The following findings from the interviews at the two school districts are organized by the CFIR domains and summarized across the two sites and the various staff interviewed. CAI included quotes that demonstrate salient findings, labeled by the interviewees and their role and a randomly-generated identification number. Table 3 provides an overall summary of themes and quotes organized by CFIR domains and constructs.
Table 3. Summary of emergent themes from qualitative interviews that influence referral system implementation
CFIR Domain 1: Intervention Characteristics
The CFIR domain, intervention characteristics, contains constructs that influence the implementation of the referral system (intervention), including evidence strength and quality, and complexity.
Evidence Strength and Quality
This construct investigated the extent to which interviewees felt that a school-based referral system will lead to the expected long-term outcomes—decrease in STI, HIV, and unintended pregnancy and increase in education attainment. Overall, interviewees reported that schools are in fact, an ideal location to implement referral system because students may not be able to access sexual health services at home or in their greater community. As one clinical services staff at a CBHP mentioned, “some young people don’t have supportive parents, they live in a strict environment…for them it provides an opportunity to be able to get access to sexual health which is so important” (Interviewee 02-CBHP). In addition, most interviewees felt that a strong referral system can ease students’ stress and anxiety in determining who and where to ask for help, thereby improving students’ ability to focus at school, school attendance, and thus, educational attainment.
During the interviews, participants overwhelmingly reported that the many layers of bureaucracy and the chaotic nature of the school system make implementation difficult. As one district staff mentioned, “the challenge we face is our bureaucracy…there's so many people that have to be involved that sometimes it hinders the process.” (Interviewee 04-District Staff). Another interviewee cited how "[The school district] is such a huge system that is very cumbersome and kind of in a transition mode. So there’s a fair amount of chaos” (Interviewee 03-CBHP).
CFIR Domain 2: Outer Setting
The second domain, Outer Setting, explores external factors that may influence the referral system, such as student needs, state and district policies, and partnerships.
Needs and Resources
Most of the interviewees believed that connecting students to sexual health services is a high need. As one interviewee states, “On a scale of one to ten based on how much students need [sexual health services], I'd probably give it an 11". (Interviewee 02 -CBHP)
One reason is the high STI rates among the adolescents, specifically where the school districts are located: “We have a hot spot for chlamydia that we’ve seen, more outbreaks of syphilis than we have seen in the past.” (Interviewee 02-CBHP). Interviewees also expressed that many students are sexually-active but are misinformed about risks, as they often share incorrect information with each other. Many interviewees expressed specific concerns for disproportionately affected populations, such as students of color and LGBTQ students.
In this context, cosmopolitanism can be defined as the degree to which each LEA is networked with other external organizations.17 While each site has myriad local and state partnerships, two types of organizations emerged as crucial partners: local health departments and CBHP. Interviewees noted that through the planning and implementation of the referral system, partnerships among these organizations were strengthened. "It was a tenuous relationship in the past but…this grant has really increased our ability to access the school board and have a seat at the table" (Interviewee 03-CBHP)
Specifically for local health departments, the interviewees expressed that they played a prominent role in supporting professional development sessions for teachers and staff, offering sexual health services to students through SBHC and assisting LEAs with monitoring and evaluation activities.
CBHP, described as “youth-friendly, LGBT-inclusive, more up-to-date than typical clinicians on the latest birth control methods and STI testing, HIV testing” (Interviewee 11-District Staff), also play active and crucial roles in the implementation of the referral system. Interviewees reported their involvement in providing sexual health services to students, delivering training and technical assistance to other CBHP, and in creating resources for LEAs (e.g., referral guides, staff professional development curricula). Interviewees also felt that these partnerships increased CBHP’s awareness of state and local policies regarding minors’ access to health services.
Additionally, interviewees from the Southeastern site mentioned that the relationship between the CBHP and the LEA has strengthened significantly in the last several years. In the past, the CBHP was not allowed on school campuses due to the larger political climate and a restrictive district policy. Several interviewees mentioned that through collaborating to create a referral system, the partnership has been strengthened: “people in the school system are much more open now and understand that having a relationship with a youth advocacy organization is a strengthening component”. (Interviewee 03-CBHP)
State and District Policies
While interviewees identified how some state laws facilitate referral system—the Western site’s state law allows students to access STI services (including HIV testing and treatment) without parental consent, other policies serve as barriers—the Southeastern state’s guidance for abstinence-only education is an obstacle for schools to deliver comprehensive sexual health education, as well as the law that contraceptive counseling cannot be provided on school campus: “not being able to talk about condoms or any contraceptives in the school is a humongous barrier” (Interviewee 12-CBHP). Further, the conflict between state- and district-level policies was observed to be a barrier in the Western site; while the state law allows for student access to sexual health services without parental consent, district policy is more restrictive: “Sexual health services has to be [provided] through a SBHC with a contract with the district. …There are very few [SBHC] in our school district, and each of those has their own contract about what can or can’t be given” (Interviewee 18-District Staff).
CFIR Domain 3: Inner Setting
The third domain, Inner Setting, refers to the location, structural, social, organization, and cultural characteristics of where the intervention takes place. Constructs that were explored included networks and communications, culture and climate, leadership, and available resources.
Networks and Communications
Networks and communications refer to the nature and quality of social networks and of formal and informal communications within the school district. Each site had distinct networks and communication systems, drawing from strong and pre-existing staffing structures and innovative marketing and communication approaches, to facilitate referral system implementation. In the Western site, the referral system was supported by nurses across different schools organized into teams called “clusters.” These clusters met monthly and often discussed successes and challenges related to referring students to sexual health services.
In the Southeastern site, the referral system was supported by a palm-sized ‘chat card,’ a communication tool used by staff to refer students to services. Chat cards have information about teen health center locations, types of services offered, and contact information. However, many interviewees from this site noted that the ‘chat cards’ might not be directive enough to link students to sexual health services.
Organizational Culture and Access to Knowledge and Information
In the Western site, most staff mentioned that the organizational culture is supportive of sexual health prevention services. However, they also mentioned that the county is more conservative, relative to the rest of the state, and that negative attitudes and stigma towards sexual health education and services exist. Interviewees felt that other school staff did not feel capable of promoting the referral system (e.g., linking students to designated referral staff or giving referral guides to students) due to general fears related to parents, legal issues, and general lack of knowledge about the referral system. One interviewee expressed that, “there is this nervousness that principals and other people have when kids go to confidential appointments when they're entrusted by their parents to be at school” (Interviewee 16-District Staff). Similarly, many staff in the Southeastern site highlighted the culturally conservative climate as negatively impacting the referral system.
Since school principals have a lot of authority on the day-to-day operation of schools, they can influence the degree of referral system implementation. Most interviewees at both sites reported that principals’ acceptance and commitment to implementing a sexual health referral system varies. A few of the interviewees stated that school-building level champions were at times hard to identify due to lack of buy-in from principals. However, district-level leadership (e.g., superintendents) and CBHP were described overall as supportive, involved, and motivated. As one interviewee stated, “the leaders here are on board with it, and they really encourage us to get the program out there for the students”. (Interviewee 07-CBHP)
Many interviewees discussed the importance of having a full-time referral staff as crucial in the success of the referral system. Further, the Southeastern site mentioned that because the district is spread out geographically and that public transportation is limited, their five SBHC are critical resources for students. As one interviewee stated, “it’s hard for a lot of the students to get to health clinics unfortunately, which is why it’s important that we are in the schools.” (Interviewee 05-District Staff). Challenges were also mentioned around SBHC, which included space, staffing, inadequate hours, and difficulty for students who attend other schools to access.
CFIR Domain 4: Characteristics of Individuals
The fourth domain describes the individuals involved with the referral system, such as district staff, school staff, CBHP and leadership. Specifically, these individuals’ knowledge and beliefs regarding sexual health services emerged as a salient construct.
Knowledge and Belief
Across the two sites, interviewees reported that staff who were the most actively involved in referral system (e.g., referral staff, program coordinator, champions) were the most knowledgeable, especially regarding the logistics of making a referral, policies, and promoting student access to health services. Interviewees stated that knowledge about the referral system is generally higher among all staff and students if the school has a SBHC onsite or if the referral system is heavily marketed through posters, flyers, and/or announcements.
However, interviewees reported that beliefs towards the referral system among school-building staff were mixed. Negative attitudes and the stigma of discussing sexual health came up as major barriers across the two sites. In the Southeastern site, interviewees reported that their colleagues are hesitant to make referrals as they do not want to appear that they are endorsing adolescents having sex. One district staff said: “…We’re in the Bible Belt and I think some of the mindsets…about the way that children should be behaving…hinder the referral process.” (Interviewee 04-District Staff). Similarly, in the Western site, one interviewee stated “Some people are worried about kids leaving campus and they don’t agree with the law and they question the law”(Interviewee 16-District Staff).
Additionally, many interviewees stated that despite having supporting policies in place at the state- or district-level, lack of knowledge or misunderstanding of the policies are barriers to sexual health service provision. Laws surrounding consent are often difficult for school staff to comprehend because it is outside of typical practice for schools to allow students to do anything without parental consent: “The school system does not do anything with young people without parental consent and engagement, except for in rare situations” (Interviewee 03—CBHP). Furthermore, many interviewees mentioned that sometimes, local- and state-policies conflict, which is confusing for school and district staff.
CFIR Domain 5: Process
The last domain looks at the entire process of the referral system through different stages of implementation. Salient constructs in this domain include engaging staff and students in the referral process and reflecting and evaluating.
Many interviewees spoke of the necessity of the Program Coordinator position to employ different strategies to engage the appropriate individuals to ensure successful implementation and use of the referral system. Examples of these strategies include: recruiting and training referral staff on referral procedures and minor consent and confidentiality laws; meeting with district and school leaders to provide updates on referral system implementation; establishing and maintaining formal partnerships with CBHPs; and distributing communication and marketing materials in schools. As one CBHP manager stated, “I've been really impressed with her ability to sort of navigate all of this…a lot of it just falls on her. She's really coordinating with everyone and working with the schools and coordinating with the partner agencies.”
Specifically, professional development proved to be important to engage designated referral staff (e.g., counselors, school nurses), to ensure that they know about Core Components of a Referral System and the health resources available for students, and to increase their knowledge in local STI, HIV, and pregnancy statistics.
Engagement of students mostly occurred through posters, flyers, palm cards, school announcements, banners, and calendars. Social media approaches (e.g., Instagram, Snapchat) are currently being developed as well in these sites.
Reflecting and Evaluating
Methods to conduct ongoing tracking and evaluating of the referral system varied depending on the school district. In the Southeastern site, the local health department develops tracking tools, collates data, and ensures data quality. In the Western site, the program coordinator developed a paper log for nurses to track data and distribute a monthly survey to collect data. Across the two sites, tracking referrals was identified as very difficult as the current data collection systems does not capture passive referrals (e.g., self-referral when student seeks out sexual health services on their own after seeing a poster) or efforts that do not result in a referral. Further, only the staff who were most involved in referral system implementation regularly receive data reports and take the time to use data to evaluate their work.