标题：Association Between Availability and Quality of Health Services in Schools and Reproductive Health Outcomes Among Students: A Multilevel Observational Study
摘要：Objectives. We determined the association between availability and quality of school health services and reproductive health outcomes among sexually active students. Methods. We used a 2-stage random sampling cluster design to collect nationally representative data from 9107 students from 96 New Zealand high schools. Students self-reported whether they were sexually active, how often they used condoms or contraception, and their involvement in pregnancy. School administrators completed questionnaires on their school-based health services, including doctor and nursing hours per week, team-based services, and health screening. We conducted analyses using multilevel models controlling for individual variables, with schools treated as random effects. Results. There was an inverse association between hours of nursing and doctor time and pregnancy involvement among sexually active students, with fewer pregnancies among students in schools with more than 10 hours of nursing and doctor time per 100 students. There was no association between doctor visits, team-based services, health screening, and reproductive health outcomes. Conclusions. School health services are associated with fewer pregnancies among students, but only when the availability of doctor and nursing time exceeds 10 hours per 100 students per week. School-based health centers (SBHCs) are health clinics located in schools that provide comprehensive and youth-appropriate health services through their accessible, low-cost, youth-focused services and comprehensive care. 1 However, current evidence of the effectiveness of SBHCs in addressing student health outcomes is limited. Kisker and Brown 2 suggested that students in schools with health centers had improved access to health care compared with a national sample of students without access to SBHCs, but there were few differences in health risk behaviors, mental health, or pregnancy rates. A study of African American adolescents from 7 Midwestern US high schools found that in schools with SBHCs, students were less likely to smoke cigarettes and marijuana than were students in schools without SBHCs, but there were few differences in alcohol use. 3 In terms of sexual and reproductive health outcomes, Kirby et al. 4 compared 4 pairs of schools (4 with and 4 without SBHCs) and 2 schools before and after the establishment of school clinics. They found evidence of improved contraceptive and condom use in schools with SBHCs, but inconsistent effects on self-reported pregnancy rates. A recent study of 12 urban California high schools (6 with and 6 without SBHCs) revealed higher rates of contraception use in schools with SBHCs, but only among female students. 5 Existing studies of school-based health services are limited by the small numbers of schools examined, inclusion of nonrepresentative samples, and use of analytic methods that do not take into account the clustering of students within schools. 6,7 A recent study by McNall et al. 8 was among the first to appropriately model the clustering of students within schools using multilevel modeling techniques, but the overall study was limited by the small number of schools used as comparisons. There are also few randomized intervention studies because these require group randomization and are difficult to conduct. 9 These issues highlight the difficulties in studying group-level interventions such as school-based health services. Previous studies have also largely ignored the variation between schools in the availability and quality of health services provided. For example, some clinics may provide comprehensive and intensive services staffed on-site by a multidisciplinary team of highly trained personnel, whereas other school clinics may provide only limited on-site services with visiting health personnel. Furthermore, provision of contraceptives, condoms, and screening for sexually transmitted infections in many schools remains controversial, thus limiting their availability. It remains unknown how variation in the availability and quality of services affects student health outcomes. To address these shortcomings of the existing literature, we aimed to determine whether school-based health services are associated with better sexual and reproductive health among students. This study is among the first to draw on a large nationally representative sample of students and use multilevel analytical techniques to examine the impact of school-based health services. We examined aspects of school-based health services such as hours of health personnel, doctor visits, and team-based services in relation to student reproductive health outcomes.
