contraceptives on-site with two schools in which contraceptives were prescribed but not dispensed found few differences in contraceptive use. The only significant variable related to use was the greater number of contacts the students had with the clinic staff (Brindis et al., 1994).

Some initiatives targeting sexual behaviors are showing promising results, however. For example, the first evaluation of the California Healthy Start initiative presented data on 40 different grantees, including, 8 youth service programs, 5 of which are school-based clinics. Adolescent clients of programs that had an explicit goal of reducing teen pregnancy were found to have initiated sexual activity much less often and to have used a reliable form of contraception much more often (Wagner et al., 1994). Among teenagers in pregnancy prevention programs, about 45 percent were found to be sexually active after six months, a significant decrease from the proportion at intake (77 percent).

One of the most systematic outcome studies of SBHCs to date—the outcomes evaluation of the RWJ School-Based Adolescent Health Care Program—showed that although SBHCs provided access to care and increased students' health knowledge significantly, no reduction in high-risk behaviors could be measured (Kisker et al., 1994b). The SBHC users showed little or no difference relative to the comparison sample in sexual activity or use of alcohol, tobacco, and marijuana. These results are consistent with other interventions to reduce high-risk behavior, which generally have found that increased knowledge has little effect unless the environment and perceived norms are changed. Further, since clients of SBHCs tend to be students with greater problems and higher rates of risky behaviors than other students, it may not be reasonable to expect that an occasional clinic visit would turn their lives around.

Although results are sometimes inconclusive, other studies have shown generally positive effects of SBHCs and other extended services on absenteeism, behavior, and academic performance and on the use of hospital emergency rooms (McCord et al., 1993; Santelli et al., 1996; Wagner et al., 1994). The findings of a GAO study of six programs targeted at students at high risk for school failure are summarized in Table 4-5 (U.S. GAO, 1993a).

Cost-Benefit Studies

Several studies have estimated the cost-benefit ratio for SBHCs. One study estimated that if young people in New York State received early preventive care through school clinics, $327 million could be saved annually in hospitalizations for delivery of teen pregnancies, low-birthweight babies, and such chronic diseases as asthma (New York State Department of Health, 1994). A cost-benefit analysis of three California school-based



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