Peers, teachers and parents were cited as trusted information sources for teens regarding contraceptives and sexual health information. Peers were overwhelmingly cited as a trusted source of information for teens regarding LARC methods. Multiple providers recounted teens coming into the health center asking for a LARC method that their friend had a good experience with. Public health officials named teachers as trusted sources of information, that they
focused on during the implementation. These comments were not based on direct observation but on research that has shown teachers to be influential in adolescent contraceptive and sexual health decision-‐making.
Providers often cited parents as influential in teens contraceptive decision-‐making when the parent was involved. Multiple providers told stories of teens who wanted LARC methods but were dissuaded by their parents due to concerns over infertility and infection.
LARC USERS VS. SBHC USERS
Demographic data from Neighborcare EHR and Seattle Public Schools
At West Seattle High the racial diversity in the school population is fairly closely
reflected in the SBHC population, with a slightly higher proportion of Black teens using the SBHC than their representation in the overall school population. LARC users are more likely to be White or Asian relative to their representation among female school-‐ based health center enrollees, while Blacks and Hispanic teens are underrepresented as LARC users.
At Chief Sealth High the school population is reflected fairly closely in the SBHC user population. The proportions of female SBHC users who are Asian/Pacific Islander and White, are similar to the percent of SBHC LARC users who identify as these races. Blacks are overrepresented, and Hispanics are underrepresented, among LARC users.
Notable is the fact that although the representation of Hispanic students is high in both the enrolled student population and those enrolled in the SBHC in each of the high schools, in neither school was one Latina student represented among LARC users.
Table 5. School population versus SBHC unique user population in the 2013-14 school year. School population from 2013-14 SPS enrollment data. SBHC user population from Neighborcare EHR data compiled 5.16.14.
Overall School
population* SBHC population total
West Seattle N=964 N=279
American Indian/Alaska Native 19(2%) 4(1%)
Asian/PI** 163(17%) 44(16%)
Black 163(17%) 60(21%)
White 443(46%) 103(37%)
Hispanic*** 125(13%) 37(13%)
One or more race 58(6%) 21(7%)
Decline to specify Not available 10(3%)
Chief Sealth N=1249 N=420
American Indian/Alaska Native 25(2%) 13(3%)
Asian/PI** 237(19%) 80(19%)
Black 250(20%) 77(18%)
White 350(28%) 102(24%)
Hispanic*** 312(25%) 95(23%)
One or more race 62(5%) 32(8%)
Decline to specify Not available 21(5%)
*Raw numbers for students by race not available in 2013-14 SPS enrollment reports. I extrapolated counts from the total students enrolled at each school and the percent of students reported in each racial category by school.
** Asian/Pacific Islander racial categories combined in the Neighborcare EHR data to reflect the racial categories of SPS. ***Hispanic race cannot be directly compared between columns because it was recorded differently in each reporting system. In SPS data parents/guardians may select more than one race for their children. If more than one race is selected they are in the “more than one race” category. If Hispanic is selected student is reported as Hispanic regardless of race. In Neighborcare data if a student reports Hispanic ethnicity they are defined as Hispanic regardless of any other race category chosen, even “decline to specify.”
Table 6. Female population comparison among SBHC Users and LARC Users by race and school for the 2013-14 school year. Information compiled from Neighborcare EHR data on 5/9/14.
SBHC (female population
total) LARC Users (female)
West Seattle N=223 N=34
American Indian/Alaska Native 2(.9%) 0
Asian/PI 32(14%) 6(18%)
Black 48(22%) 3(9%)
White 87(39%) 17(50%)
Hispanic 28(13%) 0
One or more races* 18(8%) 5(15%)
Decline to specify 8(3%) 3(9%)
Chief Sealth N=340 N=39
American Indian/Alaska Native 12(3%) 2(5%)
Asian/PI 66(19%) 8(20%)
Black 56(16%) 9(23%)
White 83(24%) 9(23%)
Hispanic 78(23%) 0
One or more races* 28(8%) 3(8%)
Decline to specify 17(5%) 8(20%)
* One or more race does not include Hispanic. Hispanic overrides all other race categories.
LARC UPTAKE AND ACCEPTABILITY
SBHC User Survey Data, HEY LARC Survey Data
When queried about their contact with the reproductive health educator, 44% of survey respondents had interacted with the health educator during the prior school year. Forty six percent of respondents said they would be somewhat or very comfortable receiving an IUD at the SBHC, and 42% reported they would be somewhat or very comfortable receiving a Nexplanon arm implant at the SBHC. About half of all respondents were aware of some form of LARC method, the majority being 59% who were aware of the Mirena IUD.
Table 7. Survey respondents interactions with health educator in both schools and self reported awareness of LARC methods(participants could select multiple answers).
N=107 N(%) N(%)
Has seen health educator
classroom presentation 14(13%) Aware of Paragard IUD 49(46%)
Has had individual contraceptive
counseling with health educator 25(23%) Aware of Mirena IUD 63(59%) Has had other interaction with
health educator 13(12%) Aware of Nexplanon arm implant 59(55%)
Has not interacted with health
Figure 5. Students surveyed self-reported comfort with getting a LARC method at the SBHC by method. N=107.
LARC UPTAKE AND ACCEPTABILITY Quantitative Data From Neighborcare EHR
Since the spring of the 2010-‐11 school year, 299 LARC methods have been inserted at all six participating sites (three middle and three high schools). LARC service delivery has steadily increased across the high school sites since the beginning of the intervention. For the purposes of this evaluation, I focused on West Seattle and Chief Sealth High School where the full range of LARC services were offered, including a full time health educator. This paper was written before the end of the 2013-‐2014 school year. As of May 16th, 2014
the two schools together have delivered 156 LARC methods of the course of four years. The percent increase in LARC use has risen dramatically between the last two school years overall. From the 2011-‐12 school year to the 2012-‐13 school year the percent increase in LARC
insertions at both schools was 39%. From the 2012-‐13 school year to May 16th of the 2013-‐14
school year, LARC insertions have increased 105% at both schools. The increase in total LARCs in both schools can be attributed to a sharp increase at West Seattle High School in 2013-‐14 from the previous school year, and a continued steady rise in LARCs at Chief Sealth.
Table 8. Number of LARC Methods Inserted Since the Start of LARC Service Delivery at Chief Sealth and West Seattle Highs by Method, School Year and Location. Data from 2013-14 school year updated 5.16.14.
Location LARC Device 2010-‐11 2011-‐12 2012-‐13 2013-‐14 School totals
West Seattle High School
LNG (Mirena) IUD 3 8 6 15 31
CuT380A (Paragard) IUD 0 0 1 2 3 Etonogestrel
(Nexplanon/Implanon) 2 10 5 19 35 Levonogestrol USP (Skyla) IUD* 0 0 0 2 2 Chief Sealth
International High School
LNG (Mirena) IUD 1 3 8 12 22
CuT380A (Paragard) IUD 0 1 0 1 2
Etonogestrel
(Nexplanon/Implanon) 3 6 19 29 55 Levonogestrol USP (Skyla) IUD* 0 0 0 0 0
Totals 9 28 39 80 156
Fig 4. Increase in LARC insertions over time by school as of 5.16.14.