Christine De Rosa, Ph.D. Patricia Dittus, Ph.D. Kathleen Ethier, Ph.D. Emily Chung, MPH, CHES

1. Increases in Reproductive Health Care, STD Screening and HIV Testing Among High School Students Following a School Based Health Care Intervention Christine De Rosa, Ph.D. Patricia Dittus, Ph.D. Kathleen Ethier, Ph.D. Emily Chung, MPH, CHES Esteban Martinez Kathy Wong, MS Peter Kerndt, MD, MPH Funded by Centers for Disease Control and Prevention; Atlanta, GA U30/CCU922283-06

2. Teen Pregnancy and STDs in Los Angeles • In LA County, 63% of 2005 Chlamydia cases were among persons 10-24 years old • 2001 15-19 year-old birth and Chlamydia rates in 12 high school attendance areas • Birth rate range 43 – 95 per 1,000 (median 62.5) • Chlamydia range 1,058-4,397 per 100,000 (median 1,624)

3. Guidelines for Adolescent Preventive Services (AMA) • Adolescents should be asked annually about sexual behavior • Sexually active adolescents should be screened for STD • Adolescents who screen positive should receive: • Diagnostic test • Treatment Plan • Prevention counseling

4. Intervention Goals and Targets • Goals: Increase access to reproductive health care services for adolescents • STD screening and treatment • Family planning services • Targets: School Nurses, Providers • Identify local community-based providers • Provide linkage and support • Facilitate youth finding care on their own

5. Formative Research • School nurses identified barriers to referring students for reproductive health care • Sending students off-campus • Liability issues • Unknown practices of providers • Lack of awareness of free services available • Youth surveys • 17% of sexually experienced youth ever screened for STD

6. Creating a Provider Referral Guide • Using DPH Chlamydia reports, identify providers • Survey identified providers • Asked about adolescent-specific treatment • Collected info on services (payment, type of Chlamydia test, family planning options) • Visit providers • Assemble guide

7. Guides for Each School • 2 sets of community providers • San Fernando Valley • South Los Angeles • 6 guides – one for each high school • Providers listed in order of proximity • Included providers who were close by and farther away

8. School Nurse Referral Guide Actual size 2’ X 3’

9. School Nurse Referral Guide Actual size 2’ X 3’ CLINICS

10. School Nurse Referral Guide Actual size 2’ X 3’ GENERAL INFORMATION PLEASE CALL CLINIC TO VERIFY HOURS EVENING APPOINTSMENTS (AFTER 5 PM) WEEKEND APPOINTSMENTS (SAT/SUN) AFTER SCHOOL APPOINTSMENTS (BEFORE 5 PM) BUS ROUTE (MAY VARY DEPENDING ON DAY AND TIME) DISTANCE FROM HIGH SCHOOL

11. School Nurse Referral Guide Actual size 2’ X 3’ GENERAL SERVICES TEEN FRIENDLY FEATURES OFFERED* GENDER OF PATIENTS SEEN

12. School Nurse Referral Guide Actual size 2’ X 3’ SEXUAL HEALTH SERVICES TYPES OF FAMILY PLANNING METHODS ECP – IN ADVANCE HORMONAL CONTRACEPTION FEMALE CONDOM ECP – AS NEEDED MALE CONDOM URINE BASED CT TEST

13. School Nurse Referral Guide Actual size 2’ X 3’ COST OF SERVICES FAMILY PACT & MEDI-CAL PROVIDER PAYMENT METHODS ADDITIONAL INFORMATION

14. Student Referral Sheet

15. Distributing the Guide • In-service for school administrators • School district policy on confidential medical services • California Department of Education Code • Discussion of barriers and concerns • Yearly updates • Process review

16. Intervention Effects • Does use of the guide increase the percent of adolescents who receive reproductive health care services? • Measures: High School Youth Survey • Receipt of reproductive health care in past year • Saw a doctor/nurse in past year for birth control or STD test/treatment • Ever tested for STD • Ever tested for HIV

17. Analyses • Chi-square analyses • Outcomes by data collection wave • Analyses performed by condition Analyses restricted to: • High School students • Sexually experienced

18. Results: Reproductive Health Care • Receipt of reproductive health care increased significantly across waves for intervention participants (23.2% - 27.1% - 27.2%; p=.01) • Males 11.7% - 16.3% - 16.2% ; p<.05 • Females 33.5% - 38.4% - 39.7%; p<.10 • Receipt of reproductive health care was not significantly different by wave among control participants • 24.7% - 23.2% - 24.6%; p>.10

19. Reproductive Health Care by Wave and Condition N=6,451 Sexually active males and females

20. Reproductive Health Care by Wave and Condition (Males) N=3,218 Sexually active males

21. Reproductive Health Care by Wave and Condition (Females) N=3,233 Sexually active females

22. Results: STD Testing • Percent ever STD tested increased significantly across waves for intervention and control participants • Significant increase among intervention but not control females • Intervention 29.2% - 38.6% - 42.0%; p<.001 • Control 27.4% - 30.6% - 31.9%; p>.10

23. Ever STD Tested, by Wave and Condition (Females) N=3,233 Sexually active females

24. Results: HIV Testing • Percent ever HIV tested increased significantly across waves for intervention participants • 20.6% - 24.4% - 24.7%; p<.001 • This finding held for both genders • Males 15.7% - 20.2% - 22.0%; p<.05 • Females 24.9% - 28.7% - 33.7%, p<.01 • Percent ever HIV tested was not significantly different by wave among control participants • 19.6% - 21.1% - 22.5%; p>.10

25. Ever HIV Tested, by Wave and Condition N=6,451 Sexually active males and females

26. Summary of Findings Intervention associated with: • Increased reproductive health care in past year, especially for boys • Increased percent STD tested, for girls • Increased percent HIV tested overall

27. Implications • Intervention appears to facilitate sexually active adolescents’ access to and use of reproductive health care, STD and HIV testing • Intervention can assist school nurses and others in making referrals for students seeking reproductive health care • Expansion of this effort could have significant impact on local teen pregnancy and STD rates

28. Advantages of Intervention Approach • Low-cost, sustainable • Empowers school nurses • Provides mechanism for collaboration between health departments, schools, community providers • Facilitates adolescents’ self-sufficiency in seeking and receiving health care • Long-term health benefits

29. Thank you! Collaborators: Nicole Liddon, PhD, Sharon Hudson, PhD, Abdelmonem Afifi, PhD, William Cumberland, PhD, Harlan Rotblatt, Ric Loya, Robin Jeffries, MPH Project Coordinators and Specialists: Emily Chung, MPH, CHES Steve Martinez, BA Kathy Wong, MS Lindsay DuPlessis, MPH …for the Project Connect Study Group