The role of the school in children's out-of-school time.

As the primary community institution in the lives of children, schools have much to contribute to plans for addressing the needs of today's youngsters during the time when classes are not being held. In recent years, demands have escalated for after-school child care, educational enrichment, and safe havens that also foster positive youth development. Many programs that respond to these needs are housed in school buildings. Some are operated by the schools, some by community-based organizations, and others by partnerships between schools and outside groups. New public funding for after-school programs often flows through the school system. This article reports the prevalence of school-based programs and discusses extracurricular activities, child care and extended-day programs, enrichment programs, and ambitious efforts to transform the schools into full-time community hubs offering something for residents of all ages. Implementation challenges accompany program expansion, and this article also examines major issues that arise in school-based programs: governance, space, program quality, funding, and accountability. If these programs fulfill their promise, the school of the future may, indeed, be open extended hours for the enrichment of the children and the sustenance of the family.

School-based health centers in the context of education reform.

The rapid proliferation of school-based health centers is taking place at the same time that school systems are seeking to improve their educational practices. Many different school reform models are being promulgated with modest success. Absence of connections between school reorganization and the provision of human services may lead to failure. The emerging community school model integrates quality education with effective health, mental health, and social services in "one stop" school centers that become student, parent, and community hubs.

Medical clinics in junior high school: changing the model to meet demands.

PURPOSE: To document the development of an initiative undertaken by the Columbia University School of Public Health to provide medical, mental health, and social services in inner city junior high school-based clinics. METHODS: Review of records, reports, and foundation proposals from 1984-1993. Site visits, interviews with clinic staff, school personnel, and students. RESULTS: Years of planning and community development produced four clinics in the Washington Heights area of New York City, the first school-based clinics located in junior high schools in the country. After seven years, the program has the capacity to serve over 4,000 students who present an overwhelming array of physical, psychological, social, and family problems. Almost 23,000 visits were made to the clinics this year: 49% for medical services, 38% for social services, and 13% for health education. As the demand multiplied, a form of triage was implemented that tracked the highest risk students into intensive individual and group interventions. Primary health screening, mental health services, and pregnancy prevention were identified among the critical needs in this deprived community. CONCLUSIONS: Over the years, the clinics have become integrated into the fabric of the schools. Strategies for working in urban junior high schools must be broad, encompassing medical and mental health services, group counseling, life planning and career orientation, along with enhancement of the total school and learning environment.

Bound and gagged: America's family planning network.

During the past decade, the number of family planning clinics receiving support from the federal government has fallen from 5,000 to 4,000 despite a growing demand for their services among poor women and teenagers. At the same time, family planning providers have been under regulatory attack, forced to fend off a "squeal rule" aimed at teenagers and to stop a "gag rule" preventing abortion referral. With the climate in Washington unlikely to change, family planners should consider integrating other services into their network or press to include family planning in other care networks. A new national commission could help break the logjam on federal legislation.

PIP: 4000 family planning (FP) clinics in the US serve about 5 million women each year most of whom are poor. They provide FP as well as screening services for hypertension, breast and cervical cancer, sexually transmitted diseases (STDs), pelvic exams, and urine tests. Even though they are the most important means of health care for these women, the US public knows little about them. The main reason for this disinterest is Americans' ambivalence about sex. The abortion issue has clouded FP. Mass media, policymakers, and politicians do not distinguish between FP and abortion. Yet few FP clinics do abortion. Public FP funds have never been used to do abortions. Many conservatives believe that FP services for teenagers promotes premarital sex, but most teenagers have been sexually active for at least a year before coming to FP clinics. Conservatives think the only way to stem adolescent pregnancy is abstinence, but 75% of all teenagers have had premarital intercourse before the end of their senior year. Some antiabortion groups harass FP providers because of their association with sexuality. The Reagan administration cut so much funding that 20% of FP clinics had to close. Yet demand for their services increased. US contraceptive services' expenditures decreased 66% during the 1980s. The Bush administration forbade FP workers at federally funded clinics from counseling clients about abortion. This restriction allowed the government to define the physician-patient relationship. Some FP clinics may give up federal funding so they can provide patients complete information and services. Some advocates suggest comprehensive reproductive health care centers that integrate FP and pre- and postnatal care while others suggest integrating FP with AIDS prevention, substance abuse, STD services, and maternal and child health care.

A review of interventions to prevent pregnancy.

PIP: Of more developed nations, the US is unique in its problem with high rates of teen pregnancy. At the heart of our failure to check teen pregnancy may lie the country's poor sexual climate, a lack of government commitment, poor health system performance, local barriers to the provision of quality sex education, and/or lack of access to contraception. Potential solutions to reduce teen pregnancy are equally wide-ranging. Programs may aim to provide better and more health and sex education, improve decision making skills, improve access to contraception and abortion, improve life opportunities as alternatives to pregnancies, restructure welfare, and/or encourage youths to refrain from premarital sex. This essay presents and discusses major prevention efforts which seem to have the highest probability of reducing pregnancy rates, and especially childbearing rates among young, unmarried teens. Literature on program successes, agency reports, and program observations are reviewed, and include programs of sex education and skills enhancement, those helping sexually active youths become better contraceptors, and those which offer life option alternatives. In the area of improving access to contraception, school-based clinics, condom distribution, and other male-oriented programs are covered. Major social structural change is, however, called for with a view to promoting equity in education, housing, and jobs. Short of such change, interventions may target school-based populations, as well as community centers to reach dropouts. Early intervention and collaboration to bolster health, social, and recreational services for children and adolescents is urged.^ieng

Family planning clinics--a story of growth and conflict.

During the 1960s, as demand for effective contraceptives increased and women expressed a desire for smaller families, an "odd lot" of groups came together to press for federally supported family planning services for low-income women. The drive culminated in 1970 with the passage of Title X of the Public Health Service Act, which authorized the funds that fed a network of family planning clinics. At the height of the national family planning program, approximately 2,500 agencies were operating clinics at more than 5,000 sites, providing services annually to almost five million patients. As part of the screening for medical methods of birth control, family planning clinics have provided basic physical examinations and related tests to millions of low-income women and teenagers who might not otherwise have had access to those services. Clinics have also been heavily utilized for pregnancy tests, screening for sexually transmitted diseases (STDs), infertility screening and referral for abortion, adoption and sterilization services. Other desired achievements have been more elusive and difficult to document--reductions in the number of high-risk and unintended pregnancies and in poverty rates, for example. The program's role in providing contraceptive services to teenagers and its involvement in the abortion controversy have led to a number of political, legislative and judicial skirmishes with conservatives, Congress and the Reagan administration. Funding for Title X declined during the 1980s and is now surpassed by Medicaid as the largest source of family planning dollars. Diminishing funds at a time when some expenses--for supplies, malpractice insurance and treatment of STDs, for example--are increasing have resulted in fewer clinic sites and other service cutbacks. The suggestion has been made that it is time to eliminate categorical funds for family planning and integrate all services into the general medical care system. Family planning providers say an integrated arrangement would not meet the needs of much of their patient population and would not provide the special attention they feel is needed for successful contraceptive practice among low-income, high-risk women. Instead, they suggest expanding the scope of services in family planning clinics, out of an awareness that the continuing high prevalence of unintended childbearing, among the young and disadvantaged in particular, is part of a larger problem of living in a desolate social environment.

School-based health clinics: three years of experience.

In the last three years, comprehensive school-based clinics have proliferated throughout the United States: There are currently 138 clinics in 30 states and the District of Columbia, and at least 65 more are in the planning stage. Clinic programs differ widely in their organizational structure, operating costs, range of services and funding sources. Although some clinics are funded by private foundations, increasingly, programs are being initiated by local public health departments supported by state funds. Only 10-25 percent of all clinic visits are for family planning services. While all of the clinics provide counseling on family planning, most of the state-funded clinics either prohibit the use of funds for contraceptive supplies and abortion referral or allow grantees to decide what to do about the issue of pregnancy prevention. To date, no study has found that rates of sexual activity increase among students who participate in clinic programs. There is some evidence indicating that participation in school-based clinics may have a positive impact on contraceptive practice.

School-based clinics: their role in helping students meet the 1990 objectives.

Service statistics and observations from site visits across the country indicate that school-based clinics (SBCs) may be having an impact on several of the problems targeted in the 1990 health objectives, including unplanned pregnancy and substance abuse. At least 120 junior and senior high schools in 61 communities are currently operating or developing clinics. Growth is attributed to increasing concern about high-risk youth, especially among educators in their roles of "surrogate parents"; to disillusion with categorical interventions and a movement toward more comprehensive services; and to student, parent, school, and community approval of the new programs. This article describes the comprehensive school-based clinic model, including its history, organizational strategies, school/community partnerships, and services.

PIP: School based clinics (SBCs) are beginning to affect the problems of the 1980s that have been identified as health objectives for the 1990s. 120 junior and senior high schools in 61 communities across the US have clinics either functioning or in the process of creation. This number is growing quickly mainly because educators have become increasingly concerned about their role as "surrogate parents." However, controversy and differing opinions about the disbursement of contraceptives remains. The history, organizational strategies and funding, services, limitations and evaluation of the SBCs are discussed. In addition, the aspects of school/community partnership and health education are detailed. Approximately 30% of the 227 health objectives for the United States could be achieved through school based clinics; however, their connection to these objectives needs to be better promoted and actualized to counteract negative perceptions. SBCs can be better utilized in the areas of accident prevention and environmental safety to decrease the number of accidents and injuries among young adults.

Contraceptive use, pregnancy intentions and pregnancy outcomes among U.S. women.

PIP: Comprehensive analysis of contraceptive use, pregnancy intentions and pregnancy outcomes among US women. Although most US women use modern methods of contraception successfully, a considerable number have unintended pregnancies even with the most effective methods. Low income women and teenagers continue to have greater difficulty than others in planning pregnancy successfully, the former mainly because they have higher contraceptive failure rates and are less likely to employ contraceptive sterilization, and the latter because they are relatively more likely to have unprotected intercourse and are increasingly dependent on withdrawal as their contraceptive method (probably because of fear of side effects from the pill). An estimated 4.4 million of America's sexually active, fecund women were unintentionally pregnant in 1978 (including 1.3 million whose pregnancies did not terminate until the next year). Another 4 million were at high risk of having an unintended conception because they used no birth control method or an ineffective method. These categories included 42% of teenagers and 30% of low income women exposed to the risk of unintended pregnancy--compared to just 20% of other women. About 2/3 of the 2.4 million low income women who used the most highly effective methods and avoided having an unintended pregnancy obtained their method from a family planning clinic.^ieng

The National Reporting System for Family Planning Services--a new look.

The National Reporting System for Family Planning Services may be dismantled or further weakened, making the program less visible and less accountable. A strengthened, full-count system is needed, making efficient use of the 42 intermediate data systems that are now in place.

PIP: The National Reporting System for Family Planning Services (NRSFPS) began as a 100% reporting system but was converted to a sample survey in mid-1977 in an economy move. Data from the NRSFPS are used for the annual report to Congress on family planning services required under Title X legislation. Such data were used at the clinic, agency, county, state, regional and national levels for program evaluation and planning, and several states developed intermediate data systems which collected statistics from agencies and submitted them to the NRSFPS contractor. As a result of the 1977 changes in design and operation of the NRSFPS, the responsibility for data collection has been decentralized and uniformity and completeness of coverage are no longer obtained by the intermediate systems. The combined costs of the new systems probably exceed that for the old system with its 100% coverage. A reporting system is needed that will summarize state and national visit totals, yield routine reports at the local level and special reports of local data that may be aggregated at higher levels. A proposal to reconstitute the NRSFPS to rely on the intermediate automated data systems already in place is advanced, and the possible advantages, disadvantages, and organization of such a system are discussed.