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This study is part of a larger evaluation of a multilevel, multistrategy federal program to reduce high school students' risk for HIV/sexually transmitted infection and unintended pregnancy. Local education agencies supported schools in implementing three strategies: delivering exemplary sexual health education, increasing student access to quality sexual health services, and enhancing safe and supportive school environments (SSE). We examined how levels of school implementation of these strategies moderated program effects on targeted student outcomes.The Youth Risk Behavior Survey was implemented in participating local education agencies in 2015 and 2017 to assess student behaviors and experiences, whereas the School Health Profiles surveys assessed school policies and practices in 2014 and 2016. We used these surveys to measure student-level outcomes and school-level program delivery, respectively, which were analyzed using multilevel modeling in a difference-in-differences framework.Levels of SSE implementation significantly moderated program effects on multiple student outcomes, including ever having sex, having four or more lifetime sexual partners, being sexually active, using hormonal birth control, dual use of a condom and hormonal birth control, ever being forced to have sex, missing school because of safety concerns, and lifetime and current marijuana use. However, we found few moderating effects of exemplary sexual health education and sexual health services dosage.We found a significant relationship between incremental increases in implementation of activities to increase the safety and supportiveness of school environments and enhanced program effects in improving multiple student health outcomes. These findings suggest that school implementation of SSE activities contributed to intended program effects.

Purpose The purpose of the study is to assess associations between exposure to a multilevel, socio-ecological health program administered by local education agencies and changes in health behaviors among high school students. Methods This analysis used a multilevel difference-in-differences approach to compare student health experiences and outcomes between schools selected by local education agencies nationwide to implement the program (exposed schools) and schools that were not (unexposed schools). We measured repeated cross-sectional outcomes using the 2015 and 2017 Youth Risk Behaviors Surveys. The final analytic sample comprised 638 schools in total (N = 64,838 students), with 237 exposed schools (n = 30,336 students) and 401 unexposed schools (n = 34,502 students). Results Students in exposed schools demonstrated significant reduction in odds compared with those in unexposed schools in ever having sex (adjusted odds ratio [aOR] = .88, 95% confidence interval [CI]: .81–.96), having four or more lifetime sexual partners (aOR = .84, 95% CI: .72–.97), being currently sexually active (aOR = .78, 95% CI: .78–.96), and using effective hormonal birth control (aOR = .7, 95% CI: .56–.88). Exposure to the program was associated with significant reduction in odds of not going to school because of safety concerns (aOR = .87, 95% CI: .78–.97), having experienced forced sex (aOR = .76, 95% CI: .68–.86), ever used marijuana (aOR = .89, 95% CI: .81–.98), and currently using marijuana (aOR = .77, 95% CI: .64–.93). Conclusions Exposure to the program was associated with significant decreases in sexual risk behaviors, experience of violence, and substance use.

PURPOSE: We examined the association of lesbian, gay, bisexual, transgender, and questioning (LGBTQ)-supportive school policies and practices with psychosocial health outcomes among lesbian, gay, bisexual (LGB), and heterosexual students. METHODS: The 2014 and 2016 School Health Profiles data from principals and health educators from 117 schools assessed LGBTQ-supportive school policies and practices. We computed the sum of school policies and practices, indicating the number available for each student. The 2015 and 2017 Youth Risk Behavior Survey data from 75,638 students from the same schools measured psychosocial health outcomes. We conducted multilevel cross-sectional logistic regressions of the associations of school-level policies and practices with student-level health outcomes by sexual identity while controlling for sex, grade, race/ethnicity, and school priority. RESULTS: Several LGBTQ-supportive school policies and practices were significantly associated with lower odds of feeling threatened at school, suicide-related behaviors, and illicit drug use among LGB students. For heterosexual students, having a gay-straight alliance or similar club was linked to multiple health outcomes, whereas other policies and practices were significantly associated with lower odds of safety concerns at school, forced sexual intercourse, feeling sad or hopeless, and illicit drug use. Increasing the sum of policies and practices was linked to lower odds of suicide-related behaviors among LGB students and safety concerns and illicit drug use among heterosexual students. CONCLUSION: These findings suggest that LGBTQ-supportive school policies and practices are significantly associated with improved psychosocial health outcomes among both LGB and heterosexual students, although more research is needed to better understand these relationships.

Lesbian, gay, and bisexual (LGB) adolescents are often at higher risk than their heterosexual peers for adverse sexual health, violence, mental health, and substance use outcomes. Schools are a vital resource for enhancing protective behaviors and reducing risk behaviors. Sixteen school districts selected schools to implement a sexual health program (exposed) or usual programming (unexposed). We analyzed LGB student health outcomes using 2015 and 2017 Youth Risk Behavior Surveys. Analyses compared LGB student health outcomes by exposure status across time points using a multilevel approach. Program exposure was associated with decreased odds of ever having sex, ever testing for HIV, and using effective hormonal birth control, and an increased odds of condom use. There were no significant findings among secondary violence, mental health, and substance use outcomes. This evaluation highlights the potential for schools to reduce sexual risk behaviors among LGB youth, and opportunities to improve access to health services.

BACKGROUND Teacher instructional competency, the set of essential knowledge and skills needed to guide teaching practice, is critical to the successful implementation of school health education. The purpose of this paper is to introduce the Health Education Teacher Instructional Competency (HETIC) framework, a new conceptualization describing teacher characteristics, essential knowledge, and essential skills, which can influence instructional practice and improve student learning outcomes in health education. METHODS Data from 17 publicly available guidance documents, professional standards, published reports, and empirical studies relevant to the fields of public education, school health education, and sexual health education were abstracted and analyzed using qualitative thematic content analysis. RESULTS The framework describes 3 domains: personal characteristics, essential knowledge, and essential skills, which are believed to contribute to teachers' instructional competencies in delivering health education. The knowledge domain asserts 5 key categories, while the essential skills domain includes 3 categories (learning environments, content and delivery, and collaboration and learning) and contains 11 unique skills. Collectively, these domains are influenced by the learner, school/community, and policy-level factors that shape health education curriculum and instruction. CONCLUSIONS The HETIC framework presents a conceptual roadmap to guide quality health education preparation, job-embedded training, and delivery. Improving teachers' instructional competencies strengthens learning and prosocial environments that are inclusive, responsive, and affirming of students' health and learning needs. Teacher who demonstrate instructional competency can help students to achieve desired education and health outcomes, specifically acquiring the knowledge and skills needed to adapt, practice, and maintain healthy behaviors throughout their lifetime.

This study adopts a socio-ecological framework and examines school- and district-level influences on sexual behaviors among high school students from 16 school districts that were federally funded to conduct a school-based, multilevel sexual health program. We drew cross-sectional data from the 2015 and 2017 Youth Risk Behavior Survey from funded school districts containing 648 schools and 101,728 students. We used multilevel modeling to determine the percentage of variance in sexual health outcomes explained at school and district levels, overall and by race/ethnicity and biological sex. We found protective behaviors such as using hormonal birth control had considerable district-level variance (10.1%) while sexual risk behaviors such as having multiple sex partners showed considerable school-level variance (12.7%). We also found significant subgroup heterogeneity in the variance. Findings indicate school-based interventions should address all levels of influences of the educational system to effectively improve a myriad of student sexual health outcomes.

PURPOSE: We examined the association of lesbian, gay, bisexual, transgender, and questioning (LGBTQ)-supportive school policies and practices with sexual health outcomes among LGB and heterosexual students. METHODS: The 2014 and 2016 School Health Profiles data from principals and lead health educators from 117 high schools in 16 local education agencies across the United States assessed LGBTQ-supportive school policies and practices (e.g., having a gay/straight alliance or similar club). The 2015 and 2017 Youth Risk Behavior Survey data from 75,638 students from the same schools assessed sexual health outcomes (e.g., being currently sexually active). We conducted multilevel cross-sectional logistic regression analyses to examine the associations between school-level LGBTQ-supportive policies and practices with student-level sexual health outcomes, while controlling for sex, grade, race/ethnicity, and school priority status. RESULTS: Several LGBTQ-supportive school policies and practices were significantly associated with lower odds of sexual risk behaviors (e.g., having four or more lifetime sexual partners) and ever being tested for human immunodeficiency virus (HIV) among both LGB and heterosexual students but not with using a condom during last sexual intercourse among sexually active gay, bisexual, or heterosexual male students. Having a greater number of LGBTQ-supportive school policies and practices was significantly associated with lower odds of ever having sex for LGB students and with sexual risk behaviors and ever being tested for HIV for heterosexual students. CONCLUSION: The study highlights the relationship between multifaceted LGBTQ-supportive school policies and practices and improving sexual health outcomes among both LGB and heterosexual students.

IntroductionThe COVID-19 pandemic required more responsibilities from teachers, including implementing prevention strategies, changes in school policies, and managing their own mental health, which yielded higher dissatisfaction in the field.MethodsA cross-sectional web survey was conducted among educators to collect information on their experiences teaching during the COVID-19 pandemic throughout the 2020–2021 academic year. Qualtrics, an online survey platform, fielded the survey from May 6 to June 8, 2021 to a national, convenience sample of 1,807 respondents.ResultsFindings revealed that overall, 43% of K-12 teachers reported a greater intention to leave the profession than previously recalled prior to the COVID-19 pandemic. Intention to leave was multi-level, and associated with socio-demographic factors (e.g., age: AOR = 1.87, p < 0.05), individual factors (e.g., perceived COVID risks: AOR = 1.44, p < 0.05), and teachers’ agency (e.g., dissatisfaction with school/district communications and decisions: AOR = 1.34, p < 0.05). We also found demographic disparities with respect to race and gender (e.g., female teachers: AOR: 1.78, p < 0.05) around teachers’ ability to provide feedback to schools on opening/closing and overall dissatisfaction with school/district COVID-19 prevention strategies implementation and policies.ConclusionThese findings are consistent with the Job-Demand and Resources Model (JD-R), which posits that lack of organizational support can exacerbate job stressors, leading to burnout. Specifically, dissatisfaction with the way school policies were implemented took a toll on teachers’ mental health, leading to a desire to leave the profession. These findings are also consistent with research conducted once in-person teaching resumed in 2020–2021, specifically that the COVID-19 pandemic exacerbated preexisting teacher shortages that led to self-reported issues of stress, burnout, and retention.ImplicationsFurther research is necessary to understand the resources that may be most useful to reduce the demands of teaching in the context of the COVID-19 pandemic. Some teachers are more likely to leave the field, and educational agencies may wish to target their teacher-retention efforts with emphasis on strong employee wellness programs that help educators to manage and reduce their stress. Education agency staff may wish to review policies and practices to provide meaningful opportunities to give input to school/district decisions and enable proactive communication channels.

Sexual minority adolescents (SMA) report more suicide risk behaviors than heterosexual adolescents. Polyvictimization (co-occurrence of multiple types of victimization) may be an important, underresearched correlate of this disparity. With the 2017 national Youth Risk Behavior Survey (N = 13,179), national estimates of polyvictimization and suicide risk were assessed among high school students by sexual minority status (SM vs. heterosexual), and multivariate relationships between sexual minority status, polyvictimization, and suicide risk were tested. Additionally, risk profiles of those who experienced polyvictimization (2 + types of victimization; n = 1,932) were compared across sexual minority status. Results confirm that SMA are more likely to experience polyvictimization than heterosexual adolescents (31.8% v. 12.9%, respectively); however, also indicate that polyvictimization does not fully explain elevated suicide risk among SMA.

The COVID-19 pandemic has been associated with established risk factors for adolescent substance use, including social isolation, boredom, grief, trauma, and stress. However, little is known about adolescent substance use patterns during the pandemic. CDC analyzed data from the Adolescent Behaviors and Experiences Survey, an online survey of a probability-based, nationally representative sample of public- and private-school students in grades 9-12 (N = 7,705), to examine the prevalence of current use of tobacco products, alcohol, and other substances among U.S. high school students. Prevalence was examined by demographic characteristics and instructional models of the students' schools (in-person, virtual, or hybrid). During January-June 2021, 31.6% of high school students reported current use of any tobacco product, alcohol, or marijuana or current misuse of prescription opioids. Current alcohol use (19.5%), electronic vapor product (EVP) use (15.4%), and marijuana use (12.8%) were more prevalent than prescription opioid misuse (4.3%), current cigarette smoking (3.3%), cigar smoking (2.3%), and smokeless tobacco use (1.9%). Approximately one third of students who used EVPs did so daily, and 22.4% of students who drank alcohol did so ≥6 times per month. Approximately one in three students who ever used alcohol or other drugs reported using these substances more during the pandemic. The prevalence of substance use was typically higher among non-Hispanic American Indian or Alaska Native students, older students, and gay, lesbian, or bisexual students than among students of other racial or ethnic groups, younger students, and heterosexual students. The prevalence of alcohol use also was higher among non-Hispanic White students than those of other racial or ethnic groups. Students only attending school virtually had a lower prevalence of using most of the substances examined than did students attending schools with in-person or hybrid models. These findings characterizing youth substance use during the pandemic can help inform public health interventions and messaging to address these health risks during and after the COVID-19 pandemic.

BackgroundThere are known associations between mental health symptoms and transgender identity among adults. Whether this relationship extends to early adolescents and to gender domains other than identity is unclear. This study measured dimensions of gender in a large, diverse, sample of youth, and examined associations between diverse gender experiences and mental health.MethodsThe ABCD study is an ongoing, longitudinal, US cohort study. Baseline data (release 2.0) include 11,873 youth age 9/10 (48% female); and the 4,951 1-year follow-up visits (age 10/11; 48% female) completed prior to data release. A novel gender survey at the 1-year visit assessed felt-gender, gender noncontentedness, and gender nonconformity using a 5-point scale. Mental health measures included youth- and parent-reports.ResultsRoughly half a percent of 9/10-year-olds (n=58) responded 'yes' or 'maybe' when asked, 'Are you transgender' at baseline. Recurrent thoughts of death were more prevalent among these youth compared to the rest of the cohort (19.6% vs. 6.4%, χ2 =16.0, p&nbsp

Youth experiencing homelessness experience violence victimization, substance use, suicide risk, and sexual risk disproportionately, compared with their stably housed peers. Yet few large-scale assessments of these differences among high school students exist. The youth risk behavior survey (YRBS) is conducted biennially among local, state, and nationally representative samples of U.S. high school students in grades 9–12. In 2019, 23 states and 11 local school districts included a measure for housing status on their YRBS questionnaire. The prevalence of homelessness was assessed among states and local sites, and relationships between housing status and violence victimization, substance use, suicide risk, and sexual risk behaviors were evaluated using logistic regression. Compared with stably housed students, students experiencing homelessness were twice as likely to report misuse of prescription pain medicine, three times as likely to be threatened or injured with a weapon at school, and three times as likely to report attempting suicide. These findings indicate a need for intervention efforts to increase support, resources, and services for homeless youth.

School health education, including sexual health education, plays a crucial role in shaping adolescents' protective health behaviors, experiences, and outcomes. Adolescents need functional knowledge and skills to practice, adopt, and maintain healthy behaviors for preventing sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), and unintended pregnancy.The US Centers for Disease Control and Prevention's Division of Adolescent and School Health (CDC/DASH) has advanced school-based approaches to STI/HIV and pregnancy prevention through surveillance, research and evaluation, and program partnership and collaboration for over 3 decades.CDC/DASH uses systematic and innovative strategies to identify the breadth of adolescent sexual health evidence; characterize key elements of effective educational curricula; and provide practical guidance to support school-based delivery. CDC/DASH's approach to effective health and sexual health education in schools has changed dramatically over the past 30 years and must continue to progress.This paper describes how and why that approach has evolved and outlines directions for the future.

BACKGROUND In an attempt to increase high school students' sexually transmitted disease (STD) testing rates, the Centers for Disease Control and Prevention's Division of Adolescent and School Health partnered with ICF and Chicago Public Schools to adapt and implement the "GYT: Get Yourself Tested" health marketing campaign for a high school. METHODS Clinic record data and student retrospective self-report surveys (n = 193) tested for differences between the GYT intervention school and a comparison school on a number of outcomes, including human immunodeficiency virus and STD testing. RESULTS Clinic record data showed that testing increased significantly more for the intervention than the comparison school during the GYT implementation period (B, 2.9; SE, 1.1, P < 0.05). Furthermore, the odds of being tested at the referral clinic were more than 4 times (odds ratio, 4.4) as high for students in the campaign school than for those in the comparison school (95% confidence interval, 2.3-8.2). Survey data did not show increased self-reported testing but, more students in the GYT school (92.7%) were aware of where to receive free, low-cost, or affordable human immunodeficiency virus and STD testing than students in the comparison school (76.0%; P < 0.01). Among sexually experienced students (n = 142), significantly more from the campaign school reported that they intended to test for STDs in the next 3 months (48.4% strongly agree and 33.2% agree) compared with those at the comparison school (27.4% strongly agree and 32.9% agree; P < 0.05). CONCLUSIONS Our pilot suggests that a student-led GYT campaign in high schools may successfully increase STD testing of students. Although some of the findings from this pilot evaluation are promising, they are limited, and broader implementation and evaluation is needed. Future evaluation efforts can include more rigorous study designs, multiple schools or districts, longer campaign and evaluation across an entire school or calendar year, or in combination with other school-based testing strategies like a mass school-based screening event.

Youths identifying as lesbian, gay, bisexual, or another nonheterosexual identity (sexual minority youths) report more violence victimization, substance use, and suicide risk than do heterosexual youths (1). These disparities are generally attributed to minority stress (the process through which stigma directed toward sexual minorities influences health outcomes) (2,3). Sexual minority youths might experience negative outcomes associated with minority stress differently across sexual identities, but to date, no nationally representative study has examined differences in victimization, substance use, and suicide risk within sexual minority youth. Using pooled data from the 2015 and 2017 national Youth Risk Behavior Surveys (YRBS), relationships between sexual identity groups and victimization, substance use, and suicide risk were evaluated with sex-stratified logistic regression models. Compared with heterosexual students, bisexual females and all sexual minority males reported more victimization; lesbian and bisexual females reported more use of alcohol, cigarettes, and marijuana; and all sexual minority youths reported elevated high-risk substance use and suicide risk. Programmatic efforts to reduce and prevent victimization, substance use, and suicide risk among sexual minority youths might benefit from consideration of issues within group differences.

Sexual minority youth often experience increased social stress due to prejudice, discrimination, harassment, and victimization. Increased stress may help explain the disproportionate use of substances like tobacco, alcohol, marijuana, and other illicit drug use by sexual minority youth. This study examined the effect of social stress on substance use disparities by sexual orientation among U.S. high school students.In 2016, data from the national 2015 Youth Risk Behavior Survey, conducted among a nationally representative sample of 15,624 U.S. high school students, were analyzed to examine the effect of school-related (threatened/injured at school, bullied at school, bullied electronically, felt unsafe at school) and non-school-related (forced sexual intercourse, early sexual debut) social stress on substance use disparities by sexual orientation, by comparing unadjusted prevalence ratios (PRs) and adjusted (for social stressors, age, sex, and race/ethnicity) prevalence ratios (APRs).Unadjusted PRs reflected significantly (p0.05 or 95% CI did not include 1.0) greater substance use among students who identified as lesbian/gay or bisexual than students who identified as heterosexual. APRs for injection drug use decreased substantially among lesbian/gay (PR=12.02 vs APR=2.14) and bisexual (PR=2.62 vs APR=1.18) students; the APR for bisexual students became nonsignificant. In addition, APRs among both lesbian/gay and bisexual students decreased substantially and were no longer statistically significant for cocaine, methamphetamine, and heroin use.School-based substance use prevention programs might appropriately include strategies to reduce social stress, including policies and practices designed to provide a safe school environment and improved access to social and mental health services.

Objective Sexual minority girls (lesbian/bisexual) and girls with overweight/obesity experience high rates of discrimination and mental distress. This study explored whether BMI or perceived weight status might compound sexual minority girls’ risk for harassment and mental distress. Methods Data on female students from the national 2015 Youth Risk Behavior Survey (n = 7,006) were analyzed. Logistic regression was used to examine differences in bullying, harassment, and mental distress across sexual identity/BMI groups: heterosexual/normal-weight, heterosexual/overweight, sexual minority/normal-weight, and sexual minority/overweight. Procedures were repeated with four analogous groups created from sexual identity and perceived weight. Results Across sexual identity/BMI groups, being overweight increased heterosexual females’ odds of being bullied or experiencing suicidal thoughts and behaviors. Regardless of weight status, sexual minority females had greater odds for each outcome than heterosexual females. Sexual minority females who perceived themselves as overweight had greater odds of suicidality than all other sexual minority/perceived weight groups. Conclusions Double jeopardy may exist for sexual minority female students who perceive themselves as overweight. Professional development with school staff on how to create a positive climate for sexual minorities and those with overweight/obesity and addressing positive identity and body image within school-based suicide prevention efforts may be important to the well-being of adolescent girls.

Background Effective school-based HIV and STD prevention improves health education, access to health services, parent engagement, and increases school connectedness (SC). SC – the degree to which students believe that adults and peers in the school care about them and their success – has long term-implications for sexual behavior, experience of sexual violence, and STD acquisition into adulthood. The current analyses examine the associations of activities to increase school connectedness and health-related experiences and behaviors among high school students in 347 schools from 17 school districts funded by CDC’s Division of Adolescent and School Health (DASH) from 2013 to 2018 to implement HIV and STD prevention. Methods We used data from DASH’s Program Evaluation Reporting System (PERS) and School Health Profiles survey (Profiles) to assess implementation of four school connectedness activities and data from the Youth Risk Behavior Survey (YRBS) to assess youth behaviors and experiences. We examine whether level of implementation of SC in Year 3 of the program was related to STD risk at the end of Year 4. Results SC, as measured by PERS, was significantly related to decreased forced sex (OR=0.99, CI=0.99–1.0, p Conclusion The DASH approach to primary prevention of HIV and STD is effective in improving sexual risk behaviors at a population level in schools. The current analyses demonstrate that increased implementation of school-connectedness specific activities are associated with reduced behaviors and experiences tied to STD acquisition, with significant implications for those experiences into adulthood. Disclosure No significant relationships.

Coordinated school health (CSH) programs address multiple factors related to students’ overall health, thereby increasing their physical and mental readiness to learn. A formative evaluation of three school districts in 2010–2011 examined strategies for sustaining the school health teams (SHT) that lead CSH efforts. Qualitative data from 39 interviews and 13 focus groups revealed facilitators and barriers for sustaining SHTs. Quantitative data from 68 questionnaires completed by SHT members and school principals examined factors associated with having more active school health teams and district and school characteristics SHT members believed to be important to their schools’ efforts to implement CSH. Facilitators of sustaining SHTs included administrative support, staff engagement in the SHT, and shared goals and responsibility. Barriers to sustaining SHTs included limited time and competing priorities, budget and funding constraints, and staff turnover. Findings provide valuable insight into challenges and potential solutions for improving the sustainability of SHTs to enable them to better support CSH efforts.

Background The Whole School, Whole Community, Whole Child (WSCC) model provides an organizing framework for schools to develop and implement school health policies, practices, and programs. The purpose of this study was to examine the presence of practices that support school health for each component of the WSCC model in US schools. Methods Data from the School Health Policies and Practices Study 2014 were analyzed to determine the percentage of schools with practices in place that support school health for WSCC components. Results Less than 27% of schools had a school health council that addressed any specific WSCC component, but more than 50% had a coordinator for all but one component. The use of other practices that support school health varied widely across the WSCC components. For example, more than 80% of schools reported family engagement for health education and nutrition environment and services, but less than 50% reported family engagement for other components. Conclusions These results indicate that many US schools are using practices that support school health and align with WSCC components, but improvement is needed. These results also highlight discrepancies in the types of practices being used.

Purpose An earlier randomized controlled trial found that two middle school sexual education programs—a risk avoidance (RA) program and a risk reduction (RR) program—delayed initiation of sexual intercourse (oral, vaginal, or anal sex) and reduced other sexual risk behaviors in ninth grade. We examined whether these effects extended into 10th grade. Methods Fifteen middle schools were randomly assigned to RA, RR, or control conditions. Follow-up surveys were conducted with participating students in 10th grade (n = 1,187; 29.2% attrition). Results Participants were 60% female, 50% Hispanic, and 39% black; seventh grade mean age was 12.6 years. In 10th grade, compared with the control condition, both programs significantly delayed anal sex initiation in the total sample (RA: adjusted odds ratio [AOR], .64, 95% confidence interval [CI], .42–.99; RR: AOR, .65, 95% CI, .50–.84) and among Hispanics (RA: AOR, .53, 95% CI, .31–.91; RR: AOR, .82, 95% CI, .74–.93). Risk avoidance students were less likely to report unprotected vaginal sex, either by using a condom or by abstaining from sex (AOR: .61, 95% CI, .45–.85); RR students were less likely to report recent unprotected anal sex (AOR: .34, 95% CI, .20–.56). Both programs sustained positive impact on some psychosocial outcomes. Conclusions Although both programs delayed anal sex initiation into 10th grade, effects on the delayed initiation of oral and vaginal sex were not sustained. Additional high school sexual education may help to further delay sexual initiation and reduce other sexual risk behaviors in later high school years.

Importance The cultural roles and expectations attributed to individuals based on their sex often shape health behaviors and outcomes. Gender nonconformity (GNC) (ie, gender expression that differs from societal expectations for feminine or masculine appearance and behavior) is an underresearched area of adolescent health that is often linked to negative health outcomes. Objective To examine the associations of GNC with mental distress and substance use among high school students. Design, Setting, and Participants Cross-sectional study based on data from the Youth Risk Behavior Survey (YRBS) conducted in 2015. The setting was 3 large urban US school districts (2 in California and 1 in Florida). Participants were a racially/ethnically diverse population-based sample of 6082 high school students representative of all public school students in grades 9 through 12 attending these 3 school districts. Main Outcomes and Measures Sex-stratified adjusted prevalence ratios (APRs) (adjusted for race/ethnicity, grade, and sexual identity) for high gender-nonconforming students (very/mostly/somewhat feminine male students or very/mostly/somewhat masculine female students) and moderate gender-nonconforming students (equally feminine and masculine students) relative to a referent group of low gender-nonconforming students (very/mostly/somewhat masculine male students or very/mostly/somewhat feminine female students). Results Among 6082 high school students, 881 (15.9%) were white, 891 (19.1%) black, 3163 (55.1%) Hispanic, and 1008 (9.9%) other race/ethnicity. Among female students (2919 [50.0% of the study population]), moderate GNC was significantly associated with feeling sad and hopeless (APR, 1.22; 95% CI, 1.05-1.41), seriously considering attempting suicide (APR, 1.41; 95% CI, 1.14-1.74), and making a suicide plan (APR, 1.52; 95% CI, 1.22-1.89); however, substance use was not associated with GNC. Among male students (3139 [50.0% of the study population]), moderate GNC was associated with feeling sad and hopeless (APR, 1.55; 95% CI, 1.25-1.92); high GNC was associated with seriously considering attempting suicide (APR, 1.72; 95% CI, 1.16-2.56), making a suicide plan (APR, 1.79; 95% CI, 1.17-2.73), and attempting suicide (APR, 2.78; 95% CI, 1.75-4.40), as well as nonmedical use of prescription drugs (APR, 1.81; 95% CI, 1.23-2.67), cocaine use (APR, 2.84; 95% CI, 1.80-4.47), methamphetamine use (APR, 4.52; 95% CI, 2.68-7.61), heroin use (APR, 4.59; 95% CI, 2.48-8.47), and injection drug use (APR, 8.05; 95% CI, 4.41-14.70). Conclusions and Relevance This study suggests mental distress is associated with GNC among female and male students. Substance use also appeared to be strongly associated with GNC among male students. These findings underscore and suggest the importance of implementing school-based programs to prevent substance use and promote student mental health that are inclusive of gender diversity in students.

BACKGROUND Previous research on associations between early sexual debut and other health risk behaviors has not examined the effect of forced sexual intercourse on those associations. METHODS We analyzed data from a nationally representative sample of 19,240 high school students in the United States, age ≥16 years, to describe the effect of forced sexual intercourse on associations between early sexual debut and other health risk behaviors using adjusted prevalence ratios (APR). RESULTS Early sexual debut and forced sexual intercourse were simultaneously and independently associated with sexual risk-taking, violence-related behaviors, and substance use. For example, even after controlling for forced sexual intercourse and race/ethnicity, students who experienced their first sexual intercourse before age 13 years were more likely than students who initiated sexual intercourse at age ≥16 years to have had ≥4 sexual partners during their lifetime (girls, APR = 4.55; boys, APR = 5.82) and to have not used a condom at last sexual intercourse (girls, APR = 1.74; boys, APR = 1.47). CONCLUSIONS Associations between early sexual debut and other health risk behaviors occur independently of forced sexual intercourse. School-based sexual health education programs might appropriately include strategies that encourage delay of initiation of sexual intercourse, and coordinate with violence and substance use prevention programs.

Introduction Early sexual debut, sexual risk taking, substance use, violent victimization, and suicidal behaviors are more prevalent among sexual minority than sexual nonminority youth. Although associations between early sexual debut and these risk behaviors exist, little is known about such associations among sexual minority youth. This study examined these associations among sexual minority U.S. high school students and their sexual nonminority peers. Methods In 2015, the national Youth Risk Behavior Survey included questions assessing sexual orientation for the first time. In 2016, data from this nationally representative sample of 15,624 U.S. high school students were analyzed to determine if associations between early sexual debut and other health risk behaviors varied by sexual orientation, by calculating adjusted (for sex, race/ethnicity, and age) prevalence ratios (APRs). Results Associations between early sexual debut and other health risk behaviors did not vary significantly by sexual orientation. Early sexual debut (first sexual intercourse before age 13 years) was associated with sexual risk taking, substance use, violent victimization, and suicidal thoughts/attempts among students identifying as lesbian, gay, or bisexual (LGB) and among students identifying as heterosexual, for example, being currently sexually active (LGB students: APR=1.82, 95% CI=1.35, 2.45; heterosexual students: APR=2.50, 95% CI=2.22, 2.81) and not using a condom at last sexual intercourse (LGB students: APR=1.50, 95% CI=1.18, 1.91; heterosexual students: APR=1.29, 95% CI=1.09, 1.52). Conclusions School-based sexual health programs might appropriately utilize strategies that are inclusive of sexual minority students, encourage delay of sexual intercourse, and coordinate with violence and substance use prevention programs.

This exploratory study examined the experiences of black and Latino teen young men who have sex with men (YMSM) and their preferences for communication with school staff about matters related to sexual orientation.Participants for this study were recruited in three urban centers in the United States and by multiple community-based organizations serving black and Latino YMSM. Eligible youth were male, black and Latino, ages 13–19, enrolled in 90 days of school in the previous 18 months, and reported attraction to or sexual behavior with other males, or identified as gay or bisexual. Participants completed web-based questionnaires (n=415) and/or in-depth interviews (n=32).Questionnaire participants reported willingness to talk to at least one school staff member about: safety, dating and relationships, and feeling attracted to other guys (63.4%, 58.4%, and 55.9%, respectively). About one-third of the sample reported they would not talk with any school staff about these topics. Exploratory analyses revealed youth who experienced feeling unsafe at school and who had higher levels of trust in the information provided by school staff were more likely to be willing to talk with school staff about safety issues, dating, or same sex attraction (adjusted odds ratio [AOR]=2.80 and AOR=4.85, respectively). Interview participants reported being most willing to talk to staff who were able and willing to help them, who would keep discussions confidential, and who expressed genuine care. Preferences for confiding in school staff perceived to be lesbian, gay, bisexual, and transgender (LGBT) and having similar racial/ethnic background were also noted.Findings suggest school staff can serve as points of contact for reaching YMSM and professional development and interventions can be tailored to reach YMSM and connect them to services they need. Additional research is needed to understand how to increase YMSM comfort talking with school staff about sexual health or sexual identity concerns.

The high prevalence of asthma among school-aged youth places a significant burden on students, families, and communities. Secondhand smoke (SHS) exacerbates asthma symptoms and attacks. Parental smoking is likely the most common and recurring source of SHS exposure among children. School-based asthma management programs can play a major role in educating students and their families about how to reduce, eliminate, and cope with SHS exposure. Between January 2007 and May 2008, a total of 121 middle and 248 elementary school students who participated in school-based asthma management programs in elementary school completed pretest and posttest surveys assessing asthma behaviors and management difficulties. Subgroups of 40 middle and 54 elementary school students participated in 15 focus groups. Quantitative data were analyzed using descriptive statistics and independent sample t tests. Thematic analysis was used to identify and interpret prominent themes within qualitative data. Quantitative analysis of elementary school student data revealed students exposed to SHS had significantly higher asthma management difficulties at pretest (2.79 vs 1.98, respectively; t = 3.4, P = .001) and posttest (2.56 vs 1.74, respectively; t = 3.8, P < .001) compared with those without SHS exposure. Qualitative results from elementary and middle school students revealed that many students reported SHS exposure resulting from family members smoking at home or in cars. Students and their families reported using ineffective methods (eg, opening a window, drinking water, holding their breath) for reducing, eliminating, and coping with SHS exposure. School-based asthma management programs should provide education to students and their families on the lasting effects of SHS on asthma symptoms and effective strategies for reducing, eliminating, and coping with SHS exposure in homes and cars. A focus on parent and community involvement can play a key role in addressing students’ asthma management needs outside of school.

BACKGROUND: A US federal mandate that school districts devise and implement local wellness policies (LWPs) has potential widespread impact on the nutritional content of foods and beverages available in schools and on the amount of physical activity that students engage in; however, evidence concerning the mandate's effectiveness is limited. This study describes the content of LWPs of 6 US school districts and steps taken toward their implementation and evaluation. METHODS: During visits to 6 school districts, we interviewed 88 school and community representatives about the content of their district's LWPs and how the LWPs were being implemented and evaluated. RESULTS: The 6 LWPs were consistent with the federal mandate, although they varied in content and degree of specificity, and none had been fully implemented. All 6 districts were pursuing strategies to ensure that foods and beverages available at school met nutrition standards but did not offer nutrition education to all K-12 students. All 6 districts offered students only limited opportunities for physical activity, and all 6 collected data to monitor process and outcomes of their LWPs. CONCLUSIONS: Partial implementation of LWPs in the districts we visited resulted in significant improvement in the nutritional quality of foods available at district schools, but only slight improvement in students' opportunities for school-based physical activity. We provide recommendations for school districts on implementation and evaluation. Future research is needed to determine the impact of these LWPs on students' health.

BACKGROUND: During the 2004–2005 school year, the Mississippi Department of Education, Office of Child Nutrition, initiated a pilot program to distribute free fruit and vegetable snacks to students during the school day. This article describes the first-year implementation of the Mississippi Fruit and Vegetable Pilot Program. METHODS: The process evaluation addressed where, when, and how produce was distributed; what was distributed; challenges and successes; and recommended modifications. Five of the 25 program schools were selected to participate in the evaluation; selection was based on grade levels served and demographic characteristics. Data were collected from program staff (N = 11) and administrators (N = 6) via interviews and logs; student (N = 42) and parent (N = 19) focus groups; student questionnaires (N = 660); and school staff questionnaires (N = 207). RESULTS: Distributing fresh fruit and vegetable snacks at school was well received by staff and students. Most schools distributed the fresh fruit and vegetable snacks at morning break in classrooms or a central courtyard. Twenty-two types of fresh fruit, 4 types of dried fruit, and 7 types of vegetables were served to students during the program year. Commonly distributed fruit included apples, oranges, pears, bananas, and tangerines. Carrots were the staple vegetable, followed by celery. Key challenges included getting students to try new foods and receiving the produce in a timely manner without spoiling. Main successes included seeing students try new fruit and vegetable snacks, having the program run smoothly, and teacher support. CONCLUSIONS: The program fit well within the school structure and could be an effective component of a multifaceted approach to enhancing child nutrition.

The authors describe application of the Systematic Screening and Assessment (SSA) Method to an initiative called the Early Assessment of Programs and Policies to Prevent Childhood Obesity. Over a 2-year period, a national network of practitioners, policy makers, and funders nominated programs and policies across five substantive areas: school district local wellness policies, school-based comprehensive physical activity programs, day care and after-school programs, access to healthy foods in low-income communities, and changes in the built environment to promote physical activity. The role of an expert panel in selecting innovations for evaluability assessment on the basis of the likelihood for a positive health impact is described. © Wiley Periodicals, Inc., and the American Evaluation Association.

Albuquerque Public Schools (APS), in collaboration with the Centers for Disease Control and Prevention, conducted an evaluation to examine whether students who were exposed to the APS asthma program in elementary school retained benefits into middle school.APS middle school students who participated in the APS asthma program in elementary school, including the Open Airways for Schools (OAS) education curriculum, responded to a follow-up questionnaire (N = 121) and participated in student focus groups (N = 40). Asthma management self-efficacy scores from the follow-up questionnaire were compared to scores obtained before and after the OAS education component. Additional items assessed students' asthma symptoms, management skills, avoidance of asthma triggers, and school impact.Although asthma management self-efficacy scores declined in middle school among students exposed to the asthma program in elementary school, they remained significantly higher than scores obtained during elementary school prior to the OAS intervention.The results indicate that although students benefited from the asthma program delivered in elementary school, they need booster sessions and continued school support in middle school.

Charlotte-Mecklenburg Schools (CMS), with assistance from the Centers for Disease Control and Prevention (CDC), conducted an evaluation of the CMS Asthma Program. Data were collected during the 2007-2008 school year through surveys of students with asthma (n = 286), interviews with school nurses (n = 11), and reviews of administrative records that included service provision and nurse ratings of the need for asthma services (based on a set of clinical indicators and symptom frequencies) for each student with asthma. Ninety percent of high-need students, 75.8% of medium-need students, 45.3% of low-need students, and 21.4% of nonrated students were enrolled in student-level services. Given the large number of students without a nurse rating for need, asthma management difficulties (AMD; a set of questions completed by all students on the student survey) were examined as a proxy indicator of need for student-level services. When looking only at need based on AMD, 46.0% of high-need students, 48.0% of medium-need students, and 35.2% of low-need students were enrolled in any student-level service. A Pearson χ2 revealed that nurse ratings of need and need based on AMD were not significantly related (χ2 = 4.1888, df = 4, P = .381); of students with nurse ratings for need, more were classified as medium and high need based on AMD than were rated medium and high need by school nurses. This suggests that many students were experiencing AMD but not coming to the attention of school nurses. Among students with asthma, additional resources and systematic procedures are needed to identify those who need student-level services, particularly for students who do not otherwise present with symptoms to the school nurse.

Black and Latino young men who have sex with men (YMSM) are at disproportionate risk for sexually transmitted diseases (STDs), including HIV. This study informs school-centered strategies for connecting YMSM to health services by describing their willingness, perceived safety, and experiences in talking to school staff about sexual health. Cross-sectional data were collected from Black and Latino YMSM aged 13–19 through web-based questionnaires ( N = 415) and interviews ( N = 32). School nurses were the staff members youth most often reported willingness to talk to about HIV testing (37.8%), STD testing (37.1%), or condoms (37.3%), but least often reported as safe to talk to about attraction to other guys (11.4%). Interviews revealed youth reluctance to talk with school staff including nurses when uncertain of staff members’ perceptions of lesbian, gay, bisexual, transgender, and questioning (LGBTQ) people or perceiving staff to lack knowledge of LGBTQ issues, communities, or resources. Nurses may need additional training to effectively reach Black and Latino YMSM.

Service learning has been identified as a promising approach to reduce sexual risk behavior, among other outcomes. This study used qualitative data analysis to offer suggestions for optimally integrating service learning into a program to reduce sexual risks among alternative school students. Data were collected from student participants in the All4You! Project using classroom materials, focus groups, and individual interviews. Project educators and project staff also provided data through summary forms and field notes. Qualitative data analysis revealed 5 strategies for creating positive service experiences for alternative school students: (1) find appropriate service-learning sites, (2) create staff support, (3) maintain appropriate student participation and behavior, (4) enhance student reflection on service-learning experiences, and (5) address students’ self-images. (J Sch Health. 2005;75(5):151-156)

Purpose To review adolescent sexual risk-reduction programs that were evaluated using quasi-experimental or experimental methods and published in the 1990s. We describe evaluated programs and identify program and evaluation issues for health educators and researchers. Methods We systematically searched seven electronic databases and hand-searched journals to identify evaluations of behavioral interventions to reduce sexual risk behaviors among adolescents. Articles were included if they were published in the 1990s, provided a theoretical basis for the program, information about the interventions, clear aims, and quasi-experimental or experimental evaluation methods. We identified 101 articles, and 24 met our criteria for inclusion. Results We reviewed these evaluations to assess their research and program characteristics. The majority of studies included randomized controlled designs and employed delayed follow-up measures. The most commonly measured outcomes were delay of initiation of sexual intercourse, condom use, contraceptive use, and frequency of sexual intercourse. Programs ranged from 1 to 80 sessions, most had adult facilitators, and commonly included skills-building activities about sexual communication, decision-making, and problem solving. The programs included a wide range of strategies for content delivery such as arts and crafts, school councils, and community service learning. Conclusions Analysis of these programs suggest four overall factors that may impact program effectiveness including the extent to which programs focus on specific skills for reducing sexual risk behaviors; program duration and intensity; what constitutes the content of a total evaluated program including researchers' assumptions of participants' exposure to prior and concurrent programs; and what kind of training is available for facilitators.

The evaluation sought to determine if a comprehensive, school-based asthma management program in a small, rural school district helped students improve asthma control.To determine if students in the asthma program demonstrated better asthma control than students in a comparison school district, the evaluation team used a quasi-experimental, cross-sectional design and administered questionnaires assessing asthma control (which included FEV1 measurement) to 456 students with asthma in the intervention and comparison districts. Data were analyzed for differences in asthma control between students in the two districts. To determine if students in the intervention experienced increased asthma control between baseline and follow-up, the evaluation team used a one-group retrospective design. Program records for 323 students were analyzed for differences in percent of predicted forced expiratory volume in one second (FEV1) between baseline and follow-up.Students with asthma in the intervention district exhibited significantly better asthma control than students with asthma in the comparison district. Percent of predicted FEV1 did not change significantly between baseline and follow-up for the intervention participants; however, post hoc analyses revealed students with poorly controlled asthma at baseline had significantly higher FEV1 scores at follow-up, and students with well-controlled asthma at baseline had significantly lower FEV1 scores at follow-up.Findings suggest that the comprehensive school-based program led to improvements in asthma control for students with poorly controlled asthma at baseline, and school-based programs need mechanisms for tracking students with initially well-controlled asthma to ensure they maintain control.

Health behaviors and mental health symptoms of parents living with AIDS (PLAs) were examined as a function of their sexual and substance-use lifestyles. The lifestyles of PLAs were classified as (1) Safe and Clean: having only protected sex and abstaining from substance use, (2) Safe Users: having protected sex, but engaging in substance use, (3) Unsafe and Clean: having unprotected sex, but abstaining from substance use, and (4) Unsafe Users: having unprotected sex and engaging in substance use. About half of the PLAs were Safe and Clean. Unsafe Users were more likely to miss doctor appointments and to have been diagnosed longer. Safe and Clean PLAs experienced fewer major life events. Changes in specific daily routines were associated with subgroup status; however, there were no consistent patterns across health behaviors linked with lifestyle. These data suggest there are different types of lifestyle changes made by PLAs when they know their serostatus. A disturbing number of PLAs continue to engage in HIV-transmission risk behaviors, demonstrating the need for preventive interventions.

Objective The purpose of this review is to synthesize the scientific literature that has examined the association between school-based physical activity (including physical education) and academic performance (including indicators of cognitive skills and attitudes, academic behaviors, and academic achievement). Method Relevant research was identified through a search of nine electronic databases using both physical activity and academic-related search terms. Forty-three articles (reporting a total of 50 unique studies) met the inclusion criteria and were read, abstracted, and coded for this synthesis. Findings of the 50 studies were then summarized. Results Across all the studies, there were a total of 251 associations between physical activity and academic performance, representing measures of academic achievement, academic behavior, and cognitive skills and attitudes. Slightly more than half (50.5%) of all associations examined were positive, 48% were not significant, and 1.5% were negative. Examination of the findings by each physical activity context provides insights regarding specific relationships. Conclusion Results suggest physical activity is either positively related to academic performance or that there is not a demonstrated relationship between physical activity and academic performance. Results have important implications for both policy and schools.

Purpose To evaluate the efficacy of two, theory-based, multimedia, middle school sexual education programs in delaying sexual initiation. Methods Three-armed, randomized controlled trial comprising 15 urban middle schools; 1,258 predominantly African American and Hispanic seventh grade students followed into ninth grade. Both programs included group and individualized, computer-based activities addressing psychosocial variables. The risk avoidance (RA) program met federal abstinence education guidelines; the risk reduction (RR) program emphasized abstinence and included computer-based condom skills-training. The primary outcome assessed program impact on delayed sexual initiation; secondary outcomes assessed other sexual behaviors and psychosocial outcomes. Results Participants were 59.8% females (mean age: 12.6 years). Relative to controls, the RR program delayed any type of sexual initiation (oral, vaginal, or anal sex) in the overall sample (adjusted odds ratio [AOR]: .65, 95% CI: .54–.77), among females (AOR: .43, 95% CI: .31–.60), and among African Americans (AOR: .38, 95% CI: .18–.79). RR students also reduced unprotected sex at last intercourse (AOR: .67, 95% CI: .47–.96), frequency of anal sex in the past 3 months (AOR: .53, 95% CI: .33–.84), and unprotected vaginal sex (AOR: .59, 95% CI: .36–.95). The RA program delayed any sexual initiation among Hispanics (AOR: .40, 95% CI: .19–.86), reduced unprotected sex at last intercourse (AOR: .70, 95% CI: .52–.93), but increased the number of recent vaginal sex partners (AOR: 1.69, 95% CI: 1.01–2.82). Both programs positively affected psychosocial outcomes. Conclusions The RR program positively affected sexually inexperienced and experienced youth, whereas the RA program delayed initiation among Hispanics and had mixed effects among sexually experienced youth.

Using a quasiexperimental design, the authors examine whether fourth- and fifth-grade students exposed to a developmental physical education (PE) curriculum, Michigan’s Exemplary Physical Education Curriculum (EPEC), demonstrated stronger motor skill—specific self-efficacy and perceptions of physical activity competence, physical activity levels, motor skills, and physical fitness than did students exposed to existing PE curricula. The authors conducted a multilevel regression analysis with data from 1,464 students in the fourth and fifth grades. Data were collected using a student survey, an activity checklist, and motor and fitness assessments. Compared to students receiving standard PE, students exposed to EPEC showed significantly stronger results in motor skills but not fitness outcomes. The authors found significant positive intervention effects on indicators of motor skill self-efficacy and physical activity levels among the fourth-grade cohort. EPEC was more effective than standard PE curricula at improving motor skill performance (fourth- and fifth-grade cohorts) and at increasing self-reported motor skill-specific self-efficacy and physical activity (fourth-grade cohort).

This study evaluated All4You!, a theoretically based curriculum designed to reduce sexual risk behaviors associated with HIV, other STDs, and unintended pregnancy among students in alternative schools. The study featured a randomized controlled trial involving 24 community day schools in northern California. A cohort of 988 students was assessed four times during an 18-month period using a self report questionnaire. At the 6-month follow-up, the intervention reduced the frequency of intercourse without a condom during the previous 3 months, the frequency of intercourse without a condom with steady partners, and the number of times students reported having intercourse in the previous 3 months. It also increased condom use at last intercourse. These behavioral effects were no longer statistically significant at the 12- and 18-month follow-ups. The All4You! intervention was effective in reducing selected sexual risk behaviors among students in alternative school settings; however, the effects were modest and short term.

Service learning has been identified as a promising approach to reduce sexual risk behavior, among other outcomes. This study used qualitative data analysis to offer suggestions for optimally integrating service learning into a program to reduce sexual risks among alternative school students. Data were collected from student participants in the All4You! Project using classroom materials, focus groups, and individual interviews. Project educators and project staff also provided data through summary forms and field notes. Qualitative data analysis revealed 5 strategies for creating positive service experiences for alternative school students: (1) find appropriate service-learning sites, (2) create staff support, (3) maintain appropriate student participation and behavior; (4) enhance student reflection on service-learning experiences, and (5) address students' self-images.

In response to requests from educators for effective programs that reduce health-risk behavior among youth, the Centers for Disease Control and Prevention initiated "Programs-That-Work" (PTW) in 1992 to identify health education programs with credible evidence of effectiveness. CDC identified as PTW two programs to reduce tobacco use and eight programs to reduce sexual risk behaviors. Eligible programs undergo a two-step external review to examine quality of the research evidence and the extent to which the programs are practical for use by health educators. If CDC identifies a programs as a PTW on the basis of external review, the program is packaged and made available for dissemination to education and youth agencies. Communities ultimately make the decision about adopting a program, and CDC does not require their use. Thousands of educators have sought information about PTW through the CDC web site, informational brochures, and training.