feasible 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. In this section, we describe two partnership strategies that schools without SBHCs have used to connect students to family planning services, either on-site or within the community.

Create partnerships with community organizations to provide sexual health education and referrals to local family planning services

Our interviews identified schools that had established community partnerships (with local health departments, hospital systems, or nonprofit organizations) to offer reproductive health and family planning education to students. Most commonly, this health education is provided by health educators or coordinators employed by the 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.

School and partner organization staff offered several recommendations for schools without SBHCs to foster successful partnerships and connect students to care:

• Establish a designated space for health educators. Some health educators may not have a designated space in the school to provide services. School staff and their partner organizations 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.
• Find unique ways to reach students. Health educators should try different approaches to raising students’ awareness of available services and resources, such as speaking to students during gym or health classes, at after-school sports practices, or at school health fairs.
• Use a team approach. A strong relationship between school staff and their partner organization can help maximize the number of young people served. For example, the school nurse can refer students to the health educator, and vice versa, based on students’ individual needs. As they are often the first person to receive a student, school nurses are essential for establishing intentional connections between health educators and the students who may benefit from their services.
• Consider offering additional family planning services. In addition to sexual health education and referrals, health educators should consider offering other services, such as pregnancy and STI tests. These additional services may not only increase the number of students accessing services, but may also let health educators more effectively serve students’ needs.
• Maximize utilization of family planning services through referrals. Health educators can improve the likelihood that students will receive the services to which they are referred by helping students prepare for their appointment. For example, health educators help students schedule appointments and make a plan for getting to the appointment.

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

Community partnerships can also be used to provide limited family planning services on or near the school campus. Providers from the partner organization can visit schools regularly (e.g., once or twice a month) to offer family planning services to students within the school. Alternatively, partner health providers can offer services outside of the school building using a mobile unit. Both approaches remove any transportation barriers that may make it difficult for students to seek care at community family planning clinics and can be implemented in schools without SBHCs. In these cases, visiting health providers and mobile clinics are often used to supplement the existing health education and referral systems within schools.

School and partner organization staff offered several recommendations for schools looking to provide family planning services using visiting providers or mobile units:

• Create and maintain strong relationships with school administrators and staff. The ability to offer family planning services on-site is often dependent on permission from school administrators and board members. Take steps to create strong working relationships with key individuals to gain this approval. For additional recommendations, see “Strengthening partnerships with school administration and school districts to begin offering family planning services in SBHCs” above.
• Connect students to local family planning clinics if they require services quickly. Because visiting providers are not on-site every day, it is important to provide students referrals to local family planning clinics when they need to be seen immediately.
• Ask health educators to connect students with visiting providers. Students may have fears or anxieties about accessing services, especially with a new provider. To alleviate stress, health educators should introduce students to visiting providers (on-site or in visiting mobile clinics) and talk through what will happen during the visit.
• Consider using mobile clinics when local or state policies prohibit family planning service provision in schools. Local or state policies often prevent schools from providing certain family planning services on-site—especially dispensing contraceptive to students. In these instances, schools can consider using mobile clinics to offer services close to schools (but not on school grounds). Mobile clinics can help remove transportation barriers students may face in seeking services in the community.

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Conclusion

Offering family planning services in school settings benefits students, schools, and their communities. School-based family planning services can increase students’ access to those services, reduce student dropout due to pregnancy or STIs, and subsequently reduce public costs associated with unintended pregnancy and STIs. This is especially true for schools serving populations with limited family planning resources. Despite these benefits, schools and SBHCS face significant barriers to offering these services, including limited funding and staff training, and prohibitive state, local, or school district policies. Creating and fostering partnerships is often an effective strategy in overcoming these hurdles.

One key benefit of offering family planning services through partnerships is the versatility of partnership approaches: Many practitioners described partnership strategies that were uniquely tailored to address specific barriers faced within their schools or SBHCS. For example, some SBHCs in our sample were limited by school regulations—often district-wide policies prohibiting the provision of contraceptives on school grounds—so decided to strengthen the partnership between the school and SBHC in order to change the policy. While this approach is often time-consuming, the SBHCs eventually received approval to offer family planning services directly on-site. In other instances, state policies (e.g., restrictions on the use of state funding) or limited resources led schools to create partnerships to connect students to family planning services in the community. These partnerships are often relatively easy to implement and several models exist for schools to emulate, such as Project Connect or Single Stop. However, students will still need to seek care in the community and may face barriers to doing so, such as lack of reliable transportation. Ultimately, schools and SBHCs should decide on a partnership strategy that will be effective based on their unique needs and resources.

The partnership strategies highlighted throughout this brief have been implemented in a diverse range of schools and SBHCS with varying levels of resources and support for family planning services. Therefore, the recommendations provided should support successful implementation of these partnership strategies in a wide range of school settings. However, in many instances, the depth and scope of our interviews did not provide information on how to create these partnerships. For schools and SBHCs interested in using partnerships to expand family planning services, please see Establishing Organizational Partnerships to Increase Student Access to Sexual Health Services for more information on identifying partners, assessing organizational readiness, and establishing formal partnerships. Ultimately, despite this limitation, it is our hope that the examples and recommendations provided in this brief spark ideas for innovative and creative ways to leverage partnerships to improve young people’s access to family planning services. Future work will include a toolkit designed for practitioners providing (or considering providing) these services that offers additional information and resources related to partnerships.