RESEARCH AND PRACTICE

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1 Association Between Availability and Quality of Health Services in Schools and Reproductive Health Outcomes Among Students: A Multilevel Observational Study Simon Denny, PhD, MPH, Elizabeth Robinson, MSc, Catriona Lawler, RN, Sue Bagshaw, MBChB, Bridget Farrant, MBChB, MPH, Fionna Bell, MBChB, MPH, Dianne Dawson, RN, Diana Nicholson, RN, Mo Hart, RN, MN, NP, Theresa Fleming, MHSci, Shanthi Ameratunga, MBChB, PhD, Terryann Clark, RN, PhD, Maria Kekus, RN, MN, NP, and Jennifer Utter, PhD, MPH 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 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. (Am J Public Health. 2012;102: e14 e20. doi: /ajph ) 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. METHODS Data for the current study were collected in 2007 as part of a large health and well-being e14 Research and Practice Peer Reviewed Denny et al. 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2 survey of high school students in New Zealand. Sample size calculations for this survey aimed to give reasonable prevalence estimates of health indicators among the 4 main ethnic groups in New Zealand. 10 To select a nationally representative sample, we used a 2-stage cluster design whereby schools were first randomly selected to participate, followed by a random selection of students from participating schools. In 2006, New Zealand had a total of 389 schools with students in years 9 through 13 (corresponding to US grades ); from these schools, we randomly selected 115, and 96 agreed to participate, for an 83% response rate. Most participating schools were publically funded (70%), coeducational (71%), and had an enrolment of fewer than 700 students (60%), reflecting the general characteristics of New Zealand secondary schools. We obtained written consent from the principal of each participating school; studentsandparentsweregivenwritteninformation about the survey, and each student gave his or her own consent to participate. In each participating school, we randomly selected students from the school roll and invited them to take part. In total, 9107 students (out of the students invited) participated, representing a 74% response rate. Most students (97%) were aged between 13 and 17 years; 65% were aged 15 years or younger. Apart from a slightly higher percentage of male students, the participating students were similar demographically to the national population of high school students. The most frequent known reason for nonparticipation was absence from school on the day of the survey. Students took the selfreported survey using Internet tablets. No keyboard data entry was required; questions and answers could also be heard through headphones, and responses were made by touching the screen with a stylus. Students could skip any question or section of the survey at any point. Trained study personnel administered the survey in all participating schools. School-Based Health Services Administrators from 88 schools (of the 96 participating schools) completed questionnaires on aspects of their school-based health services, which reduced the student sample to Administrators were asked the number of health practitioners (including doctors, TABLE 1 Weekly Hours of Availability of School-Based Health Services in High Schools: New Zealand, 2007 Variables Schools, No. registered nurses, and enrolled nurses) at their school and how many hours per week they provided services. To calculate the hours per week per 100 students, we divided health personnel hours by the school roll and multiplied by 100. Administrators were also asked if the health care providers met together as a team weekly or more often, if the health care providers met with the school counselor or health teachers each term or more often, and if routine comprehensive health screening was performed on all year-9 students. The New Zealand Ministry of Education provided data on school characteristics. School size, based on the number of students in years 9 through 13, was classified as large ( 800 students) or small (< 800 students). Schoollevel socioeconomic status was based on Ministry of Education school decile, which indicated the extent to which the school drew its students from low socioeconomic communities. The lowest decile schools were the 10% of schools with the highest proportion of students from low socioeconomic communities. Consistent Contraception Use and Pregnancy Involvement For the current analyses, we restricted the sample to students who indicated they had been sexually active (n = 2745; 36.1%). To assess consistent contraception use, sexually active students were asked 2 questions: How often do you use condoms as protection against sexually transmitted disease or infection? Weekly Hours, Mean (Range) Weekly Hours per 100 Students, Mean (Range) Registered nurses 44 (50) 23.3 ( ) 3.74 ( ) Enrolled nurses 11 (13) 26.3 (14 40) 3.91 ( ) Visiting nurses (public health, family 42 (48) 3.3 (0.5 40) 0.8 ( ) planning, etc.) Doctors 29 (33) 3.1 (1 10) 0.46 ( ) Total nursing on-site hours (registered and enrolled) 48 (55) 27.4 ( ) 4.32 ( ) Total visiting nursing and doctor hours 59 (67) 3.9 ( ) 0.79 ( ) Total nursing and doctors hours (including 78 (89) 19.8 ( ) 3.26 ( ) visiting health personnel) Note. Number of schools in the total sample was 88. and How often do you or your partner use contraception? (by this we mean protection against pregnancy), with the response options always, most of the time, sometimes, and never. We classified students who responded always or most of the time to either question as consistent contraception users. We determined involvement in pregnancy by responses to the question, Have you ever been pregnant or got someone pregnant?, with the response options yes, no, and not sure. We classified students who responded yes as being involved with a pregnancy and students who answered no or not sure as not being involved with a pregnancy. Student Demographic Variables We assessed ethnicity using the standard ethnicity question developed for the New Zealand census, where participants could select all of the ethnic groups that they identified with. Approximately 40% of students identified with more than 1 ethnic group. We created discrete ethnic populations using the New Zealand census prioritization method, by which students were assigned to 1 ethnic group in the following order: Maori (18.7%), Pacific (10.2%), Asian (12.5%), and New Zealand European and other (58.5%). We measured the socioeconomic status of each student by 8 items: number of times the student changed residence in the past year (0, 1, 2, 3 times); parents worry about having enough money to buy food (0 = never, 1 = October 2012, Vol 102, No. 10 American Journal of Public Health Denny et al. Peer Reviewed Research and Practice e15

3 TABLE 2 Characteristics of High School Health Services, by School Characteristics: New Zealand, 2007 Nursing and Doctor H/Wk per 100 Students None, No. 0 5, No. 5 10, No. > 10, No. Doctor Visitation, No. Health Team Meets Weekly, No. Health Team Meets With School, No. Year-9 Health Screen, No. Total 10 (11.4) 64 (72.7) 7 (8.0) 7 (8.0) 29 (33.0) 20 (22.7) 52 (63.4) 12 (13.6) School composition Coed 7 (11.3) 50 (80.7) 2 (3.2) 3 (4.8) 21 (33.9) 14 (22.6) 37 (64.9) 8 (12.9) Single sex 3 (11.5) 14 (53.9) 5 (19.2) 4 (15.4) 8 (30.8) 6 (23.1) 15 (60.0) 4 (15.4) No. of students < (15.5) 38 (65.5) 6 (10.3) 5 (8.6) 18 (31.0) 11 (19.0) 33 (61.1) 9 (15.5) (3.3) 26 (86.75) 1 (3.3) 2 (6.7) 11 (36.7) 9 (30.0) 19 (67.9) 3 (10.0) Socioeconomic deprivation of student population High (decile 1 3) 1 (6.6) 11 (73.3) 2 (13.3) 1 (6.7) 7 (46.7) 6 (40.0) 10 (71.4) 7 (46.7) Medium (decile 4 7) 6 (12.8) 35 (74.5) 2 (4.3) 4 (8.5) 16 (34.05) 5 (10.6) 28 (66.7) 3 (6.4) Low (decile 8 10) 3 (11.5) 18 (69.2) 3 (11.5) 2 (7.7) 6 (23.1) 9 (34.6) 14 (53.8) 2 (7.7) School funding Public 4 (6.3) 52 (82.5) 3 (4.7) 4 (6.3) 24 (38.1) 13 (20.6) 39 (67.2) 7 (11.1) Private or integrated 6 (24.0) 12 (48.0) 4 (16.0) 3 (12.0) 5 (20.0) 7 (28.0) 13 (54.1) 5 (20.0) Note. Number of schools in the total sample was 88. occasionally, 2 = sometimes, 3 = often, 4 = all the time); numbers of cars, telephones, computers, and televisions at the student s home (0, 1, 2, or 3 for each item); alternative rooms at home used as bedrooms (0 = none, 1 = other rooms that are not bedrooms, 2 = garage or caravan, 3 = living room); and the New Zealand Deprivation Score 2006 (NZDep). The NZDep is an area-based socioeconomic deprivation index that assesses 8 dimensions of deprivation (beneficiary, home ownership, single parent families, unemployment, lack of educational qualifications, overcrowding, no access to a telephone, no access to a car) using 2006 New Zealand census data. 11 During the survey, students were asked to provide their home address to ascertain the small-area geographic unit (or meshblock) in which they lived. To protect participating students anonymity, the home addresses were not saved. We calculated participating students NZDep by linking their residential meshblock number to their respective neighborhood NZDep. Data Analysis We used generalized linear models accounting for nesting of students within schools to estimate the association between school-based health services (including doctor and nursing hours per week), team-based services and health screening, and reproductive health outcomes among students. Unadjusted models and adjusted models accounting for background characteristics of students (i.e., age, gender, ethnicity, and socioeconomic indicators) were estimated separately for each aspect of schoolbased health services. Estimation techniques used maximum likelihood with adaptive Gauss- Hermite quadrature rule, using the GLIMMIX procedure in SAS version 9.2 (SAS Institute, Cary, NC). RESULTS Most schools provided some level of schoolbased health service, with 78 of 88 schools (88.6%) reporting an average 3.3 hours of nursing or doctor time per week per 100 students (Table 1). The majority of schools (48 of 88; 54.5%) employed on-site nursing services made up of registered nurses (n = 44; 50%) and enrolled nurses (n = 11; 12.5%). In schools that employed enrolled nurses, most were employed alongside registered nurses (7 of 11; 63.6% [data not shown]). Registered nurses provided an average 3.7 hours of service per 100 students and enrolled nurses 3.9 hours per 100 students per week. Visiting health professionals, including public health nurses, family planning nurses, and doctors, also provided health services in 59 schools (67.1%); about half were in conjunction with on-site nursing personnel (29 of 59; 49.2% [data not shown]). Doctors provided health services to 29 schools (33.0%) and visiting nurses provided health services to 42 schools (47.7%). Average available time of visiting doctors and nurses was much lower than that of on-site staff; per 100 students, visiting nurses were available on average 0.8 hours per week, whereas on-site registered nurses were available 3.7 hours per week. Table 2 shows the health service characteristics by school characteristics. Most schools (n = 64; 72.7%) provided low levels of health services (< 5 hours of total nursing and doctor time per 100 students), and 10 schools (11.4%) provided no health services. Seven schools (7.9%) provided 5 to 10 hours of nursing or doctor time per 100 students and 7 schools provided more than 10 hours per 100 students. Single-sex and privately funded schools were more likely to provide more than 5 hours of nursing or doctor time per 100 e16 Research and Practice Peer Reviewed Denny et al. American Journal of Public Health October 2012, Vol 102, No. 10

4 TABLE 3 Prevalence of Consistent Contraceptive Use and Self-Reported Pregnancy Among Sexually Active High School Students: New Zealand, 2007 Prevalence of Consistent Contraceptive Use (n = 1820), % (95% CI) P students compared with coeducational schools (v 2 2 = 10.3; P =.02) and publically funded schools (v 2 2 = 11.4; P =.01), respectively. School-based health services in schools in neighborhoods with high levels of socioeconomic deprivation were more likely to meet as a team (v 2 2 =8.5;P =.02) and perform year-9 Prevalence of Self-Reported Pregnancy (n = 2458), % (95% CI) P Total 85.0 (82.8, 87.2) 10.6 (9.19, 12.05) Gender Female 82.6 (78.9, 86.3) 11.7 (9.3, 14.1) Male 87.1 (84.6, 89.7) 9.7 (8.0, 11.4) Age, y (77.5, 88.0) 12.4 (8.1, 16.7) (77.6, 85.9) 9.0 (6.1, 11.9) (82.1, 88.9) 13.6 (11.2, 16.0) (82.2, 89.5) 9.5 (6.8, 12.2) (82.8, 90.1) 9.3 (7.0, 11.6) Ethnicity <.001 <.001 Maori 79.7 (76.6, 82.7) 15.1 (12.7, 17.4) Pacific 70.7 (64.7, 76.8) 13.9 (9.5, 18.3) Asian 80.6 (73.5, 87.7) 7.5 (2.9, 12.1) New Zealand European or other 90.9 (89.2, 92.6) 7.9 (6.4, 9.4) Socioeconomic < deprivation a i 91.9 (89.6, 94.1) 8.1 (6.1, 10.2) ii 89.7 (87.1, 92.3) 8.9 (6.8, 11.0) iii 85.8 (82.4, 89.2) 12.0 (9.2, 14.8) iv 73.8 (68.7, 79.0) 13.0 (10.1, 16.0) Note. CI = confidence interval. a In quartiles of increasing deprivation. comprehensive health screening (v 2 2 = 16.8; P <.001) than schools from neighborhoods with low levels of socioeconomic deprivation. The overall prevalence of consistent contraception use among sexually active students was 85.0%. Male students, students of New Zealand European or other ethnicity, and students TABLE 4 Association Between Level of School-Based Health Services and Consistent Contraception Use Among High School Students: New Zealand, 2007 Unadjusted OR (95% CI) P Adjusted a OR (95% CI) P Nursing and doctor h/wk per 100 students 1.00 (0.95, 1.06) (0.97, 1.10).51 Doctor visitation 0.99 (0.69, 1.42) (0.54, 1.05).1 Health team meets weekly 1.29 (0.87, 1.91) (0.76, 1.61).61 Health team meets with school 1.22 (0.84, 1.77) (0.72, 1.48).88 Year-9 health screen 2.11 (1.35, 3.30) (0.93, 2.59).24 Note. CI = confidence interval; OR = odds ratio. a Adjusted for age, gender, ethnicity, and socioeconomic indicators. from neighborhoods with low levels of socioeconomic deprivation were more likely to use contraception consistently (Table 3). By contrast, students of Pacific ethnicity and students from neighborhoods with high levels of deprivation were associated with lower rates of consistent contraception use. One in 10 students reported a pregnancy (theirs or partners), with Maori students, Pacific students, and students from neighborhoods with high levels of socioeconomic deprivation reporting higher rates of pregnancy involvement. Table 4 shows the association between school-based health services and consistent contraception use among students. There was an association between year-9 screening and higher rates of consistent contraception among students in the unadjusted model, but this relationship was no longer significant once student demographics were accounted for in the adjusted model. There was no relationship between hours of health personnel, doctor visits, or team-based meetings and consistent contraception use among students in either the unadjusted or adjusted models. In further analyses, however, there was a trend toward consistent contraception use among schools with greater availability of SBHC health personnel (Figure 1). In schools with more than 10 nursing and doctor hours per week per 100 students, sexually active students had higher odds of reporting consistent contraception use than sexually active students in schools with no school-based health services (adjusted odds ratio [AOR] = 2.7; 95% confidence interval [CI] = 1.03, 7.09). The associations between school-based health services and self-reported pregnancy outcomes among students are shown in Table 5. There was an association between increasing doctor and nursing hours per week and fewer students reporting involvement in pregnancy (AOR = 0.94; 95% CI = 0.89, 0.99; P =.03). There were no relationships between doctor visits, team-based meetings, or year-9 assessments and self-reported pregnancy outcomes among students in either the unadjusted or adjusted models. Further analyses demonstrated a similar trend toward lower self-reported pregnancy involvement among schools with greater availability of SBHC health personnel (Figure 2). In schools with more than 10 nursing and doctor hours per week per 100 students, October 2012, Vol 102, No. 10 American Journal of Public Health Denny et al. Peer Reviewed Research and Practice e17

5 Adjusted Odds Ratios sexually active students had one third the odds of reporting involvement with pregnancy than sexually active students in schools with no school-based health services (AOR = 0.34; 95% CI = 0.11, 0.99). DISCUSSION None > 10 Nursing and Doctor H/Wk per 100 Students FIGURE 1 Association between nursing and doctor hours and consistent contraception use among high school students: New Zealand, The current study is the first of its kind to examine aspects of school-based health services such as doctor and nursing time, teambased care, and health screening in relation to contraceptive and reproductive outcomes among students in a nationally representative study of schools and their students. We found an association between the availability of school-based health services, in terms of hours of nursing and doctor time per 100 students, and pregnancy outcomes among students. These findings are supported by Ricketts and Guernsey, 12 who, in a study in Denver, Colorado, documented a significantly greater decline in births to Black female adolescents in neighborhoods with SBHCs compared with neighborhoods lacking them. Most previous research, however, has found few or inconsistent associations between school-based health care and contraceptive behaviors and reproductive outcomes among students. 2, In reviewing the evidence of the effectiveness of SBHCs on reproductive outcomes, Kirby 15 suggested that previous studies had been limited by methodological issues such as small numbers of schools examined and inadequate numbers of control schools as comparisons. The current study looked at reproductive health outcomes among students from 88 randomly selected schools. The largest previous study we could find was of 19 schools with SBHCs compared with a national sample of urban youths without access to SBHCs 2 ; no previous research has randomly selected TABLE 5 Association Between Level of School-Based Health Services and Self-Reported Pregnancy Among High School Students: New Zealand, 2007 Unadjusted OR (95% CI) P Adjusted a OR (95% CI) P Nursing and doctor h/wk per 100 students 0.95 (0.90, 1.00) (0.89, 0.99).03 Doctor visitation 1.08 (0.80, 1.47) (0.85, 1.66).31 Health team meets weekly 0.98 (0.70, 1.39) (0.47, 1.52).79 Health team meets with school 0.98 (0.70, 1.37) (0.73, 1.49).82 Year-9 health screen 1.00 (0.63, 1.61) (0.80, 2.43).24 Note. CI = confidence interval; OR = odds ratio. a Adjusted for age, gender, ethnicity, and socioeconomic indicators. schools from national registers. SBHCs have traditionally been located in schools serving low-income students, giving rise to concerns that comparisons between schools may reflect background demographics of the student population. In the current study, we were able to use student demographic characteristics, including socioeconomic indicators, on the basis of variables that may influence which school a student attends, thereby attempting to make treatment assignment (i.e., schools with or without SBHCs) strongly ignorable. 16(p312) Shortofclusterrandomized trials implementing school-based health services in randomly selected schools, the current observational study provides the strongest evidence to date of the effectiveness of SBHCs in reducing pregnancy outcomes among students. Most previous studies have used the presence or absence of school-based health services as the main exposure variable. 4,5 However, services are quite variable between SBHCs, both in terms of availability of staff and level of services provided. We examined the number of nursing and doctor hours per 100 students as a proxy for the availability of health services within schools. To our knowledge, this is the first study to measure availability of schoolbased health services and student health outcomes. Our findings suggest that more than 10 hours of nursing and doctor time per 100 students are required before significant differences in pregnancy-related outcomes at the school level are seen. This is consistent with previous recommendations by the US National Association of School Nurses on staffing requirements for schools. 17 School health services can also vary in terms of their level of services provided, the degree of training and autonomy of health personnel, and the ability of health personnel to provide comprehensive health services. 18 Schools with higher levels of nursing and doctor hours per 100 students may allow health personnel to provide more comprehensive care to individual students without feeling pressured by time limitations and the need to see as many students as possible in their allocated time. Reproductive outcomes may depend on the ability of health personnel to provide comprehensive care not only contraceptive counseling and treatment, but also management of other health concerns such as mental health, substance use, and abuse issues that may affect e18 Research and Practice Peer Reviewed Denny et al. 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6 Adjusted Odds Ratios None > 10 Nursing and Doctor H/Wk per 100 Students FIGURE 2 Association between nursing and doctor hours and self-reported pregnancy among high school students: New Zealand, students sexual activity and their ability and motivation to use contraception. 19,20 Historically, some SBHCs have been restricted in their ability to provide a full range of contraceptive services because of communities and schools sensitivities about providing these services to adolescents. Fothergill and Feijoo, 21 using data from a national US survey of SBHCs in 1995, found that 70% of SBHCs were restricted in providing reproductive health services and that fewer than one quarter were allowed to provide condoms. In New Zealand, school nurses have also expressed difficulties in providing reproductive health care in their schools, but the extent of these difficulties is unknown. 22 One of the weaknesses of the current study is that information on level of reproductive health services provided in school clinics was not collected. The current study revealed no associations between doctor visits, team-based meetings, or year-9 assessments and reproductive health outcomes among students. Team-based meetings, both within the SBHC and with school personnel, have been identified as important features of SBHCs. 23 In New Zealand, comprehensive psychosocial screening of all year-9 students has been instituted in a number of SBHCs. These assessments aim to identify early issues that may affect student well-being and provide appropriate counseling and health promotion and treatment where necessary. Although these aspects of school health services may be important for delivering highquality and comprehensive care, the current study suggests that these factors are less important than the availability of health services within schools. Overall, the availability of school-based health services among New Zealand secondary schools is limited, with fewer than 20% of schools providing 5 or more hours of doctor or nursing time per 100 students per week. Five hours of health personnel time per 100 students equates to approximately 1 full-time health professional per 750 students. This is the recommended minimum for school-based health personnel. 17 Provision of school-based health services in New Zealand is similar to that found in a 1994 US survey of school services, where 57% of schools employed registered nurses and one third had visiting physicians. 24 Although school-based health services have continued to expand and develop internationally, spearheaded by advancements in nursing practice and multidisciplinary care, 25 it appears that the availability of school health services in New Zealand is inadequate. Limitations The current study has a number of limitations, the main one being observational crosssectional data, which raises questions as to the directionality of these associations. However, school-based health services have traditionally been targeted in schools with higher rates of health concerns and deprivation among the student body and therefore do not explain the findings observed in this study. The study also did not include students who were not at school on the day of the survey. It is well recognized that students who are absent from school engage in more health-risking behaviors and have poorer emotional well-being that students who are at school. 26 Furthermore, students who experience pregnancy are more likely to drop out of school. New Zealand has one of the highest adolescent pregnancy rates among developed countries, second only to the United States. The known pregnancy rate (a combination of births and abortions) among young New Zealand women (aged 19 years and younger) is around 51 per Approximately 55% of these pregnancies go to term, with the majority of school-aged mothers dropping out of school. 27,28 These factors may bias our results in unexpected ways. The study also used self-reported involvement in pregnancy rather than objective records. However, the rates of self-reported pregnancy involvement are similar to those of previous studies and consistent with New Zealand s high rate of adolescent pregnancy. 29 Conclusions We have described school-based health services in New Zealand and their association with student sexual and reproductive health outcomes among a large nationally representative sample of high schools. Hours of nursing and doctor time per 100 students was significantly associated with self-reported pregnancy outcomes, but only in schools that provided more than 10 hours of nursing and doctor time per 100 students. Given the nationally representative and random sample of schools and students, these findings should be generalizable to the wider secondary school population in New Zealand. Our findings suggest that schoolbased health services may be able to lower the incidence of pregnancy by providing access to comprehensive health services, including contraceptive care that is easily available and appropriate for the student population. j About the Authors Simon Denny, Bridget Farrant, and Theresa Fleming are with the Department of Community Paediatrics, and Elizabeth Robinson, Shanthi Ameratunga, and Jennifer Utter are with the Section of Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland, New Zealand. Catriona Lawler is with the Health and Wellness Centre, Otahuhu College, Auckland. Sue Bagshaw is with Christchurch School of Medicine, University of Otago, Dunedin, New Zealand. Fionna Bell is with South Seas Healthcare Trust, Otahuhu, Auckland. Dianne Dawson, Diana Nicholson, and Mo Hart are with Counties Manukau District Health Board, Manukau, Auckland. Terryann Clark is with the School of Nursing, University of Auckland. Maria Kekus is with HealthWEST, Henderson, Auckland. October 2012, Vol 102, No. 10 American Journal of Public Health Denny et al. Peer Reviewed Research and Practice e19

7 Correspondence should be sent to Simon Denny, FRACP, MPH, PhD, Department of Community Paediatrics, School of Population Health, University of Auckland, Private Bag 92019, Auckland, New Zealand ( ac.nz). Reprints can be ordered at by clicking the Reprints link. This article was accepted March 2, Contributors S. Denny was responsible for obtaining funding, the study conceptualization and design, acquisition of data, and analysis and interpretation of data; he drafted the article and did statistical analysis. E. Robinson, T. Fleming, S. Ameratunga, T. Clark, and J. Utter were involved in study conceptualization and design, analysis and interpretation of data, and critical revision of the article. C. Lawler, S. Bagshaw, B. Farrant, F. Bell, D. Dawson, D. Nicholson, M. Hart, and M. Kekus were responsible for analysis and interpretation of data and critical revision of the article for important intellectual content. All authors contributed to the interpretation of results and draft versions of the article and approved the final version for publication. Acknowledgments This research was funded by the Health Research Council of New Zealand (grant 05/216), the Department of Labour, Families Commission, Accident Compensation Corporation of New Zealand, Sport and Recreation New Zealand, the Alcohol Advisory Council of New Zealand, and the Ministries of Youth Development, Justice, and Health. Support for the electronic communication of the Youth 07 project was provided by Vodafone, New Zealand. We thank all the students, staff, and schools who participated and supported this project. We also acknowledge and thank the project team members for all their hard work, especially the teams that traveled around the country gathering the data. We thank the advisory and steering groups who supported and guided this project. Note. The funders of this study played no role in study design, collection, analysis, and interpretation of data, writing of the report, or the decision to submit the article for publication. Human Participant Protection Ethical consent was obtained from the University of Auckland Human Subject Ethics Committee. References 1. Tylee A, Haller DM, Graham T, Churchill R, Sanci LA. Youth-friendly primary-care services: how are we doing and what more needs to be done? Lancet. 2007;369(9572): Kisker EE, Brown RS. Do school-based health centers improve adolescents access to health care, health status, and risk-taking behavior? J Adolesc Health. 1996;18(5): Robinson WL, Harper GW, Schoeny ME. Reducing substance use among African American adolescents: effectiveness of school-based health centers. Clin Psychol Sci Pract. 2003;10(4): Kirby D, Waszak C, Ziegler J. Six school-based clinics: their reproductive health services and impact on sexual behavior. 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