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School clinics armed for reproductive health

Mountain Dew makes a great thirst-quencher but don’t count on it as a contraceptive.

Pediatric Nurse Practitioner Joan Neff has to explain that with alarming frequency to the teen-agers who visit the Baker School-Based Health Clinic, located adjacent to Baker Elementary School in Commerce City.

Or she’ll explain that having sex standing up does not work as birth control. Or that practicing birth control will not make it harder for you to get pregnant in the future.

“There’s a lot of misinformation,” Neff said. “I would say almost every teen we see has at least one big misconception about either birth control or sexually-transmitted infections.”

Across the state, care providers at the 35 health care centers based at middle schools and high schools in Colorado encounter the same issues: Sexually active or potentially active teens with scant knowledge of contraceptive or safe sex practices; an epidemic of sexually-transmitted infections – especially chlamydia – among teens; care providers who may be excellent at treating asthma or giving sports physicals but unsure of best practices when it comes to reproductive health care; and skittish communities that would just as soon this didn’t become a topic for public conversation.

A new resource – the Adolescent Reproductive Health Tool Kit – released in late April by the Colorado Association for School-Based Health Care may provide some help with all those issues.

The tool kit, two years in the making, provides a range of concrete resources and suggestions for school-based health care providers on topics ranging from how to talk to school boards about teen pregnancy prevention to booklets on a range of reproductive topics written in teen-friendly lingo to guidelines for health care providers on just what they should be asking and advising their teen-age patients.

“When it comes to adolescent health, the reproductive piece often gets overlooked, sometimes intentionally,” said Melinda Gonzales, Director of Adolescent Health Programs for CASBHC, and the driving force behind the tool kit. “Most people are supportive but they just don’t know how much such programs are needed. And a few are vocal in their opposition.”

By law, any adolescent in Colorado is entitled to access to reproductive health services, with or without parental consent. All the school-based health clinics serving middle and high schoolers in Colorado offer some degree of reproductive health care. Some do pregnancy testing. Some offer contraception. Most offer health education counseling. Many offer all these things in a comprehensive package.

“A lot is already going on, and we’re excited about that,” Gonzales said. But a needs assessment showed a number of gaps, both in how effective clinics are in encouraging teens to take advantage of the services available to them, as well as training in the latest best practices in dealing with adolescent reproductive health.

“Most teens don’t know that they can access reproductive health care on their own,” said Dr. Sarah Winbourn, medical director of Community Health Services, a nonprofit organization with clinics in six schools in Commerce City. “To reach out to those students, to let them know this is something they can access without parental consent, is a humongous big deal.”

Winbourn, a pediatrician, says she’s grateful for the guidelines included in the tool kit. “It’s very rare that a pediatric provider has a lot of training in reproductive health care for teens,” she said. “Having something evidence-based, having all the best practices, just makes it simple and helpful. All our nurse practitioners who are using it are now feeling more confident. It walks everyone through the best practices, and it’s changed the way some of them treat students.”

Take Pap smears, for example. Years ago, they were standard treatment for adolescent girls. But no longer, Winbourn said. “It’s really invasive and can be a traumatic experience for a teen-age girl. Under the new guidelines, very few teens would need to get a Pap smear. I think providers are glad to learn they don’t need to put them through that.”

But screening for chlamydia, on the other hand, should be much more aggressive than in the past.

“People don’t have a clue just how high the rates of sexually transmitted infections are among teens,” said Terry Lee, a nurse educator for the Denver STD/HIV Prevention Training Center. “And I don’t think people really understand that the chlamydia infection can be asymptomatic. Up to 85 percent of women with it don’t realize it. If you rely on patients to report to you when something feels wrong, you may miss an opportunity to screen and treat for STIs.” Left untreated, sexually transmitted infections can lead to infertility or the more serious pelvic inflammatory disease.

In fact, officials say that in 2007 – the most recent figures available – there were an estimated 13,164 cases of chlamydia among Coloradans between 15 and 24 years of age, compared to 2,062 estimated cases of gonorrhea and 29 cases of syphilis among the same population.

Lee said that one survey in 2008 found that the rate of chlamydia infection was 20 percent at one clinic at a juvenile detention center, 10.3 percent at one primary care clinic and 7.5 percent at a family planning clinic.

“What this says is that we really need to think outside the box,” she said. “When you have teens who come in to a clinic, you have the ability to establish rapport, to develop a relationship and start talking to them about sexual reproductive health. Don’t wait until they come to you with a problem, but take the initiative.”

Another topic that frequently gets skipped when teens visit health clinics is emergency contraception, i.e, the “morning-after pill.” Gonzales says surveys show only 28 percent of teens know that emergency contraception is available to them. “We want to make sure our providers know to council the teens on that, because some may not have been giving out that information.”

Neff’s clinic was among the four that piloted the tool kit before its introduction, and she says she’s grateful for it.

“It raises the bar to a more uniform and higher level of care given to teens,” she said. “It guides providers to give the same level of care across the board.”

Winbourn says she expects no pushback – at least, not from the medical community – on the introduction of the tool kit. But she acknowledges that any conversation about teens’ reproductive health care is bound to be controversial.

“We’ve been lucky. We’ve tried to be thoughtful about school district concerns and tread lightly,” she said. “But providing this is really important. It’s been proven over and over again that access to reproductive health care doesn’t make teens more promiscuous, it doesn’t decrease the age at which they first have sex. It doesn’t do any of those things. It’s about keeping them healthy, keeping them from getting pregnant. I feel like this tool kit really helps us approach the topic in a very educated, very responsible way.”

For more information:

Click here for more information from the Centers for Disease Control and Prevention about sexual risk behaviors among youth, as well as data and statistics on sexual behavior trends, sexually transmitted disease prevention, pregnancy prevention and other topics.

Click here to read a report on school-based health center data for the 2008-09 school year in Colorado.

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