School-linked sexual health services for young people (SSHYP): a survey and systematic review concerning current models, effectiveness, cost-effectiveness and research opportunities

Products and services

Table 2 overleaf presents the findings from the analysis of questionnaire data concerning the range of provision identified by survey participants in their responses to distinct questionnaire sections about ‘sexual health’ and ‘general health’ facilities. Overall, numbers are greater than the 205 questionnaire returns because many respondents described more than one service model within their local area. This point suggests a second reason for caution, in relation to the ‘sexual health/general health’ distinction.

Table 2 shows that, as described by school nurses, sexual health service models were viewed as providing the widest range of facilities. Apparent differences included, for example, a higher frequency of references to the provision of emergency contraception in sexual health service models than in general health models (p = 0.47); the same applied to oral contraception (p = 0.48) and to condom distribution (p = 0.19). However, it is notable that the percentage of general health models reported to offer relationship advice was slightly higher. These points are discussed further in the concluding section of this chapter.

Staffing and skill mix

Table 3 below provides a breakdown of data concerning staffing and skill mix in school-based service models. The analysis does suggest that there may be differences between sexual health and general health service models; in particular, medical practitioners were described more commonly as part of the staffing mix in sexual health models than in general health models. Sexual health models also included more examples of multidisciplinary teamwork; ‘other staff’ named included counsellors, drug workers and staff with training in trained gender and sexuality work, as well as youth workers and peer educators. Overall, therefore, sexual health service models were associated with a broader skill mix than general health service models, as well as appearing to offer a wider range of expertise and services to young people. There was a notable lack of social care staff within both sexual health and general health service models.

Funding in school-based services

Table 4 provides information about the funding arrangements for school-based sexual health and general health service models. As can be seen overleaf, the majority of funding came from the NHS for both types: 70.5% of sexual health model funding and 85.4% of general health model funding. However, there was a greater degree of joint funding from the NHS and local authorities (LA) for sexual health service models (11.4%) compared with general health service models (2.4%).

In addition to mainstream NHS and LA education funding, a very large number of ‘other’ sources of funding were listed by respondents, sometimes as sources of pump-priming or pilot project money used to initiate services. The following funding sources were identified for all forms of school-based services:

• formal strategic partnership funding, particularly through local Teenage Pregnancy Partnerships, but also including Children and Young People’s Partnerships

• informal pooling of funds, for example from education, youth services and the school nursing budgets

• jointly agreed funding between school(s), college(s) and primary care trust(s) [PCT(s)]

• short-term Youth Action programme

• the Welsh Assembly

• voluntary organisations

• Care Trust Plus (a PCT that also has additional responsibilities for adult social care, public health and children’s services).

Summary

An analysis of questionnaire responses suggests considerable diversity between forms and levels of school-based sexual health provision across the UK, in terms of the staffing mix and the services offered. Services described as ‘sexual health’ services appear to be more likely than ‘general health’ services to involve a wide range of practitioners, including medical practitioners in some locations. In turn, this broader staffing base may be associated with a wider range of facilities. However, for reasons discussed further at the end of this chapter and in Chapter 4, the distinction between ‘sexual health’ and ‘general health’ emphases may not be a robust one. Nevertheless, the data suggest that there are different service models being implemented, which offer the potential for comparison in terms of user take-up and of impact on outcomes. This point is developed further in Chapter 10.

Products and services

Table 5 provides an overview of products and services offered in school-linked service models. Both sexual health and general health service models of ‘school-linked’ provision offered ‘sex advice’, although this was slightly more frequent in sexual health models (97%) than general health models (89.2%); the same was true of ‘relationship advice’ (89% vs 84.9%, in contrast with the finding concerning school-based models). However, the sexual health service models were described as providing contraception and pregnancy testing more commonly than the general health services. Other examples of sexual health models providing more sex-oriented products or services include condoms (97% vs 57%), pregnancy tests (93% vs 52.7%) and emergency contraception (61% vs 49.5%). The greatest difference was in relation to provision of oral contraceptives (73% vs 30.1%), as might be expected.

‘Other’ contraceptive services included:

• contraceptive patch

• Depo-Provera (depot medroxyprogesterone acetate)

• Implanon

• intrauterine device

• Femidom.

Services described as sexual health service models were more likely to include emergency contraception (p = 0.001), oral contraception (p < 0.001), other contraception (p < 0.001) and pregnancy testing (p = 0.019). As illustrated in the next section, these services were also described as having a more extensive range of practitioners engaged in delivery.

Staffing and skill mix

School nurses were mentioned most frequently as those staffing school-linked service models: 66% with reference to sexual health service models, and 87% with reference to general health models (Table 6). Youth workers were the second most frequently mentioned staff group (44% and 27%, respectively). It can also be seen that school nurse involvement was more significant (as a percentage) in general service models than sexual health service models. However, this may have reflected the broader range of other staff involved in sexual health service models, particularly at the levels of youth work and medical practitioner participation.

‘Other’ staff mentioned as involved in school-linked sexual health service models included:

• Child and Adolescent Mental Health Services (CAMHS)

• psychologists

• contraception and sexual health (CASH) advisers

• sexual health nurses

• Connexions advisers.

Other staff mentioned as involved in school-linked general health service models included:

• Connexions advisers

• CASH nurses

• drug workers

• health visitors

• school counsellors

• community link workers.

As suggested above in connection with school-based services, the analyses of these aspects of the questionnaire data suggest that differences in skill mix are associated with differences in service provision.

Funding

Table 7 provides information about the funding arrangements for school-linked service models. As can be seen, the vast majority of funding came from the NHS for both types of service models (76% for sexual health and 79.5% for general health service models). The level of LA funding was lower than in school-based service models, and also more evenly matched between sexual health services (3.1%) and general health services (3.4%).

Summary

There were parallels between the analysis of questionnaire data concerning school-linked services and the findings summarised earlier about school-based services. The key points about diversity, and about the relationship between skill mix and service provision, apply to both.

Local services: perceived gaps

Pressures on staffing emerged as the most common concern, with specific reference to the lack of staff with specialist sexual health training. This was followed closely by concerns about barriers to service access, both in terms of timing and location, especially for young people living in rural areas. Comments were also received about the need to broaden the range of facilities and products available.

Statements about perceived shortages of school nurses and other appropriately trained staff were often quite detailed; they also suggested that school-linked services were vulnerable to cutbacks in some areas:

There simply are not enough school nurses to meet all the Public Health demands on our service. Our nurses are run off their feet with so much vulnerable children work that they won’t be able to continue at the pace they are working at. As a consequence pupils do not receive the service they are entitled to.

(0642)

Staffing difficulties were sometimes associated with organisational barriers, either within schools or within local partnerships, and faith schools were frequently mentioned as unwilling to develop sexual health services:

Services were stopped as joint funding was not agreed. Currently the school nurse has stopped delivery because ‘training’ and ‘time’ was not jointly paid and funded.

(0793)

Not all schools and school nurses offer the same service, due to mainly politics both in the PCT related to commissioning and due to governors’ opinions.

(0092)

School nurse drop-ins only happen monthly due to staff shortages and often not in faith schools.

(1030)

Examples of barriers to access, for young people, were raised frequently. Here, too, there were many practical examples from local settings, concerning both location and opening hours. These barriers were relevant both in school-based and in school-linked services:

Contraception and sexual health service at local clinic runs 9.30–12.30 one day a week, [it] is a one mile walk from local secondary school, who only have a 40 minute lunch break.

(0784)

Clinics should open around 4.15 p.m. 6.30 p.m. start difficult for teenagers.

(0381)

Due to lack of school nurses I have to offer drop-ins on inappropriate days e.g. Thursday – not good for emergency contraception after weekend sex.

(0598)

Facilities adapted and shared so not ideal. We need a purpose-built room which will allow a pleasant environment in which we can offer a professional service.

(0382)

Respondents from all areas of the UK except London identified provision for young people in rural areas as problematic:

Access to GUM clinic very difficult – several bus changes needed. These pupils living in rural areas have no access to advice/support after school.

(0415)

Rural area problematic due to children bussed into school and bussed home. Providing an after school service difficult, does not reach whole school population.

(0251)

There is NO family planning service accessible to adolescents (except GP) for 20 miles. There is NO provision of sexual health information for adolescents in school – the curriculum is open to the individual interpretation of each school and is very poorly covered.

(0854)

Some respondents wished to see gaps in provision addressed through wider use of outreach services:

Although we run three youth clinics, there are areas that are not covered. . . Would love to see a bus that travels round these areas and gives same service as youth clinics.

(0521)

Local services: planned new developments

The majority of planned new developments centred on expanding existing, established services to other schools in the area. The ‘Clinic in a Box’ scheme was mentioned most frequently. Plans for future expansion were not confined to on-site provision but included a variety of potential venues such as pupil referral units, sixth form colleges, a sexual health clinic in a town centre (near to a secondary school), the youth offending service and youth centres:

It is envisaged that ‘clinic in a box’ will be operational in all high schools in the near future.

(0179)

To expand the extended open-door service across all schools to include chlamydia screening, condom distribution and pregnancy testing.

(1303)

We will be offering ‘clinic in a box’ to the youth offending service and another youth centre.

(0501)

Elsewhere, school nurses reported trying to gain agreement to enhance existing services through the addition of particular interventions. Frequently mentioned examples included the distribution of condoms, pregnancy testing, chlamydia screening and emergency contraception:

Awaiting confirmation from school governors to distribute condoms, emergency contraception to undertake pregnancy tests.

(1012)

While there were many references to hopes and plans for future developments, many of these were expressed in aspirational terms, rather than being described as formally approved. For many, lack of funding was identified as a key obstacle to progressing with implementation, and indeed, one school nurse had left her post for these reasons:

No progress on issue for past 4 years – have left my job as feel banging my head against brick wall!

(0227)

School-based and school-linked services: perceived strengths

The most frequently cited strengths of school-linked and school-based services concerned their potential to facilitate take-up among young people by providing easy access, confidentiality and a safe environment with trusted staff. Opportunities to make links with SRE and with other local health services were also identified as important.

Easy access was a point noted in relation to school-based facilities in particular. However, a further consideration was the ability to tailor services and follow-up processes to local needs:

Accessible, confidential, able to follow up young people easily, not putting themselves at risk – we had a young girl with STI symptoms who travelled to GUM clinic on the bus (with a friend) during the school day – parents unaware. 15 mile round trip, then needed to repeat the process for treatment for gonorrhoea the following week.

(0784)

Based on premises, easy access, easier follow up, more pupils access and are aware of service.

(0595)

Can tackle local issues and follow up individual young people.

(0381)

Participants also highlighted staffing continuity, approachability and skills in identifying and working with vulnerable young people:

School nurses are able to provide a safe environment where students can discuss sensitive issues.

(1078)

If young people know there will be a recognisable person on their first visit it helps reduce the fear.

(0548)

A robust approach to protecting confidentiality was seen as crucial; this was seen by some as a reason why some young people might prefer school-based or school-linked services to GP surgeries:

They don’t like to go to their GP as somebody might see them and tell their parents.

(0242)

However, protecting confidentiality within school environments is a complex issue, and this is discussed further both in relation to perceived weaknesses of services, and in Chapter 4. A final ‘strength’ referred to by some respondents was the scope to develop interprofessional cooperation, specifically via joint work with SRE staff:

One strength is that the school nurse. . . also runs drop-ins. [And] . . . also contributes to sexual health education within [the] classroom, to help connect what is taught in [the] classroom to linking with service provision.

(0709)

School-based and school-linked services: perceived weaknesses

Many of the examples given in response to perceived weaknesses concerned resources, access and equity issues, professional attitudes and aspects of service implementation and management; i.e. they were locally specific, rather than being intrinsic features of school-based or school-linked services. However, one of the issues raised that could be seen as an intrinsic weakness concerned the lack of provision during school holidays. A second intrinsic limitation was related to the needs of children and young people who are not at school either regularly or at all:

Does not embrace hard to reach young people, those educated otherwise, young offenders, travellers, etc.

(0362)

Another general issue raised by many respondents was the variable pattern of service availability, created partly by the relative autonomy of schools:

Need consent of governors. Some schools may be more accepting than others. This may mean inequitable service.

(0112)

Not all schools allow contraceptive services or even listening service. School can dictate what can and cannot be done.

(0964)

Secondly, while the potential to offer a confidential setting was mentioned as a ‘strength’, there were also concerns that both policy differences and physical locations could undermine this:

Interference by teachers whilst pupils are waiting, moving them on, objecting to noise and noting who is there (confidentiality).

(0140)

In a small school, anonymity is a problem, therefore, best to have general drop-in so people don’t know it is a sexual health issue being dealt with.

(0607)

Differences in confidentiality policies between health and school professionals.

(1012)

Tensions between different professions were sometimes a larger concern, over and above agreements about confidentiality:

Some teachers view teenagers as children and worry about the reputation of the school. This can prevent access to services and support.

(0399)

School nurses have set up three health drop-ins in secondary schools but none are particularly successful as the schools fail to promote them in the way agreed at multiagency meetings . . . [One] Head Teacher has banned pupils coming into school at break time so the children could not access the room. . . . A great deal of negotiation has taken place with the schools and the pupils completed questionnaires on what they want. If there is no one person to drive it inside the school then pupils cannot access in accordance to their needs.

(0462)

Respondents in most areas mentioned examples of hostile or ambivalent reactions to proposed services, from parents, staff and governors, and some wrote at length on this issue. The reluctance of faith-based schools to provide sexual health services was also highlighted:

Local opposition – threats to school, threats to staff.

(1038)

Cultural/faith issues hinder development of all schools opting into school-based sexual health services.

(0115)

At the same time, there was recognition of a need to address the perspectives of teachers, governors and parents:

For schools to fully support and promote a service there also needs to be some sense of ownership/benefit for the school.

(0772)

A very small number of respondents expressed a concern that school-linked facilities may create dependency, and undermine young people’s abilities to take up mainstream NHS services. A tiny minority also expressed concerns that sexual health services might promote or encourage sexual activity. A different tiny minority was concerned about media depictions of the service as doing this:

The media saying we are promoting/encouraging sex.

(1012)

Desired changes in local or national policy

Responses to this issue tended to focus on specific types of service expansion or improvements rather than on desired changes to policy per se. A majority of participants wanted an increase in the scope and availability of school-based services, with school nurses taking on expanded roles:

It would be helpful if school nurses could issue emergency contraception, do pregnancy testing and screen for chlamydia.

(0285)

Respondents in every country and region wanted improvements in PSHE/SRE, and most expressed the view that it should be compulsory (the survey predated the policy review that took place in 2008, and the proposed move in this direction). Many respondents also wished the government to tackle inequities in provision by requiring schools to adopt a minimum level of provision:

Policy should strongly advise all school heads/governors to allow a full sexual health service to be available inclusive of condoms, emergency contraception (EC) pregnancy tests, chlamydia screening and testing.

(0405)

Many participants expressed concerns about funding levels and sustainability:

The service is reliant on short term funding . . . There is a sexual health strategy but everyone is paying lip service to it.

(0709)

Not to fund us for nearly 6 years then drop us whilst still expecting us to do the job with fresh air!

(0102)

Many also criticised the emphasis of current policy and suggested a need to emulate the successful strategies used by other nation states. Some did not challenge overall policy direction, but simply wanted clearer guidance:

More emphasis on relationships and less on the mechanics of sex.

(0558)

More emphasis on positive aspects of sexual health rather than trying to meet targets. More FP [family planning] nurses, school nurses. Increased profile for sexual health.

(0936)

More clarification on provision of emergency contraception and condoms under age 13. Grey area between age 12–13 in current policy.

(0598)

There were specific policy and legal concerns in relation to Northern Ireland:

Reduce legal age in NI from 17 years to 16 years in keeping with rest of UK. Ensure all schools commit to adequate sexual health lessons. Law in NI needs to change to offer legal abortion where required.

(1038)

Finally, a small minority wanted a general shift in emphasis in policy direction, such as stressing abstinence and/or reducing the perceived acceptance of sexual activity early in adolescence:

A drive for later onset of sexual intercourse. Reducing acceptance of early sex by publishing how many 18 year olds have not had sex. Talking to boys to discourage kudos of many partners – teaching parents to teach relationships, etc. Present policy has not worked.

(0381)

A considerable number of respondents answered ‘no’ to this question about desired policy changes; a smaller number answered in the affirmative but without elaborating further. A wide range of materials were cited including the DfES Extended Schools guidance, Teenage Pregnancy Guidance documents, SEF publications, and local reports or evaluations. Liaison with local teenage pregnancy coordinators was widely reported in relation to accessing guidance and information. Some respondents cited the National Service Framework for Children, Young People and Maternity Services but they did not provide details about any specific element of this framework. With the exception of ‘The Social Exclusion Report’ and the ‘Teenage Pregnancy Strategy’, however, precise titles and/or publication details were rarely offered for any of the documents cited.

Priorities for future research

This question elicited many specific topics. These can be grouped into the thematic areas outlined below, and are summarised here as a representation of school nurses’ perspectives on potential areas of interest. In terms of assessing how far these areas have already been the subject of published research, some topics go beyond the scope of this report (e.g. some of the broader aspects of young people’s views about sexuality and some very specific points about child protection procedures). Most, however, are related to the assessment of available research evidence concerning the impact of SBSHS and SLSHS, and this will follow in Chapters 6–8. In Chapter 11, priorities for future research are proposed, and under-researched topic areas from the list below are included.

Level 1: school-based general health provision but no distinct sexual health service

Almost all interviewees stated that some schools in their local areas had no sexual health service at all, beyond SRE teaching within the curriculum, and possibly access to a school nurse for general health advice. Two reasons were offered for the lack of services: religious ethos and the influence of governing bodies:

Some schools have refused to have any clinics – mainly faith schools.

(Participant 9)

In almost every region and country within the UK, interviewees described having prioritised the development of school-linked services in areas seen as having high teenage pregnancy rates. Most saw themselves as aspiring to extend services to other schools as and when resources permitted. Nevertheless, there was clearly enormous variation in the pace of development.

Level 2: school-based minimal sexual health service, offering advice and signposting only

Some schools were described as having an on-site service limited to the provision of sexual health advice, leaflets and signposting to other services outside the school. For some, this included a condom card scheme, but not actual condom distribution. School policies and opposition or ambivalence from governing bodies were cited as the key obstacles which restricted, or indeed prohibited, the availability of products or treatments:

It has to be information, advice and guidance without actually being provided with condoms or pregnancy tests.

(Participant 37)

However, in other examples, a lack of staff with appropriate training was the limiting factor:

What they can offer is very much dependent on how qualified the nurse is to deliver a particular service.

(Participant 36)

Level 3: school-based or school-linked basic service, offering advice, information and some products and/or services

Services in this category included the provision of advice, information about other services (referral pathways) and access to some products and services. This could include some but not all of the following: condoms, emergency contraception, pregnancy testing and/or chlamydia screening. The actual range of provision available, however, was often dependent upon skill mix and staffing levels:

Although it’s presented as a tailored service delivery, in effect, it very much depends on the particular skills of individual practitioners servicing the clinic on any particular day.

(Participant 35)

Headteachers’ views and/or the views of governing bodies also proved very important. Even where service provision was generally accepted and relatively extensive in remit, condom distribution was commonly portrayed as problematic:

It’s the condom bit that they’re more worried about. It’s bizarre. They’ll let you do emergency contraception actually in the school . . . because there’s no packets of condoms involved in it. You know, what they’re worried about is kids then playing with the condoms and parents seeing it and things like that.

(Participant 7)

Level 4: school-based or school-linked intermediate service, offering information, advice and a wide range of products and/or services

This group of services offered information, advice and range of services that was not comprehensive, but was substantially greater than Level 3. This included most but not all of the following: condoms, emergency contraception, pregnancy testing, STI screening and referral to termination services.

Level 5: school-based or school-linked comprehensive service, offering information, advice and a full range of products and services specific to sexual health needs

These services offered everything provided by Level 4 services but also offered STI screening and treatment and other forms of contraception in addition to emergency contraception. Some of these services were also linked to GUM services for STI treatment and to family planning services for additional forms of contraception such as intrauterine devices (IUDs) and implants. A few also offered human immunodeficiency virus (HIV)/hepatitis B and C (Hep B&C) screening. However, this level of ‘holistic’ provision was described by only a minority of respondents:

We thought we needed to do holistic drop-ins but have a nurse there who was specially trained and offer the full range of contraception services, but for the young people, they can be coming for anything. So there’s a school health advisor . . . a specialist nurse in contraception and sexual health . . . so those services in the school provide condoms, emergency contraception, advice, general contraception, hormonal contraception.

(Participant 24)

Service delivery: locations, opening hours and staffing resources

Many of the service delivery issues illustrated by interviewees in the quotations below were common to all services spanning Levels 2–5. There were specific concerns about accessibility and confidentiality, in relation to location and to opening hours.

In terms of physical locations and facilities for school-based services, many interviewees stated that they lacked access to a permanent, purpose-built venue. Even when consultation rooms were available, staff did not necessarily consider them appropriate for the delivery of clinical services. For some, the location of services differed from day to day, depending on room availability. This could cause problems:

One of them is some rooms that are used by speech therapy and a classroom that’s no longer used that the school health advisor’s been given to use . . . they’re not ideal.

(Participant 24)

There’s a whole variety of rooms . . . lots of different venues.

(Participant 3)

A different, and atypical approach was the use of specific buildings which were located on the school site but which were separate from the main school buildings. Sometimes this was described as a youth service or health facility:

Some of that (service provision) is by Youth Service that are on site in a separate building . . . One of our schools does have an on-site clinic, which is a contraception clinic run by Health.

(Participant 31)

Sometimes the choice of location reflected a way of managing ambivalence from school management about a sexual health service:

It used to be the caretaker’s bungalow and it’s been turned into a sort of advice and drop-in type of thing. The school look at that as being out of school even though it’s on site. Yeah, because when the chlamydia coordinator went to do some sort of talks around chlamydia and some screening, they [school management] wouldn’t let them use the toilets in the school. They had to go to the bungalow to use the toilet!

(Participant 29)

The agreement we had with the governors was that we wouldn’t do it [operate a drop-in service] during school hours in the school building, but they were happy that it happened, you know, within campus after school.

(Participant 37)

Interviewees suggested that recently built schools were more likely than older schools to provide dedicated premises, although some reported that the same specification that emphasised spatial arrangements, designed to prevent bullying, conflicted with the requirements for a confidential sexual health facility:

One of the issues has been with a lot of the new-builds – they’re designed so that there’s no confidential space really. I think it’s a sort of anti-bullying kind of design and so it’s quite hard sometimes to find confidential spaces.

(Participant 18)

Nevertheless, a few interviewees did identify early opportunities for collaboration with school redevelopment programmes, and were able to influence planning decisions in order to facilitate sexual health service provision:

The school’s due to be replaced by an Academy next year . . . it’s at the planning stage at the moment . . . We’re going to make contact fairly soon to make sure that when the Academy opens, the clinic will open at the same time. So we’ll be able to get in there.

(Participant 28)

Locations for school-linked services included LAs and health premises such as youth service facilities and health clinics. Staff involved in delivering sexual health services would then make the necessary arrangements to meet young people at an agreed venue:

Some of the schools have said that they don’t want [sexual health provision] happening actually in the school premises, so what the school nurses do is they arrange then to meet the young people in the local health centre.

(Participant 7)

Interviewees reported that off-site premises offered some advantages, for example in relation to confidentiality. This was particularly the case when sexual health services were developed and delivered in conjunction with other services for young people:

A lot of young people felt if they went to these ‘Health For You’ sessions that they would be identified by their peers as going for sexual health reasons . . . a lot of the young people were saying that they wouldn’t feel as comfortable accessing sort of sexual health services within school and also sort of designated sexual health clinics, but that they would feel more comfortable accessing them in more sort of mainstream services.

(Participant 16)

Youth workers and youth clubs received particularly positive comments for their focus on, and involvement with, young men:

We find as well that young men prefer to access the youth service contacts.

(Participant 6)

This point is discussed further in relation to take-up among young people.

Opening hours

In terms of opening hours, lunchtime sessions were the most commonly described pattern for school-based services. Interviewees reported that lunchtime opening was advantageous because young people did not have to leave lessons nor ‘hang around’ after school finished for the day. Services accessible during lunchtime were particularly important for students living in rural areas, who were reliant on public transport:

You can run some of them [services] after school, but it doesn’t really work in rural areas where kids are dependent on buses.

(Participant 2)

Although many school-linked services offered dedicated after-school clinics, these were described as being less frequent than on-site lunchtime services. The majority of services offered at least one weekly lunchtime drop-in session, sometimes with an additional after-school session. A smaller number offered multiple drop-in sessions throughout the school week. The frequency of sessions was often dependent on the availability of the school nurse and/or of other appropriately trained staff. This could mean substantial intervals in the week during which no service was available:

There’s a clinic here on a Wednesday afternoon and a Friday morning, so basically if you ring up on a Friday afternoon there’s no way you’re going to get seen.

(Participant 40)

Staff working in school-based facilities often signposted students to school-linked services, where they might access services or advice beyond that available from the on-site location:

Some of that’s after school; some of that is by Youth Service [staff] that are on site in a separate building . . . One of our schools does have an on-site clinic, so they would offer consultation and then signpost them.

(Participant 31)

Mobile clinics were sometimes used to provide school-linked services, thereby optimising very limited resources:

It’s a Landrover and a trailer basically and we run like a little clinic out of the trailer and park it in the vicinity of the school.

(Participant 28)

One disadvantage associated with this type of school-linked service provision, especially if availability was restricted to school hours, was that students needed permission to leave the school premises. To a lesser degree, school-based services operating outside lunchtime breaks suffered from the same constraint, as students still needed formal exemption from lessons to attend. In both cases, confidentiality could be compromised:

It’s open access all day [but students need] to get permission and have a slip from teacher to go.

(Participant 44)

To summarise, interviewees described a range of pragmatic arrangements, both for school-based and school-linked facilities. Purpose-built or tailor made facilities were rare. At the same time, it was clear that the design and location of facilities was an important influence in either promoting or undermining confidentiality. In terms of opening hours, a mix of lunchtime, during school and after-school examples was described. A common concern was that these were not frequent enough to meet the needs of young people fully.

Organisational contexts: rationales and funding sources for services, marketing and ‘branding’

In some areas services had been initiated in response to explicit strategy developments, whereas elsewhere networking and sharing of ideas between agencies and practitioners had prompted development. Overall, 22 interviewees mentioned that provision in their areas had been informed by the sexual health strategy in their locality; five indicated that they accessed no formal local strategy, and the remaining 24 made no specific comment about the presence or absence of a local strategy.

Most interviewees, however, reported that local service provision had been influenced by national strategies or policies, including the National Sexual Health Strategy, Teenage Pregnancy Strategy, and/or Chlamydia Screening Strategy. Not surprisingly, policy documents and guidelines directly related to sexual health were the most frequently mentioned by participants, with the DfES’s Extended Schools: Improving Access to Sexual Health Advice Services (2007) being the most frequently cited single document:

The extended schools guidance is quite useful as well – and the one that came out on sexual health in further education – for targeting the sixth forms and, you know, we can link it back to government guidance. The teenage pregnancy documents, I’ve taken to them [schools], ‘Accelerating the strategy’ and ‘Next Steps’.

(Participant 28)

A small number of interviewees described locally specific strategies, for instance ‘Healthy Respect’, a programme that promotes general health and well-being in schools, and also includes information about specific sexual health issues for young people. Targets – both national and local – were widely regarded as prompting new initiatives, and shaping service provision; these were almost always related to the Teenage Pregnancy Strategy. For example, the first services in an area were often located in teenage pregnancy ‘hot spot’ neighbourhoods:

The area where the college is based, it’s on the outskirts of quite a large council estate and we had really, really high numbers of teenage pregnancy and there was a lot of money put into the local area to try and bring those teenage conception rates down.

(Participant 17)

Within that [Teenage Pregnancy] strategy there’s key actions and performance actions around the delivery of on-site sexual health services for schools and PHSE and SRE delivery targets within the strategy, and we have a lead person responsible for delivering on that, which is from our school improvement service.

(Participant 33)

Among interviewees who cited factors other than national or local strategies, three reported that on-site services were introduced in direct response to students’ requests.

Student surveys [revealed] that they actually wanted their own sexual health service on site.

(Participant 48)

Others reported being influenced by examples from other colleagues working in sexual health. Networking was widely regarded as an important activity, and the SEF was a key organisation in this respect:

The Sex Ed Forum stuff is brilliant . . . That’s been really, really good to see that actually you’re not alone and loads of people have been doing this for years, you know. So that’s great.

(Participant 7)

Partnership arrangements with colleagues working in LA settings and/or the voluntary sector were also cited as a positive contribution to service development at local level. Some examples were given of local guidelines or strategy documents that had provided an impetus to disseminate research messages and to prompt new initiatives:

We work very closely in partnership with the Local Authority and voluntary sector.

(Participant 15)

There was, a few years ago, a paper that I think came out of the North West about setting up school based services. We used that when we first started talking to schools about services. And I think just rather than what was already happening in schools, it was more research that was saying that access to contraception is the most important fact in reducing teenage conception.

(Participant 38)

To summarise, guidance and funding sources linked to the Teenage Pregnancy Strategy were described as prominent in underpinning local initiatives to establish or extend school-based and school-linked services. In many instances local networking and sharing of experiences had complemented these services.

Funding resources: patterns and concerns

Respondents identified numerous funding streams, with many variations across the sample in terms of their origins and duration. Overall, 35 respondents described local funding patterns in specific terms, and there were six distinct permutations in their responses:

1. Full PCT mainstream funding (n = 14). Funding was provided via the school nursing budget, contributing both to staffing and (where relevant) to the provision and maintenance of premises.

2. Combined funding from PCT and LA budgets (n = 4). Funding came from both organisations at levels set locally. Budgets were sometimes, but not always, managed through a strategic agreement between the PCT and LA; in the absence of formal agreement resource allocation was considered to be more vulnerable to reduction or removal.

3. Combined funding from PCT, sexual health services and Teenage Pregnancy Strategy budgets (n = 6). Where the initiation and maintenance of services required multiple sources of funding, interviewees often reported concerns about sustainability; this was particularly relevant to Teenage Pregnancy Strategy funding.

4. Combined funding from LA sexual health services and Teenage Pregnancy Strategy budgets (n = 6). Here, the LA funding element could be provided by one or more of the following: Youth Service, Education Service, Connexions and Neighbourhood Renewal Initiatives.

5. Full funding from NHS Acute Hospital Trust budget (n = 2). Occasionally, interviewees reported that the school nursing budget was held by an Acute Hospital Trust rather than a PCT. In such cases, GUM services (as part of an Acute Hospital Trust) were also involved in budgeting decisions.

6. Full funding from Government Health Departments (n = 2). This was the pattern in Scotland and Wales.

Access to funding sources and uncertainty over the longevity of funding was a major issue for many interviewees. Well-established, successful services were not immune to these difficulties:

Even the PCT acknowledges that it is very worthwhile and they will give, you know, vocal support to it. Unfortunately, they won’t give us any financial support. They did give us some money for two months to try and pay some health professionals, but that stopped. I mean they admit that it’s a brilliant service, but unfortunately they won’t or can’t financially support us. The college is a very forward-thinking college [and] we are so well supported by all of the senior management because they see it as a vital part of the students’ welfare.

(Participant 35)

Well, my post was 2 years and they’ve just got funding for another 3 years. It’s like 2 years in April when it runs out and then after that, you know, you don’t know what’s going to happen.

(Participant 10)

Where funding was obtained from a number of different providers, this could create additional complications and uncertainties:

The main bit is funded by the PCT, but we’re still trying to get money for the youth work element from the Local Authority, but I mean basically it’s [fully funded].

(Participant 38)

Reliance upon multiple funding sources could also create problems in developing a coherent strategy for SBSHS. Teenage pregnancy coordinators expressed particular concerns that their ‘pump-priming’ funds might be used as substitutes for longer-term, mainstream funding from the NHS or local authorities:

It needs to be PCT mainstream budget that funds the school nurse, that funds any sort of contraception supplied and things like that. What we would probably just fund is sort of the development of promotional materials and things like that as a one-off with the expectation that they pick it up because teenage pregnancy money is not always going to be around and we don’t want people relying on it.

(Participant 7)

Service ‘branding’ and marketing

As indicated above, the range of service titles sometimes reflected provider caution about making sexual health services visible within school contexts, and advertising or marketing them to young people. At the same time, interviewees also described the ways in which government targets and policies exerted pressure to increase service take-up, particularly via the Teenage Pregnancy Strategy. There could thus be a degree of tension between the need to promote services and the need to address sensitivities within schools and to avoid the risk of hostile media coverage. There were diverse approaches to managing this tension, some of which acknowledged the stigma that might be associated with attending a sexual health service, reinforcing once again the importance of confidentiality:

Yeah, I think it is recognised as a sexual health service. When we’re putting some of that information into schools we don’t make the sexual health element of it as explicit, So we’ve got different levels of marketing, but young people themselves recognise it as a sexual health service.

(Participant 27)

They did get a bit of press and the schools got a little bit of a hounding, so our schools asked us if for the pilot we could, you know, keep it fairly . . . not secret, but discreet . . . and to date it’s been fairly honoured.

(Participant 12)

We don’t want it to be biased around contraception and sexual health because of the stigma, so it’s about branding that will encompass all health issues for young people really.

(Participant 7)

These concerns sometimes resulted in service providers camouflaging or repackaging sensitive materials in a more acceptable form, for example by emphasising the relationship advice aspect of a service:

[The service was sold as] sexual health but because of the implications with sex and education, what we’ve done is we’ve put the emphasis very much on the relationships.

(Participant 48)

Selling it as a holistic health provision and not just about condoms . . . that you’re not encouraging sex and actually what you are encouraging is responsibility. They [services] all have the same branding and leaflets and information racks and banners and we hope that it’s easier to make links into these services for young people.

(Participant 25)

We weren’t allowed to say that emergency contraception was available, and pregnancy testing.

(Participant 45)

In Chapter 2, questions were raised about whether the distinction between general health provision and sexual health provision, in school-based and school-linked services, was a robust one. The examples above underline the importance of this point: the ways in which services were presented and publicised to schools and to young people reflected a wide range of influences and concerns. The sexual health emphasis in a particular service might be made very explicit, or might instead be subsumed within broader messages about health provision. In some instances, the impetus to do this came from schools’ preferences or ambivalence; in others, interviewees described it as a means to protect privacy and confidentiality for service users. For these reasons, basing descriptions on location, staffing and products/services provided is likely to be more reliable than categorising facilities with reference to a sexual health emphasis or general health emphasis. This point is followed up in Chapters 9 and 10.

Relationships between services and young people: factors affecting take-up and levels of participation among young people

Some service coordinators described the take-up of sexual health services as reflecting the phases of the school year, including assessment and curriculum pressures, as well as specific SRE or PSE requirements:

[Service take-up] does vary . . . It goes much quieter come, say, June and July because [of] exams and they leave the college and also June and July they have a lot of extra things to take them out of the college. They have curriculum enrichment weeks etc. so, you know, certain times of the year we know we will probably be quieter than others.

(Participant 35)

You get a lot of the curious and sexually inquisitive youngsters come across when we’ve done their [PSHE] sessions in school but I would say our regular users who are coming in for their condoms are predominantly Year 10 and Year 11.

(Participant 12)

Many interviewees were of the opinion that providing quick and easy access for young people was more important than registering a large volume of service users:

. . . it’s not vast numbers, but you do get young people coming to you who think they’re pregnant. I mean it’s one of those things that normally they’ve waited for ages, but they want an answer that minute.

(Participant 40)

Interviewees also described differences between neighbourhoods, and between girls and boys, in relation to patterns of service take-up:

. . . we’ve got a clinic in [x neighbourhood] which is quite a middle-class area, so predominantly what we get there is girls will come in and, you know, the issues they talk about will be completely different to the girls in another area. So they come in and they come in to see the nurse and to get the pill or something like that. So we don’t get a lot of boys coming to that one, whereas our other one, situated in [y neighbourhood] we see a lot of boys and the boys’ll come in for condoms. So, you know, you’ll see a difference.

(Participant 30)

Where we’re distributing condoms, it’s boys. Where we’re doing more around emotional health, girls.

(Participant 33)

Slightly more boys use the library service but more girls go for advice drop-ins at the school itself. This is likely to be because girls often need LT [long term] contraception and are referred elsewhere but the boys wanting condoms can do so from the library.

(Participant 37)

Many emphasised the importance of both school-based and school-linked services in attracting boys and young men. One Youth Service location and/or staffing input was understood to positively facilitate access for this group:

Interestingly, young men don’t access us in school, but they do come to the drop-in clinic [Youth Service] and it’s been quite a success because other male services that we’ve offered have never had the numbers of attendance that we have with this one.

(Participant 37)

When young men come in for condoms they come in large numbers and in some services it’s overwhelmingly . . . young men that come for condoms in big groups, but usually that drops off and then you get more young women coming in for contraception and pregnancy testing.

(Participant 43)

What is interesting is that regularly we see 50% to 55% young men accessing the service and that’s basically because we go to where they are and we offer the service to them so they don’t have to come and look for us. So we see a lot of young men under these circumstances.

(Participant 45)

Young people who returned to access sexual health services were regarded as evidence of successful provision; repeated use was also seen as proof of effective marketing.

About 30% of the young people we see in the course of a year will be return users to the service.

(Participant 45)

Ethnicity was rarely mentioned, possibly because monitoring relies on self-disclosure. Nevertheless, some minority ethnic groups were identified as having particular access needs:

The main ethnic group who attend are settled gypsy travellers who quite often don’t state that that’s their ethnic group.

(Participant 37)

There were some criticisms in the evaluation in terms of how accessible we are for, say, young Somali women. So, you know, there will be groups of young people who it’s not particularly accessible for I think.

(Participant 38)

To summarise, most respondents described school-based and school-linked facilities as being well attended by young people. Findings also suggest that the involvement of youth workers may play a part in encouraging boys and young men to access services.

Young people’s influence in shaping services

Although levels and forms of participation varied considerably, most interviewees reported that young people were involved – at least to some degree – in consultation, planning, service delivery and/or feedback processes. A small number reported that local young people were routinely and fully involved in all aspects of service provision, including evaluation.

Guidance on setting up sexual health services was widely available from Teenage Pregnancy Coordinators, the SEF and other sources, which stressed the importance of involving young people throughout planning processes. The DfES (2007) guidance on Extended Schools, mentioned earlier, added impetus to consultation initiatives:

We’re doing it under the umbrella of Extended Schools, really, and we then need to consult with local young people.

(Participant 7)

Interviewees generally recognised the importance of establishing some degree of user-consultation or involvement. At the same time, there was a sense that the actual degree of inclusion was variable and that systems for incorporating young people’s contributions in a consistent and coherent manner were still evolving. For many, the principle of user involvement was embedded in routine feedback processes rather than discrete planning or decision-making initiatives:

[it’s] more a kind of on-going dialogue with them rather than a, ‘Let’s ask them before we put it somewhere’ and then, you know, that’s where we put it. It’s more feedback on an on-going kind of basis.

(Participant 38)

The reason we’re changing the supplier of contraception is because the young people have asked us to, because they said the ones we’ve got are rubbish. So we’ve changed.

(Participant 30)

Interviewees volunteered that young people in their localities were often involved in discrete aspects of service provision including choosing a title and/or designing a logo. However, it was much less common for young people to be involved in significant decision-making processes over a longer period. Young people’s involvement in planning discussions was thus sometimes regarded as tokenistic or ad hoc:

They’ve done the initial ‘Do you want this service? What’s the best day of the week?’ and that’s been it.

(Participant 4)

We’ve had them involved with when we’ve done the advertisements and things. We’ve like kind of done some asking them what they think about it . . . I think we’ve always asked what the kids thought . . . you know, how do they rate it, which do they like best, the logo and things like that.

(Participant 10)

Consultation processes often included young people as one of a number of interested parties:

. . . consultation with all of those, you know, with the governors, the parents, the students and the teaching staff is crucial in making that model work.

(Participant 36)

Some interviewees described how consultation exercises were occasionally employed for tactical purposes, for example when the outcome was already known, when there was no real scope for choice, or when young people’s views were important in overcoming opposition:

Now the young people’s clinics originally were set up following consultation with young people because that is, well . . . I say that’s what they said they wanted. I think it was a little bit . . . I think it was decided this is what was going to happen.

(Participant 40)

But, you know, asking them . . . you have to be realistic because sometimes there are no options about where the clinic is based.

(Participant 36)

We’ve done an awful lot of consultation with young people. Just in the process of another raft of consultation with young people in the school to see, you know, what it is that they want and we’re going to use that to support us when we access the governors to say, ‘This is what the young people are saying they would like.’

(Participant 37)

Less frequently, young people were invited to join steering groups and staff recruitment panels. Their presence was seen to inform the content and direction of services and the setting and implementation of service standards, including assessment procedures:

Obviously young people are involved in interviewing for staff posts and also they were involved when we consulted about the name. So yeah, it’s quite sort of on-going really.

(Participant 41)

We have what we call the . . . reference group . . . a sample of students from our biggest eight or ten high schools and they meet together once a term to look at sort of the sexual relationship education they’re being offered, but also sort of wider issues. So I think that group’s been used as a form of, you know, listening to the views of young people about what they want in schools and I think that’s probably informed the overall direction.

(Participant 21)

We have seven standards for our drop-ins. Based on what young people told us they wanted from services . . . is a report called ‘All I Want’. We took what young people said and turned it into an operating manual called ‘All I Want, [Life] Standards’ and the first one of those is consult with young people about where it is, what opening times, what services are produced and maintaining feedback . . . we have an assessment workbook that we go through to make sure they’re [staff in drop-ins] applying the standards.

(Participant 25)

Interviewees identified a number of specific barriers to involving young people in shaping service provision, for example, excessive staff workloads:

At the moment I’m working 25 hours a week and overseeing 500 staff in 88 sites which is a nightmare, so we’re recruiting a project support worker in April or May and one of his or her responsibilities is going to be literally to focus on young people’s involvement.

(Participant 6)

Funding cycles and deadlines were also a factor:

Young people to begin with, I must admit, they weren’t involved with it and the scheme just appeared without consultation, but it’s the way that funding works. The funding was there, ‘Let’s do this . . .’

(Participant 39)

Finally, respondents in rural areas reported that many young people experienced considerable difficulty in accessing services and this complicated attempts by service providers to involve them in consultation processes.

To summarise, involvement among young people ranged from brief, superficial forms of consultation to sustained participation in processes such as the design of facilities and the recruitment of staff. Most interviewees described examples of the more superficial types of involvement. Nevertheless, findings included some very positive examples of more extensive partnership work with young people, which have the potential for wider dissemination.

Responses from schools and parents: support and opposition

Overall, eight interviewees talked entirely in terms of schools being supportive throughout all aspects of service development and provision. Most described themselves as having played a major role in winning over both schools and parents after careful, and often protracted, negotiations. In general, interviewees focused much more on difficulties, and how to approach them, than on positive accounts of supportive responses:

We always have to go through the governors . . . it’s awful, and we’ve had some really difficult meetings. What they do is they bring the parents in . . . it’s been really tough . . . I mean, some of them are not as bad as others . . . some of the teachers as well, they’ll say ‘Could you put those condoms in a bag please? We don’t want you walking round school with them’.

(Participant 10)

However, the abiding picture was that obstacles could be overcome, usually through personal contact, persistence, negotiation and undertaking in-depth consultations in advance, particularly with school heads and governors. While a minority of interviewees expressed frustration with this process, most simply talked in terms of dealing with it. Resistance from headteachers and governing bodies, and from faith schools, together with the prospect of media exposure, were seen as the most prominent barriers to local service development. Importantly, however, not all interviewees reported problems:

Funnily enough, it was staff within the school that challenged that [emergency contraception provision], not necessarily the governors.

(Participant 12)

Overall it’s been really supported by governors and headteachers.

(Participant 20)

In one locality, a Teenage Pregnancy Coordinator reported using ‘strong-arm tactics’ to negotiate with local headteachers, with positive results:

We went and visited the Heads of the five schools [with above average conception rates] and they said, ‘Oh marvellous, what are you going to do about my teenage pregnancy rates?’ and I said, ‘No, what are you going to do?’ So we shifted it quite clearly . . . One Head said to me, ‘I can tell you at Year 7 who’s going to be pregnant [in] Year 11’ and I said, ‘Well what are you doing about it?’ So we said ‘Either you sign up to our strategy which we’re paying for or you go in and write your own school strategy and you pay for it. Your choice, but it has to be evidenced-based, young people led . . .’, which was slightly a strong arm tactic but, you know, it was becoming quite stark that the schools not engaging were the schools with high [conception] rates. And most Heads took it quite positive.

(Participant 47)

Interviewees reported wide variations in their day-to-day interactions with teachers, particularly in connection with SRE. Mutually supportive arrangements prevailed in some areas, while school nurses and teenage pregnancy coordinators in other areas were unable to access the support they needed:

We were finding that teachers weren’t necessarily confident to be able to deliver the SRE work, and so by having this external [sexual health] team who delivered the work, it was actually achieving quite a lot of knowledge . . . awareness raising, but also attitude change.

(Participant 11)

We’re going to meet with all the PSHE leads and hopefully come up with a coordinated curriculum of some sorts so that obviously we can go in and deliver this package and that they can share best practice, and then hoping that we can expand PSHE out into the community.

(Participant 30)

The PSHE coordinator gives out what’s supposedly positive messages, but she’s actually quite blocking in a way. Communications are very poor within the school.

(Participant 28)

Where collaboration was difficult, this was sometimes related to larger organisational problems within the school, including staff attitudes and communication processes:

We can’t ignore . . . what young people are saying really. . . Except schools, which never listen to young people, obviously.

(Participant 29)

The relative autonomy schools enjoyed occasionally included ‘gate-keeping’ practices; this was particularly noted with respect to faith schools:

I think the problem is that each school is virtually independent now, aren’t they, so they can make a decision whether they have a particular service or input.

(Participant 16)

I know that the [SN] finds it difficult to sort of cover a lot of basic stuff within some of the faith schools and we’ve had so many other things to deal with that we’ve never gone down that road.

(Participant 45)

There were examples of progress being made, however:

It’s mainly the Catholic schools that don’t provide all [advice/services]. It’s been identified there’s a need as well – the SRE team have started to work in one Catholic school.

(Participant 16)

Most interviewees described a context in which school nurses were employed through the local PCT. However, the small number of schools that employed their own nurses sometimes imposed restrictions on their roles, especially with respect to the provision of sexual health services:

Here the schools actually employ their nurses direct and they’re not provided by the NHS – I think we’re a bit of an anomaly in that – and the school nurse they employed was very keen to expand her remit around sexual health, but she was sort of slapped down and basically her role was to stick plasters on and look after the headaches, and she got very frustrated and in the end she left.

(Participant 50)

The girls’ school [in our area] went and employed their own school nurse, not through Health . . . So she was bound by the school’s confidentiality [approach]. It didn’t work. She left 3 months later . . . They were also the school who wanted to know who’d been to see her, and what about.

(Participant 47)

As is evident from the quotation above, confidentiality was widely reported as both a problematic and complex issue. Staff employed through the NHS could see that teachers felt a specific responsibility towards their students, and towards parents, which was sometimes in tension with NHS norms about patient confidentiality:

The [teachers] feel that – this is what some of them have said – they feel that they’ve got a responsibility for those young people within their school setting, and it’s almost as though they’re deceiving the parent, you know, and they’ve got to share that information. Well, we [NHS staff] don’t share that kind of information. It must be confidential.

(Participant 15)

Legal requirements regarding the welfare and rights of minors were also in tension with needs for confidentiality with respect to this group:

I suppose another thing which does restrict is our child protection guidelines, which we’ve had a bit of a problem with recently in that under 14, they’re supposed to be reported to Social Services, and that can be a barrier as well, because sometimes you’ll find that the young people, you know, won’t disclose these things to you that they may be concerned about.

(Participant 19)

Cultural barriers (not specifically defined) were mentioned very occasionally as problematic, mainly in relation to ethnic identity. One interviewee suggested that black and ethnic minority (BEM) students’ needs and preferences could be overlooked in contexts where all, or most staff were white. Another referred to the difficulties staff encountered when dealing with students who had undergone female genital mutilation whilst problems associated with language and communication, where students and staff did not share a common language, were also reported.

Lastly, processes associated with restructuring and reorganisation could also create barriers to service provision:

I worked really closely with the Drugs Action Team. It was fantastic because it was a joint initiative and we trained the students really well. So of course I wanted to roll that out this year and I can’t because the Drugs Action Team structure has changed . . . so we’ve lost that. We’ve lost that initial intervention which is where I see it working.

(Participant 48)

To summarise, service coordinators described responses from school headteachers, staff and governors as being relatively complex. While there were examples of unqualified support and in-depth collaboration, there were also examples of tension with respect to confidentiality procedures, and to some extent with respect to wider values and principles underpinning work with young people. This suggests that prevailing ethos and leadership within schools are crucial factors to consider, both in terms of establishing services and of evaluating their effectiveness.

Research and development: monitoring and evaluation

Levels of monitoring and evaluation were very variable across services and localities. In total, 18 respondents were either unsure of local evaluation resources, or clearly stated that no form of monitoring or evaluation was in place. A further 18 described routine monitoring of attendances at school-based and school-linked services. Eight described conducting periodic user surveys, in addition to routine monitoring, and three reported that an independent, external evaluation had taken place in their area.

Although respondents generally recognised the need for regular monitoring and thorough service evaluations, a lack of resources often hampered efforts to engage in this work:

One of my frustrations is that we’ve got a really good model here, and I would like to see it replicated in other areas, but you know, actually not having the time or the energy to really concretely measure the impact . . . we’ve had a huge reduction in our teenage pregnancy rates – you know, one of the highest in the country – and I do think it has really been the impact of the work we do in schools.

(Participant 11)

I know we should write it all up, but we haven’t had time. We’ve just got on with it, really.

(Participant 24)

Nevertheless, as indicated above, the majority of interviewees reported that systems had been established for monitoring service use and some form of internal evaluation:

As part of the evaluation obviously we’ve asked young people who use the clinic about their experience and, you know, whether any improvements [and] we’ve asked people who don’t use the clinic to find out why. We’ve asked the staff as to, you know, whether they knew about the clinic when the students asked them and whether they were able to give the advice and whether it impacts upon the student teaching . . . you know, if they’re missing anything there and whether it’s having an impact on that and what they felt about it.

(Participant 15)

Independent evaluations were highly regarded, particularly for their ability to produce evidence which could be acted on promptly by service providers and perhaps also reinforce the case for funding:

Part of the evaluation that’s just been done by the University of the West of England, they had focus groups with young people to talk about what they thought of the services, which will lead to some changes.

(Participant 38)

Recently we’ve presented kind of a short report to the Teenage Pregnancy Board as well, trying to actually now get extra funding, or for them to commission us, so that we can actually expand.

(Participant 49)

At the same time, considerable variations were reported with respect to the ways in which different agencies collected and analysed routine data, and established systems were sometimes adversely affected by organisational change:

The Youth Service and the PCT both collect data. In the past, the PCT would collect what year the young people were in, date of birth, what they’ve come for . . . We keep that, but the Youth Service also obviously have to track it through, maybe how many have come in to browse, what short of advice you give. We collate that at every drop-in.

(Participant 30)

We had some good systems in place – well, I did – and then when the projects got mainstreamed by the PCT and the Local Authority, they went elsewhere and data collection has not been fabulous.

(Participant 47)

Some interviewees reflected on the limitations of evaluations:

A group of girls came in after they completed the survey and laughed and giggled between themselves and said ‘I just put this down’ and ‘I just put that down’. So it’s kind of, you wonder how accurate the statistics will be at the end of it . . . Data collection does worry me because a lot depends on that, you know, and resources can change as a result and actually the resources could be maybe better spent elsewhere.

(Participant 26)

To summarise, there was a general recognition of the importance of monitoring and evaluation, and a desire to examine the effectiveness of particular service models. However, staff time and resources to engage in evaluation were very limited, and only a small minority of the services described had benefited from an external evaluation.

Planned future developments

Overall, most respondents expressed a wish to both consolidate and expand local service provision. However, many also reported difficulties in accessing secure, sustainable levels of funding which meant that expanding (or indeed maintaining) current levels of provision could not be guaranteed:

What are we doing about sustainable funding? . . . that’s the next step . . . it is very unsustainable at the moment.

(Participant 39)

At the moment we can’t think kind of too far ahead because without more funding there’s no chance anyway.

(Participant 50)

Organisations with well-established links to with PCTs, and with other local agencies engaged in delivering sexual health services for young people, articulated the most positive responses:

[We’re] fortunate that the PCT has just bid successfully for a lot of money for sexual health development.

(Participant 37)

Where sexual health services were not prioritised, short-term goals and constant compromise appeared to be regular features of local provision:

To be honest, the C card scheme would never have got off the ground if the [NHS] Trust had had to pay. Unfortunately, no-one ever looks at sort of like, ‘Well, if we pay out 9p for a condom we might prevent a pregnancy’. As long as they’re looking at a yearly budget, they’re not looking ahead, are they?

(Participant 40)

Many respondents articulated intentions to continue to explore funding opportunities to secure existing initiatives, at least in the medium term. However, interconnected issues such as staffing resources and interagency collaboration were also raised, arguing that the barrier to service development

[It] isn’t always about money but that’s about school nurses working with youth workers and Connexions and anybody else to do a proper service that is not just a bit of an add-on about contraception, that, you know, will provide a range of different, holistic health support services.

(Participant 7)

In this context, the decision in 2008 to introduce human papillomavirus (HPV) screening was offered as a rationale for one service not planning any further developments. Maintaining the quality of current service provision was viewed as equally important as further expansion. Early service initiatives were sometimes reported to have failed to take account of the range and complexity of issues affecting the lives of service users. For some, future plans included trying to address these issues, while also responding to demands for increased provision:

The majority of young people that attend for sexual health issues, but there are young people also that attend where the sexual health issues often bring up other issues . . . if they’re taking sexual health risks they’re often drinking alcohol, there’s often smoking issues, there’s sometimes self-esteem issues . . . they often run together and obviously some young people come about completely different issues to do with puberty or anxieties about eating or family health or family issues . . . Both the schools [in this town] would like more. In fact the second school that we’ve gone into there’s been a huge demand and that is an area probably with the highest teenage pregnancy rates and the young people have come for a lot of sexual health advice . . . they would actually like a second day and they would like it to run during the holidays as well, which is great. So obviously that’s the kind of thing that we’re looking at with the business plan to get commissioned because to take these services forward we’re going to need resources.

(Participant 24)

Overall, respondents described a range of future improvements that they wanted to see, both in service delivery processes and in the scope of provision. At the ‘process’ level, effective networking and collaboration were prioritised, particularly in relation to links between health professionals and youth workers:

. . . [more] school nurses working with youth workers and Connexions.

(Participant 7)

Linking better to Connexions – more young people said they would feel more comfortable accessing services here as less exposed.

(Participant 16)

Work more closely with the Youth Service because I know there are certain youth clubs that aren’t distributing [programme materials] at the moment.

(Participant 39)

Training more staff in sexual health work was also a clear priority, both to enable school nurses to offer long-acting reversible contraception options and to enable a broader range of staff to specialise in working with young people:

The next stage is to encourage them to do the young people-friendly training so that they’re actually trained as staff and they know all the issues about sexual health because a lot of them, even though they do health themselves, are out of touch with the sexual health stuff.

(Participant 49)

Rolling out (or handing over) a successful programme often required existing staff to identify additional training needs and to deliver programmes appropriately so that

. . . health advisors are competent and ready to deliver even without us [because] often it’s only when they come to actually have a go at practising it they realise they’ve got quite a lot to learn.

(Participant 24)

In terms of the actual scope of provision, many respondents described gaps that they wanted to see addressed. The most prominent examples were the following:

• Expansions in the advice available from trained staff, for example to cover domestic violence, emotional well-being, child abuse, bullying, substance misuse, health promotion.

• Expansion in services, to offer STI screening, pregnancy testing, and a full range of emergency and routine contraceptive options on a consistent basis, particularly in areas where high teenage pregnancy rates or other factors indicate high levels of need.

• Improvements in facilities, to include appropriate, confidential rooms for on-site services, and more mobile outreach services (particularly in rural areas, and to reach vulnerable young people not in mainstream school – for example, looked-after young people and those in pupil referral units).

• Expansion of services to include some holiday and weekend provision.

Inclusion criteria

The inclusion criteria for the reviews were as follows.

Exclusion criteria

Studies were excluded if:

• They did not fulfil the above criteria.

• The sexual health services were not school-based or school-linked, and were provided for the general population.

Searches were performed in January 2008 by an information specialist (AS) after the development of a search strategy based on a number of test searches. The resulting search strategy employed a combination of the following terms, full and truncated versions of free text words and, where available, database keywords: school or school-based clinic or SBHC (school-based health centre); and clinic or outreach or service; and sexual or STI or STD or pregnancy or conception. The following databases were searched for published material: the Cochrane Library (1991–), MEDLINE, PREMEDLINE (2007–), CINAHL, EMBASE, AMED, ASSIA (1987–), IBSS, ERIC, PsycINFO, Science Citation Index (SCI) and Social Science Citation Index. The following databases were searched for unpublished material and grey literature: the Social Care Institute of Excellence Research Register; the National Research Register (1997–), REFER; Index to Theses, and HMIC. The focus on UK research databases in the search for unpublished and grey literature was consistent with the study objective of maximising the relevance of the review to the UK setting; however, some relevant grey literature from the USA, but not the UK, was identified through ERIC and reference tracking. The date limits of all of searches were from 1985 onwards, unless the inherent date limitations of the databases dictated otherwise (date limits are given for relevant databases above). Citations were downloaded into a reference manager database and duplicates were removed.

Two reviewers (CC, MLJ) screened the citations for relevance (based on the inclusion criteria) after a satisfactory inter-rater reliability score (0.9) had been achieved and recorded on a test sample of 100 titles and abstracts. In cases where one reviewer could not make a decision about inclusion based on title and abstract, citations were checked by a second reviewer. Disagreements were either resolved by discussion or the full paper was retrieved in order to make a definitive judgement. Full papers of all relevant and potentially relevant citations were then screened using the same process. Data were extracted from included papers using a form developed specifically for this review, and piloted on a sample of two papers. Data extraction and quality assessment of each paper was performed for each review by a single reviewer, and thoroughly checked by a second reviewer. Disagreements were resolved by discussion and reference to the original paper. Reviewers were not blinded to author, institution or journal, as this has previously been shown to be unnecessary. 32,33

For the review of effectiveness studies (Review 1), data consisted principally of descriptive statistics and, in some cases, comparative statistics, such as odds ratios and related p-values. Because of missing data, it was not possible to calculate comparative statistics for many of the studies that did not report them, and therefore such statistics as are included in this report only when they were calculated and reported by the original investigators. Because of the heterogeneity of the complex interventions evaluated, and the diversity of populations (in terms of location, ethnicity and sexual activity) and outcomes being measured, this review took the form of a narrative synthesis of the available evidence. Data extraction was performed by both reviewers (MLJ, CC), and analysis was performed by a single reviewer (MLJ), and checked thoroughly by a second reviewer (CC).

Because of the range of study designs used by the research studies included in Review 1, a specific critical appraisal checklist was not used. Instead, a hierarchy of study designs was drawn up for use in this particular context, and the particular characteristics of each individual study were appraised within this hierarchy (for details, see Chapter 6).

For the review of qualitative data of people’s views concerning SBSHS or SLSHS (Review 2), data extracted for analysis consisted of either verbatim quotations from study participants or findings reported by authors that were clearly supported by study data. Thematic analysis was used. 31 This method produces a synthesis grounded in the data. The aim was to identify and classify into themes the reasons behind students’ use or non-use of SBSHS or SLSHS. This involved the reviewer familiarising themselves with the data and then identifying themes that reflected or captured these data; a thematic framework was then developed by considering how the themes identified related to one another. A framework thus emerged from the analysis that aimed to explain all the data in a new way, consisting of broad overarching themes and more detailed subthemes. One reviewer (CC) carried out the primary analysis of the data. Two other reviewers (MLJ and JC) validated the analysis by examining whether the lead reviewer’s interpretations of the data were plausible and by offering competing interpretations where appropriate. A refined and mutually agreed framework was then drawn-up. The aim was to generate a new thematic framework to describe and explain people’s experiences of, and views concerning, SBSHS or SLSHS.

The quality of the included research studies in Review 2 was assessed using appropriate critical appraisal checklists, most frequently for case studies or surveys,34,35 to afford a basic idea of the quality of individual studies, while appreciating that it may not always be appropriate to exclude qualitative research studies simply on the basis of quality assessment of study design. 36

For the review integrating quantitative and qualitative data (Review 3), the results of these analyses were synthesised by two reviewers (CC, MLJ) using a method developed by Oliver et al. 37–39 A matrix was laid out with the barriers to, and facilitators of, service use identified by the review of qualitative data, clustered under themes identified by this review, alongside descriptions of evaluated interventions from the review of effectiveness studies. The reviewer then assessed whether or not the intervention had addressed the barriers or included the facilitators described by young people, parents, or clinic staff. If an evaluated intervention did so then this was stated and it was recorded whether or not the intervention was effective (see Table 13). In an effort to enhance the robustness and reliability of the synthesis, only the most ‘sound’ data from the quantitative and qualitative reviews were included. Consequently, only intervention studies that used a control group were included. In the hierarchy of study designs,40 these types of study are more able to demonstrate impact or effect than uncontrolled studies. From the review of qualitative data, triangulation was used to identify themes, and their inherent barriers and facilitators, for inclusion: if a theme and its barriers and facilitators had been identified by more than one study using different data collection methods then that theme was included, by virtue of the validation offered by triangulation of the evidence. 41 The aim was to produce a synthesis that could be used to inform the development of an intervention based firmly on the best available quantitative and qualitative evidence. The resulting synthesis was then reviewed by a third reviewer (JC), with the aim of challenging or validating its findings. A final, agreed synthesis was produced.

Number and type of studies included

In this review of data relating to the effectiveness of school-based and SLSHS, there is a discrepancy between the number of projects which have been included and the number of publications which relate to them. Because many research studies are reported in multiple publications, it is not unusual for a systematic review to include more publications than individual studies, and many of the projects included in this review are indeed represented by several publications. Some of the included publications evaluate one single-centre project. Others present aggregated data from a number of sites, either located in a relatively small geographical area (e.g. the schools participating in the Seattle Condom Availability Program42) or very widely spread (the SBHCs throughout the USA sponsored by the Robert Wood Johnson Foundation and evaluated by Kisker et al. 43,44). Unusually, however, this review also includes two studies which essentially take the form of a number of separate case studies of individual projects: they compare outcome data from the individual projects, but generally do not aggregate those data. These studies are Kirby et al. ’s evaluation of six individual SBHCs in different parts of the USA,45 and Stout et al. ’s46 evaluation of a number of SBHCs in Oregon. Kirby et al. present no aggregated data, and although Stout et al. present some aggregated data from five schools with, and four without, SBHCs, the data most relevant to this review (relating to the three schools whose SBHCs had been open for at least five school months at the time of the baseline survey and their paired controls) are presented only in unaggregated form. For the purposes of this review, therefore, each SBHC included in these two studies has been treated as an individual project reported in an individual case study. (For details of the included projects and the publications which relate to them, see Appendix 1.)

On this basis, 26 projects met the review inclusion criteria. These were:

• Thirteen individual comprehensive SBHCs, or groups of SBHCs, in the USA [in Dallas,45 Denver,47 Gary,45 Jackson,45 Kansas City,48 Muskegon,45 Oregon (Schools A, B and C evaluated by Stout et al. ,46 and 15 SBHCs evaluated by Zimmer-Gembeck and Riddell49), Quincy,45 San Francisco45 and USA-wide43].

• A school-linked sexual health service in Brazil, which paired schools with reproductive health clinics located no further than 5 kilometres away. 50

• A school-based drop-in clinic in Oxfordshire (the Bodyzone Project). 51

• A programme specifically designed to reduce the rate of repeat pregnancies in parenting adolescents in St Paul, Minnesota. 52

• A pregnancy prevention programme targeted at junior high school students perceived to be at particular risk of unintended pregnancy (the New York City ‘In Your Face’ programme53).

• Two studies of the specific effect of introducing on-site dispensing of hormonal contraception in SBHCs in the USA (in Minneapolis54) and an urban area of the north-western USA (probably Oregon). 55

• An intensive contraceptive continuation programme introduced into existing SBHCs in Baltimore. 56

• Five condom availability schemes (in Los Angeles County,57 Massachusetts,58 New York City,59 Philadelphia60 and Seattle42).

• A school-based programme of screening and treatment for chlamydia and gonorrhoea in New Orleans. 61

Five projects were not identified by the electronic searches: the Massachusetts,58 New York City,59 and Philadelphia60 condom availability schemes, the St Paul Pregnancy-Free Club52 and the Bodyzone Project. 51 At least one publication relating to each of the remaining 21 projects was identified by the electronic searches.

Some studies did not clearly identify the individual participating schools, and consequently some schools may be included under more than one project. Thus, it seems likely that some of the SBHCs included in Kisker’s USA-wide study43 were also included in other evaluations. The specific schools involved in this evaluation were not named, but it was stated that most of the students who took part lived in the West (in Los Angeles, San Jose and Denver), with approximately one-fifth in the Midwest (in Detroit, Minneapolis, and St Paul), and an eighth in the South (in Birmingham, East Baton Rouge and Memphis) and the north-east (in New York City and Jersey City);44 a number of these locations also feature in other studies. It is also possible that the 15 SBHCs in Oregon schools, which were evaluated by Zimmer-Gembeck and Riddell,49 may include some or all of those evaluated by Stout et al. 46

Number and type of studies excluded, with reasons

As may be seen (see Chapter 5, Results), a very substantial number of the citations identified by the electronic searches were excluded as part of the sifting process because they did not meet the review inclusion criteria. Details are therefore given only of those citations with an abstract which were included at the abstract stage but were either excluded after a full reading or could not be obtained within the study timescale. These citations are listed in Appendix 4, together with the reasons for their exclusion.

Relevance to current UK service provision

A few of the projects included in the effectiveness review appear to fall into the first broad type of service provision identified by the mapping study, namely services staffed by school nurses. These were the St Paul Pregnancy-Free Club, staffed by public health nurses,52 the New Orleans chlamydia and gonorrhoea screening programme, run by school nurses,61 and perhaps also the Baltimore contraceptive continuation pilot, run by nurse practitioners and physician assistants, but located within SBHCs whose staffing was not specified. 56 The Oxfordshire Bodyzone Project,51 the SBHCs in Oregon Schools A and B,46 and the Philadelphia condom availability scheme60 fall into the second category of services provided by a multiprofessional team with no medical input. It is possible that some of the SBHCs in Oregon evaluated by Zimmer-Gembeck and Riddell49 and Zimmer-Gembeck et al. ,55 whose staffing arrangements were not described in detail, may also fall into this category, as may the school-based clinics in Minneapolis that took part in a project evaluated by Sidebottom et al;54 however, it is also possible that, like the majority of included projects, they may fall into the third category of services staffed by a multiprofessional team that included medical practitioners.

Four of the five condom availability projects did not fit comfortably into any of the three categories identified by the mapping study: these were the New York City programme staffed by volunteer teachers,59 the unstaffed schemes in Los Angeles County62 and Seattle,42 and the Massachusetts programme in which, although most schools distributed condoms through school nurses, a large proportion used other personnel, generally members of the teaching staff. 58

For details of the individual projects, see Appendix 2, Table 26. More general information on the nature of the services represented by the projects is included in Appendix 3.

Quality of research available

The quality of the identified research was generally not good. None of the identified projects was evaluated using a well-designed RCT, widely recognised to be the gold standard design for answering questions relating to the effectiveness of an intervention. A controlled before/after design is the next most appropriate study design for this purpose: if the intervention and control sites are well matched, it is possible to distinguish between changes which can be attributed to the intervention and those due to other factors in a way which is not possible in an uncontrolled before/after study. Controlled case studies or cross-sectional surveys present data from only a single point in time and therefore admit the possibility that differences in outcome between the intervention and control groups may be due not to the intervention but to unreported differences in the study populations. However, case studies can add a wealth of contextual information, which may suggest why some interventions may be more successful than others (for further discussion of study designs see Appendix 5).

Some of the included studies used designs that were suited to their purposes, whereas others used less suitable designs. Because some studies did not state what methodology was used, and others used different terms to describe what were essentially the same designs, for the purposes of this review studies have, where necessary, been recategorised according to the classification of study designs set out in Appendix 5. For the purposes of the effectiveness review, controlled before/after studies have been considered to be higher-quality studies, and all other study designs have been classed as lower-quality studies.

The broader categories of study design included a number of different approaches, as follows:

1. Controlled before/after studies, including:

   1. Case studies (Stout et al. ’s 46 evaluation of three SBHCs in Oregon).

   2. Repeated cross-sectional surveys (the evaluations of the Philadelphia60 and Seattle42 condom availability schemes).

   3. A quasi-cohort study (Magnani et al. ’s evaluation of the Brazilian SLSHS, originally planned as a true cohort study, and subsequently modified because of high attrition rates50).

2. A quasi-controlled before/after study (Cohen et al. ’s evaluation of the New Orleans chlamydia screening programme61 – for details, see Sexually transmitted infections).

3. Controlled quasi-before/after studies:

   1. Ricketts and Guernsey’s retrospective review of routinely collected data in which the ‘baseline’ data postdated the introduction of SBHCs in Denver. 47

   2. Kisker and Brown’s USA-wide evaluation in which students completed the ‘baseline’ survey towards the end of their first year in high school, and the follow-up survey during the spring of their expected graduation year; the investigators assumed that the SBHCs would have had little or no effect on student outcomes during the student’s first year. 43 The choice of controls in this study is also potentially problematic: they were drawn from cities that did not have SBHCs sponsored by the Robert Wood Johnson Foundation, and it is not clear either how similar the control cities were to those where the intervention SBHCs were located, or whether the control cities contained schools with SBHCs sponsored by other organisations. A stronger design, using control students attending schools similar to those with SBHCs and located in the same geographical areas, was rejected for fear of reigniting controversy over the establishment of SBHCs. 44

4. Uncontrolled before/after studies, including:

   1. A repeated prospective cross-sectional study (the evaluation of the Los Angeles County condom availability scheme57).

   2. A retrospective review of routinely collected data (the evaluation of the introduction of onsite dispensing of hormonal contraception in Minneapolis54).

   3. A review of routinely collected data, probably conducted retrospectively (the evaluation of the introduction of onsite dispensing of hormonal contraception in north-western USA55).

   4. A study linking repeated cross-sectional surveys with routinely collected data (the evaluation of the New York ‘In Your Face’ pregnancy prevention programme53). Because of the difficulty of identifying comparable schools to act as controls, this evaluation was designed as an uncontrolled before/after study, although the authors claimed that withdrawal of programme funding from one school in the final year of the evaluation effectively created a crossover control site.

   5. Three case studies (the evaluations of comprehensive SBHCs in Quincy and San Francisco45 and of the St Paul repeat pregnancy reduction programme52).

   6. An uncontrolled cohort study (the evaluation of the intensive contraceptive continuation programme in Baltimore56).

5. Controlled case studies [the evaluations of four SBHCs in the USA (in Dallas, Gary, Jackson and Muskegon45), and the UK Bodyzone Project51].

6. Controlled cross-sectional studies (the evaluations of SBHCs in Kansas City48 and Oregon,49 and condom availability schemes in Massachusetts58 and New York City59). The Kansas City study was actually undertaken as a controlled before/after study, but is categorised here as a controlled cross-sectional study because its baseline data predate 1985 and therefore do not meet this review’s inclusion criteria.

When assessing the effectiveness of sexual health services for young people, the primary outcomes of interest are rates of unintended conceptions and STIs. Although a number of the studies included in this review reported pregnancy or birth rates, none specifically identified unintended conceptions, and none provided data relating to terminations of pregnancy, while few reported STI rates (Table 9). However, in the context of STI prevention, researchers at the American Centers for Disease Control and Prevention have emphasised the importance of sexual activity and condom (non-)use as surrogate outcome measures. 69 Such data have therefore been included in this review as secondary outcomes, as have data relating to the uptake of hormonal contraception, which can be highly effective in preventing unintended conceptions. Finally, in reviewing any health-care intervention, it is important to assess the extent to which that intervention is used by, and acceptable to, the target population. Data relating to the use of SBSHS or SLSHS by sexually active students are therefore also summarised in this chapter.

A brief tabulation of projects with summary information on the intervention, study design, and reported outcomes is included in Table 9. For further details of study design and reporting quality, see Appendix 2, Table 27.

The aforementioned outcomes will be discussed in the following order:

1. rates of sexual activity

2. use of SBSHS or SLSHS by sexually active students

3. contraceptive use

4. pregnancy rates

5. rates of STIs.

Generalisability of the evidence

The major issue relating to the generalisability of the evidence is that the overwhelming majority of the data derive from a health-care system that is very different from that currently operating in the UK. Of the 26 projects included in the review, 24 were located in the USA, one in Brazil, and only one in the UK. The nature of the US health-care system influenced the development, in the USA, of SBHCs designed to provide free primary health care and preventative services to students in deprived areas, many of whom lacked health insurance and thus had limited access to other sources of health care. By contrast, in the UK, in the absence of comparable barriers to general health care, most UK school-based health initiatives have focused on specific areas such as substance misuse, sexual health and mental health, rather than on the provision of general health care. 63

Perhaps surprisingly, the most important factor affecting the generalisability of the US data to the UK may not be the pressure to use SBHCs exerted on US students by the US insurance-based health-care system. In 1995, a survey of students attending three US schools with SBHCs found that utilisation rates were highest in students with private health insurance or Health Maintenance Organisation (HMO) coverage and not, as might have been expected, in those with Medicaid or with no health insurance. In this survey, the reasons most frequently given for using SBHCs related to trust, convenience or quality of services; only 9% of students were motivated by cost, and 7% because they had no alternative source of health care. 72 Rather, the key factor appears to be the provision by US SBHCs of a comprehensive range of health services. This affects the generalisability of the data in two ways. Firstly, because most student visits to US SBHCs are for reasons unrelated to sexual health,45 attendance at a comprehensive SBHC is likely to be associated with less stigma than attendance at a UK school-based clinic offering a more limited range of services. This relative anonymity and lack of stigma may encourage attendance by students requiring sexual health services. Edwards et al. 73 noted that, in the USA, when a pioneer school-based clinic, which initially provided only reproductive health care, began to offer other services in addition, this provided some anonymity for the sexually active student. Secondly, students who attend US SBHCs for reasons unrelated to sexual health may then be encouraged to use the sexual health services when they would not otherwise have done so. Unfortunately, there are insufficient UK data to be able to assess whether the proportion of sexually active students who use UK SBSHS or SLSHS is lower than the proportion of sexually active students who use the sexual health services provided by comprehensive SBHCs in the US.

In addition, the evidence is almost wholly limited to SBSHS. Only one evaluation of a school-linked service was identified, that by Magnani et al. 50 in Brazil, and this may be of limited relevance to the UK for a number of reasons, not least that the clinics generally failed to adopt ‘youth-friendly’ features, such as a special patient flow or special entrance for adolescents; only one of the six clinics had a receptionist who had been specially trained to deal with adolescent clients.

Finally, it should be noted that the data presented in the included studies are largely restricted to heterosexual sexual activity. There are several reasons for this. One is that a major goal of many US interventions was to maximise attendance at, and graduation from, high schools in deprived areas; pregnancy prevention was therefore particularly important as a means of increasing attendance and graduation among female students. Another probable reason, although one which is seldom explicitly mentioned, is the unacceptability of homosexuality to a substantial proportion of the US population, and the consequent wish to avoid drawing attention to homosexual activity for fear of provoking opposition to SBSHS. Last, but not least, is a pragmatic reason. As has been seen, relatively few of the studies included in this review reported statistically significant results. In purely practical terms, it would be even more difficult to design a study large enough to achieve statistical significance specifically in relation to students engaging in homosexual activity because such students form a relatively small proportion of the school population. For this reason, in their evaluation of the Los Angeles County Condom Availability Scheme, Schuster et al. 57 did not analyse the data they collected relating to condom use among males reporting same-sex fellatio or anal sex, stating that the reported prevalence was too low to yield meaningful results. As a result, there are no data regarding the uptake of SBSHS or SLSHS specifically by students engaging in homosexual activities, and very limited data on the use of services by students in relation to heterosexual activities other than vaginal intercourse. In Los Angeles County, Schuster et al. 62 noted that, at follow-up, 55% of students who had had heterosexual vaginal intercourse during the previous year had used condoms obtained from the school condom availability programme, but the comparable figures for heterosexual fellatio with ejaculation and heterosexual anal intercourse were only 5% and 25%, respectively. These data suggest that services may fail to meet the needs of students who do not engage in heterosexual vaginal intercourse, but the reasons for this are not clear. Schuster et al. attributed the very low use of school condoms for fellatio to the fact that they were lubricated; they did not explore the reason for the low use of school condoms for anal intercourse. However, it is possible that, in both cases, low uptake may relate to a failure on the part of some students to understand the need for condom use other than for pregnancy prevention.

Issues related to the primary outcome measures

One problem inherent in this review is the tension between its two primary outcome measures: pregnancy rates and rates of STIs. Initiatives that seek to maximise pregnancy prevention generally promote hormonal methods of contraception, as they are more reliable than barrier methods. However, as hormonal methods alone do not offer protection against STIs, such initiatives may have a negative impact on STI prevention. Garside et al. 74 have noted that teenagers who replace condoms with hormonal methods for pregnancy prevention rarely continue to use condoms for STI prevention. Thus, they may substantially reduce their risk of pregnancy at the same time as they increase their risk of contracting an STI. Conversely, Blake et al. 58 have expressed concern that condom availability schemes promote condoms at the expense of more effective contraceptive methods and thus, while offering increased protection against HIV and other STIs, may increase the risk of unwanted pregnancy.

Another problem relating to the primary outcome measures is the difficulty of evaluating the impact of interventions intended to reduce pregnancy and STI rates in teenagers. The difficulties inherent in designing evaluations that have STIs as their outcome measures have been discussed above. There are also inherent problems in the use of pregnancy as an outcome measure. Even in high-risk groups, teenage pregnancy is a relatively rare event, and, as such, is susceptible to random variation. So, Kirby et al. 75 noted that, between 1971–2 and 1986–7, the birth rates in five individual schools in St Paul, Minnesota, fluctuated dramatically from year to year: in any given year, they might rise in some schools, while falling in others. To avoid giving too much weight to year-to-year fluctuations, especially in individual schools, Kirby et al. 75 recommended comparing the mean birth rate for several years before the introduction of a service with that for several years after its introduction. They also recommended aggregating data across a group of schools in which the same service was introduced. In the projects included in this review, the pregnancy data are susceptible to random variation because of the small numbers involved, but, unfortunately, because the published data almost invariably take the form of percentages or rates, we have been unable to aggregate them in either of the ways recommended by Kirby et al. 75

It may also take some time for services to have a noticeable impact on pregnancy outcomes. So, Ricketts and Guernsey47 noted that no decline in births to 15- to 17-year-old black females who were resident in the attendance areas of schools with SBHCs was seen until about 4 years after those SBHCs opened. Some of the projects included in this review were evaluated within a year or two of opening, probably too soon to allow them to demonstrate any effect on pregnancy outcomes. Kirby et al. 45 also note that self-reported pregnancy data may be unreliable: specifically, they may underestimate actual pregnancy rates because students who become pregnant are more likely to drop out of school, and therefore will not be represented in the survey; those who do not drop out may either not wish to report a previous pregnancy (especially one which ended in abortion), despite promises of confidentiality, or may only recognise a pregnancy as such if it ended in a live birth. In most cases, factors relating to the accuracy of self-reported data are likely to affect the intervention and control schools equally. However, this may not be true of pregnancy data: schools with SBHCs may differ from those without SBHCs in terms of the extent to which they encourage and enable pregnant and parenting students to remain in school, and this will then affect the pregnancy rates among their students.

Issues related to the secondary outcome measures

In the context of the current review, sexual activity and contraceptive use are secondary outcome measures acting as surrogates for pregnancy and STIs because the latter, primary, outcomes are rarer and more difficult to measure. Both the USA and the UK have seen opposition to the provision of SBSHS or SLSHS on the grounds that they will promote teenage sexual activity, which some view as undesirable in itself, and undermine parental authority. 76,77 Because of this political pressure, the impact of services on rates of sexual activity has often been regarded as an outcome measure in its own right. However, contraceptive use is of interest only as a surrogate for pregnancy and, in the case of condoms, STIs.

Contraceptive use is a potentially problematic outcome measure for several reasons. The first of these is that, like sexual activity, it is a self-reported outcome which is not readily susceptible to external validation. So, although some studies included in this review provide information about the quantities of contraceptives dispensed, or the numbers of students to whom they were dispensed, this cannot prove either that those contraceptives were actually used by the students to whom they were issued, or that their issue resulted in an increase in either the proportion of sexually active students who used them or the proportion of occasions on which they were used. Moreover, a study that compared daily activity diaries completed by 37 sexually active, non-monogamous, heterosexual college students with their recall 6–12 months later found that, at the later date, they over-reported the number of occasions on which they used condoms. 78 In the context of the current review, it is not clear whether this would affect the intervention and control groups equally, or whether students in schools with sexual health services might be more likely to over-report contraceptive use.

Although it seems intuitively likely that the provision of SBSHS would increase contraceptive use, this may not be so. Brown et al. 67 suggested that school condom availability programmes reduce potential barriers to obtaining condoms by:

• reducing embarrassment (if condoms are made available privately)

• eliminating or reducing the cost of condom use

• increasing the physical accessibility of condoms for young people who may not have a car or may have difficulty going to a store or family planning clinic alone.

However, Kirby et al. 42 found that when condoms were made available in Seattle schools the proportion of sexually active students who used condoms did not increase, although students who already used condoms switched to obtaining them from the school rather than from another source. Thus, although the Seattle Condom Availability Scheme distributed many condoms, it did not increase overall condom use. This phenomenon of provider substitution was also identified, in relation to general contraceptive use, in Dallas, Jackson, Muskegon and Quincy. 45

The second issue is that the relevance of contraceptive use as a surrogate for pregnancy, although intuitive, has not been demonstrated by this review, as included projects that reported statistically significant differences in contraceptive use between the intervention and control groups did not report corresponding statistically significant differences in pregnancy rates (Table 21).

Personal factors

The first review: what is the evidence about service effectiveness?

As explained in Chapters 5 and 6, almost all of the studies identified for this review came from the USA. The methodological quality was very uneven. No RCTs of school-linked or school-based sexual health interventions were located. There were controlled before/after studies, including case-studies, cross-sectional surveys and one quasi-cohort study. There were also uncontrolled before/after studies. Very few studies addressed the primary outcomes of interest to this review, i.e. unintended conceptions and STI rates. Some relevant secondary outcomes were addressed, however, specifically patterns of sexual activity and condom use/non-use.

Analyses of the US studies produce a number of positive findings. First, in connection with sexual activity, there is no evidence that school-based and SLSHS are associated with any increase in rates of sexual activity among young people, or with a lowering of the age of first intercourse. Indeed, there is some evidence that these services may be associated with a reduction in the proportion of students reporting recent sexual activity, and with a reduction in the proportion of students reporting high numbers of sexual partners. Second, in connection with teenage pregnancy, there is some evidence that the services may be associated with a reduction in live births to teenage mothers (however, the limitations of available studies make it impossible to determine whether this is due to increased termination rates or to decreased conception rates, or to a combination of both). Third, with respect to STIs, there is evidence from the US that a programme of school-based screening and treatment for chlamydia and gonorrhoea may be associated with a reduction in chlamydia prevalence in male students. However, there is no good-quality evidence that SBSHS or SLSHS are associated with an increase in contraceptive use.

Overall, the findings from the effectiveness review underline the point that further research is needed, in order to examine whether the types of service identified in the mapping review, in the UK, affect pregnancy rates and STI rates.

The second review: views from service users, staff, parents and community members

This review was based on an analysis of 25 qualitative studies, of which eight focused on UK services. Most focused on school-based rather than school-linked services, and most reflected the views of young people; a smaller number addressed the views of staff, parents and other community members. The methods used included focus groups, interviews and surveys; as with the studies located for the effectiveness review, their quality was variable.

Through thematic analysis, the team identified two sets of factors as influencing young people’s decisions about whether or not to access school-based and school-linked services: personal factors and service delivery factors.

The factors identified in relation to both school-based and school-linked services converged closely with many of those identified during the mapping study. For example, in terms of personal factors, it was clear that young people were concerned about confidentiality principles and procedures, and apprehensive about being judged or stereotyped by staff. Other important personal factors concerned levels of awareness and perceived need among young people. Here, it is important to acknowledge the enormous diversity in socioeconomic circumstances, sexual orientations and relationship status in the age range under consideration in this study, as it spans the transition from childhood to adulthood.

This point underlines the importance of flexibility in service provision and service emphasis, perhaps reinforcing the positive aspects of the tailoring of local provision to specific contexts that was mentioned above, in relation to the mapping study. In terms of service delivery factors, there was evidence that young people valued the flexible access offered by school-linked and school-based services, and found school-based and school-linked locations convenient; however, the quality and appropriateness of physical settings was important, as was the availability of specific products and/or services. There was some evidence for a preference among young people for services that presented themselves as broadly based, rather than focused particularly on sexual health. However, there were indications that both gender differences and ethnic identification may play a part in young people’s preferences in this respect, and this needs further investigation.

The third review: barriers and facilitators

This review was based on a mixed-methods approach, in order to provide a synthesis of findings from the most robust available quantitative and qualitative studies. The studies selected were all relevant in terms of participants’ age and gender; limitations also apply, however, as the evaluation studies included only focused on school-based services, the three based in the USA date back over 10 years and only one was conducted in the UK. However, the specific barriers and facilitators identified were very similar to those found in the mapping study, which does encourage confidence in the findings.

The barriers and facilitators identified by young people were confidentiality concerns; access limitations; staffing (gender mix, attitudes); the physical environment and location; the inclusion of pregnancy testing and STI screening. Most of these features had not been addressed in the most robust evaluations of service effectiveness. These are, therefore, potential priorities for investigation in future research.

Some barriers and facilitators identified by the review of qualitative data were addressed by specific intervention studies, but their impact on pregnancy rates and/or STI rates was not evaluated. Initiatives to increase awareness of services, the absence of any requirement for parental consent to access certain types of contraception, the inclusion of medical professionals in staff teams and the provision of information and advice were all in this category. As above, these remain priorities for future investigation in relation to pregnancy rates and STI rates.

The review does provide evidence that the take-up of contraception by young people can be increased both by addressing their concerns about privacy and visibility, and by providing free contraception. Findings from some studies suggest that young people feel less anxiety and embarrassment when attending broad-based services than when attending dedicated sexual health services, in a school context. The implications of this finding for policy and practice are discussed in the next chapter. The current diversity in service models within the UK suggests that there is some scope to investigate the effectiveness of different service models in depth, as well as to evaluate their impact on STI and pregnancy rates. The findings of this review relating to contraceptive use were less positive. Access to services generally, rather than access to school-based services in particular, appears to improve self-reported contraceptive use.

The main findings of this synthesis, therefore, are to highlight a number of priority areas for future investigation. There is a need to research the impact of different service models on sexual behaviour, and on conception and STI rates, in relation both to individual service components and to each intervention as a whole.

Is there evidence to support the development of school-linked and SBSHS?

Yes. This study does provide some evidence to support the continued use and further development of school-linked and SBSHS. First, the objection has been raised in some quarters that these facilities contribute to young people starting sexual activity earlier and increasing their sexual activity overall; this view is not supported by available research. In fact, there are indications that some services may be associated with small delays and reductions in teenage sexual activity. Second, there is some evidence from the USA of associations between school-based services and reductions in teenage births and in chlamydial infection rates (among young men). Third, studies from both the USA and the UK report positive responses from young people about the accessibility and user-oriented nature of many school-based and school-linked services. This last point may be particularly relevant in terms of improving the uptake of sexual health services among boys and young men. However, it is important to remember that almost all of this evidence is based on a small number of US studies, and that most had significant methodological weaknesses. There are also substantial gaps in the available research, and these are discussed further below.

Is there evidence to show which types of service work best?

No. The absence of controlled, experimental studies means that there is no clear evidence about the advantages and disadvantages of different forms of school-based and SLSHS in terms of their impact on outcomes such as pregnancy and STI rates. However, there is some evidence about the preferences of young people and of staff involved in service delivery. Both the mapping study and the systematic review indicate that service models that situate sexual health advice within a broad range of health provision are preferred by many young people and by practitioners, because they minimise stigma and maximise service access. In addition, both the mapping study and the synthesis of evidence have identified a number of criteria that young people and staff see as characterising high-quality services. This evidence suggests that the following principles should inform the development of new services, and the evaluation of established services:

• robust procedures to safeguard confidentiality, agreed between all agencies and professions contributing to the service

• consultation in advance with potential user groups of young people and engagement of young people in the design and implementation of routine monitoring and evaluation processes

• consultation in advance with school headteachers, governors, staff and parents’ groups, to secure informed leadership and support

• close liaison and (where possible) joint work with teaching staff who deliver PSHE

• design of locations and session times to protect privacy of service users

• establishment of a multiprofessional staff team, including both male and female members, and including school nurses, youth workers, medical practitioners and other specialist staff where appropriate (e.g. drug and alcohol workers)

• clear incorporation of local and national child protection guidelines and requirements, along with liaison with relevant local agencies

• provision of comprehensive sexual health services (i.e., including relationships advice, prescriptions for oral and emergency contraception, other forms of contraception, STI screening and pregnancy testing, signposting and referrals for specialist services not offered on site)

• access to continuing professional development for staff, including specialist sexual health training

• marketing of the service as broad-based, rather than restricted to sexual health

• a secure funding basis.

Are there particular priorities for service development?

Evidence from the mapping study – and from the recent SEF survey – shows that school-linked and SBSHS are unevenly distributed, both between UK countries and regions, and within them. Developing services for young people in rural areas, and in Northern Ireland was described as an important priority in qualitative findings from the mapping study. More generally, it is important for commissioning bodies (PCTs and local authorities) to review the provision in their areas, and to consider how to address gaps in provision.

Baltimore SBHCs

1. Santelli J, Alexander M, Farmer M, Papa P, Johnson T, Rosenthal B, et al. Bringing parents into school clinics: parent attitudes toward school clinics and contraception. J Adolesc Health 1992;13(4):269–74.

2. Santelli J, Kouzis A, Newcomer S. Student attitudes toward school-based health centers. J Adolesc Health 1996;18(5):349–56.

Baltimore Comprehensive School Health Services Program: contraceptive continuation pilot project

1. Bearss N, Santelli JS, Papa P. A pilot program of contraceptive continuation in six school-based clinics. J Adolesc Health 1995;17(3):178–83.

Baltimore Pregnancy Prevention Program

1. Zabin LS, Stark HA, Emerson MR. Reasons for delay in contraceptive clinic utilization. Adolescent clinic and nonclinic populations compared. J Adolesc Health 1991;12(3):225–32.

Bodyzone, Oxfordshire, UK

1. Anonymous Case study, 2004. URL: www.doh.gov.uk/Children/Nsfcasestudies.nsf/35ccb39eb7b47ce880256f5b004de49c/6d5519fb495b0c4a80256f6a003f23f1?OpenDocument

2. Carlson C, Peckham S. Bringing health care to schools: first phase evaluation of the Bodyzone Project. Health Educ 2004;104(4):241–53.

3. Peckham S, Carlson C. Bringing health care to schools. Nurs Stand 2003;17(20):33–8.

Brook Sexual Health Outreach in Schools Service, Bristol, UK

1. Salmon D, Ingram J. An evaluation of Brook sexual health outreach in schools. Bristol: Centre for Public Health Research, University of the West of England; 2008.

Clinic in a Box, North Staffordshire, UK

1. Barna D, McKeown C, Woodhead P. Get real: providing dedicated sexual health services for young people. London: Save the Children; 2002.

Croydon school-based drop-in clinics

1. Allen B. Drop-in clinics in secondary schools: the perception and experiences of school nurses. Educ Health 2004;22(3):39–43.

2. Allen B. Lunchtime drop-in clinics accessible in schools. Br J School Nurs 2007;2(5):205–11.

3. Allen B, Davies C, Kay C, Morgan D, Sykes S, Tripp J. The experiences of school drop-in services by pupils and school nurses in Croydon. Croydon: Croydon NHS Primary Care Trust; 2003.

4. Kay CM, Morgan DL, Tripp JH, Davies C, Sykes S. To what extent are school drop-in clinics meeting pupils’ self-identified health concerns? Health Educ J 2006;65(3):236–51.

Dallas, Texas (comprehensive SBHC in Pinkston High School)

1. Kirby D, Waszak C. School-based clinics. In Miller BC, Card JJ, Paikoff RL, Peterson JL, editors. Preventing adolescent pregnancy. Model programs and evaluations. Newbury Park, CA: Sage Publications; 1992. pp. 185–219.

2. Kirby D, Waszak CS, Ziegler J. An assessment of six school-based clinics: services, impact and potential. Washington DC: Center for Population Options; 1989.

3. Kirby D, Waszak C, Ziegler J. Six school-based clinics: their reproductive health services and impact on sexual behavior. Fam Plan Perspect 1991;23(1):6–16.

Denver, Colorado (comprehensive SBHC)

1. Ricketts SA, Guernsey BP. School-based health centers and the decline in black teen fertility during the 1990s in Denver, Colorado. Am J Publ Health 2006;96(9):1588–92.

Florida Supplemental School Health Programme

1. Emihovich C, Herrington CD. Sex, Kids, and Politics. Health Services in Schools. New York, NY: Teachers College Press; 1997.

Gary, Indiana (comprehensive SBHC in Roosevelt High School)

1. Kirby D, Waszak C. School-based clinics. In Miller BC, Card JJ, Paikoff RL, Peterson JL, editors. Preventing adolescent pregnancy. Model programs and evaluations. Newbury Park, CA: Sage Publications; 1992. pp. 185–219.

2. Kirby D, Waszak CS, Ziegler J. An assessment of six school-based clinics: services, impact and potential. Washington DC: Center for Population Options; 1989.

3. Kirby D, Waszak C, Ziegler J. Six school-based clinics: their reproductive health services and impact on sexual behavior. Fam Plan Perspect 1991;23(1):6–16.

Healthy Respect, Lothian, Scotland

1. Street J, Whatling E. Access all areas. Linking education and health services for young people. Healthy Respect; 2004.

Integrated ARH project, Brazil

1. Magnani RJ, Gaffikin L, de Aquino EM, Seiber EE, Almeida MC, Lipovsek V. Impact of an integrated adolescent reproductive health program in Brazil. Studies in Family Planning 2001; 32(3):230–243.

Jackson, Mississippi (comprehensive SBHC in Lanier High School)

1. Kirby D, Waszak C. School-based clinics. In Miller BC, Card JJ, Paikoff RL, Peterson JL, editors. Preventing adolescent pregnancy. Model programs and evaluations. Newbury Park, CA: Sage Publications; 1992. pp. 185–219.

2. Kirby D, Waszak CS, Ziegler J. An assessment of six school-based clinics: services, impact and potential. Washington DC: Center for Population Options; 1989.

3. Kirby D, Waszak C, Ziegler J. Six school-based clinics: their reproductive health services and impact on sexual behavior. Fam Plan Perspect 1991;23(1):6–16.

Kansas City, Missouri (comprehensive SBHCs)

1. Seybert JA, Doucette DS, Welch QB, Kitzi G, Hill-Young J. Health habits of urban high school students: evaluation of school-based clinics. Paper presented at the Annual Meeting of the American Educational Research Association, New Orleans, LA, 5–9 April 1988.

London sexual health drop-in service

1. Washkansky G. Sexual health drop in service. 2008.

Los Angeles County Condom Availability Scheme

1. Schuster MA, Bell RM, Berry SH, Kanouse DE. Students’ acquisition and use of school condoms in a high school condom availability program. Pediatrics 1997;104(689):694.

2. Schuster MA, Bell RM, Berry SH, Kanouse DE. Impact of a high school condom availability program on sexual attitudes and behaviors. Fam Plan Perspect 1998;30(2):67–72, 88.

Louisiana SBHCs

1. Zeanah PD, Morse EV, Simon PM, Stock M, Pratt JL, Sterne S, et al. Community reactions to reproductive health care at three school-based clinics in Louisiana. J School Health 1996;66(7):237–41.

Massachusetts Condom Availability Programs

1. Blake SM, Ledsky R, Goodenow C, Sawyer R, Lohrmann D, Windsor R. Condom availability programs in Massachusetts high schools: relationships with condom use and sexual behaviour. Am J Publ Health 2003;93(6):955–62.

Minneapolis (on-site contraceptive distribution in comprehensive SBHCs)

1. Sidebottom A, Birnbaum AS, Nafstad SS. Decreasing barriers for teens: Evaluation of a new teenage pregnancy prevention strategy in school-based clinics. Am J Publ Health 2003;93(11):1890–2.

Minnesota SBHCs

1. Bar-Cohen A, Lia-Hoagberg B, Edwards L. First family planning visit in school-based clinics. J School Health 1990;60(8):418–22.

Muskegon, Michigan (comprehensive SBHC in Muskegon Heights High School)

1. Kirby D, Waszak C. School-based clinics. In Miller BC, Card JJ, Paikoff RL, Peterson JL, editors. Preventing adolescent pregnancy. Model programs and evaluations. Newbury Park, CA: Sage Publications; 1992. pp. 185–219.

2. Kirby D, Waszak CS, Ziegler J. An assessment of six school-based clinics: services, impact and potential. Washington DC: Center for Population Options; 1989.

3. Kirby D, Waszak C, Ziegler J. Six school-based clinics: their reproductive health services and impact on sexual behavior. Fam Plan Perspect 1991;23(1):6–16.

New Orleans STI screening and treatment programme

1. Cohen DA, Nsuami M, Etame RB, Tropez-Sims S, Abdalian S, Farley TA, et al. A school-based Chlamydia control program using DNA amplification technology. Pediatrics 1998;101(1):E1.

2. Cohen DA, Nsuami M, Martin DH, Farley TA. Repeated school-based screening for sexually transmitted diseases: A feasible strategy for reaching adolescents. Pediatrics 1999;104(6):1281–5.

3. Nsuami M, Cohen DA. Participation in a school-based sexually transmitted disease screening program. Sex Trans Dis 2000;27(8):473–9.

New York City Schools Condom Availability Program

1. Guttmacher S, Lieberman L, Hoi-Chang W, Ward D, Radosh A, Rafferty Y, et al. Gender differences in attitudes and use of condom availability programs among sexually active students in New York City public high schools. JAMWA 1995;50(3/4):99–102.

2. Guttmacher S, Lieberman L, Ward D, Radosh A, Rafferty Y, Freudenberg N. Parents’ attitudes and beliefs about HIV/AIDS prevention with condom availability in New York City public high schools. J School Health 1995;65(3):101–6.

3. Guttmacher S, Lieberman L, Ward D, Freudenberg N, Radosh A, Des Jarlais D. Condom availability in New York City public high schools: relationships to condom use and sexual behavior. Am J Publ Health 1997;87(9):1427–33.

4. Rafferty Y, Radosh A. Attitudes about AIDS education and condom availability among parents of high school students in New York City: a focus group approach. AIDS Educ Prev 1997;9(1):14–30.

New York City ‘In Your Face’ pregnancy prevention programme

1. Tiezzi L, Lipshutz J, Wrobleski N, Vaughan RD, McCarthy JF. Pregnancy prevention among urban adolescents younger than 15: results of the ‘In Your Face’ program. Fam Plan Perspect 1997;29(4):173–6.

Oregon, School A (comprehensive SBHC)

1. Stout JW, White LC, Alexander T. Oregon school-based health centers: a follow-up report. Department of Human Resources, Oregon Health Division, Oregon, 1996.

Oregon, School B (comprehensive SBHC)

1. Stout JW, White LC, Alexander T. Oregon school-based health centers: a follow-up report. Department of Human Resources, Oregon Health Division, Oregon, 1996.

Oregon, School C (comprehensive SBHC)

1. Stout JW, White LC, Alexander T. Oregon school-based health centers: a follow-up report. Department of Human Resources, Oregon Health Division, Oregon, 1996.

Oregon (comprehensive SBHCs)

1. Zimmer-Gembeck MJ, Riddell C. School-Based Health Centers in Oregon: Adolescents Report Their Needs, Use, Behaviors, and Attitudes. Health Division, Oregon State Department of Human Resources, Portland, Oregon, 1996.

‘An urban area of the north-western United States’ – apparently Oregon (on-site dispensing of hormonal contraceptives in comprehensive SBHCs)

1. Zimmer-Gembeck MJ, Doyle LS, Daniels JA. Contraceptive dispensing and selection in school-based health centers. J Adolesc Health 2001;29(3):177–85.

Philadelphia Condom Availability Scheme

1. Furstenberg FF, Jr, Geitz LM, Teitler JO, Weiss CC. Does condom availability make a difference? An evaluation of Philadelphia’s Health Resource Centers. Fam Plan Perspect 1997;29(3):123–7.

2. McGrory G, Weiss C, Mahoney W, Armstrong K, Hazan H. Assessing the first two years of Philadelphia high school condom distribution program: a unique model. The American Public Health Association, 122nd annual meeting, Washington DC, 30 October–3 November 1994.

Quincy, Florida (comprehensive SBHC in Shanks High School)

1. Kirby D, Waszak C. School-based clinics. In Miller BC, Card JJ, Paikoff RL, Peterson JL, editors. Preventing adolescent pregnancy. Model programs and evaluations. Newbury Park, CA: Sage Publications; 1992. pp. 185–219.

2. Kirby D, Waszak CS, Ziegler J. An assessment of six school-based clinics: services, impact and potential. Washington DC: Center for Population Options; 1989.

3. Kirby D, Waszak C, Ziegler J. Six school-based clinics: their reproductive health services and impact on sexual behavior. Fam Plan Perspect 1991;23(1):6–16.

San Francisco (comprehensive SBHC in Balboa High School)

1. Kirby D, Waszak C. School-based clinics. In: Miller BC, Card JJ, Paikoff RL, Peterson JL, editors. Preventing adolescent pregnancy. Model programs and evaluations. Newbury Park, CA: Sage Publications; 1992. pp. 185–219.

2. Kirby D, Waszak CS, Ziegler J. An assessment of six school-based clinics: services, impact and potential. Washington DC: Center for Population Options; 1989.

3. Kirby D, Waszak C, Ziegler J. Six school-based clinics: their reproductive health services and impact on sexual behavior. Fam Plan Perspect 1991;23(1):6–16.

Seattle Condom Availability Program, Seattle, Washington

1. Brown NL, Pennylegion MT, Hillard P. A process evaluation of condom availability in the Seattle, Washington public schools. J School Health 1997;67(8):336–40.

2. Hillard P, Peterfreund N, Moe K. Seattle public schools 1995 teen health risk survey. Seattle, WA: Seattle Public Schools; 1996.

3. Kirby D, Brener ND, Brown NL, Peterfreund N, Hillard P, Harrist R. The impact of condom availability [correction of distribution] in Seattle schools on sexual behavior and condom use. [Erratum appears in Am J Publ Health 1999;89(3):422.] Am J Publ Health 1999;89(2):182–7.

St Paul Pregnancy-Free Club, St Paul, Minnesota

1. Schaffer MA, Jost R, Pederson BJ, Lair M. Pregnancy-Free Club: a strategy to prevent repeat adolescent pregnancy. Publ Health Nurs 2008;25(4):304–11.

Time 4U, Worcestershire, England

1. Nelson M, Quinney D. Evaluating a school-based health clinic. Health Visit 1997;70(11):419–21.

2. Tanner K, Kirton A, Stone N, Ingham R. Evaluating the effectiveness of Time 4U services and associated educational interventions in Worcestershire. Summary of main findings. Sexual Health Education Unit, Sexual Health Service, South Worcestershire Primary Care Trust; 2003. URL: www.worcestershire.gov.uk/home/cs-con-toolkit-time4uresearch.pdf

US-wide evaluation of school-based adolescent health-care programme (comprehensive SBHCs)

1. Kisker EE, Brown RS. Do school-based health centers improve adolescents’ access to health care, health status, and risk-taking behavior? J Adolesc Health 1996;18(5):335–43.

2. Kisker EE, Brown RS, Hill J. Healthy caring: outcomes of the Robert Wood Johnson Foundation’s school-based adolescent health care program. Princeton, NJ: Robert Wood Johnson Foundation; 1994.

US-wide study of acceptability of school-based HIV prevention and condom availability programmes

1. Ryan JG, Fowler GC, Aday LA, Miller SM. Family physicians’ support for school-based HIV prevention education programs. Arch Fam Med 1993;2(6):637–44.