Dissertations and Theses

Date of Degree

6-1-2020

Document Type

Dissertation

Degree Name

Doctor of Public Health (DPH)

Department

Health Policy and Management

Advisor(s)

Stacey Plichta

Committee Members

Meredith Manze

Alexis Pozen

Subject Categories

Health Policy | Health Services Research | Public Health | Urban Education | Women's Health

Keywords

Birth Rate, Drop Out Rate, SBHCs

Abstract

Background: Gaining an understanding of how school reproductive health policies impact adolescent sexual health and academic outcomes is a public health priority in the United States (U.S.) since it has the highest rates of adolescent pregnancy and sexually transmitted infections among developed nations. Adolescence is a critical developmental period and influences in this period affect reproductive health and social well-being over a person’s entire lifespan. Almost all adolescents spend the majority of their time in school settings; therefore local school reproductive health policies may have substantial lifetime impacts. Policies such as providing comprehensive sexual health education and contraceptive access in the school setting have been shown to delay sexual début and improve contraceptive use. In New York City (NYC), the School-Based Health Center Reproductive Health Project (SBHC RHP) used evidence-based psychosocial theories to establish a standard of care to provide to adolescents in lower-income NYC school settings. The SBHC RHP provided a pathway for adolescents to gain reproductive autonomy by eliminating key barriers to care, including access, travel, and cost. It did not address other barriers that adolescents in these neighborhoods face, including income inequality and job insecurity as well as a long collective history of reproductive health violations in the U.S. inflicted upon those who are young, poor, immigrant, disabled or of color.

Aims: This study’s aims were informed by a modified Brindis & Moore’s framework to evaluate local policies and their ability to improve adolescent health. The first aim was to examine the impact of SBHC RHP on academic and reproductive health outcomes in NYC adolescents. The second aim was to evaluate the impact of SBHC RHP on high school dropout rates.

Methods: Data for this study was obtained from New York City Department of Health & Mental Hygiene public health surveillance, Bureau of Vital Statistics and the New York City Department of Education School Quality Report. Research questions and hypotheses were informed by a modified Brindis & Moore’s framework. Aim I’s study population is 15 to 19-year-old NYC residents during 2005, 2006, 2007, 2011, and 2012. The intervention group was adolescents in neighborhoods served by high school SBHCs, and the control group was adolescents in non-SBHC neighborhoods. The dependent variables were chlamydia, gonorrhea, and birth rates. Aim II’s study population consisted of adolescents attending public schools in NYC for the period between 2005 through 2012. The intervention group was high schools with SBHCs (n=74) and the control group was high schools without SBHCs (n= 66). The dependent variable was high school dropout rates. After cleaning the data, differences in differences regression models were used to test the study hypotheses. In difference in differences, the trend in the control group approximates what would have happened in the intervention group in the absence of the policy.

Results: The results did not support the study hypotheses in this population. During the study period, there were 77,531 reported cases of chlamydia, 13,961 reported cases of gonorrhea, and 65,815 live births among 15- to 19-year-old NYC residents. SBHC RHP did not statistically impact chlamydia and gonorrhea rates for all adolescents, with one exception. Regression adjusted estimates showed that SBHC RHP had a greater effect (by 448) on White adolescents since gonorrhea rates increased at a higher rate as compared to Asian adolescents (p<.05). Pre-intervention SBHC gonorrhea rate mean was 355.15 for Asian adolescents and 57.59 for White adolescents and the post-intervention SBHC gonorrhea rate was 238.96 for Asian adolescents and 375.95 for White adolescents. The study did not find evidence that SBHC RHP decreased adolescent birth rates in SBHC neighborhoods. Pre-intervention SBHC birth rate mean was 34.36 and the post-intervention SBHC birth rate was 24.43. Whereas the pre-intervention non-SBHC birth rate mean was 28.13 and the post-intervention non-SBHC birth rate was 21.01. It also did not support the hypothesis that SBHC RHP decreased dropout rates in high schools with SBHCs. Pre-intervention SBHC dropout rate mean was 10.03 and the post-intervention SBHC dropout rate was 10.22. Whereas the pre-intervention non-SBHC dropout rate mean was 10.84 and the post-intervention non-SBHC dropout rate was 10.20.

Conclusions: Other studies have supported the importance of school-based policies to adolescent health. This study did not support the hypothesis that reproductive health policies had an effect on adolescent health and academic achievement. It may be that distal factors (income inequality, job insecurity and historic reproductive and academic injustice) had an influence on reproductive health that this study could not ameliorate. Regarding high school dropout it may also be that the SBHC RHP was not effective because it did not address school engagement. Alternatively, the limitations of this study (non-differentiation of SBHC user versus non-users and spillover effect) limited the ability of the study to detect changes. Future research needs to conduct qualitative research to better understand adolescents’ and staff’s perspectives on SBHC RHP’s impact so as to better inform the evaluation and employment of similar school-based initiatives in NYC and other large urban areas in the U.S.

Available for download on Wednesday, May 19, 2021

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