School-Based Health Clinics: Improving Adolescent Sexual and Reproductive Health in British Columbia – An Integrative Literature Review By Carmen Schalles BScN., Douglas College, 2015 PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING UNIVERSITY OF NORTHERN BRITISH COLUMBIA OCTOBER 2020 ©Carmen Schalles, 2020 ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS ii Abstract This integrative literature review strives to determine if the delivery of reproductive and sexual health services provided through high school-based primary care clinics can improve BC adolescent sexual and reproductive health. Adolescent sexual and reproductive health not only impacts life-long health; it also has significant societal implications. Although BC has begun to focus on adolescent health, innovative health service solutions are needed to improve adolescents’ health. Systematic search through the University of Northern British Columbia online library databases and Google scholar and the evaluation of the literature using CASP analysis tools resulted in the inclusion of 10 articles. Findings suggest school-based health clinics (SBHCs) decrease barriers that adolescents experience when accessing health services as well as public health system costs. Moreover, SBHCs are an effective mechanism to support adolescent reproductive and sexual health needs, especially in those populations with elevated levels of sexual and reproductive risk factors. However, for SBHCs to be effective, sustainable funding needs to be sourced, and barriers adolescents experience when accessing services need to be evaluated and addressed. SBHCs can complement current adolescent-friendly services to meet this unique population’s needs; however, further research is needed. More robust research on various demographics, health outcomes, and Canadian-based examination is required to strengthen SBHC implementation recommendations. Keywords: adolescents; contraception, primary health care, unintended pregnancy; adolescent pregnancy, school-based health clinic, sexual health, reproductive health ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS iii Acknowledgements First, I would like to express my appreciation to my supervisory committee - Linda Van Pelt, Lisa Creelman, and Lela Zimmer. Not only has their passion for the Nurse Practitioner Profession been inspiring, but their support and encouragement have helped to develop this literature review to what it has become. Thank you to my family and friends for encouraging me to follow my dreams and supporting me through this process. While I worked on this paper and this degree, you provided the encouragement and the listening ear I needed to succeed! To my classmates of the UNBC Master of Science in Nursing (FNP), the laughter, joy, encouragement and support you all have provided is irreplaceable. Thank you for taking this journey with me! ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS iv Table of Contents Abstract ........................................................................................................................................... ii Acknowledgements ........................................................................................................................ iii Table of Contents ........................................................................................................................... iv List of Tables and Figures.............................................................................................................. vi Glossary of Terms ......................................................................................................................... vii Chapter One: Introduction .............................................................................................................. 1 Chapter Two: Background .............................................................................................................. 3 What are Sexual and Reproductive Health? ............................................................................... 3 Adolescence ................................................................................................................................ 4 Adolescent Sexual Growth and Development ........................................................................ 5 Social Connection. .............................................................................................................. 6 Sexual and Reproductive Health Risk and Protective Factors................................................ 8 Contraception Accessibility. ............................................................................................. 10 Sexual Health Knowledge..................................................................................................... 13 What are Adolescent-Friendly Health Services? ...................................................................... 15 Adolescent Health Services ...................................................................................................... 17 History of Adolescent School-Based Health Services in BC ............................................... 17 School-Based Health Clinics ................................................................................................ 18 Current Adolescent Health Services in BC ........................................................................... 20 Primary Care Providers. .................................................................................................... 20 Foundry Network. ............................................................................................................. 20 Options for Sexual Health ................................................................................................. 21 SBHC in BC. ..................................................................................................................... 22 Chapter Three: Literature Search Methods ................................................................................... 23 Database Selection and Search Terms ...................................................................................... 23 Inclusion and Exclusion Criteria ............................................................................................... 26 Critical Analysis........................................................................................................................ 27 Chapter Four: Findings ................................................................................................................. 30 Review of the Literature ........................................................................................................... 30 Literature Themes ..................................................................................................................... 31 Stakeholder SBHC Priorities and Barriers ............................................................................ 32 Reproductive Health Outcomes ............................................................................................ 37 Health Equity and SBHC Costs ............................................................................................ 40 Chapter Five: Discussion and Recommendations......................................................................... 43 Synthesis of Findings ................................................................................................................ 43 SBHCs and Sexual and Reproductive Health Access........................................................... 43 SBHCs and Sexual and Reproductive Health Outcomes ...................................................... 46 SBHCs and Health Equity and Costs .................................................................................... 47 Recommendations for Practice ................................................................................................. 48 Recommendations for Further Research ................................................................................... 50 Research Limitations ................................................................................................................ 51 Gaps in Literature ................................................................................................................. 52 Other Considerations and Limitations .................................................................................. 52 Chapter 5: Conclusion................................................................................................................... 54 ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS v References ..................................................................................................................................... 55 Appendix A: Search Strategy........................................................................................................ 69 Appendix B: Literature Review Matrix ........................................................................................ 71 ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS vi List of Tables and Figures Figure 1 Prisma Diagram ............................................................................................................. 26 Table 1 Inclusion and Exclusion Criteria for Research Article Selection .................................... 27 Table 2 Practice Recommendations.............................................................................................. 48 ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS vii Glossary of Terms Adolescent: Adolescence includes the ages between 13-18 years. It is a period of distinct health and developmental needs and a stage of knowledge and skill development that aids in assuming the adult role (World Health Organization [WHO], 2014b). Adolescent-Friendly Health Services: Incorporates elements of equitability, accessibility, acceptability, appropriateness, and effectiveness with consideration to the adolescent population and health services provision (WHO, 2009, 2012). Health Equity: Is included as a component of health care assess and is defined as the absence of imbalanced and avoidable or remedial health disparities among socially, economically, demographically, or geographically defined population groups (WHO, 2020). Health care Access: A multi-dimensional concept that includes health service availability, utilization, relevance, effectiveness, equity, and related barriers to access (Gulliford et al., 2002). High School (also known as secondary school): An academic institution that follows elementary school, because the elementary grades vary from province-to-province high schools have included grades 7 to 13 (ages 13-18). High schools vary in type (academic, vocational, technical, composite) and can be public (free) or private (fee-charging; Fine-Meyer, 2013). Medical Home (also known as patient medical home): Is a care delivery model that provides longitudinal comprehensive primary care that facilitates partnerships between patients and providers. Medical homes provide primary care that is patient-centred, comprehensive, team-based, coordinated, accessible and committed to quality and safety (Primary Care Collaborative, 2020). Primary Health Care Services: Primary health care functions to provide first-contact health services and ensures continuity and ease of movement across the health care system so that care remains integrated when Canadians require more specialized services (Government of Canada, 2012). Primary Health Care: An approach to health and a spectrum of services beyond the traditional health care system, including social determinants of health (Government of Canada, 2012). Primary Care: An element within primary health care that focuses on health care services, including health promotion, illness and injury prevention, and the diagnosis and treatment of illness and injury (Government of Canada, 2012). Primary Care Provider: Providers such as family physicians, nurse practitioners, pharmacists, and telephone advice lines (Government of Canada, 2012). Reproductive Health: A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and its functions and processes (WHO, 2006, p. 4). ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS viii Reproductive Health Services: Sexual health services that specialize in sexual and reproductive health, including family-planning, education and services for prenatal care, safe delivery, and post-natal care, prevention of unsafe abortion1and management of the consequences of abortion, prevention and treatment of sexually transmitted infections, and other reproductive health conditions and education and counselling, as appropriate, on human sexuality, reproductive health and responsible parenthood (United Nations, 2017). Sexual and Reproductive Health Risk Factors: Factors that increase odds of adverse sexual and reproductive health outcomes, including early pregnancy and sexually transmitted infections (STIs). Sexual and Reproductive Health Protective Factors: Factors that decrease odd of adverse sexual and reproductive health outcomes, including early pregnancy and STIs. School-Based Health Clinic/Center: A health clinic that is in or near a school facility that is organized through school, community, and health provider relationships and provides primary health services to adolescents (Social Security Act, 2018). Sexual Health: “…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled” (WHO, 2006, p.5). Social Determinants of Health: Specific groups of social and economic factors that determine individual and population health. Social determinants relate to an individual's place in society, such as income, education, or employment (Government of Canada, 2020). ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 1 Chapter One: Introduction According to Boislard and Poulin (2011), early sexual onset is linked to depression, antisocial behaviour, poor academic achievement, and substance use. A British Columbia (BC) adolescent survey reported that 34% of sexually active adolescents had intercourse before the age of 15 (Poon et al., 2015), and 46% of all adolescents have had intercourse by the age of 18 (Smith et al., 2019). While the Government of Canada (2017) has pledged to invest $650 million to promote sexual and reproductive health and rights internationally, including support for contraceptive access, barriers to these services remain in Canada. The need to address adolescent sexual and reproductive health is particularly important because behavioural habits formed during the adolescent period have significant impacts on the health status during adulthood (National Research Council and Institute of Medicine, 2009). Historically, adolescent sexual and reproductive health has vastly been overlooked despite the adverse health outcomes, including increased risk of sexually transmitted infections (STIs), HIV, adolescent pregnancy, sexual coercion, exploitation, and violence (Morris & Rushwan, 2015). In Canada, the rates of STIs continue to trend upward (Public Health Agency of Canada [PHAC], 2019), with those aged 15-24 years having the highest confirmed cases of STIs (British Columbia Centre for Disease Control [BCCDC], n.d.). Over the 5-year period between 20132017, Canadian adolescents between the ages of 15-19 saw a 10% increase in Chlamydia cases and a 37% growth in Gonorrhea cases (PHAC, 2019). Sedgh et al. (2014) further note that up to 40% of Canada’s pregnancies are unintended, with rates likely higher than this in younger populations. In BC, those aged 17 and younger had a total of 624 births during the 2016-2017 year and 211 abortions in 2017 (Canadian Institute for Health Information, n.d.; Perinatal Services BC, 2018). Adolescent pregnancy has a greater risk for unfavourable outcomes at both ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 2 individual and societal levels, encompassing adverse physical and mental health risks, lower academic achievement, and high economic costs (Patel & Sen, 2012). Adverse outcomes can be related to delayed or lower health visit rates (Fleming et al., 2015). Barriers to sexual and reproductive health services can be attributed to a range of factors, including concerns about confidentiality, the unfamiliarity of services available, perceived attitudes of clinicians, limited access, and financial constraints (Douthit et al., 2015; Fleming et al., 2015). This project aims to explore whether adolescent-oriented reproductive health care can be applied to improve BC adolescent health. A literature review was conducted using the "PIO" model (problem, intervention, outcome) to develop the research question: Can sexual and reproductive health care services delivered to adolescents within a high school-based primary care clinic improve BC adolescent sexual and reproductive health? Chapter two will provide a background on adolescents, their growth and development, health care, adolescent sexual and reproductive health, interrelated concepts, and current adolescent health services available in BC. An overview and definition of school-based clinics will follow. The background chapter will be followed by the methods section describing the literature review approach used to find relevant articles to answer the clinical question. Next, the findings and critical analysis from the literature will be presented. Subsequently, a synthesis of the findings will be organized from themes found in the literature, recommendations for practice, and implications for future research. Finally, the literature review’s limitations will be considered, and the paper’s key points will be summarized. ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 3 Chapter Two: Background This chapter will offer descriptions of key concepts and context to support this integrative review, including background on the adolescent population, examination of adolescent health care, sexual health concerns, and school-based health clinics (SBHCs) and costs. What are Sexual and Reproductive Health? According to the World Health Organization (WHO, 2006), sexual and reproductive health are essential for “responsible, safe, and satisfying sexual lives” (p.1). Sexual health requires an understanding of the factors that shape human sexual function and behaviour, including their relationship to physical and mental health, well-being, and maturation (WHO, 2006). The organization contends that sexual health is included as part of reproductive health and has defined reproductive health as: A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive health therefore implies that people can have a satisfying and safe sex life and that they have the capacity to reproduce and the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility which are not against the law, and the right of access to appropriate healthcare services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. (WHO, 2006, p. 4) It is further noted by the United Nations (2017) that the information and services should incorporate access to family planning services, including safe and effective contraception, ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 4 prevention, and treatment of reproductive health conditions including STIs, education and counselling on human sexuality, reproductive health, and parenthood. The definition of sexual health expands on reproductive health; WHO (2006) maintains that it is: A state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. (p.5) Sexual health rights, according to the United Nations (2014), are a fundamental human right. Moreover, WHO (2006) stresses that all individuals should be free of coercion, discrimination, and violence, enabling them to attain the highest level of sexual health and reproductive health care services. Although adolescents have the same rights as adults, age, social status, and lack of autonomy lead to increased barriers to adolescent reproductive and sexual health (WHO, 2006). Adolescence Adolescence is a stage marked by physical, cognitive, and emotional growth as they begin to move into adulthood. WHO (2014b) describes adolescence as a period of distinct health and development needs and a stage of knowledge and skill development that help to assume the adult role. Historically, the characterization of adolescence has been defined by age and biological changes such as the onset of puberty and social role transitions, including obtaining employment (Sawyer et al., 2012). However, biological changes and social roles differ from one country to another; therefore, there is little consistency in the definition. For this paper, adolescents will include ages 13-18, as it describes the high school population this literature ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 5 review seeks to explore. In addition, the ages of 13-18 are accepted as adolescence through search databases. Adolescent Sexual Growth and Development Sexual development is a crucial component of adolescent growth and development. During adolescence, reproductive maturity is achieved, and intimate partner relationships are often initiated. Hormonal increases are central to pubertal transitions; these same hormones affect neural alterations (Suleiman et al., 2017). Hormones, including testosterone, estrogen, oxytocin, and dopamine, all enhance the way sexuality is experienced. Oxytocin, as well as dopamine, contribute to enhanced feelings of love and connection. During puberty, testosterone increases height and musculature in males, deepens their voices and increases facial hair. In addition, testosterone has been associated with brain neural activation that affects risk-taking, threat avoidance, reward processing, and influences romantic and sexual behaviours (Suleiman et al., 2017). Along with testosterone, increases in estradiol and progesterone also contribute to remodelling and activation in the brain neurons. Estradiol and progesterone among both females and males are associated with social, sexual, and risk-taking behaviours (Suleiman et al., 2017). Furthermore, estradiol in young females is involved in the earliest components of puberty, including breast development. As a result, adolescent females are often perceived as sexually attractive long before reproductive maturity, and neurodevelopmental changes occur, increasing concerns regarding body image (Suleiman et al., 2017). Conversely, young males start producing sperm well before physical sex characteristics emerge in the pubertal stage. Cognitively, adolescents are more motivated to seek rewards and engage in social relationships, including romantic relationships. Sawyer et al. (2012) stress that significant ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 6 transformations in the brain occur during adolescence. The limbic system, which controls reward processing, and pleasure-seeking, develops fully during adolescence. Conversely, the prefrontal cortex does not fully develop until after adolescence and governs planning, emotional regulation, decision making, multitasking, and self-awareness. The maturation of these two areas of the brain causes a developmental imbalance leading to increased risk-taking during the adolescent phase, as behaviours are driven by emotion and reward rather than rational decision making (Sawyer et al., 2012). Various theorists worldwide have investigated adolescent risk behaviour, including behavioural psychological, neuro-behavioural, developmental, and sociological theorists (Peeters et al., 2019). It is widely agreed among these experts that experimentation during this period is normative; however, it does increase risk behaviour among adolescents (Peeters et al., 2019). Peeters et al. (2019) point out that although some risk behaviours are normative and socially adaptive in controlled and social ways, others negatively impact the successful transition from adolescence to adulthood. Sexual and reproductive risk behaviours include early sexual debut, multiple sexual partners, and a lack of contraception use, all of which can influence long termhealth outcomes (Poon et al., 2015). Moore et al. (2018) suggest that positive, supportive relationships with parents and others during this experimental phase help insulate adolescents against unhealthy risk behaviours and promote health and well-being. Social Connection. Social factors can have a significant impact on sexual development. According to Smith et al. (2019), adolescents require "caring, supportive relationships, opportunities to grow, develop and challenge themselves, and the resources to participate in their community" (p.76). Satisfying and high-quality relationships with family, peers, and school staff ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 7 have been found to help adolescents develop their sense of identity and encourage positive health outcomes (Moore et al., 2018; Province of BC, 2016; Ragelienė, 2016; WHO, 2014c). Although adolescence is characterized by increased independence from family, researchers have found that parents remain the primary attachment figure, especially in times of stress (Chen et al., 2017). As characterized by high parental responsiveness and control levels, positive parental involvement is associated with positive behaviours that help guide adolescents from risky behaviours and promote resilience (Animosa et al., 2018). Chen et al. (2017) point out that peers and romantic relationships are referred to as a primary attachment figure only a quarter of the time As individuals progress through the adolescent phase, they spend more time with their peers. Peer groups support identity development through group norm role modelling and play a role in social status and emotional support (Chen et al., 2017). Adolescent behaviour is commonly influenced by friends’ behaviour, suggesting these relationships can either increase positive behaviours or risk behaviours and related outcomes, including the use of alcohol and drugs, and adolescent pregnancy (Animosa et al., 2018). School connections are defined as “the presence of supportive and caring relationships within schools” (Animosa et al., 2018, p. 53). Schools provide adolescents opportunities to interact with peer groups and build respectful adult-adolescent relationships and have been shown to influence adolescent self-concept and behaviour (Animosa et al., 2018; Ragelienė, 2016). These positive relationships have been found to be protective against pregnancy and risk behaviours, including substance use (Animosa et al., 2018; Chen et al., 2017; Moore et al., 2018; Ragelienė, 2016). Despite this, nearly 20% of BC adolescents report they do not have an adult to speak to about serious problems, and only 40% claim they feel connected to their community ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 8 (Province of BC, 2016). Adolescent-directed health services can improve community connectedness and decrease other risk factors in adolescent life (Foster et al., 2017). Sexual and Reproductive Health Risk and Protective Factors Poon et al. (2015) highlight that personal life experiences and social and economic conditions can affect sexual and reproductive health. Many adolescents engage in sexual risk behaviours resulting in adverse health outcomes. It is important to understand these risks and protective factors to enable the use of services that will reduce risks and improve health. In the BC adolescent sexual health survey, Poon et al. (2015) explored various aspects of sexual and reproductive health, identifying the following as major sexual risk behaviours: (1) sexual debut before the age of 15 years; (2) having three or more sexual partners in the past year; (3) not using a condom or other barrier method or at last sexual encounter; (4) not using contraception at last sexual encounter; (5) using alcohol or drugs before having sexual intercourse (Poon et al., 2015). It was also found that societal effects influenced sexual risk behaviours. School absenteeism has been linked to risky sexual behaviour, suggesting they may have fewer sexual educational opportunities and supportive adult relationships. Those frequently absent from school were less likely to use barrier methods during the last sexual encounter and were more likely to use alcohol or drugs before intercourse (Poon et al., 2015). According to the BC adolescent survey, 34% of sexually active adolescents had intercourse before the age of 15 (Poon et al., 2015). Furthermore, nearly half (46%) of sexually active gay males and 51% of sexually active bisexual males had their first experience before the age of 15. Comparatively, 49% of bisexual females and 56% of transgender adolescents had sexual intercourse before 15 years. These numbers highlight the need to support this vulnerable population more effectively. Boislard and Poulin (2011) also discovered that specific friendship ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 9 elements, including gender, age, and substance use, all impacted sexual debut. Adolescents with higher portions of opposite-sex friends and substance use are correlated with younger age of sexual debut. The authors also noted that first intercourse was delayed in the presence of positive parent-child communication and adolescent self-disclosure (Boislard & Poulin, 2011). According to Poon et al. (2015), adolescents who had intercourse before the age of 15 were more likely to have fewer friends and two or more sexual partners in the past year (33%). Among BC adolescents who have had intercourse, 20% had three or more partners in the past year, with males exhibiting this risk factor more frequently than females (21% vs. 19%). Those adolescents with three or more partners were more likely to reach sexual debut before age 15 and contract an STI. Of the adolescents with three or more partners in the past year, 9% had contracted an STI compared with 1% of adolescents with one sexual partner. STIs can have short- and long-term health effects, including infertility. Another risk factor for contracting an STI is the lack condom use or barrier method. Poon et al. (2015) found that 31% of adolescents in BC did not use a condom or other barrier method the last time they had intercourse, and 83% of adolescents did not use a barrier method the last time they had oral sex. Lack of barrier methods during oral sex may indicate that adolescents are unaware of STI risks involved with this sexual activity (Poon et al., 2015). The survey found that condoms were the most common form of contraception among young people aged 12-18 in BC (Smith et al., 2019). Oral contraceptives were the second most common form of contraception and were utilized in 48% of last sexual encounters. Of note, 10% of sexually active adolescents used the withdrawal method as their only contraceptive method, and 46% used this method the last time they had intercourse (Smith et al., 2019). Withdrawal not only does not protect against ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 10 STIs but with a failure rate of 20%, it is also a very ineffective form of pregnancy prevention (Jones, 2018). Poon et al. (2015) report that 24% of sexually active adolescents used alcohol or drugs before their last encounter, with 4% of 17-year-olds reporting sexual violence or assault after using substances. The use of alcohol or drugs before sexual interactions can significantly impact the appropriate use of contraception and hinders one’s ability to consent to sexual activities. Non-consensual sex was reported more commonly with older adolescents, with Poon et al. (2015) reporting up to 4% of 17-year-old adolescents experiencing sexual assault after substance use in the past year (vs. 2 % of 15-year-old adolescents). Among BC adolescents, access to medical help was limited for 6% of males and 10% of females when they felt they needed it (Poon et al., 2015). Health care access is a multidimensional concept that includes components of service availability, utilization, relevance, effectiveness, equity, and related barriers to access (Gulliford et al., 2002). The literature suggests that confidentiality is a key barrier for adolescents regarding health services (Bender & Fulbright, 2013; Shaw et al., 2016). In BC, adolescents identified barriers to medical help, including being seen by someone they knew and concerns regarding what the practitioner may say (Poon et al., 2015). Moreover, Poon et al. (2015) identified inconvenient clinic hours and transportation difficulties as obstacles adolescents face when seeking health services. The health survey further found that transportation options, including public transportation and hitchhiking, had negative implications for contraceptive access and increased adolescents' likelihood of not using contraception (50%; Poon et al., 2015). Contraception Accessibility. Across Canada, there are 39,000 unplanned adolescent pregnancies each year, with an associated cost of more than $60 million annually (Black et al., ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 11 2019). In The Ensuring Human Rights in the Provision of Contraceptive Information and Services document by WHO (2014a), it is proposed that unmet contraceptive needs are highest amongst vulnerable people, including adolescents, low-income, and rural populations. Contraceptive access is a human right that enables women to choose if and when to have children and provides greater control over their bodies and futures (WHO, 2014a). Adolescent pregnancy has a substantial impact on the social determinants of health and is associated with lower educational levels, job insecurity, and lower-income levels (Fleming et al., 2015; Patel & Sen, 2012). Social determinants of health include social and economic considerations such as income, education and employment and have significant individual and population health effects (Government of Canada, 2020). During adolescence, pregnancy can increase maternal anemia, preterm delivery, and postpartum hemorrhage (Kawakita et al., 2016). In a study by Fleming et al. (2015), the authors found that mood disorder rates are almost twice as high among pregnant adolescents when compared to adult pregnant women and nonpregnant adolescents. Mood disorders can have long-lasting adverse effects on maternal mental and physical health (Patel & Sen, 2012). In addition, children of adolescent mothers are more commonly hospitalized for respiratory, digestive, neurological, and infectious illnesses (Jutte et al., 2010). In BC, prescribed contraceptive methods to teenagers have decreased from 49% in 2013 to 46% in 2018 (Smith et al., 2019). As costs are a significant barrier to contraception, multiple Canadian organizations have called for no-cost contraceptive access in Canada, including the Canadian Paediatric Society (2019) and a joint call for action by the Canadian Association of Midwives, Action Canada, OXFAM Canada, and the National Aboriginal Council of Midwives (2019). These groups point out that consistent contraceptive use dramatically reduces the risk of unintended pregnancy and the provision of contraception reduces health care costs (Canadian ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 12 Association of Midwives et al., 2019). The Canadian Paediatric Society further underscores that adolescents are disproportionately affected by cost barriers and are more likely to utilize available methods at no cost, such as condoms. Black et al. (2019) argue that the use of longacting reversible contraception (LARC) such as intrauterine devices and subdermal implants has a 99% pregnancy prevention rate and can decrease the costs of unplanned adolescent pregnancies by up to $3 million (American Sexual Health Association, 2014). However, the upfront costs of these highly effective contraceptives make these options vastly unattainable for adolescents (Canadian Paediatric Society, 2019). Historically, Canada has had various programs to address contraceptive cost barriers, including government-run clinics and non-profits that offer low-cost or no-cost contraception. However, contraceptive options are frequently restricted due to budget constraints. The Canadian Medical Association and the Society of Obstetricians and Gynaecologists both propose that health care plans cover 100% of all contraceptive costs for all Canadian women through both provincial/territorial and federal funding. The Canadian Paediatric Society (2019) suggests this move could save $320 million in direct medical expenses related to unintended pregnancies. Existing restrictive policies may impede health services delivery based on age, sex, social status, disability, or other disparities and must be addressed. In Canada, most health care services are under provincial jurisdiction and thereby dictate how funds are disbursed. Provincially, the government can allocate funds for adolescent health and low-cost or free contraception, strengthening adolescent health. However, the federal government provides money through federal transfers and can significantly improve adolescent health. The federal government can place conditions on fund transfers to the provinces to achieve specific health goals (Government of Canada, 2014). Conditional funds could secure adolescent health resources and communicate ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 13 federal commitments to our future generations. Policies and procedures at the federal, provincial/territorial, and clinic-level can ensure adolescent-friendly health services are provided. The Canadian Paediatric Society (2019) proposes that legislative changes to ensure adolescents' confidentiality when accessing private family insurance plans are needed to decrease adolescent reproductive health barriers. Sexual Health Knowledge As adolescents become more aware of their sexuality, attractions, sexual orientation, and gender identity, they experiment with different roles (Stangor & Walinga, 2014). Adolescent sexual knowledge is established through adult-child interactions, including family knowledge and attitudes, school-based sexual education programs, the internet, and peers, significantly impacting sexual health and attitudes. According to a Canadian study by Black et al. (2018), adolescents most often use the internet (52.2%) to source sexual health information. Family practitioners were the second most used resource (48.8%), with friends next (44%), followed closely by schools (41%; Black et al., 2018). This study demonstrates that primary care providers (PCPs) continue to be a valuable source for health information among Canadian adolescents and raises concerns about the quality of the information provided through online sources. The Province of BC has a mandated sexual health program called Physical and Health Education, which incorporates sexual health concepts into the school curriculum (Province of BC, n.d., 2016). Sexual health education concepts that are offered by teachers through this curriculum, include healthy and abusive relationships, body image and gender identity, consent, contraception, and STIs (Province of BC, n.d.). Despite this, 15% of BC adolescents feel they are still not learning enough about sexual health, and a further 5% feel they would like to learn more ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 14 about gender identity and sexual orientation (Smith et al., 2019). In a Canadian study by Cohen et al. (2012), it was reported that although teachers support school-based health education, only portions of the sexual health curriculum are being taught. Factors influencing teachers' willingness to teach the sexual health curriculum include comfort and knowledge with specific sexual health topics, lack of sexual health education, community attitudes toward sexual education, and topics that conflict with personal beliefs (Cohen et al., 2012). These findings are echoed by a BC youth survey in 2017-18 that found a wide range of sexual education programing is provided in schools; while some include LGBTQ+ content, others provided little beyond heterosexual relationships (YouthCo, n.d.). Deficits in sexual health knowledge and teaching can lead to significant health risks, including unplanned or unprotected sex, increased risk of STIs, unintended pregnancy, and abortion (Manlove et al., 2015). Online health information can enhance adolescent sexual health knowledge and provide a comfortable environment to explore sensitive topics in private. However, the internet also contains unscientific and poor-quality health information that may hinder health (Tonsaker et al., 2014). Navigating online sources to find reliable information can be challenging, particularly for adolescent populations. PCPs have a greater ability to ensure adolescents have medically valid information that is communicated to fit their level of health literacy (Tonsaker et al., 2014). Despite this, a nation-wide Canadian study evaluating disadvantaged populations and providers working in the area of sexual health found that inconsistent sexual health education and limited, biased, and outdated practitioner practices are chief barriers to reproductive health (Hulme et al., 2015). Hulme et al. (2015) had several respondents reflect on the absence of unbiased and confidential providers for reproductive health services, resulting in the refusal to prescribe contraception or refer for abortion. The reluctance to prescribe often targeted specific ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 15 populations, such as adolescents, when these services conflicted with the practitioner’s values and beliefs. The authors recommend specialized reproductive services, including youth clinics, and piloting internet medical consultations for rural medical abortions to address these issues (Hulme et al., 2015). Mazur et al. (2018) also argue that providing services tailored to adolescents and having employees who are friendly, respectful, and non-judgmental are essential components for adolescent-friendly sexual and reproductive health services. What are Adolescent-Friendly Health Services? Adolescents experience physical, emotional, and intellectual changes as well as changes in expectations, social roles, and relationships, which creates unique health needs (WHO, 2014b, 2014c). Adolescent-friendly services improve client-provider relationships and continuity of care, which are essential for reproductive health (Ambresin et al., 2013; Daley et al., 2019; Lim et al., 2012; WHO, 2009, 2012). If services fail to meet adolescent needs or make them feel unwelcome and embarrassed, adolescents will seek other types of less effective interventions (WHO, 2009). WHO (2012) states that for health services to be considered adolescent-friendly, they must be: equitable, accessible, acceptable, appropriate, and effective. Equitability requires adolescent-friendly services for all adolescents and at the same level of care regardless of age, sex, ability or disability, social status, cultural or ethnic backgrounds (WHO, 2009). Accessibility, acceptability, and relevance highlight that these services are available to all adolescents and in ways that meet adolescent expectations and are tailored to the population’s needs. Community members, including parents, should be informed of services to promote accessibility. Moreover, clinic policies need to promote non-judgmental and considerate care that is low-barrier (easily available), including drop-in appointments and materials that are easy to understand. Kuzma and Peters (2015) and the BC Integrated Adolescent Services ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 16 Initiative (BC-IYSI, 2015) recommend adolescent-friendly exam rooms, flexible clinic hours, appointment times, and walk-in appointments as methods to increase accessibility, acceptability, and appropriate adolescent health services. It is vital that healthcare providers are knowledgeable and competent to provide adequate and effective care for adolescents (WHO, 2009). The Canada Health Act (1985) supports these five tenants of adolescent-friendly health services listed by the WHO (2012), advocating that Canadian healthcare should abide by five principles: the provision of publicly provided services, comprehensive, universal, portable, and accessible to all individuals. In recent years, BC has made significant efforts to provide more adolescent health services. In a policy framework released by the Province of BC (2016), the Ministry of Health advised the transformation of a health system focused on acute care, calling to establish integrated, comprehensive, and “wrap around” community-based services. This type of service is essential for adolescents, as noted in the BC-IYSI report in 2015, stating integrated health services build on health determinants, improving adolescent resilience and wellness. The report also proposes making services more accessible through locations near services commonly accessed by adolescents or through non-traditional access points, including educational sites. The province acknowledges that communities, health authorities, school boards, ministries, families, and adolescents need to work together to find positive ways to affect this population’s health and well-being (Province of BC, 2016). However, the province also emphasizes the importance of trialling innovative programs and evaluating and demonstrating success before these programs are expanded to other communities (Province of BC, 2016). ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 17 Adolescent Health Services Adolescent health services are commonly provided through community health centres and private practices, including family medicine clinics. PCPs strive to address the basic needs of health promotion, illness, and injury prevention, and diagnose and treat injuries and illnesses (Government of Canada, 2012). There are various sexual health services across BC, including adolescent-directed services both on and off school campuses. Most health clinic models involve comprehensive primary health care providing a variety of services. These services all attempt to respond to a variety of calls for action concerning adolescent health access. History of Adolescent School-Based Health Services in BC Historically, BC school health has mostly been a public health nurse (PHN) role, which began in the early 1900s with the School Medical Inspection Act (Green, 1984). The act stressed the need for adolescent health and provided one doctor's medical check-up to every adolescent in the province on an annual basis with PHN assistance. Green (1984) states that the PHN role quickly expanded to include independent screening for health and behavioural issues, controlling communicable and other contagious diseases, and providing health teaching within schools, including sexual and reproductive health (Green, 1984). The PHN role also extended to the home to provide health information and health guidance for families as a whole. PHN roles varied based on school board and medical inspector wishes and priorities identified by the PHN, allowing services to be tailored to each individual, family, and community. Since then, the PHN role has changed significantly, including removing PHNs from providing sexual health education in schools (Kirk, 2020), a service that supported adolescents in developing reproductive and sexual health knowledge. A BC-based study found that PHNs felt they lacked support, autonomy, and flexibility in practice, eroding PHN control, professionalism, and school ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 18 relationships (Kirk, 2020). The author suggests that provincial and organizational changes have altered the planning, funding, and delivery of PHN services, reducing and, in some cases, eliminating PHN programs, making it difficult to anticipate and respond to local health issues. A study of Vancouver school reintegration of PHNs into high schools illustrates the need for improved adolescent school health services, with one principal stating: ...now that she’s [the PHN] here, you realize that you’re probably just scratching the surface of our population here. Like her day is filled with students coming before school and staying after school here. I could probably double her time here and have her not sit around twiddling her thumbs. So it’s just now you kind of go, oh, gees, now that you know that demand--it’s hard not to justify wanting to advocate for more because you feel as though that would be good and appropriate use. (Saewyc et al., 2014, p.18) School-Based Health Clinics Schools are an innovative method for adolescents facing health barriers to receive needed health services directly and efficiently (Yau & Newton, 2013). SBHCs are defined as a clinic “that is located in or near a school facility that is organized through school, community, and health provider relationships and provides primary health services to adolescents provided by primary care providers and other health professionals” (Social Security Act, 2018). For this review, SBHCs are defined as clinics that provide health services to adolescents aged 13-18. Although SBHCs typically offer comprehensive health services, this integrative review will focus on sexual and reproductive health. While there is very little literature regarding SBHCs in Canada, within the United States, the total number of SBHCs has doubled over the last two decades, with a total of 2,584 SBHCs in 2018, which provide services to adolescents beyond the student population, including those ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 19 not attending school (Love et al., 2018). It is important to recognize that while school and health systems in the USA differ from those in Canada, the population, interventions, and health outcomes seen in the USA SBHCs are also relevant to Canadian adolescent populations. The WHO Global School Health Initiative (2017) stresses that school health programs must address equity issues and determinants of health and well-being. Health equity is an integral part of health care access and is defined as the absence of imbalanced and avoidable or remedial health disparities among socially, economically, demographically, or geographically defined population groups (WHO, 2020). School health clinics provide low-barrier access to birth control, STI testing, mental health support, and lifestyle counselling provided by various health practitioners, including doctors, nurse practitioners, public health nurses, social workers, and counsellors (Daley & Polifroni, 2018; Moradi, 2018). These services are provided in both the USA and Canadian SBHCs and have similar implications for risk behaviours and contraception use (Daley & Polifroni, 2018; Moradi, 2018; Shaw et al., 2016). Love et al. (2019) further indicate that 77% of schools with access to SBHCs receive government financial assistance (Medicaid) as they have high numbers of low-income families, thereby serving adolescent populations at the highest risk of poor health (Love et al., 2019). Shaw et al. (2016) also suggest that Canadian schoolbased health focuses on lower socioeconomic areas and those served by social assistance programs, similar to the USA’s publicly funded Medicaid program. Love et al. (2019) found that placing SBHCs in areas of greatest need improved health equity. According to Love et al. (2018), SBHCs work in various models, including in mobile locations or fixed sites on a school campus or clinics linked to the school but located near a school campus, as well as telehealth. Community needs and available resources determine services at each clinic. Some SBHCs prescribe and provide contraception, while other clinics ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 20 refer out for these services. This review will consider various sexual and reproductive delivery models and approaches, including critical components such as confidentiality, developmentally appropriate education, STI testing and treatment, provision of contraception including hormonal and non-hormonal contraception, pregnancy testing, and reproductive health exams (Santa Maria et al., 2017). Although this integrative review focuses specifically on sexual and reproductive health, a holistic view of adolescent health must be considered as mental and physical health are interconnected with sexual and reproductive health. Current Adolescent Health Services in BC There are various sexual health services across BC, including adolescent services both on and off school campuses. Most health clinic models involve comprehensive primary health care and provide a variety of services. These services respond to various calls to action on adolescent health access and equity. Primary Care Providers. In accordance with the Canadian Paediatric Society (2020), most adolescents see family practitioners through community clinics for ongoing health care. Even so, a 2014 study found that one-third of all adolescents do not have reproductive health included in their health maintenance visits (Alexander et al., 2014). When reproductive health does arise, only 3% of the appointment time is dedicated; however, conversations last, on average, only 40 seconds (Alexander et al., 2014). Family practitioners list several barriers to wholesome adolescent reproductive health maintenance, including lack of time, confidence, follow-up services, complexity of issues, and concerns regarding adolescent comfort (Burechailo & Collins, 2016). Foundry Network. The Foundry Network resulted from a proposal entitled: Transforming Access to Health and Social Services for Transition-Aged Adolescents. ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 21 This proposal called for the creation of health and social services throughout BC to provide adolescent and family services to individuals aged 12-25 years with mental health disorders (Foundry, 2018). The network proof of concept involved five health centres and found that nearly half of respondents surveyed stated they would not have accessed services elsewhere in the absence of a Foundry. Initially, the northernmost site was in Prince George; however, the network has since expanded to ten sites with one site further north than Prince George and more proposed (Foundry, n.d.). Even so, Foundry sites are only located in larger cities and regional hubs throughout BC, limiting adolescent access because of cost and transportation. Foundry Network clinics' goal is to transform adolescent health care through integrated adolescent service centres that provide a "one-stop-shop" setting for health services, including primary care (physical and sexual health), mental health and substance use services, social services, and peer support. Furthermore, these centres link to schools, communities, and social service organizations, easing adolecent's transition to adult services. Adolescents reported that these services were easy to access and had an adolescent-friendly environment (Foundry, 2018). The proof of concept also found that integrated care has significant benefits and warrants more integrated care initiatives for the adolescent population (Foundry, 2018). Options for Sexual Health. Options for Sexual Health is a non-profit society that provides sexual health services to over 60 locations across BC. The organization supports sexual health for all people, providing inclusive sexual and reproductive health care, information, and education (Options for Sexual Health, n.d.). The clinics are staffed by an array of health providers, including nurses, doctors, and trained volunteers. Services include low-cost contraception, STI screening, cervical cancer screening, pregnancy testing, sexual health counselling, and general sexual health information (Options for Sexual Health, n.d.). However, ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 22 many communities remain underserved by restricted operating hours or are without clinics, with some clinics only operating four hours a month (Options for Sexual Health, n.d.). SBHC in BC. Throughout BC, there are several SBHCs, including a clinic at Salmon Arm Secondary School that provides services to adolescents one day a week, and another at Nechako Valley Secondary School in Vanderhoof, providing weekly clinics to adolescents in this rural community. Furthermore, the South Island Division of Family Practice is actively involved in opening SBHCs, with three SBHCs open in this area. The John Barsby Secondary School Wellness Centre in the Nanaimo Lady Smith School District was their first endeavour, opening in 2016 in partnership with Island Health, First Nations community organizations, and other community groups (Moradi, 2018). This clinic is multidisciplinary, including nurses, child adolescent mental health workers, social workers, counsellors, and PCPs (Kenning & Devesa, 2016). Public health nurses provide pregnancy testing, low-cost birth control, and emergency contraception, while PCPs operate at a full scope, providing diverse services including assessment, diagnosis, and specialty referrals. The clinic is open four days a week, offering operating hours during and after school, Monday to Friday (Kenning & Devesa, 2016). These services complement other adolescent-friendly services within BC. This chapter has discussed the purpose of this integrative review and explored the main concepts involved to provide a background and support its subsequent stages (Torraco, 2016). The following section will discuss the methods used to select the articles included in this integrative literature review and answer the question: Can sexual and reproductive health care services delivered to adolescents within a high school-based primary care clinic improve BC adolescent sexual and reproductive health? HIGH SCHOOL CLINICS AND REPRODUCTIVE AND SEXUAL HEALTH 23 Chapter Three: Literature Search Methods An integrative literature review is undertaken to examine, critique, and synthesize the literature on a specified topic, organize current knowledge, and propose new perspectives and understanding (Torraco, 2016). This chapter will explore the research methodologies in this review, as guided by Torraco (2016). Torraco (2016) maintains that methods must be clearly described, including how the literature was selected, databases and the key terms used, literature inclusion or exclusion criteria, and literature analysis methods. This chapter will discuss these items in detail and expand on the analysis tool used, the Critical Appraisal Skills Program (CASP) tool. Database Selection and Search Terms The search for current, 2010-2020, peer-reviewed articles was conducted using the University of Northern British Columbia online library. Databases that were searched included CINAHL Complete, Medline (EBSCO), PubMed, and Women's Studies International. CINAHL Complete and PubMed have been utilized as they are large databases and contain current nursing and allied health literature. Medline using EBSCO was selected as a reliable source of full-text resources for medical journals. As pregnancy is intrinsically a gendered issue, the women's studies database: Women's Studies International was also searched. A focused search of Google Scholar was completed to include a variety of article types, including gray literature. In addition to database searches, resources were chosen from graduate study course work and literature reference lists. Each database was searched with similar terms; however, terms varied slightly due to the key terms utilized by each database. Boolean operators AND / OR were used to combine search terms. ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 24 The search process began with brainstorming alternate phrases for key search terms, including "adolescent," "teen pregnancy," "health promotion/services," and "school health" to obtain a broad search. The expansion of alternate phrases was aided by using "suggested subject terms" in databases and exploding them when applicable. Additional search terms were gathered by using subjects linked to articles found while searching the databases. Combinations of specific search terms such as: "sexual health" and "adolescent health services" resulted in severely limited results (less than 20); therefore, a broader search strategy was utilized. CINAHL Complete, a database containing nursing and allied health publications dating back to 1937, served as the literature search’s starting point. CINAHL was searched using CINAHL headings, including "adolescent medicine," "adolescent health services," "pregnancy in adolescence," "preventative healthcare," and "sexual health," as well as other variables and key terms (non-CINAHL headings). This search produced 316 articles before exclusion criteria were applied. The Medline using EBSCO was searched using MeSH headings and key terms (nonMeSH headings) with similar search terms used in the CINAHL database. Search terms included "adolescent," "school health services," and "sexual behaviour," resulting in a total of 29 sources. PubMed, a digital archive for life sciences literature at the National Institutes of Health, is a free and unrestricted source for health literature. This database has a unique search tool that generates comprehensive searches by enabling the searcher to enter key terms or concepts. The database then utilizes multiple tools and applies MeSH headings and key terms (non-MeSH headings) to produce a search. PubMed was searched using the term: “school based health clinics and adolescents and reproductive and sexual health,” the database then generated several related search terms used to obtain articles. The PubMed search-algorithm produced 323 articles. The ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 25 Women's Studies International database combines six databases and provides sources for women's studies literature. The database was searched using key terms as no specific headings were available to search this database and led to a total of 1,979 articles. Finally, Google Scholar was searched using the terms: "school-based health clinics" and "pregnancy prevention" and “adolescence” resulting in 107 articles within the date range described in the inclusion criteria. A full summary of the search process can be reviewed for each database in Appendix A. The process of excluding and including literature is also represented in a PRISMA flow chart (Figure 1). One reviewer completed the literature analysis for inclusion, which began with removing duplicate articles and reviewing abstracts. A total of 18 articles were selected for the final full-text review, with 10 meeting selection criteria for inclusion in this integrative review. Articles were excluded if they did not meet inclusion criteria, if they were unrelated to the research question, or had an inadequate quality of evidence as assessed using the CASP analysis tool. ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 26 Figure 1 Prisma Diagram Database and gray literature n = 2,758 Number after Date exclusion applied n = 2,135 Number Duplicates n = 275 Number after exclusion criteria applied to title and abstract review n = 28 Number of articles excluded per exclusion criteria and analysis after full article review n = 18 Total articles included in review n = 10 Inclusion and Exclusion Criteria The search was focused by applying inclusion and exclusion criteria. Articles were restricted to the English language, and adolescent age was set to 13-18 years as it is the accepted age range in several search databases. Searches were further restricted to industrialized countries, as non-industrialized populaces are less comparable to the Canadian population and challenges experienced concerning social determinants of health. Search results were further limited to articles dated between 2010-2020 and peer-reviewed literature to ensure current and evidencebased research. A full summary of the inclusion and exclusion criteria is provided in Table 1. ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 27 Table 1 Inclusion and Exclusion Criteria for Research Article Selection Inclusion Criteria Exclusion Criteria • Published between 2010-2020 • Published before 2010 • English Language • Not published in English • Reported data from Population ages 13-18 years • Exclusive focus on STIs • Human Subjects • Editorials, press releases, opinion articles • U.S.A, Canada, Europe, Australia, New Zealand • Brazil, Uganda, South Africa • Peer reviewed • Family-based education, school-based curriculums, or peer education • Mental health focus • Unpublished manuscripts • Expert opinion reviews Critical Analysis Torraco (2016) stresses that critical analysis is designed to deconstruct literature into basic elements and lays the foundation for critiquing articles. Critical analysis functions to identify the strengths and weaknesses of literature and expose knowledge taken for granted to help develop a more complete sense of the topic (Torraco, 2016). The quality of evidence was evaluated using the CASP checklist tool. This tool provides a standardized method to assess the trustworthiness, results, and relevance of studies to the research question (CASP, 2020a). CASP checklists provide a series of questions that screen each article for applicability to current research, as well as assess the research design, data collection, analysis, and implications of outcomes (CASP, 2020b). Utilizing a three-point rating system established by Feder et al. (2006), each article’s scores have been calculated (also see Duggleby et al., 2012; Norhayati et al., 2015). Each question in sections B and C of the CASP checklists is provided with a score between 1-3. A score of 1 (weak) is assigned to questions with poor explanations of the issue, including where, when, or how data was collected. A score of 2 (moderate) is applied for each question that addresses the issue but does not fully answer the question. Finally, a score of 3 (strong) is assigned to questions where the article provides broad ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 28 justification and explanation of the issue. A total of 24 or 36 points could be assigned to each article, as CASP checklists and the number of questions varied based on the type of research. Table 2 shows the critical analysis CASP rating and quality rating of each citation. Table 2 CASP Rating and Quality of Literature Author/Date Bersamin et al. (2018) Title Oregon school-based health centers and sexual and contraceptive behaviours among adolescents CASP Rating 29/36 Good Quality Fisher et al. (2019) Provision of contraception in New York City school-based health centers: Impact on teenage pregnancy and avoided costs, 20082017. 25/36 Good Quality Daley & Polifroni (2018) Contraceptive care for adolescents in school-based health centers is 21/24 essential!": The lived experience of nurse practitioners High Quality Daley et al. (2019) The essential elements of adolescent-friendly care in school-based 20/24 health centers: A mixed methods study of the perspectives of nurse Good Quality practitioners and adolescents Minguez et al. (2015) Reproductive health impacts of a school health centre Patel et al. (2016) Postpartum teenagers' views on providing contraception in school- 24/36 based health clinics Good Quality Sabharwal et al. (2018) Examining Time to Treatment and the Role of School-Based Health 31/36 Centers in a School-Based Sexually Transmitted Infection Program High Quality Shaw et al. (2016) Teen clinics: Missing the mark? Comparing pregnancy and sexually 31/36 transmitted infections rates among enrolled and non-enrolled High Quality adolescents Knopf et al. (2016) School-based health centers to advance health equity: A community 20/24 guide systematic review Good Quality Ran et al. (2016) Economic evaluation of school-based health centers: A community 21/24 guide systematic review High Quality 26/36 Good Quality A literature matrices in Appendix B have been provided to help organize articles and visually represent each article's main components, including sample, key findings, and weaknesses and strengths. Torraco (2016) suggests that literature matrices can help organize article key concepts and increase the readers' understanding of the literature and strengthen the author's findings. This chapter presented the methods used to search, select, and analyze ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS literature for this integrative review. In the following chapter, data analysis will continue by comparing related ideas in the included articles and identifying themes. 29 ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 30 Chapter Four: Findings Through an integrative literature review process guided by Torraco (2016), the question: Can sexual and reproductive health care services delivered to adolescents within a high schoolbased primary care clinic improve BC adolescent sexual and reproductive health? was developed and explored. As discussed in chapter three, a systematic search and critical analysis of literature were completed using CASP checklist tools. Upon completion of this process, 10 relevant articles were chosen as they discussed the specific intervention and population presented in the research question. Critical analysis of each study included in this review resulted in common patterns; this chapter will synthesize this data and present themes from the literature related to SBHC effectiveness. Review of the Literature The systematic search identified a limited quantity of high-quality literature on SBHCs. Moreover, Canadian sources were not well represented. Despite this, eight primary studies and two systemic reviews relevant to the BC context were included in this integrative review of SBHC services. The primary studies included quasi-experimental studies (n=6; Bersamin et al., 2018; Fisher et al., 2019; Minguez et al., 2015; Patel et al., 2016; Sabharwal et al., 2018; Shaw et al., 2016), qualitative studies (n=1; Daley & Polifroni, 2018), mixed methods studies (n=1; Daley et al., 2019). Of these, only one study was conducted in Canada (Shaw et al., 2016), the remaining seven were completed in the USA (Bersamin et al., 2018; Daley & Polifroni, 2018; Daley et al., 2019; Fisher et al., 2019; Minguez et al., 2015; Patel et al., 2016; Sabharwal et al., 2018). The systematic reviews (n=2) were both completed in the USA and explored the economic costs and benefits of SBHCS (n=1; Ran et al., 2016) and educational and health outcomes of SBHCs in disadvantaged adolescents (n=1; Knopf et al., 2016). The primary studies ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 31 included in this review investigated adolescent contraceptive use (n=3; Bersamin et al., 2018; Fisher et al., 2019; Minguez et al., 2015), use of reproductive health services (n=1; Minguez et al., 2015); impact on STI, pregnancy, birth and abortion rates (n=3; Fisher et al., 2019; Sabharwal et al., 2018; Shaw et al., 2016), provider and adolescent perceived perceptions and priorities of SBHC care (n=3; Daley & Polifroni, 2018; Daley et al., 2019; Patel et al., 2016), and health care costs associated with SBHCs (n=1; Fisher et al., 2019). Two of the primary studies compared lower-income and minority populations with higher socioeconomic status students (Bersamin et al., 2018; Shaw et al., 2016). CASP appraisal and quality assessment found the literature consisted of predominantly “good” quality articles (n=6; Bersamin et al., 2018; Daley et al., 2019; Fisher et al., 2019; Knopf et al., 2016; Minguez et al., 2015; Patel et al., 2016), with the remaining articles “high” quality (n=4; Daley & Polifroni, 2018; Sabharwal et al., 2018; Ran et al., 2016; Shaw et al., 2016). Literature matrices in Appendix B provide a full overview of the key elements of the included literature. Literature Themes Whittemore and Knafl (2005) argue that data analysis requires a constant comparison process to examine literature to identify patterns, themes, and relationships. To strengthen the organization, facilitate data analysis, and the development of topics, matrices were used for article information, including sample, methods, and outcomes. The data was then organized into types of research, and similarities in data were compared to support the development of topics. The literature analysis found a lack of consensus on SBHC services, making it difficult to compare the literature. More rigorous research on SBHC effects and outcomes is recommended. ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 32 Even so, the literature suggests that SBHCs can increase overall adolescent health and reduce risky health behaviours. Through the analysis process, the following themes were identified: 1) Stakeholder priorities and barriers to school-based reproductive health services 2) SBHC effects on reproductive health outcomes related to a. Contraceptive use b. Pregnancy/birth and abortion c. STI and high-risk behaviours 3) SBHC sexual and reproductive health services health equity and costs The remainder of this chapter will focus on expanding these themes from the analyzed literature. Stakeholder SBHC Priorities and Barriers WHO (2012) notes that stakeholder participation in the development, implementation, and ongoing evaluation of health services can improve systems to meet population needs. Stakeholders can include the Ministry of Health officials, health professionals, local organizations, and adolescents themselves. Two studies from the USA discuss stakeholder priorities and barriers, including a qualitative study from a PCP perspective (Daley & Polifroni, 2018) and a mixed-method study investigating PCP and adolescent perspectives (Daley et al., 2019). Daley et al. (2019) found, through consensus (0.75+), that SBHC priority elements were confidentiality, accessibility, flexibility, respectful staf and a comfortable atmosphere, diverse service provision, and school-clinic relationships. The PCPs deemed SBHCs an ideal setting to protect privacy and confidentiality, declaring that adolescents felt comfortable, accepted, and cared for, and the on-campus location made it easier for adolescents to access follow-up appointments (Daley & Polifroni, 2018). Daley et al. (2019) discovered in adolescent focus ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 33 groups that adolescents felt confidentiality and privacy were the most important components, followed by accessibility, respectful SBHC staff, range of services available, comfortable SBHC environment, and positive school-clinic relationships. Students indicated that the confidential relationships with SBHC clinicians and staff members facilitated open communication and increased access to reproductive services, remarking “whatever happens in Vegas, stays in Vegas – whatever happens there, stays there” (Daley et al., 2019, p.10). Minguez et al. (2015) quantified this finding in their USA population study, reporting SBHC intervention schools were more willing to access reproductive health service (80%, p<.001) when compared to schools without SBHCs (37%, p<.001). Daley and Polifroni (2018) further supported these findings on the importance of confidentiality, stressing that some adolescents declined to attend community agencies for fear of being seen by a parent or neighbour. Disrupting confidentiality can be farreaching, with the erosion of relationships extending to all health providers, not just those directly involved (Daley & Polifroni, 2018). The authors suggest that building trusting relationships eases confidentiality concerns, facilitates comfort, continuity of care and timely access to services. Daley et al. (2019) found that adolescents valued SBHC staff efforts in maintaining user privacy. These findings are further supported by the systematic review by Knopf et al. (2016) suggesting that adolescents are generally satisfied with SBHC care, and the establishment of SBHCs that supplement, rather than replace or duplicate community services, can improve the quality and acceptability of adolescent care. Students in a study by Daley et al. (2019) presented potential insufficiencies that compromised confidentiality and privacy, including thin clinic walls and small office sizes, and suggested making clinic rooms larger to mitigate this risk. ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 34 Surprisingly, none of the participants expressed reluctance to use the SBHC due to thse concerns (Daley et al., 2019). The accessibility and comprehensiveness of onsite services were emphasized by both Daley and Polifroni (2018) and Daley et al. (2019). One PCP highlighted the importance of integrating family planning into all health encounters stating, “…if they don’t need it now they may need it sometime in the future, and they will remember that we talked about birth control and that it is available here” (Daley & Polifroni, 2018, p. 370). The PCPs in this study also maintained that onsite provision of contraception was essential since adolescents had several barriers to obtaining contraception. One practitioner stated onsite provision of contraception had “taken away one of the big frustrations because I knew there were times a kid was never going to get over to the main clinic or pharmacy” (Daley & Polifroni, 2018, p.374). This finding was further confirmed by Daley et al. (2019) as adolescents in this study felt the most important health services at SBHCs were reproductive healthcare services that encompassed prescribing and dispensing medications, STI testing and treatment, and prevention education. For adolescents, accessibility incorporated positive environmental energy, an accessible location, flexibility in appointments, and services' availability (Daley & Polifroni, 2018; Daley et al., 2019). Although not all SBHCs are located within schools, adolescents felt these clinics removed transportation barriers for themselves and their parents; furthermore, students asserted that SBHC services were provided in fast and at convenient times that did not interfere with school responsibilities (Daley et al., 2019). Knopf et al. (2019) complement these findings arguing that onsite SBHCs have added benefits, including increased parental work time, reduced childcare, transportation time and costs. SBHC providers provided flexibility in follow-up ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 35 appointments, and students felt like active participants in their health decisions, increasing adolescent satisfaction and access to health services. Student participants reported feeling comfortable, respected, and listened to by clinic staff and valued the consistent relationships they did not find from other community providers (Daley et al., 2019). The authors concluded that trusting and comfortable relationships were essential to the adolescent experience of SBHC and had a significant impact on willingness to engage in services, continuity of care, and adolescent perception of privacy and confidentiality (Daley et al., 2019). Daley and Polifroni (2018) also prioritized the respectfulness of staff and clinic environments, observing that counselling and supporting the adolescent’s reproductive health decisions were priorities for PCPs at every visit. Practitioners stressed the significance of “being an askable provider” and “gaining a sense of trust,” thereby facilitating access to comprehensive services throughout high school (Daley & Polifroni, 2018, p.371). Although the development of trusting relationships takes time, Daley et al. (2019) propose that mechanisms that enhance continuity of care and distribute control are necessary. Because adolescents have unique development needs and are moving towards independence, health services need to be tailored to increase adolescent participation. The authors advise that staff working with adolescents need training, taking into account sexual and reproductive health, to tailor services to adolescents' diverse needs in a way that will involve them in care (Daley et al., 2019). Additionally, more research is essential to determine the effects of appointment times on adolescent-friendly care, the delivery of anticipatory guidance, and health outcomes. Despite the facilitators to reproductive health, practitioners also pointed out barriers to the provision of services in SBHCs (Daley & Polifroni, 2018). PCPs felt that stakeholder misunderstandings regarding adolescent reproductive health restricted the prescribing and ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 36 dispensing of contraception. For example, it is a common concern and misunderstanding of parents, schools, and communities that contraceptive services increase adolescent promiscuity and STIs (Daley & Polifroni, 2018). In addition, stakeholders, including parents, may not be familiar with the extent of SBHC services, further facilitating resistance. Daley and Polifroni (2018) remind us that an effective mechanism for building trust with the community and key stakeholders is to listen to and address concerns by supporting responses with appropriate evidence. From an adolescent point of view, students felt school policies and a lack of knowledge about SBHCs hampered their accessibility to reproductive health services (Daley et al., 2019). Students reported that not all school staff were well informed about their SBHC and available services, creating access barriers (Daley et al., 2019). Daley et al. (2019) argue that health care providers need to advocate for adolescent sexual and reproductive health rights, the provision of these services, and help eliminate policies and procedures that impede adolescent access. For example, students reported having to carry a hall pass if they wanted to go to the SBHC in a study by Daley et al. (2019), which obstructed clinic access. Posting of flyers and signs around the school and advising users of SBHCs to tell friends about SBHC services were listed as ways to increase student knowledge of the clinics (Daley & Polifroni, 2018; Daley et al., 2019). To address school staff knowledge and stakeholder buy-in and engagement, the authors suggested inviting teachers to tour the clinic and attending faculty meetings to educate them on available services. Overall, these results suggest that SBHCs can provide essential adolescent-friendly care elements, including accessibility, confidentiality, and the development of trusting relationships. ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 37 Reproductive Health Outcomes Six primary studies examined reproductive health outcomes including contraceptive use, pregnancy, birth, abortion and STI rates, and risk behaviours (Bersamin et al., 2018; Fisher et al., 2015; Minguez et al., 2015; Patel et al., 2016; Sabarwal et al., 2018; Shaw et al., 2016). Contraception. Providing contraception at SBHCs enhances access to services in an adolescent-friendly manner, strengthening prescribing, dispensing, and the effective use of contraception (Bersamin et al., 2018; Knopf et al., 2016; Minguez et al., 2015). Multiple studies show that school health clinics have higher contraception rates (Bersamin et al., 2018; Daley & Polifroni, 2018; Knopf et al., 2016; Minguez et al., 2015). Moreover, Minguez et al. (2015) and Fisher et al. (2019) suggest that contraception with lower failure rates, such as the patch, pill, ring, injectables and LARCs, were more likely to be used by students with access to SBHCs. In a USA study by Minguez et al. (2015), the use of hormonal contraception was higher in the intervention school (with an SBHC; 70%) compared to those in the non-intervention school (without an SBHC; 26%). Male users of SBHC at the intervention school were more likely to use condoms (70%, p<.000) versus nonusers (54%, p<.026) and comparison school students (52%, p<.026). Additionally, 80% of females and 41% of males who used SBHCs reported that SBHCs were their usual source of contraception (Minguez et al., 2015). Bersamin et al. (2018) reported comparable results with an increase of more than 30% in contraceptive use in SBHC schools than schools without SBHCs. Furthermore, the systematic review by Knopf et al. (2016) included two studies that found onsite contraception increased contraceptive uptake and reduced adolescent pregnancy rates. Pregnancy, Births and Abortion. The provision and correct use of contraception directly influences pregnancy, birth, and abortion rates. In a cross-sectional study of postpartum ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 38 adolescents, most participants felt that contraceptive education was not sufficient for pregnancy prevention (Patel et al., 2016). In this study, 82% of the postpartum adolescents favoured having contraceptive services within school clinics. However, 18% felt such services would not have changed their pregnancy outcome (Patel et al., 2016). Fisher et al. (2019) found that the provision of onsite contraception at SBHCs contributed to 28% of overall city decline of adolescent pregnancy (n=3,667), 28% of overall city decline of births (n=1,206), and 26% overall city decline in abortions (n=2,131) between 2007-2015, thereby decreasing associated health care costs. Other authors also reported reduced pregnancy and childbirth numbers with SBHCs (Knopf et al., 2016; Ran et al., 2016; Shaw et al., 2016). A large Canadian study (n= 181,444) examining pregnancy rates in adolescents not enrolled in school and students enrolled in school with and without SBHCs (Shaw et al., 2016). The authors found that the highest pregnancy rates occurred in non-enrolled adolescents and low-income areas (Shaw et al., 2016). Adolescents not enrolled in school represented 55% of total pregnancies, with a rate of 87.9 per 1,000 females. Students without SBHCs were often located in higher-income areas and had the lowest pregnancy rates (31.8 per 1,000 females). Although schools with SBHCs had a pregnancy rate of 42.8 per 1,000 females, they also accounted for higher percentages of low-income quintile geographical areas than those without SBHCs. Shaw et al. (2016) argue that although SBHCs reach high-risk populations, they do not adequately address unenrolled students’ health inequities. The authors suggest additional strategies need to be considered to support these individuals. STIs and Risk Behaviours. In a retrospective cross-sectional study examining students who tested positive for an STI (n=540) through a school-based education and screening program, Sabharwal et al. (2018) determined that onsite STI treatment was faster than if adolescents were ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 39 treated elsewhere. The diagnosis and treatment rate has implications for individual health outcomes, including fertility and STI transmission to other individuals. The study found that the average time to treatment at an SBHC was 17 days. Conversely, treatment from a community STI clinic was 28 days, and treatment elsewhere took an average of 47.5 days (p=<.0001). Although this study did not examine the reasoning behind the differences in treatment times, the authors suggest that the SBHC location and ease of access contributed to the reported results. Additionally, this assertion matches those seen by other studies discussed earlier in the chapter (Daley & Polifroni, 2018; Daley et al., 2019). Minguez et al. (2015) investigated the impact of SBHCs through a quasi-experimental cross-sectional research design exploring the effect of SBHCs on access, quality of services and student use. The authors found that SBHC groups demonstrated an increase in sexual health counselling, including contraception, compared to the control group, thus reducing risk behaviours. Moreover, it was concluded that SBHCs improved HIV and STI knowledge in these students compared to participants without access to an SBHC, suggesting that onsite clinics can decrease the risk of acquiring and transmitting STIs (Minguez et al., 2015). However, the data collected in this study need to be interpreted with caution since the attrition rate was substantial in both intervention (22.7%) and control groups (32.8%), exposing the study to bias and limiting generalizability. In keeping with the results found by Minguez et al. (2015), a Canadian study further strengthened these SBHC results in enrolled students (Shaw et al., 2016). However, Shaw et al. (2016) also examined STI rates among non-enrolled students finding this population had the highest rates. Of all STIs reported in this study, 48% were in students not enrolled in school (Shaw et al., 2016). Taken together, these studies outline that SBHCs have positive effects on reproductive health outcomes and the reduction of risk behaviours. ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 40 Health Equity and SBHC Costs Several of the included studies examined health equity and costs associated with SBHCs (Bersamin et al., 2018; Fisher et al., 2019; Ran et al., 2016; Shaw et al., 2016). Bersamin et al. (2018) and Shaw et al. (2016) highlight that SBHCs are often funded in areas with a greater number of high-risk and socioeconomically disadvantaged students, suggesting that SBHCs are a successful strategy for targeting reproductive health in populations at most need. This claim is further supported through the systematic review by Knopf et al. (2016) arguing that SBHCs can improve health equity because lower socioeconomic populations are the most common users of SBHC services. However, Shaw et al. (2016) state that SBHCs within high schools do not reach high-risk adolescents not enrolled in school. The authors advise that SBHCs can reduce the number of non-enrolled students by increasing academic outcomes, reducing dropout rates, and further recommend targeted health services for prevention and intervention in this population. Shaw et al. (2016) also suggest that working with other organizations, along with SBHCs to increase health services and continuity of care, will have a more significant impact on health at the population level. In the USA, Medicaid and collaborations with various agencies for service supports and grants are often utilized as funding mechanisms at SBHCs (Daley & Polifroni, 2018; Fisher et al., 2019; Ran et al., 2016). This system of funding can also be seen within the Canadian system, as discussed in this paper’s background. For students on Medicaid, obtaining and using contraception is subsidized; however, additional costs associated with copayments or fees continue to create barriers. Calls for free contraception, as discussed in chapter two, are reiterated by Daley & Polifroni (2018), with one practitioner expressing, “someday maybe we ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 41 will give it away for free or the laws will change so there will be no copay for birth control” (p. 374). Academically, SBHCs improve adolescent health status and health equity; however, economic implications need to be considered when providing these services. Ran et al. (2016) completed a systematic review of SBHCs across the USA, analyzing 21 studies on the cost and benefit of SBHCs. Both start-up and operating expenses were considered, as well as avoided health care costs and productivity. The authors found a wide range of operational and start-up costs depending on renovations necessary to develop the clinic, the number of services and users and the number of hours of operation and type of clinicians on staff. The authors determined that provider costs accounted for the bulk of operating expenses (Ran et al., 2016). Despite this, it was concluded that SBHCs contribute to economic, societal, and healthcare payers (including Medicaid and patients) benefits that outweigh SBHC costs (Ran et al., 2016). At the patient and parent level, the authors found that SBHCs avoided treatments due to health care access bariers, loss of productivity, and transportation costs. In addition, it is concluded that SBHCs contribute substantial savings to the public system. Multiple American studies identify that Medicaid, a low-income assistance program that pays for medical expenses (US Department of Health & Human Services, 2015), is commonly used by SBHC populations (Bersamin et al., 2018; Daley & Polifroni, 2018; Fisher et al., 2019; Ran et al., 2016). These program services are comparable to social assistance programs within Canada. In a New York City study, Fisher et al. (2019) determined that Medicaid covers most adolescent births and pregnancies and that SBHCs supply accessible reproductive services that avoided substantial public health and Medicaid costs. Both Knopf et al. (2016) and Ran et al. (2016) conclude that a reduction in emergency department use is also seen with SBHC services’ introduction. Knopf et ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 42 al. (2016) included seven articles that found SBHCs that provided a range of four or more services resulted in the most significant reduction in emergency department use (Median reduction of 25.1%). Daley et al. (2019) advise that continued research of SBHC impact on adolescent health and education is vital for the continued growth and adaptation to meet patient population needs. Data on types and numbers of nationally visited SBHCs are needed to expand and increase funding for these services (Daley et al., 2019). These integrated review findings suggest that SBHCs can provide adolescents with appropriate reproductive health and increase adolescent involvement in health services. Despite this, strong quality research remains limited. The next step in this review is to synthesize the findings to generate new ways of thinking (Torraco, 2016). Chapter five will discuss recommendations for future practice and research, and explore limitations and biases that may impact this integrative review. HIGH SCHOOL CLINICS AND REPRODUCTIVE AND SEXUAL HEALTH 43 Chapter Five: Discussion and Recommendations Torraco (2016) contends that literature synthesis builds upon critical analysis to create new ways of thinking. This chapter will discuss the themes discovered in this paper’s findings section regarding the research question: Can sexual and reproductive health care services delivered to adolescents within a high school-based primary care clinic improve BC adolescent sexual and reproductive health? Reducing barriers to adolescent sexual and reproductive health is complex; however, the literature on SBHCs has been applied to in the cotect of BC populations and proposes practice recommendations for primary care providers. Finally, areas of future research and limitations of the literature review will be offered. Synthesis of Findings Findings from the review of 10 articles, as presented through three major themes, found that SBHCs improve adolescent reproductive and sexual health, prevent STIs, and increase health equity. The three themes found in Chapter four were: 1) Stakeholder priorities and barriers to school-based reproductive health services 2) SBHC effects on reproductive health outcomes related to a. Contraceptive use b. Pregnancy/birth and abortion c. STI and high-risk behaviours 3) SBHC sexual and reproductive health services health equity and costs SBHCs and Sexual and Reproductive Health Access The findings of this integrated review show that adolescents face various obstacles when accessing health services. The provision of adolescent-friendly services, including through SBHCs, can reduce these barriers and increase health access and health professional interaction. ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 44 Many elements affect access to services, including confidentiality, clinic staff, the range of services offered, transportation limitations, and clinic hours of operation (Daley & Polifroni, 2018; Daley et al., 2019; Knopf et al., 2016). Health services that are accessed by adolescents in BC are not free from these barriers. As noted in this paper’s background, access to Options for Sexual Health clinics is limited by hours of operation and the lack of clinics in many communities. Foundry Network clinics offer inviting environments for adolescents; however, access to these clinics is often limited due to barriers associated with transportation. Community clinics may be limited, particularly in smaller communities, by the risk of being seen by family or family friends in waiting rooms. Moreover, community clinics often do not adapt services to the unique needs of adolescents. PCP training regarding these needs can increase the practitioner’s ability to provide effective care and decrease the chance of missing important adolescent developmental health needs (Daley & Polifroni, 2018; Daley et al., 2019; Shaw et al., 2016). Confidential and respectful clinic staff as well as shared decision-making is essential to adolescents and can determine if they engage in sexual and reproductive health services (Daley & Polifroni, 2018; Daley et al., 2019). Discussing psychosocial elements, including home, education and employment, peer group activities, drugs, sexuality, and suicide and depression during clinic appointments can increase communication and feelings of respect and address developmental needs. Having a presence inside the school beyond the clinic can help to build trusting relationships and enable students to get to know practitioners. Reproductive health is a crucial element of adolescent health; however, it also has associations with many other health components, including mental and physical health. Adolescent health clinics utilized as primary medical homes increase the centers’ ability to provide provider continuity, supportive and ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 45 respectful relationships, and comprehensive services. This idea of “wrap around” service is also advocated for by Canadian literature in the background of the paper. Furthermore, the provision of holistic, comprehensive care removes equity and access obstacles adolescents encounter for all health services. Finally, findings in this review establish that the clinic environment and stakeholders have considerable impacts on the provision of sexual and reproductive health services (Daley & Polifroni, 2018; Daley et al., 2019; Ran et al., 2016). Misconceptions about adolescent sexual and reproductive health can limit services; conversely, partnerships involving community members, agencies, adolescents, and parents can inform service needs and improve access. Education and collaboration with stakeholders are important to increasing adolescent services. Concerns regarding the confidentiality and competence of providers are raised in the background and findings of this paper. Providing provider education can support PCPs in contraceptive prescribing and the provision of adolescent care. Furthermore, linkages with community agencies and school staff can be sources of referrals, and partnerships with community health services can ensure continuity of care by providing accessible health services to adolescents, even when the SBHC is closed. Moreover, SBHCs that are jointly operated through partnerships between hospitals, schools, and partner agencies increase the range of expertise and resources. This stakeholder involvement also aids in providing equitable, accessible, acceptable, appropriate, and effective services for adolescents, as discussed in the background. SBHC funding is often a concern; therefore, it is essential to address sustainability and financing as part of community dialogue. Moreover, to reduce barriers, clinical environments need to be developed to provide care in an adolescent-friendly manner. These barriers are unique ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 46 to each community and require evolving strategies to address issues; therefore, ongoing assessment opportunities are vital. SBHCs and Sexual and Reproductive Health Outcomes The review of the literature has emphasized the importance of contraceptive prescribing and dispensing at SBHCs. Multiple authors found that students were more likely to use contraception properly when they received them at SBHCs (Bersamin et al., 2018; Knopf et al., 2016; Minguez et al., 2015). The immediate provision of contraceptives has a clear impact on the likelihood of adolescents obtaining contraception. Regardless of the health access point, contraceptives must be readily available. However, contraceptive costs remain a major barrier, particularly the most effective forms of contraception, such as LARCs. This paper’s background and findings sections advocate for no-cost contraception (Canadian Paediatric Society, 2019; Canadian Association of Midwives et al., 2019; Daley & Polifroni, 2018). Although the findings emphasized the importance of providing contraception at SBHCs, it also established that contraceptive misconception limits practitioner prescribing (Daley & Polifroni, 2018), reinforcing the need to engage and educate key stakeholders. Advocacy and engagement in these areas promote awareness and highlight the importance of adolescent sexual and reproductive health. Both the Canadian and USA literature included maintain that the prescribing and dispensing of contraception in SBHCs improve adolescent health through the reduction of pregnancy, birth, and abortion rates (Fisher et al., 2019; Knopf et al., 2016; Ran et al., 2016; Shaw et al., 2016). However, the findings suggest that students not enrolled in school do not have the same level of benefit from SBHCs (Shaw et al., 2016). As discussed in the background, not all SBHCs are located at schools, and those that are, may offer services to those not attending ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 47 school, which could be a method to engage these students in health and educational services. Increased accessibility reduces the barriers to follow-up care and has significant implications for health education, risk behaviour management, and STI screening and treatment. Moreover, diversity in the provision of adolescent health services can help meet the needs of a broader range of adolescents, making the exploration of innovative options for adolescent-friendly care important. SBHCs and Health Equity and Costs Health equity and costs associated with SBHCs were further highlighted in the included literature and an important consideration in implementing any health initiative. SBHC services target marginalized and socioeconomically disadvantaged populations (Bersamin et al., 2018; Fisher et al., 2019; Knopf et al., 2016; Ran et al., 2016; Shaw et al., 2016). As noted in the background, these populations have the greatest sexual and reproductive risk factors and have the greatest individual gain and impact on health resources. Ran et al. (2016) reported a wide range of costs associated with the initiation and running of SBHCs. This paper’s background also notes that clinic locations and services may vary according to needs and resource availability, highlighting the need for clinics to be community/population-focused. Community focus is also vital for funding, collaborations with various community partners, including school districts and health authorities, and the utilization of quality improvement initiatives to enhance SBHC sustainability. Knopf et al. (2016) and Ran et al. (2016) suggest that economic benefits of SBHCs are a result of multiple elements, including increased uptake in preventative services, contraceptive use, and prenatal care, as well as the decrease in emergency department and hospital admissions, and health risk behaviours. The reduction of sexual and reproductive risk behaviours, including adolescent pregnancy, birth, abortion and STIs, have compounding ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 48 impacts across the lifespan and society. SBHCs within these areas in BC can create the most significant cost savings for the public system. Recommendations for Practice Although the SBHC model does not suit all circumstances and adolescent populations, the articles cited in this review support health clinic integration of SBHCs. SBHCs are in line with Canada Health Act tenants and should be used to supplement current health services in BC to increase health care access and education as well as appropriate contraceptive use and reduce unwanted pregnancies. Furthermore, the literature supports consideration in expanding or adjusting current health services to meet adolescent health needs (Knopf et al., 2016; Shaw et al., 2016). Table 3 presents practice recommendations gathered through the analysis of literature and suggestions for implementation. Table 2 Practice Recommendations Recommendations for Practice Suggestions for implementation Supporting Literature Increase adolescent access to sexual and reproductive health services through adolescent-friendly environments and services and the formation of respectful, trusting staffadolescent relationships • Bersamin et al., 2018; Daley & Polifroni, 2018; Daley et al., 2019; Knopf et al., 2016; Minguez et al., 2015; Patel et al., 2016; Ran et al., 2016; Sabharwal et al., 2018; Shaw et al., 2016 • • • • Formation of SBHCs in communities/schools of greatest need through needs assessment Ongoing assessment of adolescent health care barriers through community needs assessment and stakeholder feedback Expansion or adjustment of current services to ensure adolescent-friendly environments Implementation of adolescent-friendly procedures at community providers and other agencies providing health services for adolescents Implement strategies that encourage continuity of care and comprehensive services, including: o Transportation supports: If the health center is not on school grounds, implement a mechanism to facilitate safe transportation from school to the health centre o Linking SBHCs with other community clinics to ensure students have access to service beyond SBHC hours of operation SBHCs as Primary Care homes o Offer SBHC services to student beyond those attending that school o Hours of operation are to be accessible to the target population, and the ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS • • • Increased contraceptive accessibility provision of clinic services during times the SBHC is closed should be arranged and clearly communicated o Assessment of psychosocial elements of adolescent health by utilizing a tool such as HEADSS (BCCH, n.d.) o Assess sexual and reproductive health into all adolescent health visits and provide comprehensive services, including education, guidance and assessment, pregnancy testing, pre/postnatal care, contraceptive prescribing and dispensing, and STI screening and treatment Provide patient-centred care and shared decision making by providing clear communication of educational resources and all treatment choices to reduce power imbalances o Encourage adolescents to express opinions, feelings, and preferences regarding care decisions Recognize the leadership role PCPs possess; advocates for policy change that supports adolescent sexual and reproductive health, including supportive school, healthcare, and government policies. Acknowledge and adhere to professional responsibilities regarding confidentiality • • • Community and stakeholder partnerships, engagement, and education 49 • • • • • • • Dispensing of all forms of contraception onsite/ in office SBHCs as primary care homes Recognize the leadership role PCPs possesses; advocate for policy change that supports adolescent sexual and reproductive health including supportive school, healthcare, and government policies. Educate stakeholders (including community members) regarding the need for evidencebased adolescent sexual and reproductive services Offer stakeholders opportunities to raise concerns through public meetings Collaborate with stakeholders (including adolescents) to identify priority sexual and reproductive health needs to determine services offered in each clinic and aid in the creation of supportive policies o Yearly evaluation through annual needs/resource assessments – including feedback from both clients and other stakeholders Posting flyers around the school to increase student awareness of clinic services Develop partnerships to enhance sustainability and funding Link SBHCs with community clinic to increase accessibility Attend school faculty meetings and offer clinic tours to increase knowledge and Bersamin et al., 2018; Daley & Polifroni, 2018; Daley et al., 2019; Knopf et al., 2016; Minguez et al., 2015 Bersamin et al., 2018; Daley & Polifroni, 2018; Daley et al., 2019; Knopf et al., 2016; Ran et al., 2016; Shaw et al., 2016 ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS • 50 engagement regarding clinic services and changes in these services Identify a colleague mentor to support ongoing improvements in provider adolescent-friendly care and contraceptive knowledge support Recommendations for Further Research The analysis of the literature presented several areas of focus that are needed to understand SBHC benefits fully. Literature included various definitions and services provided regarding SBHCs; however, research must be completed comparing more heterogeneous adolescent health services. Furthermore, better descriptive information on the components of SBHCs being evaluated and populations’ attributes are required for optimal program assessment, design and targeting. The impact on hours of SBHC accessibility, service comprehensiveness and school employee relationships with the clinic will help stakeholders allocate health funds in the most effective manner. The sustainability of SBHCs within the public system is a significant concern for key stakeholders. Although several studies have shown positive economic outcomes, funding sources for SBHCs are often through grants and other precarious funding sources. Further exploration into sustainable and innovative funding sources, such as collaborations between different sectors, including health, educational, and community partnerships, is needed. Additionally, research on the long-term effectiveness of SBHCs, including academic achievement, income, and health, can help obtain more secure sources of funding. Additionally, much of the literature has focused on SBHCs regarding minority, lowincome and high-risk populations in urban settings and older adolescents. Studies, including more diverse populations, are needed to understand the effects of SBHCs fully. The background of this review indicated that there are several SBHCs in BC. However, only one Canadian research article was included due to a lack of Canadian literature investigating SBHC outcomes. ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 51 Most of the literature found was from the USA, of which has substantial differences in their health care system, for example, private versus public insurance and contraceptive options, including implantable contraception, which is limited in Canada (Island Sexual Health, n.d.). This makes the generalizability of these results more difficult as the populations may experience differences in access and barriers. Further research is needed with a Canadian population focusing on a wide variety of ages, genders, races, and ethnicities to enhance understanding of the impacts and applicability of SBHCs in Canada. Within Canada, individuals living in rural communities generally have poorer health outcomes and socioeconomic status than urban residents (Province of BC, 2016). Rural community members face additional barriers in accessing health care, among them the scarcity of services, particularly specialized services, financial constraints, poor internet, stigma, discrimination, and concerns regarding confidentiality and transportation (Douthit et al., 2015; Province of BC, 2016). To use SBHCs in rural communities, these factors, and different models, including telehealth, need to be explored to understand their applicability and effects on health. Research Limitations Integrative literature reviews help guide clinicians and policymakers by providing comprehensive information from numerous studies, defining gaps in knowledge, and areas for further research. However, bias can occur at any stage of the integrative review, including study design, data collection, and analysis (Pannucci & Wilkins, 2010). Assessing researcher bias is vital to avoid nonobjectivity and provide an effective critical assessment of the findings. To help avoid these biases, the study was guided by the University of Northern British Columbia (2018) document and Torraco (2016) to support structured methods, including vital components and organizational strategies. Despite this, several limitations to the integrative review findings exist. ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 52 Gaps in Literature As noted earlier in this paper, much of the literature is based in the USA, because of this, the internal validity of the findings based on the BC population is limited. It is important to point out that the impacts of SBHCs on sexual and reproductive health in the BC population cannot be based solely on this integrated review. Furthermore, although SBHCs should be community and population-focused, the literature lacked heterogeneity of SBHC definition, services, providers, and roles, making it difficult to compare outcomes. The quality of the literature found for this review contained various gaps and methodological deficits that could increase potential biases. Some studies included were short in duration (Bersamin et al., 2018; Minguez et al., 2015; Patel et al., 2016; Sabharwal et al., 2018), contained a small number of participants (Daley & Polifroni, 2019) or had a significant amount of attrition (Minguez et al., 2015), potentially impacting the validity of results and statistical power. Moreover, many studies were quasiexperimental and lacked randomization of participants. A purposive sample was used in two studies (Daley & Polifroni, 2018; Daley et al., 2019), raising concerns that segments of SBHC user experiences were not captured. Focus on methodological aspects, including clear sample collection, numbers, and definitions of SBHCs, services, providers, and roles in future studies, would help strengthen research results and recommendations. Other Considerations and Limitations The overall lack of literature reporting on the effectiveness of SBHCs on sexual and reproductive health further limited this literature review. Although this review involved a nonexhaustive search of databases, broader searches among various areas of study are needed to ensure that all data has been explored. Data synthesis bias may be diminished by using the CASP ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 53 Appraisal Tool that assessed each article's level and quality, ensuring a standardized and systematic assessment. Finally, as the sole writer of this integrative review, my personal beliefs and biases must be recognized. It is important to consider that in previous roles, I have worked with the adolescent populations most likely to benefit from SBHCs. Acknowledgement and personal reflection of how this could impact my interpretation of results has been considered throughout the research process. To limit bias, the research process has been guided by Torraco (2016), ensuring clear documentation of methodologies and the use of a standardized assessment tool (CASP tool) to help to increase objectivity and systematic evaluation. Furthermore, support from my supervisory team provided valuable quality checks and guidance throughout the research process. HIGH SCHOOL CLINICS AND REPRODUCTIVE AND SEXUAL HEALTH 54 Chapter 5: Conclusion According to WHO (2009), for many sexually active adolescents, “reproductive health services, such as the provision of contraception and treatment for sexually transmitted infections, either are not available or are provided in a way that makes adolescents feel unwelcome and embarrassed” (p1). This integrative review was completed to answer the research question: Can sexual and reproductive health care services delivered to adolescents within a high school-based based primary care clinic improve BC adolescent sexual and reproductive health? The paper highlights the barriers experienced by adolescents and provides innovative evidence-informed solutions to addressing health equity and access to adolescent and reproductive health. Key findings from this integrated review found that confidentiality, provider approach, and accessibility of services significantly impacted adolescent health service access. Furthermore, SBHCs must be population and community-focused, making facilities and services provided by clinics unique to each community. The literature suggests that SBHCs can reduce access barriers and health care costs while increasing population health, especially among socioeconomically disadvantaged groups. With the ability to increase contraception use, health education, and shared health decision-making, SBHCs can help adolescents' transition into the adult role as healthy members of society. 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Sex ed is our right! http://d3n8a8pro7vhmx.cloudfront.net/youthco/pages/1943/attachments/original/1536258 468/SexEd_Reportfinal.pdf?1536258468 HIGH SCHOOL CLINICS AND REPRODUCTIVE AND SEXUAL HEALTH 69 Appendix A: Search Strategy Literature Search of CINHL Complete Search # Search Term used 1 Adolescent Medicine OR Adolescent Health OR Adolescent Health Services OR School health Services OR school based health centers (keyword) Adolescence+, pregnancy in adolescence+, adolescence None (keyword), teenager (keyword) Preventative Health Care OR Community Health services OR None maternal Health service OR School Health nursing OR school health OR school health services, OR Sexual Health OR reproductive health OR Contraception OR none Hormonal Contraception, Or Contraceptives, Oral combined OR Family planning 1 OR 2 and 3 and 4 Date 2 3 4 5 6 Limits applied None Number of Results 528,930 Date Searched (mm-dd-yyyy) 07-12-2020 535,265 301,472 12,490 316 185 Removal of duplicates 9 Literature search of Medline using EBSCO Search # Search Term used 1 5 Adolescent") OR (MH "Adolescent Medicine") OR (MH "Adolescent Health Services") OR (MH “Adolescent Health”) OR (MH "Adolescent Health") OR (MH "Pregnancy in Adolescence") OR (MH “Students”) “adolescence” (keyword), “teenager” (keyword) (MH "School Health Services+") OR (MH "Schools, Public None Health") OR (MH "Community Health Centers") OR "school based health center" (keyword) (MH "Primary Health Care") OR (MH "Primary Care Nursing") None OR (MH "Delivery of Health Care") OR (MH "Comprehensive Health Care") (MH "Sexual Behavior") OR (MH "Reproductive Behavior") OR None (MH "Health Risk Behaviors") OR (MH "Family Planning Services") OR (MH "Reproductive Health Services") OR (MH "Contraception") OR (MH "Hormonal Contraception") OR (MH "Contraception Behavior") OR (MH "Sexual Health") 1 and 2 and 3 and 4 None 6 Date 2 3 4 Limits applied None Number of Results 2,072,370 30,967 168,882 94,303 29 12 No duplicates Date Searched (mm-dd-yyyy) 07-12-2020 ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 70 Literature Search of PubMed Search # 1 Search Term used School: "educational status"[MeSH Terms] OR ("educational"[All Fields] AND "status"[All Fields]) OR "educational status"[All Fields] OR "schooling"[All Fields] OR "education"[MeSH Terms] OR "education"[All Fields] OR "school's"[All Fields] OR "schooled"[All Fields] OR "schools"[MeSH Terms] OR "schools"[All Fields] OR "school"[All Fields] based: "based"[All Fields] OR "basing"[All Fields] health: "health"[MeSH Terms] OR "health"[All Fields] OR "health's"[All Fields] OR "healthful"[All Fields] OR "healthfulness"[All Fields] OR "healths"[All Fields] clinics: "ambulatory care facilities"[MeSH Terms] OR ("ambulatory"[All Fields] AND "care"[All Fields] AND "facilities"[All Fields]) OR "ambulatory care facilities"[All Fields] OR "clinic"[All Fields] OR "clinic's"[All Fields] OR "clinical"[All Fields] OR "clinically"[All Fields] OR "clinicals"[All Fields] OR "clinics"[All Fields] adolescent: "adolescences"[All Fields] OR "adolescency"[All Fields] OR "adolescent"[MeSH Terms] OR "adolescent"[All Fields] OR "adolescence"[All Fields] OR "adolescents"[All Fields] OR "adolescent's"[All Fields] reproductive: "reproduction"[MeSH Terms] OR "reproduction"[All Fields] OR "reproductions"[All Fields] OR "reproductive"[All Fields] OR "reproductively"[All Fields] OR "reproductives"[All Fields] OR "reproductivity"[All Fields] sexual health: "sexual health"[MeSH Terms] OR ("sexual"[All Fields] AND "health"[All Fields]) OR "sexual health"[All Fields] Limits Number of applied Results Date 323 2010-2020 Date Searched (mm-dd-yyyy) 07-13-2020 Literature Search of Women Studies International Search # 1 2 Search Term used Limits Number of Results applied Adolescence and Adolescent health or adolescent health 1,979 services or preventative health care or community health services and school health nursing and Sexual health Date 269 Removal of duplicates 254 Date Searched (mm-dd-yyyy) 07-12-2020 Google Scholar Search # 1 2 Search Term used Limits applied "school-based health clinics" and "pregnancy prevention" none and “adolescence” Date Number of Results 350 107 Excluded Duplicates 12 Date Searched (mm-dd-yyyy) 07-12-2020 Study Design and Data Collection Sample/ Context Intervention Conditions Study Period: 2015 Bersamin, M., Study focus: Explore Study design: Sample: Conditions: Paschall, M.J., & the association Quasi-experimental School districts and 74% of SBHC Fisher, D.A. (2018) between SBHC, schools were prescribed sexual behaviour and Data collection randomly sampled contraceptives Oregon schoolcontraceptive use method and time 51.9% of SBHC based health among 11th graders points: SBHC N= 3,555 prescribe and centers and sexual Use of the Oregon No SBHC N= 8,285 dispense and contraceptive Setting: High School Healthy Teens (OHT) contraceptives behaviours among survey in 2015 – surveyTotal N= 11,840 Country: voluntary and Eleventh graders adolescents Oregon, USA anonymous from 134 high (administered once) schools (27 with SBHCs) Descriptive analyses and multilevel Mean age: 16.6 regression analyses conducted Gender: 51.5% female Survey response rate 87% (n=11, 840) Authors, Date, and Study Focus and Title Setting Primary Studies Strengths/ Weaknesses 71 Findings suggest that exposure to SBHCs in general, and Among SBHC schools, prescribing and dispensing contraceptives onsite was positively related to contraceptive use among students who had sex within the past 3 months (OR = 1.77, p < .01). Question: Strengths: SBHCs will have a more • Controlled for substantial effect on Adolescent school-level Sexual Reproductive Health (1) characteristics in schools with a greater • Large sample proportion of low-income students and or a higher Weaknesses: percentage of minority • Cross-sectional data adolescents and (2) at the making it difficult to individual level among lowermake causal income adolescent and/or inferences regarding minority adolescent SBHC effects Outcomes: • Differences between Multilevel logistic regressions SBHC services no found positive associations accounted, e.g., between SBHC presence and provision of condoms healthy sexual behaviour (OR = vs prescription 1.23, p < .05) and contraceptive contraception use (OR = 1.31, p < .01). • Limited to Grade 11 students – may limit Associations were stronger at generalizability schools with at least 50% of • Sample attrition – students receiving free or potentially impacting reduced-price lunch. outcomes of study Key Outcomes and Results Appendix B: Literature Review Matrix HIGH SCHOOL CLINICS AND REPRODUCTIVE AND SEXUAL HEALTH availability of specific reproductive health services are effective population-based strategies to support healthy sexual behaviours among youth. 72 Fisher, R., Danza, Study Focus: Study Design: Sample: Conditions: Question: Strengths: P., McCarthy, J., & Evaluate the impact of Quasi-experimental SBHC N= 84,401 SBHCs staffed by What is the impact of increasing • Accounted for nonTiezzi, L. (2019) increased availability counterfactual method nurse practitioners or availability of and access to onSBHC RHP and accessibility Comparison group physician assistants, site contraceptive services at contraceptive Provision of contraceptive services Data Collection (non-SBHC RHP) some staffed by SBHCs has had on contraceptive methods and contraception in through SBHCs Method(s) and Time N= Not listed physicians use among sexually active demographic New York City including public Points: Utilized - Offer primary care female adolescents in NYC, and differences school-based health costs, publicly available local Age: 15-19 services consequently on city wide • Large sample health centers: reductions in data and program- Can 3rd party bill, adolescent pregnancies, births, Weaknesses: Impact on teenage pregnancy, birth, and specific data Gender: Female including Medicaid and abortions from 2008-2017? • Many data sources pregnancy and abortions - NO out of pocket Outcomes: including primary avoided costs, Adjusted for population costs for services Higher levels of moderatelydata sources or 2008-2017. Setting: High School (female) when possible regardless of most effective contraception use combined primary insurance status. in SBHC RHP clients than those data analysis with Country: Estimate of averted methods in the non-SBHC RHP data estimates from New York City, USA events among SBHC Increase in the group (49-64% vs 10-16%) studies resulting in was based on provision of hormonal potential calculation contraceptive methods contraception noted Estimated number of events error dispensed/used by over period of study averted: • Estimated sexual clients and the with 36/44 SBHCs Pregnancies N= 5,376 activity was contraceptive method providing Births N= 2,104 consistent throughout authors estimated these contraception in 2008, Abortions N= 3,085 the year clients would have used to 75/75 SBHCs in • Assumed SBHC if not had access to the 2016-2017 Citywide Declines clients used center (counterfactual - SBHC RHP contributed a dispensed comparison). 28% decline in pregnancies in contraception for full NYC residents aged 15-19 school year – SBHC contraceptive between 2007-2015 potential to methods gathered from - a 28% decline in Births and over/underestimate the SBHC 26% decline in abortions in outcomes Reproductive Health NYC residents aged 15-19 • Comparison group N Project (RHP) clinical between 2008-2015 not listed data. • Limited Time points: 2008Costs avoided - 2008-2017 generalizability of 2015 - 1,908 avoided births would results have been covered by Medicaid Non-SBHC representing $29,468,401in contraceptive methods avoided public health costs ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS - 2,379 avoided abortions that would have been covered by Medicaid representing $891,951 in public costs 73 Minguez, M., Study Focus: Study Design: Sample: Conditions: Question: Strengths: Santelli, J.S., Examines the impact Quasi-experimental SBHC N= 2,700 - SBHC staffed by Is there an increase the • Survey questions Gibson, E., Orr, M., of a New York City No SBHC N= 1,316 full-time adolescent willingness of students to use previously validated & Samant, S (2015) public (SBHC) Data Collection Total N= 4,016 medicine trained the SBHC for reproductive • Results controlled for providing Method and Time physicians or NN, health care, reproductive health gender, ethnicity, and Reproductive comprehensive Points: Age: not listed. mental health education, and contraceptive sexual experience health impacts of a reproductive health, Pre-tested 64 item – Grade 9-12 students providers, and health counseling and use of • Used 2 statistical school health by measuring paper and pencil educators contraception in comparison methods (Interaction centre students' willingness questionnaire modeled Gender: - Primary care and with a similar NYC high school Method and to use the SBHC for after the 2007 NYC SBHC 46.5% reproductive health without a SBHC? Stratification these services, receipt Youth Risk Behaviour female services provided Method) Outcomes: of reproductive health Survey Non-SBHC 37.6% Students in the SBHC were Weaknesses: education and Time Point: Sept 2009 Female more likely to report receipt of • Baseline data not contraceptive health care provider counseling collected before counseling, and use of Response rates: Grade 9 students and classroom education about students had access contraception - SBHC school served as Baseline reproductive health and a to SBC 77.3% (N=2087) research subjects; willingness to use an SBHC for • Small sample size Setting: High School - No SBHC 67.2% returning students reproductive health services. • Limited sample for (N=884) (grade 10-12) had contraception use Country: New York varying years of Use of hormonal contraception • Attrition bias City, USA Study Period: 2009 SBHC intervention measured at various time points • Self-report data bias evaluating effects over exposure (first sex, last sex, and ever • Recall bias past 1,2 and 3 years Study Period: Nov 2008- June 2017 Contraceptive failure rates calculations based on 2006-2010 National survey for Family Growth NYC DOHMH Bureau of Vital Statistics for teen pregnancy, birth, and abortion data Time points: 20072015 used the NYC Youth Risk Behaviour Survey Time points: 2009. 2011, 2013, and 2015 ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS Study Period: Not stated Gender: Female Age: 31-64 years (Mean 52.3) Daley, A., Polifroni, Study Focus: Study Design: Sample: E. (2018) Explore the lived Qualitative research Purpose stratified experience of NPs sampling Contraceptive care providing Descriptive for adolescents in contraceptive care to phenomenological NPs recruited school-based adolescents in SBHCs method through statewide health centers is to better understand (Connecticut) essential!": The the issues influencing Data Collection SBHC contact list lived experience of contraceptive access Method and Time nurse practitioners to adolescent Points: Inclusion criteria: Open-ended interviews English speaking Setting: High School until saturation of licensed NPs that themes worked in a high Country: school SBHC for Connecticut, USA Interviews were audio- minimum 1 year recorded and transcribed N= 12 Comparing students in the nonintervention school to SBHC nonusers and SBHC users, found stepwise increases in receipt of education and provider counseling, willingness to use the SBHC, and contraceptive use. Most students in grades 10-12 using contraception in the SBHC reported receiving contraception through the SBHC. used) was greater among students in the SBHC. 74 Conditions: Question: Describe the lived Strengths: Descriptive • Approved by a experience of nurse practitioners phenomenological review board (NPs) providing contraceptive open-ended care to teens in SBHCs in hopes • An initial pilot study interviews beginning to shape health completed with: Outcomes: • Stratified sampling “Please explain the 3 themes emerged: • Interviews continued experience of (1) Contraception is an essential until saturation of providing part of care for adolescents themes contraceptive care to using SBHCs Weaknesses: adolescents in (2) There are many hurdles to • Purposive sampling – SBHCs. Describe negotiate, e.g., SBHC policies may not capture all your experiences, restricting contraceptive experiences thoughts, feelings, services; adult misconceptions regarding the and perspectives until regarding teens and sex – provision of you have no more to contraceptive access will contraception to say. You are welcome increase teen sex; Lack of teens in SBHC to provide clinical awareness of SBHC services; examples to illustrate confidentiality concerns your experience. (3) Practitioners are torn There are no correct between proving care needed or incorrect answers.” and what they can legally provide according to health Probes to continue statutes and restrictions they conversation were encountered from school district used as needed policies or parental exclusions ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS Daley, A., Polifroni, Study Focus: E., & Sadler, L Identify essential (2019) elements of adolescent-friendly The essential care in SBHCs from elements of the perspectives of adolescent-friendly NPs providing the care in schoolcare and adolescents based health receiving these centers: A mixed services methods study of the perspectives of Setting: Adolescent nurse practitioners SBHC and adolescents Country: USA 75 Sample: Conditions: Questions: Strengths: NPs Recruited Quantitative Strand: 1) What does an expert panel of • Diversity in sample through professional NPs asked to respond NPs identify as the essential and SBHC sites organizations and to question: elements of providing • Evaluated two personal contacts “What are the adolescent-friendly health care perspectives of Data Collection essential elements of services to teens in SBHCs? essential elements of Method: Adolescents providing adolescentadolescent-friendly Quantitative strand recruited through friendly care in 2) What is the adolescent care in SBHCs (phase 1): purposive sampling school-based health perspective on the essential • Clear research Delphi technique to elements of adolescent-friendly centers?” questions and establish consensus NPs N= 21 health care services specific to - Rounds 2-3 methods from panel of NPs on Attrition of 1 NP panelists were asked SBHCs? Weaknesses: essential elements of Adolescents N= 30 their level of • Purposive sampling adolescent-friendly care 3) How do the perspectives of agreement of each • Limited at SBHC. Age: element (1 = strongly NPs and adolescents intersect generalizability to 4 Panelist Rounds NPs: Not reported disagree; 5= Strongly regarding the essential elements populations beyond Adolescents: 13-19 agree) of adolescent-friendly care in those the Qualitative strand Mean age 16.5 SBHCs? - Rounds 3-4, Northeastern region (Phase 2): panelists were asked Outcomes: of USA Multiple-category focusGender: to consider remaining 1) Confidentiality/Privacy, • Adolescent answers groups with adolescents NPs: elements in terms of accessibility, clinician/staff, were based on NP Total of 6 focus groups 100% female group response and SBHC clinical services, SBHC determined essential with 3-8 Adolescents: make changes as environment, and relationship elements of SBHCs individuals/group 43.3% female desired between school and SBHC 56.7% male (Consensus  0.75 level Data was audio Qualitative Strand: [N=200]) recorded and Focus group questions transcribed verbatim were generated from 2) Confidentiality/Privacy into Atlas.ti7, and phase 1. (32%); Accessibility (18.7%); analyzed using content - adolescents were Clinicians/staff (14%); types of analysis provided 5 dots, and services offered/provided able to place dots (14%); SBHC environment Mixing of quantitative based on importance (14%); Relationship between and qualitative data or value of each school and SBHC (8%) (Phase 3): “essential element” Data from each found in phase 1 and 3) Shared Perspectives: previous phase was briefly explain the Confidentiality – what happens compared and element. Participants in the SBHC stays there and the contrasted through were able to allocate importance of a private setting: connected analysis as many of their dots Accessibility - services available to each item as they when needed and are flexible Study Period: saw fit. SBHC services – Mental health Not Reported and reproductive care Study Design: Mixed methods Qualitative and Quantitative ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS Relationship with school and SBHC – Need to work collaboratively 76 Sabharwal, M., Study Focus: Study Design: Sample: Conditions: Question: Strengths: Masinter, L., & Examines whether Quasi-experimental Schools recruited Testing and STI Do school-based STI screening • Clear research Weaver, K. (2018) students who tested Retrospective Cross- for SB STI education located on programs improve time to question positive for STIs in a sectional study screening via a high school campus treatment? • Considerable sample Examining Time to school-based verbal presentation size Outcomes: Treatment and the screening program Data Collection to school's principal Mass education Overall, 540 students had Weaknesses: Role of Schoolhad differing times to Method and Time and SBHC staff through 20 min video positive results. • Research does not Based Health treatment based on Points: that teaches about 427 had chlamydia (79.1%), 59 identify why SBHC's Centers in a treatment location Time to treatment of 42 schools bacterial and viral had gonorrhea (10.9%), and 54 were able to provide School-Based students who tested participated STIs had dual infections (10.0%); 144 faster follow-up, only Sexually Setting: High School positive and received were tested in a school with a hypothesizes in Transmitted treatment was Schools with SBHCChicago Department SBHC on site (26.7%). discussion Infection Program Country: Chicago, measured from the date N = 7 of Public Health • Limited USA contacted STI positive generalizability Patel, P.R., Huynh, Study Focus: Study Design: Sample: Conditions: Question: What are the Strengths: M.T., Alvarez, C.A., Explore opinions of Quasi-experimental Approached in the Interview surveys opinions of post-partum • Approval from a Jones, D., Jennings, postpartum teenagers A cross-sectional study postpartum unit conducted face-toadolescents regarding having review board K. & Snyder, R.R. in Texas regarding of postpartum teens (within 5 days of face by principal contraceptive services available • Teen perspective (2016) offering contraceptive delivery) at the John investigator and in in high school clinics • Large sample services in SBHCs Data Collection Sealy Hospital private Outcomes: Weaknesses: Postpartum Method and Time (Galventon, Texas) 82% (332 participants) were in • Only explored teenagers' views on Setting: Hospital/ Points: Upon completion of favour of having contraceptive postpartum teenagers' providing High School Interview Survey – 18 N= 404 (95%) interview respondents services at school clinics opinions on contraception in multiple choice were reimbursed for contraception school-based Country: questions regarding Mean Age: 17 +/- 1 their time Of the 18% that were not in • Condoms not health clinics. Texas, USA socio-demographic year favour of contraceptive services included in background, pregnancy For statistical at SBHCs, most of these contraception options history, contraceptive Gender: Female analysis, marginal individuals felt it would not for this study history, sexual and testing was done have made a difference • Limited contraceptive education using regarding pregnancy generalizability as Fisher's Exact Test, sample only from Study Period: while multivariate In multivariate modeling, factors one hospital in Texas July 2013-July 2014 testing was based on a associated with more than one logistic regression pregnancy: older age, young age model and standard of sexual debut, marriage Chi-square coefficient test. Contraceptive education is not enough to prevent teen pregnancy ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS Treatment for STIs after diagnosis was faster in SBHC compared to adolescents that were treated elsewhere (47.5 days, P<0.0001) 77 Shaw, S. Y., Metge, Study Focus: Study Design: Sample: Conditions: Hypothesis: Strengths: C., Taylor, C., Compare pregnancy Quasi-experimental All adolescents in Teenagers classified (1) adolescents not enrolled in • Large sample size, Chartier, M., and positive STI rates Retrospective Manitoba enrolled as not enrolled in school will have higher STI and making results Charette, C., Lix, L., between three groups: population-based study in high school, or school were those generalizable pregnancy rates than in- school. . . PATHS Equity adolescents enrolled not with continuous with no enrolment adolescents, as pregnancy has • Collection of data Team (2016) in schools with Data Collection health coverage record each year, been shown to be associated and analysis is school-based clinics, Method and Time between 2003-2010 excluding students with school drop out clearly outlined Teen clinics: adolescents enrolled Points: graduating in the year (2) that STI and pregnancy rates • Attempted to address Missing the mark? in schools without PATHS data Resource SBHC School of interest, or in the in schools with clinics will be several confounding Comparing school-based clinics files: Students years prior to the year higher (lower) than schools elements, e.g., pregnancy and and adolescents who 1. Manitoba Health N= 26,223 of interest. without clinics, as clinics were stratification for sexually were not enrolled in Insurance Registry, in schools in “higher needs” wealth transmitted school demographic No SBHC School Students in schools areas • Attempted to avoid infections rates information Students that did not have recall bias with the Outcomes: among enrolled Setting: High School 2. Hospital Abstracts, N= 123,154 Grade 12 were also (1) Non-enrolled adolescents use of administrative and non-enrolled which contain excluded data had higher STI and Pregnancy adolescents SBHCs were in areas information on all Not Enrolled in rates Weaknesses: of “high need” hospitalizations School Adolescents Students who (2) STI and Pregnancy rates • Did not address all (including birth) in N= 32,067 transferred schools were lower in schools with variables (e.g., STI Country: Manitoba, Manitoba mid-year were SBHCs when compared to those rates) 3. Medical Services, Total N= 181,444 excluded Canada without SBHCs • Lacks details of the information on impacts of SHC and ambulatory physician Age: 14-19 Pregnancies were Non-enrolled adolescents were adolescent-directed visits in Manitoba defined with a more likely to reside (40%) in services Gender: previously published . Students tested for patients advising them Of the 483 students who STIs N= 6,915 to follow-up with received treatment (89.4%), health provider those treated at a SBHC had a Data was analyzed Student's tested + faster time to treatment using SAS version 9.3 for STI N=540 compared to STI clinics (median to assess descriptive 17 days versus 28 days, statistics of the sample, Mean Age: 17 respectively, p<.001). and median time to treatment for both Gender (tested + For students testing positive in groups of students for STI): the Chicago school-based STI 68.5% female program, time to treatment is Study Period: 31.5% male accelerated in locations with Oct 2012-June 2013 SBHCs. of the test to date of treatment. ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS Study Period: 2003-2009 4. Cadham Provincial SBHC: Laboratory 51% female 5. Statistics Canada 49% Male Census information, use to determine area- No SBHC: level income, 51.1% Female 6. Social Assistance 48.9% Male and Management Information Network, Not Enrolled in information on all School: individuals and families 55.1% Female receiving provincial 44.9% Male Employment and Income Assistance. 7. Child and Family Services Information system, include information Manitoba children and their families receiving child welfare services, including in-home services and out-ofhome placements. 8. Education data, Enrollment, Marks, and Assessment data for all high school students in Manitoba schools including information on special education needs and funding. Study SBHC implementation is successful at targeting high-risk populations STI Rates - Non-enrolled 47.6% - SBHC 15.5% - No SBHC 36.8% low-income quintile area, receive child welfare services (4.5%), and have a history with child welfare services (41%). All STI tests are Non-SBHC students were least performed at the likely to reside in low-income Cadham Provincial areas, receive child welfare Laboratory we were services or have a history of able to define positive involvement in child welfare STI cases as positive services laboratory tests for chlamydia, gonorrhea, -Low-income areas had higher or syphilis pregnancy rates compared to high income areas Pregnancy Rates - Non-enrolled 55.3% - SBHC 10.1% - No SBHC 34.5% administrative case definition using hospital abstracts ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS • • Participants not randomized Difficulty in comparing SBHC as services varied among SBHCs 78 Study Focus and Setting Study Design, Data Collection and Quality Assessment Sample Intervention Conditions Key Outcomes and Results Strengths/ Weaknesses 79 Ran, T, Study Focus: Study Design N=22 15 studies reported on Question: What are the Strengths: Chattopadhyay, S., Evaluates the Systematic review costs of SBHCs economic costs and • Costs and expenditures were Hahn, R. A., & economic cost and 17 peer-reviewed benefits of SBHCs? adjusted to 2013 US dollars Community Guide benefit of SBHCs Data Collection journal articles 10 studies reported on Outcomes: to ensure comparability of the Systematic Review Method: benefit of SBHCs studies SBHC benefits outweigh (2016) Country: Databases N=7 3 non-journal - 3 societal • costs and area effective and USA PubMed, EconLit, articles were perspective efficient setting for health Weaknesses: Economic - Northwest (5) ERIC, JSTOR, Social reports on cost and - 4 Medicaid care delivery • Only 2 studies reported startevaluation of - Northeast (6) Sciences Citation benefit of SBHCs perspective - Operation costs range up costs school-based - Midwest (2) Index, databases at the - 2 patient perspective from $16,300 – • Only 4 studies reported # of health centers: A - Southeast (2) Centre for Reviews & Studies evaluated - 1 from both societal $659,684 per year per SBHC users – creates community guide - Whole USA (7) Dissemination at the SBHCs providing and Medicaid SBHC potential error when systematic review University of York, services to students perspective - Major operation cost evaluating per user costs and Google Scholar pre k-grade 12 driver was salaries and 3 studies reported on benefits (80-90% of Quality Assessment both cost and benefit of operation costs) SBHCs Information on study SBHCs contribute methods, results and economic benefits to interpretation was Society, healthcare payers abstracted following (e.g., Medicaid) and the Community Guide patients systematic economic - Societal perspective: review methods total annual benefit per SBHC between $15,028Study Period $912,878 Literature collected - Societal Benefit-cost from Jan 1985- Sept ratio ranged from 1.38 – 2014 3.05 - Patient level: included Analysis conducted in averted treatment, lost 2014 productivity, and transportation costs - Health payer perspective: SBHCs are related to net savings to Medicaid between $30- Authors, Date, and Title Systematic Reviews HIGH SCHOOL CLINICS AND REPRODUCTIVE AND SEXUAL HEALTH Decrease in Medicaid and hospitalization cost in the presence of SBHCs $969/visit and $46-1,166 per person 80 Knopf, J.A., Finnie, Study Focus: Study Design: N=46 - 23 studies assessed Question: Strengths: R.K.C., Peng, Y., Explore the Systematic Review SBHC whole-school How effective are SBHCs • Clear SBHC definition and Hahn, R.A., effectiveness of 32 studies effects by comparing in improving the research question Truman, B.I., SBHCs on Data Collection published after all students in SBHCs educational and health • Search strategy provided Vernon-Smiley, M.,educational and Method: 2000 with all students in outcomes of disadvantaged • Inclusion/exclusion criteria Johnson, V.C., health outcomes of Databases N= 8 non-SBHC settings (14 students? clearly presented, but only Johnson, R.L., disadvantaged PubMed, Embase, 4 studies published studies) or students in Is intervention explored health and Fielding, J.E., students CINAHL, ERIC, before 1990 schools before and effectiveness affected by: educational databases Muntaner, C., Hunt, Google, NTIS, Web of after the - Extent of services • Described level of evidence P.C., Phyllis Jones, Country: Science and WorldCat Predominantly implementation of - The focus of SBHC on in primary studies C., & Fullilove, Articles from USA urban context SBHCs (8 Studies); specific health issues • Review results were M.T. (2016) (45) and New Quality Assessment: 10 studies one study included - Availability of services transparent Zealand (1) 2 Reviewers conducted in mixed both comparisons. by time and proximity Weaknesses: School-based independently rural and urban or - Demographic • Methodologic limitations of health centers to evaluated each study suburban areas - 17 studies assessed characteristics of individual studies: lack of advance health SBHC user–only population served randomization (selection bias) equity: A Disagreements were 26 studies effects by comparing - Services offered by • Few studies adjusted for community guide resolved through evaluated high users with non- users SBHCs background health differences systematic review consensus school SBHC within SBHC schools - Out of pocket costs vs no • SBHC effects may have been (8 studies) or SBHC cost to student under/overestimated because Information on study 1 study evaluated users with users of Outcomes: evaluators did not obtain methods, results and middle school health- care sources in SBHC improve educational baseline data interpretation was SBHC non-SBHC settings (9 and health-related abstracted following studies). outcomes in disadvantaged standard Community 7 studies evaluated students, therefore can be Guide criteria methods pre-k or elementary - 4 studies assessed effective in improving school SBHC both whole-school and health equity Study Period: SBHC user–only Literature collected 12 studies assessed effects. SBHCs improved from first available combinations of contraceptive use among dates to July 2014 grade levels - 2 studies compared females, decreased SBHCs - 1 comparing childbirth and improved Analysis conducted in an SBHC with onsite prenatal care 2014-15 contraceptive services with an SBHC without Onsite access to onsite contraceptive contraceptives was services and the other associated with increased ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS comparing an SBHC contraceptive uptake and before and after reduced pregnancies implementation of onsite contraceptive More services and more services—thus hours of availability evaluating the including outside of school effectiveness of the hours was associated with contraceptive services greater reductions in ER use ADOLESCENT REPRODUCTIVE HEALTH AND SCHOOL CLINICS 81