Can Dispensing Hormonal Contraceptives On-site in School-Based Health Centers Improve Use of Contraceptives among Young Females? Jill Daniels, RN, MS, Melanie Zimmer-Gembeck, PhD, & Linda Doyle, MPH Multnomah County Health Department & Oregon Health Sciences University Portland, Oregon

ABSTRACT Objectives. To determine if a policy to begin dispensing hormonal contraceptives (birth control pills, Depo-Provera injections, and Norplant) on-site in six school-based health centers (SBHCs) improved initiation and consistent use of hormonal contraceptives. Methods. Patterns of selection of hormonal contraceptives were compared between two cohorts of females attending urban high schools housing SBHCs. The first cohort accessed SBHC family planning care the school year before a policy to dispense was established. The second cohort accessed SBHC family planning care the school year after the implementation of this policy. Results. Dispensing hormonal contraceptives on-site in SBHCs was associated with earlier initiation of hormonal contraceptives and consistent selection of hormonal contraceptives for a longer period of time. Conclusions. This study demonstrated that high school age females who want to use hormonal contraceptives access care from SBHCs more regularly, select these contraceptives sooner and select these methods more consistently if the clinics in their schools can dispense hormonal contraceptives on-site. However, a substantial proportion of females discontinued family planning care after one visit or never selected hormonal contraceptives while receiving care.

SBHC HISTORY & TIMELINE Feb 1986: First high school SBHC opens with dispensing of ALL contraceptive medication prohibited.Clients received prescriptions for contraceptives, but filled them at other locations. 1987: 3 more high school SBHCs open. 1990: 3 more high school SBHCs open . Mar 1992: One school district approves condom dispensing for STI prevention in high schools. Mar 1994: A survey of students and parents identified parental support for clinic services and dispensing of contraceptives. Feb 1996: On-site dispensing of hormonal contraceptives begins at high school locations for one school district (six high schools). Currently: SBHCs operate in coordination with 3 school districts with one elementary school location, four middle school locations, and seven high school locations.

Strategy to Gain Approval for Dispensing On-Site in High School SBHCs County Health Department commitment Parent support School board support Board of County Commissioners leadership and support Consistent messages from SBHC staff

2. select methods of hormonal contraception more consistently? To investigate whether on-site dispensing of hormonal contraceptives improved patterns of selection of hormonal contraceptives (birth control pills, Depo-Provera injections, and Norplant) among females receiving family planning care in SBHCs. STUDY GOAL Compared to females who received family planning care at SBHCs in a school year BEFORE dispensing, did females who received care in the same SBHCs in a school year AFTER dispensing 1. select methods of hormonal contraception sooner during family planning care? 2. select methods of hormonal contraception more consistently? STUDY QUESTIONS STUDY SETTING Females receiving family planning care at six high school SBHCs in a mid-sized urban area of the Northwestern United States were included. All SBHCs had been in operation for 8 years or more. DATA SOURCE Health Department Health Information System (HIS) data based upon the client visit record (CVR) developed by Ahlers and Associates was the source of information. The CVR is used in over 400 clinics in 19 states. As part of the CVR, health care providers code the contraceptive method reported by clients at the beginning of family planning visits and selected by clients at the end of family planning visits. The primary method of contraception was coded.

SAMPLE & COHORT SELECTION We identified all females from the HIS who had at least one family planning visit at the 6 SBHCs early in the school years of interest. BEFORE DISPENSING: Sept 1, 1994 to Dec 1, 1994 called the “Before Cohort” AFTER DISPENSING: Sept 1, 1996 to Dec 1, 1996 called the“After Cohort” We selected data on all family planning visits at SBHCs for these two cohorts of females for the entire school years of interest (July 1, 1994 to June 30, 1995, and July 1, 1996 to June 30, 1997). The Before Cohort included 804 females. The After Cohort included 915 females. Next, we selected a subgroup of females who were most likely candidates for newly selecting methods of hormonal contraceptives and received at least two family planning visits during the school year. This included 355 females from the Before Cohort (44%) and 378 females from the After Cohort (41%). So, we excluded females who -reported use of hormonal contraceptives at their first family planning visits (38% of the Before Cohort, and 39% of the After Cohort ) -had only one family planning visit (18% of both cohorts) -were abstinent (6% of the Before Cohort , and 10% of the After Cohort, p<.01) -and were members of both cohorts (n=27; 4%).

Contraceptive Selections (Table 1) RESULTS Demographics, Use of Family Planning Care, and Cohort Differences Mean age was 16.3. There were no age differences when comparing the Before and After Cohorts. Race/ethnicity was diverse including 58% White, 26% Black, 7% Asian descent, 5% Hispanic, 2% Native American, 2% did not have a race/ethnicity recorded. There were no cohort differences when comparing race/ethnicity. The mean number of family planning visits was about 4.7 visits for both cohorts. The mean number of days from first to last family planning visits was about 155 days for both cohorts. Contraceptive Selections (Table 1) About 53% of females selected oral contraceptives at the end of at least one of their family planning visits, 36% selected hormone injection, less than 1% selected hormone implants, 17% selected condoms and foam, 54% selected condoms only, and 35% selected no method of contraception. Some selections differed by cohort.

Patterns of Visits, Selection of Hormonal Contraceptives, and Consistent Selection (Figure 1) For descriptive purposes, we provide detail of numbers of visits, when females first selected hormonal contraceptives, and consistent selection of contraceptives in Figure 1. Figure 1 displays proportions of females within each cohort who first selected hormonal contraception, had not selected hormonal contraception, and who were consistent and inconsistent selectors of hormonal contraception for up to 6 family planning visits. This figure illustrates that a higher proportion of females in the 96-97 cohort selected hormonal contraceptives at their first visit (24% vs. 17%), and a higher proportion of females who received family planning care in 96-97 consistently selected hormonal contraceptives at each visit.

EARLIER SELECTION AFTER DISPENSING? We expected it would take fewer days and fewer family planning visits for the After Cohort to first select hormonal contraceptives when compared to the Before Cohort. It did take fewer days and visits for the After Cohort to first select hormonal contraceptives. The After Cohort took 40 days (2.2 visits), while the Before Cohort took 57 days (2.5 visits) to first select hormonal contraceptives (p<.001 for both). Females in the After Cohort were also more likely to select hormonal contraceptives at their 1st or 2nd visits (72% of the After Cohort vs. 59% in the Before Cohort, p<.001).

MORE CONSISTENT SELECTION AFTER DISPENSING? Females in the After Cohort were expected to consistently select hormonal methods of contraception for a longer period of time when compared to the Before Cohort. We measured days of consistent selection of hormonal contraception by counting days starting when each female first selected a hormonal method at the end of a family planning visit. Counting of days continued as long as hormonal contraceptives were reported to be used at the beginning and selected at the end of subsequent family planning visits. Therefore, an inconsistency was defined as a ‘skip’ in this pattern and the counting of days was stopped. Hence, to investigate this question, we then had to exclude females who never selected hormones because they had no chance to be consistent selectors of these methods of birth control. The After Cohort consistently selected hormonal methods of contraception for longer period of time (mean=95 days) when compared to the Before Cohort (mean = 80 days, p<.05). In addition, a higher proportion of the After Cohort consistently selected hormonal contraceptives for 90 days or more (47% of the After Cohort vs. 38% of the Before Cohort, p < .05). Yet, controlling for patterns of family planning visits in multivariate models, tempered these findings.

SUMMARY On average, among a subgroup of females, dispensing hormonal contraceptives on-site in SBHCs is associated with -earlier selection of hormonal contraceptives after accessing family planning care. -longer periods of consistent selection of hormonal contraceptives. Dispensing was not associated with -an increase in the proportion of females who selected hormonal contraceptives. -a reduction in the proportion of females who expressed abstinence.

STUDY LIMITATIONS Although the results of this study appear promising, this study did have limitations. Many of the limitations of this study are a result of questions regarding the validity and reliability of using existing HIS data for evaluation and research purposes. For example, in this study we were careful to state that the analyses focused on improvements in females' patterns of "selecting" hormonal methods of contraception rather than claiming that "use" of birth control had improved. Another potential limitation is the reliance on multiple health care providers to consistently record data. There were nine changes in health care provider personnel in the SBHCs included in this study from the 94-95 school year to the 96-97 school. However, all nine providers who were new in the 96-97 school year had sought transfers to the SBHC program. All were employees in other clinics within the same county health department during the 94-95 school year.