Last July, Louisiana Governor Mike Foster, a Republican, signed a $2.65 million line item in the state budget that authorized significant new funds for school-based health centers.

This would not be so unusual unless one takes into account that, only a few years before, Las Vegas odds makers would have cast the probability of this outcome as something approximating the cancellation of Mardi Gras.

What happened over time in Louisiana was due, in large measure, to superb public relations work, and it's symptomatic of a trend that has seen school-based health centers grow from 350 nationally in 1992 to nearly 900 this year.

School-based healthcare that addresses a wide range of health problems traces its origins to the early 70s when medical visionaries in Boston, St. Paul and Dallas independently recognized that bringing healthcare to children in schools could overcome barriers to needed care. For many children, health problems - from sports injuries to depression, from asthma to substance abuse -stood a much better chance of being prevented and treated in schoo ls than in traditional medical settings.

After all, emergency rooms weren't designed to solve basic health problems, and for children who lacked a regular source of care, a doctor's office or a community clinic was either unaffordable or located away from home or school. In the latter case, getting care was difficult for working parents and others who rarely have hours available to arrange appointments, travel to the health provider, and return home hours later.

Though the notion of scho ol-based health care has an "apple pie" quality - who could be against it? - its implementation has sometimes run up against fierce opposition in communities across the country. Since patient confidentiality is sacrosanct in most healthcare settings, some parents went through an education process in which they learned that their adolescent children were entitled to confidentiality in their relationships with doctors, nurses, or counselors. And, since sensitive matters such as sexuality were certain to come up, some church leaders led efforts to warn communities that school-based health centers would become little more than referral centers for contraceptives and abortions.

These concerns couldn't have found more fertile ground than in the State of Louisiana - a state in which the Christian Coalition picked up the theme of school-based healthcare as a threat to parental rights and adolescent chastity. But the Louisiana story is perhaps the best example of the enormous impact of accurate information conveyed in understandable terms by hard-working and passionate advocates.

As was reported in ACCESS, the newsletter of the Making the Grade school-based healthcare program, Louisiana's school-based health centers faced accusations of violating the state's ban on abortion referrals and distribution of contraceptives. Governor Foster wanted to make sure that the centers were indeed in compliance with the law before approving the funding. Press headlines at the time indicated that Foster was inclined to veto the line item for the health centers.

Foster's ultimate decision to fund the centers boiled down to two factors, according to Andy Kopplin, special assistant to Foster for policy and planning. First, the centers and their advocates were able to show their commitment to and "vigilance" in following the law. And second, Kopplin noted that "there were enough community members who were familiar with the work the centers did and who could credibly make the case that they were providing valuable services, that they were following the law, and that if they weren't (following the law), they should be shut down."

"The coalition for school-based health centers has been building for eight years," said Sylvia Sterne, director of adolescent and school health for the Louisiana Office of Public Health. "People have had a chance to see their benefits." By the time the line item became an issue, "there was so much support that had already built up for the centers, and it become such a visible thing that it had taken on a life of its own."

Stern recalled that opposition first became visible more than two years ago when full-page ads appeared in local newspapers claiming that the health centers would be forced by the federal government to perform abortions, hand out contraceptives, and diminish parents' rights over their children. Needless to say, public relations played a crucial role every step of the way. Cheron Brylski, a consultant to the Louisiana program, observed that "there was a lot of misinformation about the program at the state level." Something had to be done to turn the situation around.

Advocates prepared very simple fact sheets that explained what school-based health centers do. They constantly built up their factual base. They conducted statewide surveys, documented why students used the health centers, compiled that information, and then distributed it to the public, the media and legislators.

Meanwhile, many of the newspapers in the state published editorials backing the health centers. One paper even supplied readers with contact information for Foster's office. "I don't know of any press that did not support the health centers," reported Sterne.

Brylski noted that the program has always maintained an open-door policy with the news media and tries to keep them informed of new activities or developments, even when that information does not generate news coverage.

Support also came from a variety of lobbyists, among them Louisiana's Maternal and Child Health Coalition, the Agenda for Children, and a number of hospitals, including several Catholic institutions.

Foster's office was overwhelmed by phone calls, letters and faxes from people on both sides of the issue, but in the end school-based health center proponents carried the day. Said Brylski, "In the best grassroots fashion, our local school-based health centers had taken the time to educate these people, and it paid off in a very big way."

The Louisiana story is perhaps the most dramatic, but it typifies a national trend that has brought school-based health centers from the fringe of chil dren's health care reform to the mainstream in states and communities across the country. In each case, nothing could be taken for granted, and advocates have had to learn basic public relations skills to persuade the skeptics and rally supporters.

In Connecticut, against a backdrop of Governor Rowland's pledge to slash the state budget, school-based health centers are thriving - and with the governor's support. The state developed a plan for ensuring that school-based health centers are able to continue delivering essential health care services to those Connecticut adolescents most at risk. The plan has a number of specific strategies: aggressive media relations, including targeted pitches to talk shows on local radio stations and cable TV; networking with children's advocacy groups to place school-based health centers onto their state legislative agendas; writing and distributing a newsletter dedicated to this topic; and presentations before community-based organizations in towns across the state.

Advocates in Connecticut also have been careful to segment their markets and to draft messages that acknowledge the different needs of individual constituencies. For example, political leaders constitute one key audience, and one message aimed their way is that "providing primary care and preventive services in a timely manner can save the state, towns and taxpayers the cost of more serious, long-term health and social problems." For managed care providers, the "sell" is along these lines: "With their avoidance of high-tech medicine and their emphasis on prevention and early detection, school-based health centers are able to intervene before youngsters are forced to use the more expensive services of a hospital or emergency room."

In Minneapolis and St. Paul, two administrators used public relations strategies to attract policy makers to the idea of school-based health centers. Minneapolis' Anne St. Germaine invited then-Mayor Donald Fraser and 100 other important figures in city government to a breakfast at which 30 received awards for their support of public health. St. Germaine rode the coattails of a documentary produced by the office of C. Everett Koop, Surgeon General in the Reagan Administration. The documentary, which was shown on public television, featured the work Minneapolis had done in bringing health services to schools through its school-based health centers.

Mayor Fraser, in an interview with the newsletter ACCESS, hailed his community' 5 efforts to fight back against organized opposition to the centers. "We have a well-informed community which is willing and able to respond effectively to any questions, concerns, or criticisms," he said. "Our community support network will respond and call the city council and school board to express their support and correct any misinformation. Instead of a vocal minority, we have a vocal majority."

In neighboring St. Paul, Donna Zimmerman testified before the U.S. Senate Labor and Human Resources Committee. The invitation to testify was made possible through concerted and consistent efforts to obtain visibility for the school-based health care projects in St. Paul. Zimmerman says that improving the social marketing skills of center staff is key to successful promotion of school-based programs.

"Clinic staff must be able to articulate the mission of the program in the neighborhood and beyond," she said. "It has been very important to develop leadership qualities in our social workers and nurse practitioners. We want to get the word out about our programs while demonstrating our expertise."

In Memphis, Tennessee, Kathy Johnston used dramatic statistics to catch people's attention. "I made sure everyone knew that the babies in our school-based clinic day care program were 100 percent immunized," she said.

She knew her efforts had paid off when former first lady Rosslyn Carter and Betty Bumpers, wife of Arkansas Senator Dale Bumpers, brought their immunization campaign to Tennessee and made a stop at one of Memphis' school-based health centers. It didn't hurt that they were joined by Tipper Gore and Mary Sasser, wives of two other U.S. Senators. Not surprisingly, the health center was turned into a wildly successful photo opportunity, as both print and broadcast media converged for what turned out to be a major local story.

Some of today's leaders in the school-based health care movement received some of their marching orders from the late Bob Maynard, the former editor and publisher of The Oakland (Calif.) Tribune and one of the foremost American journalists of his day. Speaking to advocates from around the country in 1991, he cited aggressive public relations generally and media relations in particular as strategies for engaging public officials. He urged the center directors and others to forge coalitions in support of teen health and to praise journalists and government officials who merit special recognition for their sensitivity to children's needs. "Start early, contact often, and be persistent, " he said.

From Louisiana to Minnesota, from Tennessee to Connecticut, Maynard's admonition has clearly struck a chord. All the evidence points to a movement that is taking off, ready to arrive in the mainstream after years on the fringe of public health and education. PRQ

Andrew Burness is the founder of Burness Communications, a Washington, D.C. -area firm that provides public relations support to nonprofit organizations in the United States and abroad. Since 1986, his company has served more than 130 organizations. These include several of the nation's largest and most respected foundations; public and private universities; science and health associations; and international organizations, such as UNICEF, the World Bank, and a number of the world's leading agricultural research centers. His firm provides a range of services, including media relations, publications writing and production, conference organizing, and strategic planning. Mr. Burness holds a Bachelor of Arts from Duke University and a Masters in Business Administration from the University of Maryland. Before starting his firm, he was liaison with the public and primary spokesperson for the Robert Wood Johnson Foundation, the largest private health philanthropy in the United States. Prior to that, Mr. Burness served as public information officer for the President's Commission on Medical Ethics. He was also a legislative assistant for health and education policy in the U.S. House of Representatives. Mr. Burness serves on the Board of Visitors of the Georgetown University School of Nursing. 7910 Woodmont Ave. #1208, Bethesda, MD 20814, 301-652-1558, fax 301-654-1589.

1. How will you communicate what you're doing (a) in the communities with school-based health centers, and (b) across the state?

2. Which journalists in your state should know about school-based health centers? Who will maintain ongoing relationships with these people?

3. How will you liaison with corporate leadership in your state, and who will coordinate this effort? Which corporate leaders will take the initiative in advocating school-based health centers in the business community?

4. How will you liaison with advocacy groups? Which groups will you approach as partners in this project ? Who will have responsibility for implementing an "advocacy strategy"?

5. What is your strategy for encouraging educators to consider school-based health centers in their school districts? What materials will these educators need to be positioned to become active champions of school-based health centers?

6. Does your target population include children or parents from other cultures or countries? If so, does your strategy take translation services and cultural differences into account? - A.B.