MORE ABOUT THE STRATEGY USED IN THIS CASE STUDY Reproductive health and education, School-based supports for child health and well-being
In the early 2000s, sexual education curricula in Minneapolis high schools varied widely. Schools also rarely adjusted instruction based on the sexual health issues observed in school-based clinics. Despite statewide declines in rates of teen pregnancy and sexually transmitted infections, rates among Black, Hispanic, and American Indian residents in outpaced their White peers in Minneapolis. To address the disparities, Hennepin County Commissioners called for action.
In 2011, the Minneapolis Health Department launched the Safer Sex Intervention (SSI) program. SSI is an evidence-based sexual health and wellbeing curriculum delivered by trained health educators in school-based clinics. Health educators meet with students one-on-one for an intake session and then in three supplemental sessions over the next six months.
Keys to the program’s success include support from school leaders to integrate health educators into school operations; using the rollout of SSI as an opportunity to make additional improvements to clinic operations; rigorous hiring and training of health educators; and implementing SSI in school-based clinics, which allowed easier integration with educators and students.
Challenges faced by the program included an outdated initial curriculum, staff turnover during initial implementation, and mental health issues in schools that increased demand for clinic services.
Results & accomplishments
Safer Sex Intervention (SSI) participants were 6 percentage points less likely to engage in unprotected sex than those in a control group, according to an Abt randomized control trial study on Hennepin County (MN) and two other jurisdictions implementing the model.
SSI participants were 7 percentage points more confident in their ability to refuse sex over the long-term (18 months) than their peers.
54% of all student visits to school-based clinics during the 2018-2019 school year focused on reproductive health, including nearly 1,900 SSI visits alone.
- Delivering high-impact, evidence-based sexual education for a decade: Since its 2012 implementation in Minneapolis school-based clinics, the Safer Sex Intervention (SSI) program has provided consistent, reliable service for high school students — even during the COVID pandemic. Turnover rates among health educators are low, a major factor in the program’s long-term stability and capacity to build strong relationships with students.
- Creating a gateway to other services: School-based clinic staff members report that SSI often serves as an entry point to other clinic services, especially for reproductive health (i.e. STI testing, contraception, and pregnancy testing) and mental health counseling. Students participating in SSI are more likely to return to the clinic for such services than non-participants.
- Winning federal grants: The health departments in Minneapolis and Hennepin County filed a joint application for a grant focusing on teenage pregnancy reduction from the Office of Adolescent Health within the U.S. Department of Health and Human Services. After winning the grant, SSI launched in Minneapolis high schools. It was then scaled and sustained using two other HHS program grants: one from the Federal Youth Services Bureau (FYSB) and another from the Personal Responsibility Education Program (PREP). As a result, school-based clinics (there are 8 total) have expanded and improved their sexual health and wellbeing services at limited cost to the jurisdiction.
What was the challenge?
- Inconsistent sexual education curriculum in Minneapolis schools: Across Minneapolis high schools in the early 2000s, students received highly varied sexual health and well-being education. In most cases, curricula focused on sexually transmitted infections, with little emphasis on safe sex, pregnancy, and other reproductive health issues. There were almost no opportunities for students to engage one-on-one with trained reproductive health professionals at school.
- Inefficient sexual health and education services: In addition to inconsistent curricula, Minneapolis high schools struggled to link sexual health services (delivered in school-based clinics) with sexual health education (delivered in classrooms). As a result, upstream issues were rarely addressed (i.e. the same student could come back multiple times to a school-based clinic for STI treatments without ever learning about prevention methods).
- Persistent racial disparities in teen pregnancy rates: Despite significant reductions in statewide teen pregnancy rates (the rate dropped from 59 to 29.9 pregnancies per 1,000 teenage girls between 1990 and 2010) in Minnesota, teen pregnancy and birth rates among Black, Hispanic, and American Indian residents far outpaced those of their white peers. Similar trends existed for sexually transmitted infections.
- County commissioners seek action: Recognizing that inconsistent education and siloed service delivery could be contributing to disparities in pregnancy rates and other sexual health and wellbeing outcomes, several Hennepin County Commissioners called on the county health department to research evidence-based interventions. Hennepin County Health Department leaders then pursued a partnership with their counterparts at the Minneapolis Health Department (MHD), who managed school-based clinics in seven of the city’s high schools. Minneapolis makes up roughly 70 percent of Hennepin County.
What was the solution?
- Evidence-based, one-on-one reproductive health education in school-based clinics: The Safer Sex Intervention is an evidence-based sexual health and wellbeing curriculum. It is delivered by a trained health educator in intermittent sessions throughout a year — typically a 45-60-minute intake session, followed by three supplemental sessions provided at one, three and six months after the initial session. In Minneapolis, seven public high schools have a health educator who delivers SSI at a school-based health clinic.
- Model anchored by health educator: The model relies on a health educator to take a student through the complete SSI experience. During an intake session, the health educator uses motivational interviewing techniques to discuss general sexual health and wellbeing topics, explore options for contraceptives, and provide some basic medical services (such as STI tests and emergency contraception). The health educator may also use the session to refer the student to other clinic services, such as reproductive health care and mental health counseling. Lessons from the intake session are reinforced during the periodic booster sessions throughout the school year.
- Integrating SSI into school operations: From the earliest stages of implementation, the model has been most effective when delivered in school-based clinics (other sites include community clinics and federally qualified health centers). This is largely the result of three factors: the elimination of distance and transit needs as a barrier to access, since students can schedule visits during the school day; the health educator’s direct engagement with students through school programming and informal interaction; and a strong internal referral system from both school and clinic staff. School-based clinic services are free to students, with some services billable to insurance for those who have it.
What factors drove success?
- Implementing SSI in school-based clinics: While Hennepin County implemented the SSI model in four different settings, school-based clinics produced the strongest outcomes. This is in large part the result of complete integration within the school, including internal referrals both from clinic and school staff; regular, direct interaction between health educators and students in informal school settings like lunch or in the hallways; and the elimination of travel as a barrier to accessing the health educator, since the school-based clinic is physically located within the same building as students.
- Investing in committed health educators: The SSI model relies heavily on a single staff member at each site: the health educator. Initially, Minneapolis sought to redeploy existing staff members (registered nurses) to take on the health educator role, but quickly recognized this was not a good fit. So, the Minneapolis Health Department prioritized rigorous hiring and training processes over speed. This included cultivating training partnerships with community colleges for motivational interviewing and the University of Minnesota for SSI, as well as recruiting and hiring professionals with experience discussing sensitive topics with students. While time intensive, this approach has resulted in limited turnover among health educators over the past five years.
- Using SSI as a vehicle for clinic-wide improvement: Minneapolis school-based clinics used the SSI implementation as an inflection point for operational improvements that persist a decade later. These include more robust student engagement (for instance, school-based clinics added a youth council to represent student voices and raise awareness of available services); improved data collection processes (which initially stemmed from an SSI grant requirement); a stronger internal referral system; and more adolescent friendly mental and physical medical care (health educators were trained in new techniques that could be applied across the clinic).
- School leaders champion health educators: Across Minneapolis high schools, principals and other senior staff have championed the SSI model and sought to integrate health educators into regular school operations. For instance, despite being employees of the county health department, health educators are listed alongside school staff in directories and on email lists; lead school-wide assemblies on a range of sexual health topics; and teach classes throughout the school year. This buy-in from school leadership results in deeper clinic-school integration, and, in turn, heightened engagement from students.
What were the major obstacles?
- Narrow curricular focus: The original SSI curriculum was designed in the 1990s for heterosexual teenage girls. With male and LGBTQ+ students in need of many of the same services, Minneapolis health educators had to sacrifice curriculum fidelity in order to better serve their communities. Today, health educators continue to iterate on the original SSI curriculum to make it appropriate for individual student needs.
- Early turnover for nurses: During the initial implementation of SSI, Minneapolis employed a single dedicated health educator and sought to repurpose on-staff nurses to focus a portion of their time on the SSI curriculum while also balancing other nursing duties. This required a different skill set and daily routine. Ultimately, Minneapolis phased out nurses altogether, instead hiring for a more holistic health educator role focusing on candidates with a stated interest in delivering the model.
- Mental health crisis in schools: In the summer of 2020, Minneapolis high school students grappled both with the COVID crisis and the murder of George Floyd. Health educators and other school-based clinic staff report that this combination of events contributed to a mental health crisis among students, which led to overwhelming demand for school-based clinic services.
After the State of Minnesota passes a minor consent and confidentiality law, Minneapolis and St. Paul open school-based health clinics in the majority of their districts’ high schools. The clinics offer a wide range of medical services, including sports physicals for athletes, vaccinations, mental health counseling, access to a nutritionist, and more.
Dr. Lydia Shrier, an adolescent health expert in Boston, develops a theory-based sexual health curriculum — the Safer Sex Intervention. Recognizing the value of individualized engagement with at-risk teens, she prioritizes one-on-one learning sessions that employ motivational interviewing techniques.
Researchers conduct a randomized control trial to study the impacts of the Safer Sex Intervention on high-risk adolescent girls at Children’s Hospital in Boston. The results are promising, including increased condom use and a decrease in sexual partners with an STI. The report concludes by calling for more extensive research on the model in varied settings.
In response to growing racial disparities in teen pregnancy rates, the Hennepin County Board of Commissioners passes a resolution creating the Teen Pregnancy Prevention Project. The organization works closely with the Hennepin County Research and Planning Department to issue 10 subcontracts for the implementation of evidence-based sexual health and wellbeing programs. Today, the project, which is now known as Better Together Hennepin, partners with the Minneapolis Health Department to support the SSI model.
Building on the momentum from the Teen Pregnancy Prevention Project, the Hennepin County Health Department, with support from the Minneapolis Health Department, wins a 5-year grant (along with 74 other jurisdictions) from the U.S. Department of Health and Human Services’ Office of Adolescent Health. Grantees must choose to implement at least one of 28 evidence-based programs that address teen pregnancy; among the options is SSI.
The Minneapolis Health Department’s first dedicated health educator pilots the program in three high schools, with three registered nurses piloting SSI in three more high schools. With promising results from the pilot, MHD hires an additional health educator in 2012 to broaden the program’s reach and ensure adequate service provision across all six locations.
Using learnings from the year-end pilot, MHD continues to implement SSI through a health educator or nurse trained in SSI at each school-based clinic. At the same time, Abt Associates launches a 3-year randomized control trial to study the model’s impact as part of the HHS grant.
The Abt Associates study finds that across the three implementation sites (which also included Orlando (FL) and Knox County (TN)), SSI participants are less likely to have sexual intercourse without birth control and are more likely to report positive attitudes toward using protection.
A decade after Hennepin County implements SSI, the University of Minnesota’s Prevention Research Center publishes a report showing a significant drop — 75.9 percent — in the teenage pregnancy rate over the past two decades. The report underscores, however, that significant racial disparities persist, and that continued investment in programs like SSI remain crucial to addressing that gap.
As Minneapolis schools close for nearly a month during a teachers strike, the school-based clinics remain open. Clinic utilization drops during that time, underscoring the value of physical proximity to students.
How did leaders confront the problem?
- Minneapolis schools struggle to deliver high-quality sexual education: Across Minneapolis’s seven high schools, students experienced significant differences in sexual health and wellbeing education and supports. None of the varied models successfully addressed racial disparities in teenage sexual health outcomes.
- Local government leaders seek teen pregnancy intervention: Despite teen pregnancy and STI rates dropping in the region, local government leaders in Hennepin County recognized the need for a more comprehensive, consistent approach to sexual health and wellbeing. At the time the grant was awarded to Hennepin County, 82 percent of teenage girls were sexually active.
- Expanding evidence-based teen pregnancy prevention programs in Hennepin County: As momentum grew among local government leaders, Hennepin County launched the Teen Pregnancy Prevention Project in 2007. The agency, now known as Better Together Hennepin, awarded subcontracts for community service providers to deliver evidence-based teen pregnancy reduction interventions.
- City-county collaboration to deliver SSI: With promising outcomes reported from Better Together Hennepin’s support of various evidence-based teen pregnancy reduction interventions, leaders from the Minneapolis and Hennepin County health departments decided to apply jointly for a 5-year HHS grant, which would support a large-scale implementation of an additional program. Doing so allowed the agencies to draft a stronger grant proposal while also eliminating potential competition between the overlapping jurisdictions.
How was the strategy designed?
- Confidential, one-on-one sexual health and wellbeing education: To deliver the SSI model in school-based clinics, MHD hires, trains, and places a health educator in each high school. The health educators are trained in both the SSI model and related skills, such as motivational interviewing.
- Referrals primarily from clinic and school staff: To provide students in need with guidance and support on sexual health and wellbeing, both clinic and school staff are encouraged to refer teens to the health educator for an intake session. For instance, if a student visits the school-based clinic for an STI test, a medical provider or nurse practitioner would likely provide some initial information on SSI and offer to set them up with an intake session.
- Delivering the model through an intake session: To immediately engage students who could benefit from SSI, the first visit between a student and health educator serves as the model’s core learning opportunity. The health educator uses motivational interviewing (an evidence-based counseling method) to guide a student toward safe and healthy sexual behaviors. Sessions last roughly 45-60 minutes. Following the session, health educators may also refer students to other services in the clinic, such as mental health counseling, and provide some forms of testing, such as for STIs.
- Advancing with booster sessions: To build on the initial intake session and measure outcomes, health educators typically schedule booster sessions at one-, three-, and six-month intervals. During the booster sessions, which run for 15-30 minutes, health educators engage students on topics around safe sexual behavior and reinforce lessons from the intake session, such as on where to obtain condoms or how to discuss consent with a partner.
- Partnerships to deliver training: To prepare health educators for both the knowledge-based and skill-based elements of delivering SSI, the Minneapolis Health Department partners with local academic institutions. MHD health educators receive SSI curriculum training and ongoing professional development from the University of Minnesota. For motivational interviewing, the key skill necessary to deliver SSI, health educators are trained at local community colleges.
- Integrating SSI into school-based clinics: To maximize direct engagement and follow-up with students, Hennepin County dedicated the plurality of its grant funding to implementing SSI in school-based clinics. SSI is a flexible model that can be delivered in a variety of settings (in Hennepin County, it was implemented in six different types of medical centers or clinics). Students frequently visit school-based clinics for a range of needs, including physicals, vaccinations, therapy, and nutrition.
How was the plan implemented?
- Selecting the model: After being awarded the HHS grant, the Hennepin County and Minneapolis Health Departments had to choose from a menu of 28 different evidence-based teen pregnancy reduction models. The teams quickly reached a consensus on SSI, given that it could be delivered in a range of clinical settings, including within schools — a natural fit in Minneapolis.
- Hiring health educators — and identifying outcomes for them to track: With the curriculum in place, MHD launched a job search for health educators. At the same time, MHD staff worked closely with the Hennepin County Health Department to identify key metrics and develop a data management system that the health educators would use regularly.
- Partnering with colleges for training: Before starting in schools, health educators had to be trained in the SSI curriculum, which was delivered by licensed staff at the University of Minnesota. Similarly, health educators had to master motivational interviewing, with trainings offered at several local community colleges.
- Launching in school-based clinics: After arriving in schools, health educators first engaged closely with the rest of the school-based clinic staff: a nurse practitioner or medical provider; a mental health counselor; a medical assistant; and, in some cases, a nutritionist. These early meetings — effectively relationship- and knowledge-building efforts — are especially crucial: clinic staff often serve as the primary referrers to SSI and must understand the model to effectively execute on that responsibility.
- Building relationships with students and school staff: Finally, health educators conducted proactive outreach to their school-wide communities. This included running assemblies on sexual health and wellbeing topics like consent; guest-lecturing in health classes; and meeting with teachers to explain criteria for referral to SSI. As health educators more closely integrated into the school community, some also took on school-based roles, such as joining the freshmen orientation planning committee.
How was the approach funded?
- Launching with HHS grant: SSI was launched in Minneapolis school-based clinics with a five-year, $1.12 million grant from the U.S. Department of Health and Human Services’ Teen Pregnancy Prevention Program. The grant primarily covered the cost of funding health educators (including training, salary, and benefits).
- Additional federal funding to sustain SSI and general clinic operations: Today, the Minneapolis Health Department relies on several federal grants to operate its school-based clinics. These include two HHS grants with specific allocations to SSI: the Teen Pregnancy Prevention Program and the Personal Responsibility Education Program. In recent years, the clinics have also received ARPA and TANF funding. Such grant funding provides a third of the clinics’ overall revenue.
- Patient revenue: While services at the school-based clinics can be delivered for free, students with insurance (public or private) are billed when possible. Patient revenue comprises roughly a third of the clinics’ annual operating budget.
- State and local investments: The final third of school-based clinic revenue comes from a mix of public health state block grants (such as one focused on youth mental health from the Minnesota Department of Human Services), annual allocations from the Minneapolis Health Department, and a Hennepin County allocation from its Teen Pregnancy Prevention Initiative.
- Boosting staffing through CDC program: To supplement clinic staff and ensure it can meet student demand, MHD serves as a host site for the CDC’s Public Health Associates Program. Each year, several Associates — early-career public health professionals who commit to two years of service — fill school-based clinic roles. The Associates’ salaries and benefits, which are valued at roughly $80,000 per year, are funded by the CDC.
How was the approach measured and refined?
- Analyzing data to inform booster sessions: A key component of the SSI model is collecting data on sexual attitudes and behaviors during the intake session, which can then be used as a baseline to measure the impact of each session. As health educators become more familiar with individual student needs, they use motivational interviewing techniques to identify which elements of the SSI curriculum to focus on at one-, three-, and six-month month intervals.
- Adapting the SSI curriculum to school needs: The original SSI curriculum was written in the 1990s to serve heterosexual teenage girls. In Minneapolis school-based clinics, health educators engage with a wide range of students. To ensure they are equipped to do so, health educators use supplemental curricula and models. To further underscore the expansion of the original SSI model, health educators are also shifting to a more inclusive title, “health mentors.”
- Shifting away from registered nurses as health educators: Initially, Minneapolis sought to redeploy registered nurses on staff to serve as health educators. Both the Minneapolis Health Department and the nurses recognized that this was not a long-term fit. MHD then moved to hire professionals who were eager to focus on teen sexual health and wellbeing, especially in an individualized setting and using specialized techniques like motivational interviewing. Today, all health educators are specialists in the field.
- Integrating more deeply into schools: Initially, health educators operated primarily within the confines of the school-based clinic. As the program matured in Minneapolis, however, health educators increasingly engaged with the broader school population, including through leading school-wide assemblies, teaching health classes, and participating in other school activities, like orientation, open house events, parent/caregiver conferences, and lunch table outreach.
Results for America would like to thank the following individuals for their support in writing this case study: Alison Moore, Barbara Kyle, Elizabeth Govrik-McCoy, and Lisa Dornick of the Minneapolis Health Department; Emily Scribner-O’Pray of the Hennepin County Health Department; and Meredith Kelsey of Abt Associates.
This case study was written by Gavriel Remz and Ross Tilchin.