Transgender high school students (those whose gender identity differs from their sex assigned at birth) experience disparate health outcomes and challenges in school, including violence and discrimination, compared with cisgender students (those whose gender identity aligns with their sex assigned at birth). Until recently, population-based data describing the experiences of transgender students and students questioning whether they are transgender (questioning) have been limited. In 2023, the national Youth Risk Behavior Survey assessed transgender identity, providing the first nationally representative data about transgender students. This report describes the demographic characteristics of transgender and questioning high school students and examines differences in the prevalence of experiences of violence, poor mental health, suicidal thoughts and behaviors, school connectedness, and unstable housing among transgender, questioning, and cisgender high school students nationwide. In 2023, 3.3% of U.S. high school students identified as transgender, and 2.2% identified as questioning. Transgender and questioning students experienced a higher prevalence of violence, poor mental health, suicidal thoughts and behaviors, and unstable housing, and a lower prevalence of school connectedness than their cisgender peers. Compared with 8.5% of cisgender male students, 25.3% of transgender students and 26.4% of questioning students skipped school because they felt unsafe. An estimated 40% of transgender and questioning students were bullied at school, and 69% of questioning students and 72% of transgender students experienced persistent feelings of sadness or hopelessness, a marker for experiencing depressive symptoms. Approximately 26% of transgender and questioning students attempted suicide in the past year compared with 5% of cisgender male and 11% of cisgender female students. Intervention opportunities for schools to create safer and more supportive environments for transgender and questioning students can help address these disparities. The findings of this report suggest that more effort is necessary to ensure that the health and well-being of youths who are socially marginalized is prioritized.

The strength of American Indian and Alaska Native (AI/AN) communities comes from generations of Indigenous traditions, language, culture, and knowledge. These strengths have been challenged by a complex set of systemic, structural, and social factors related to historical and intergenerational trauma that affects the health of AI/AN communities. Furthermore, AI/AN population health data often are inaccurate because of analytic coding practices that do not account for multiracial and ethnic AI/AN identification and inadequate because of statistical suppression. The 2023 national Youth Risk Behavior Survey included a supplemental sample of AI/AN high school students. Coding of race and ethnicity was inclusive of all AI/AN students, even if they also identified as another race or as Hispanic or Latino, providing comprehensive data on health behaviors and experiences among AI/AN high school students nationwide. Adult caretaker engagement and school connectedness and their association with 13 health behaviors and experiences were examined, including five types of current substance use, four indicators of emotional well-being and suicide risk, and four types of violence. Pairwise t-tests and adjusted prevalence ratios from logistic regression models identified significant associations between exposure and outcome variables. Among AI/AN students, having an adult who always tried to meet their basic needs, high parental monitoring, and high school connectedness were associated with lower prevalence of certain measures of substance use, poor emotional well-being and suicide risk, and violence. Compared with non-AI/AN students, the prevalence of current electronic vapor product use, current marijuana use, attempted suicide, and experience of sexual violence was higher among AI/AN students.This report presents the most comprehensive, up-to-date data on substance use, indicators of emotional well-being and suicide risk, and experiences with violence among AI/AN high school students nationwide. The findings suggest the importance of engaged household adults and school connectedness in promoting emotional well-being and preventing substance use, suicide-related behavior, and experiences of violence among AI/AN students. Understanding the historical context and incorporating Indigenous knowledge when developing interventions focused on AI/AN youths are critical to ensure such interventions are successful in improving AI/AN health and well-being.

School connectedness, defined as students' belief that adults and peers in their school care about their learning as well as about them as persons, has been linked to positive educational, behavioral, and health outcomes in adolescence and into adulthood. Data from the 2021 nationally representative Youth Risk Behavior Survey, conducted during the COVID-19 pandemic, were used to estimate prevalence of students' perception of school connectedness and examine associations between school connectedness and seven risk behaviors and experiences: poor mental health, marijuana use, prescription opioid misuse, sexual intercourse, unprotected sex, experiencing forced sex, and missing school because of feeling unsafe. Prevalence estimates were generated and pairwise t-tests were used to detect differences among student subpopulations by sex, grade, race and ethnicity, and sexual identity; Wald chi-square tests were used to detect differences in risk behaviors by level of connectedness within a subpopulation. Logistic regression models were used to estimate prevalence ratios comparing the prevalence of risk behaviors and experiences of students with high connectedness with students with low connectedness, stratified by demographics. During 2021, 61.5% of U.S. high school students reported feeling connected to others at school. In addition, school connectedness was associated with lower prevalence of every risk behavior and experience examined in this study, although certain associations differed by race and ethnicity and sexual identity (e.g., school connectedness was associated with better mental health outcomes for youths with heterosexual, bisexual, and questioning or other sexual identities, but not for youths who identified as lesbian or gay). These findings can guide public health interventions that promote youth well-being by creating school environments where all youths have a sense of belonging and feel they are cared for and supported.

Disruptions and consequences related to the COVID-19 pandemic, including school closures, social isolation, family economic hardship, family loss or illness, and reduced access to health care, raise concerns about their effects on the mental health and well-being of youths. This report uses data from the 2021 Adolescent Behaviors and Experiences Survey, an online survey of a probability-based, nationally representative sample of U.S. public- and private-school students in grades 9-12 (N = 7,705), to assess U.S. high school students' mental health and suicidality during the COVID-19 pandemic. The study also examines whether mental health and suicidality are associated with feeling close to persons at school and being virtually connected to others during the pandemic. Overall, 37.1% of students experienced poor mental health during the pandemic, and 31.1% experienced poor mental health during the preceding 30 days. In addition, during the 12 months before the survey, 44.2% experienced persistent feelings of sadness or hopelessness, 19.9% had seriously considered attempting suicide, and 9.0% had attempted suicide. Compared with those who did not feel close to persons at school, students who felt close to persons at school had a significantly lower prevalence of poor mental health during the pandemic (28.4% versus 45.2%) and during the past 30 days (23.5% versus 37.8%), persistent feelings of sadness or hopelessness (35.4% versus 52.9%), having seriously considered attempting suicide (14.0% versus 25.6%), and having attempted suicide (5.8% versus 11.9%). The same pattern was observed among students who were virtually connected to others during the pandemic (i.e., with family, friends, or other groups by using a computer, telephone, or other device) versus those who were not. Comprehensive strategies that improve feelings of connectedness with others in the family, in the community, and at school might foster improved mental health among youths during and after the COVID-19 pandemic.

Parents have an important role in the promotion of healthy adolescent behaviors that can influence positive developmental trajectories and health outcomes. Parental monitoring is a central component of the parent-child relationship with the potential to reduce adolescent risk behaviors. Data from CDC's 2021 nationally representative Youth Risk Behavior Survey were used to describe the prevalence of parental monitoring reported by U.S. high school students and examine associations between parental monitoring and adolescent behaviors and experiences. Behaviors and experiences included sexual behaviors, substance use, violence, and indicators of poor mental health. This report marks the first national assessment of parental monitoring among U.S. high school students. Point prevalence estimates and corresponding 95% CIs were generated in the bivariate analyses between parental monitoring and the outcomes, stratified by demographic characteristics (sex, race and ethnicity, sexual identity, and grade). Multivariable logistic regression analyses were conducted to estimate the main effects of parental monitoring (categorized as high = always or most of the time and low = never, rarely, or sometimes) for each outcome, controlling for all demographics. Overall, 86.4% of students reported that their parents or other adults in their family know where they are going or with whom they will be all or most of the time. Reports of high parental monitoring were protective for all risk behaviors and experiences, with models controlling for sex, race and ethnicity, sexual identity, and grade. Results highlight the need for public health professionals who develop public health interventions and programs to conduct further research on the relation between parental monitoring and student health outcomes.

PURPOSE: A number of factors may contribute to disparities in mental health and suicidality for lesbian, gay, bisexual, and questioning (LGBQ) students, including parental abuse. METHODS: The Centers for Disease Control and Prevention's (CDC) Adolescent Behaviors and Experiences Survey included a nationally representative sample of US high school students during the COVID-19 pandemic. The current analyses examined experiences of verbal and physical abuse in the home with mental health and suicidality among LGBQ students compared to heterosexual students. RESULTS: The relationship between abuse and mental health and suicidality was significant for all students; however, LGBQ students experienced substantially more abuse and had significantly poorer mental health and greater suicidality than heterosexual students. DISCUSSION: Experiencing verbal or physical abuse in the home is strongly associated with poor mental health and suicidality among youth, regardless of sexual identity; however, among LGBQ students who experienced abuse, the prevalence of poor mental health and suicidality reached crisis levels.

INTRODUCTION: The COVID-19 pandemic has had unprecedented socioeconomic and health impacts in the U.S. This study examined racial/ethnic and school poverty status differences in the relationship between parent job loss, experiences with hunger, and indicators of mental health problems among public high-school students nationwide during the COVID-19 pandemic. METHODS: The study analyzed data from the Adolescent Behaviors and Experiences Survey, conducted in January-June 2021. The Adolescent Behaviors and Experiences Survey was a 1-time, cross-sectional, online survey that used a stratified, 3-stage cluster sample to obtain a nationally representative sample of high-school students in the U.S. This study was limited to public-school students (n=7,379). RESULTS: Among public high-school students nationwide, 36.9% experienced poor mental health during the pandemic, and during the past year, 43.9% experienced persistent feelings of sadness or hopelessness, 19.8% seriously considered attempting suicide, and 9.1% attempted suicide. Parent job loss and having gone hungry were associated with indicators of mental health problems overall and across racial/ethnic groups and school poverty status levels. CONCLUSIONS: Students who experience parent job loss and hunger are likely to also experience poor mental health and may be at higher risk for suicide.

PURPOSE: 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. METHODS: 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. RESULTS: 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. DISCUSSION: 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.

In March 2020, schools across the United States closed to reduce the transmission of SARS-CoV-2, the virus that causes COVID-19. As a result, youth experienced disruptions to their academic, social, and emotional support systems. In the spring and summer of 2020, high profile incidents of abject racism (highlighted by the murder of George Floyd, an unarmed black man killed by white police officers) led to racial tension, societal unrest, protests, and unprecedented levels of emotional distress among the US population [1]. School closures drastically limited the availability of services, such as meals and health services, as well as important connections to peers and supportive adults in the school setting. By late 2020, studies began to show that families with school-age youth were struggling with economic and food insecurity, with a greater burden among Black and Hispanic families and families with low income [2]. Many youths experienced poor mental health [3] and violence at home [4]. For a more comprehensive understanding of how the COVID-19 pandemic impacted student health and well-being, CDC administered the Adolescent Behaviors and Experiences Survey (ABES) among a nationally representative sample of high school students (grades 912) sampled through their schools JanuaryJune 2021 [5].

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.

In March 2020, efforts to slow transmission of SARS-CoV-2, the virus that causes COVID-19, resulted in widespread closures of school buildings, shifts to virtual educational models, modifications to school-based services, and disruptions in the educational experiences of school-aged children. Changes in modes of instruction have presented psychosocial stressors to children and parents that can increase risks to mental health and well-being and might exacerbate educational and health disparities (1,2). CDC examined differences in child and parent experiences and indicators of well-being according to children's mode of school instruction (i.e., in-person only [in-person], virtual-only [virtual], or combined virtual and in-person [combined]) using data from the COVID Experiences nationwide survey. During October 8-November 13, 2020, parents or legal guardians (parents) of children aged 5-12 years were surveyed using the NORC at the University of Chicago AmeriSpeak panel,* a probability-based panel designed to be representative of the U.S. household population. Among 1,290 respondents with a child enrolled in public or private school, 45.7% reported that their child received virtual instruction, 30.9% in-person instruction, and 23.4% combined instruction. For 11 of 17 stress and well-being indicators concerning child mental health and physical activity and parental emotional distress, findings were worse for parents of children receiving virtual or combined instruction than were those for parents of children receiving in-person instruction. Children not receiving in-person instruction and their parents might experience increased risk for negative mental, emotional, or physical health outcomes and might need additional support to mitigate pandemic effects. Community-wide actions to reduce COVID-19 incidence and support mitigation strategies in schools are critically important to support students' return to in-person learning.

Community mitigation activities (also referred to as nonpharmaceutical interventions) are actions that persons and communities can take to slow the spread of infectious diseases. Mitigation strategies include personal protective measures (e.g., handwashing, cough etiquette, and face coverings) that persons can use at home or while in community settings; social distancing (e.g., maintaining physical distance between persons in community settings and staying at home); and environmental surface cleaning at home and in community settings, such as schools or workplaces. Actions such as social distancing are especially critical when medical countermeasures such as vaccines or therapeutics are not available. Although voluntary adoption of social distancing by the public and community organizations is possible, public policy can enhance implementation. The CDC Community Mitigation Framework (1) recommends a phased approach to implementation at the community level, as evidence of community spread of disease increases or begins to decrease and according to severity. This report presents initial data from the metropolitan areas of San Francisco, California; Seattle, Washington; New Orleans, Louisiana; and New York City, New York* to describe the relationship between timing of public policy measures, community mobility (a proxy measure for social distancing), and temporal trends in reported coronavirus disease 2019 (COVID-19) cases. Community mobility in all four locations declined from February 26, 2020 to April 1, 2020, decreasing with each policy issued and as case counts increased. This report suggests that public policy measures are an important tool to support social distancing and provides some very early indications that these measures might help slow the spread of COVID-19.

INTRODUCTION: With the ongoing opioid overdose epidemic in the U.S., it is important to explore how prescription opioid misuse correlates with health behaviors that increase the risk for adverse health outcomes among adolescents. The objective of this study is to determine if lifetime nonmedical use of prescription opioids is associated with health risk behaviors among adolescents. METHODS: Data from the 2017 nationally representative Youth Risk Behavior Survey (14,765 high school students in Grades 9-12) were used to explore associations between lifetime nonmedical use of prescription opioids and 29 health risk behaviors. Logistic regression models (adjusted for sex, race/ethnicity, grade, and sexual identity) estimated adjusted prevalence ratios and 95% CIs. Analyses were completed in 2018. RESULTS: Nonmedical use of prescription opioids was associated with all but 1 of the health risk behaviors included in the analyses. Substance use ranged from adjusted prevalence ratio=2.46 (current alcohol use) to adjusted prevalence ratio=17.52 (heroin use); violence victimization from adjusted prevalence ratio=1.80 (bullied at school) to adjusted prevalence ratio=3.12 (threatened or injured with a weapon); suicidal thoughts/behaviors from adjusted prevalence ratio=2.23 (considered suicide) to adjusted prevalence ratio=3.45 (attempted suicide); and sexual behavior from adjusted prevalence ratio=1.06 (did not use a dual pregnancy prevention method) to adjusted prevalence ratio=3.42 (4 or more sexual partners). Poor academic performance (adjusted prevalence ratio=1.53), receiving an HIV test (adjusted prevalence ratio=1.77), and having persistent feelings of sadness/hopelessness (adjusted prevalence ratio=1.80) were also associated with nonmedical use of prescription opioids. CONCLUSIONS: Nonmedical use of prescription opioids is associated with many health risk behaviors. Opportunities to reduce nonmedical use of prescription opioids include screening pediatric patients for opioid use disorder, improved prescribing practices, and, from a primary prevention perspective, integrated evidence-based health education programs in schools.

BACKGROUND: Because little is known about long-term effects of adolescent protective factors across multiple health domains, we examined associations between adolescent connectedness and multiple health-related outcomes in adulthood. METHODS: We used weighted data from Waves I and IV of the National Longitudinal Study of Adolescent to Adult Health (n = 14 800). Linear and logistic models were used to examine associations between family and school connectedness in adolescence and self-reported health risk behaviors and experiences in adulthood, including emotional distress, suicidal thoughts and attempts, physical violence victimization and perpetration, intimate partner physical and sexual violence victimization, multiple sex partners, condom use, sexually transmitted infection (STI) diagnosis, prescription drug misuse, and other illicit drug use. RESULTS: In multivariable analyses, school connectedness in adolescence had independent protective associations in adulthood, reducing emotional distress and odds of suicidal ideation, physical violence victimization and perpetration, multiple sex partners, STI diagnosis, prescription drug misuse, and other illicit drug use. Similarly, family connectedness had protective effects for emotional distress, all violence indicators, including intimate partner violence, multiple sex partners, STI diagnosis, and both substance use indicators. Compared to individuals with low scores for each type of connectedness, having high levels of both school and family connectedness was associated with 48% to 66% lower odds of health risk behaviors and experiences in adulthood, depending on the outcome. CONCLUSIONS: Family and school connectedness may have long-lasting protective effects across multiple health outcomes related to mental health, violence, sexual behavior, and substance use. Increasing both family and school connectedness during adolescence has the potential to promote overall health in adulthood.

PROBLEM: Health-risk behaviors contribute to the leading causes of morbidity and mortality among youth and adults in the United States. In addition, significant health disparities exist among demographic subgroups of youth defined by sex, race/ethnicity, and grade in school and between sexual minority and nonsexual minority youth. Population-based data on the most important health-related behaviors at the national, state, and local levels can be used to help monitor the effectiveness of public health interventions designed to protect and promote the health of youth at the national, state, and local levels. REPORTING PERIOD COVERED: September 2016-December 2017. DESCRIPTION OF THE SYSTEM: The Youth Risk Behavior Surveillance System (YRBSS) monitors six categories of priority health-related behaviors among youth and young adults: 1) behaviors that contribute to unintentional injuries and violence; 2) tobacco use; 3) alcohol and other drug use; 4) sexual behaviors related to unintended pregnancy and sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection; 5) unhealthy dietary behaviors; and 6) physical inactivity. In addition, YRBSS monitors the prevalence of other health-related behaviors, obesity, and asthma. YRBSS includes a national school-based Youth Risk Behavior Survey (YRBS) conducted by CDC and state and large urban school district school-based YRBSs conducted by state and local education and health agencies. Starting with the 2015 YRBSS cycle, a question to ascertain sexual identity and a question to ascertain sex of sexual contacts were added to the national YRBS questionnaire and to the standard YRBS questionnaire used by the states and large urban school districts as a starting point for their questionnaires. This report summarizes results from the 2017 national YRBS for 121 health-related behaviors and for obesity, overweight, and asthma by demographic subgroups defined by sex, race/ethnicity, and grade in school and by sexual minority status; updates the numbers of sexual minority students nationwide; and describes overall trends in health-related behaviors during 1991-2017. This reports also summarizes results from 39 state and 21 large urban school district surveys with weighted data for the 2017 YRBSS cycle by sex and sexual minority status (where available). RESULTS: Results from the 2017 national YRBS indicated that many high school students are engaged in health-risk behaviors associated with the leading causes of death among persons aged 10-24 years in the United States. During the 30 days before the survey, 39.2% of high school students nationwide (among the 62.8% who drove a car or other vehicle during the 30 days before the survey) had texted or e-mailed while driving, 29.8% reported current alcohol use, and 19.8% reported current marijuana use. In addition, 14.0% of students had taken prescription pain medicine without a doctor's prescription or differently than how a doctor told them to use it one or more times during their life. During the 12 months before the survey, 19.0% had been bullied on school property and 7.4% had attempted suicide. Many high school students are engaged in sexual risk behaviors that relate to unintended pregnancies and STIs, including HIV infection. Nationwide, 39.5% of students had ever had sexual intercourse and 9.7% had had sexual intercourse with four or more persons during their life. Among currently sexually active students, 53.8% reported that either they or their partner had used a condom during their last sexual intercourse. Results from the 2017 national YRBS also indicated many high school students are engaged in behaviors associated with chronic diseases, such as cardiovascular disease, cancer, and diabetes. Nationwide, 8.8% of high school students had smoked cigarettes and 13.2% had used an electronic vapor product on at least 1 day during the 30 days before the survey. Forty-three percent played video or computer games or used a computer for 3 or more hours per day on an average school day for something that was not school work and 15.4% had not been physically active for a total of at least 60 minutes on at least 1 day during the 7 days before the survey. Further, 14.8% had obesity and 15.6% were overweight. The prevalence of most health-related behaviors varies by sex, race/ethnicity, and, particularly, sexual identity and sex of sexual contacts. Specifically, the prevalence of many health-risk behaviors is significantly higher among sexual minority students compared with nonsexual minority students. Nonetheless, analysis of long-term temporal trends indicates that the overall prevalence of most health-risk behaviors has moved in the desired direction. INTERPRETATION: Most high school students cope with the transition from childhood through adolescence to adulthood successfully and become healthy and productive adults. However, this report documents that some subgroups of students defined by sex, race/ethnicity, grade in school, and especially sexual minority status have a higher prevalence of many health-risk behaviors that might place them at risk for unnecessary or premature mortality, morbidity, and social problems (e.g., academic failure, poverty, and crime). PUBLIC HEALTH ACTION: YRBSS data are used widely to compare the prevalence of health-related behaviors among subpopulations of students; assess trends in health-related behaviors over time; monitor progress toward achieving 21 national health objectives; provide comparable state and large urban school district data; and take public health actions to decrease health-risk behaviors and improve health outcomes among youth. Using this and other reports based on scientifically sound data is important for raising awareness about the prevalence of health-related behaviors among students in grades 9-12, especially sexual minority students, among decision makers, the public, and a wide variety of agencies and organizations that work with youth. These agencies and organizations, including schools and youth-friendly health care providers, can help facilitate access to critically important education, health care, and high-impact, evidence-based interventions.

Background: The mental health impact of the 2014-2016 Ebola epidemic has been described among survivors, family members and healthcare workers, but little is known about its impact on the general population of affected countries. We assessed symptoms of anxiety, depression and post-traumatic stress disorder (PTSD) in the general population in Sierra Leone after over a year of outbreak response. Methods: We administered a cross-sectional survey in July 2015 to a national sample of 3564 consenting participants selected through multistaged cluster sampling. Symptoms of anxiety and depression were measured by Patient Health Questionnaire-4. PTSD symptoms were measured by six items from the Impact of Events Scale-revised. Relationships among Ebola experience, perceived Ebola threat and mental health symptoms were examined through binary logistic regression. Results: Prevalence of any anxiety-depression symptom was 48% (95% CI 46.8% to 50.0%), and of any PTSD symptom 76% (95% CI 75.0% to 77.8%). In addition, 6% (95% CI 5.4% to 7.0%) met the clinical cut-off for anxiety-depression, 27% (95% CI 25.8% to 28.8%) met levels of clinical concern for PTSD and 16% (95% CI 14.7% to 17.1%) met levels of probable PTSD diagnosis. Factors associated with higher reporting of any symptoms in bivariate analysis included region of residence, experiences with Ebola and perceived Ebola threat. Knowing someone quarantined for Ebola was independently associated with anxiety-depression (adjusted OR (AOR) 2.3, 95% CI 1.7 to 2.9) and PTSD (AOR 2.095% CI 1.5 to 2.8) symptoms. Perceiving Ebola as a threat was independently associated with anxiety-depression (AOR 1.69 95% CI 1.44 to 1.98) and PTSD (AOR 1.86 95% CI 1.56 to 2.21) symptoms. Conclusion: Symptoms of PTSD and anxiety-depression were common after one year of Ebola response; psychosocial support may be needed for people with Ebola-related experiences. Preventing, detecting, and responding to mental health conditions should be an important component of global health security efforts.

Early initiation of sexual activity is associated with having more sexual partners, not using condoms, sexually transmitted infection (STI), and pregnancy during adolescence (1,2). The majority of adolescents initiate sexual activity during high school, and the proportion of high school students who have ever had sexual intercourse increases by grade; black students are more likely to have ever had sexual intercourse than are white students (3). The proportion of high school students overall who had ever had sexual intercourse did not change significantly during 1995-2005 (53.1% to 46.8%) (Division of Adolescent and School Health, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, unpublished data). To assess whether changes have occurred in recent years in the proportion of high school students who have ever had sexual intercourse, CDC examined trends overall and by grade, race/ethnicity, and sex among U.S. high school students, using data from the 2005-2015 national Youth Risk Behavior Surveys (YRBSs) and data from 29 states* that conduct the YRBS and have weighted data. Nationwide, the proportion of high school students who had ever had sexual intercourse decreased significantly overall and among 9th and 10th grade students, non-Hispanic black (black) students in all grades, and Hispanic students in three grades. A similar pattern by grade was observed in nearly half the states (14), where the prevalence of ever having had sexual intercourse decreased only in 9th grade or only in 9th and 10th grades; nearly all other states saw decreases in some or all grades. The overall decrease in the prevalence of ever having had sexual intercourse during 2005-2015 is a positive change in sexual risk among adolescents (i.e., behaviors that place them at risk for human immunodeficiency virus, STI, or pregnancy) in the United States, an overall decrease that did not occur during the preceding 10 years. Further, decreases by grade and race/ethnicity represent positive changes among groups of students who have been determined in previous studies to be at higher risk for negative outcomes associated with early sexual initiation, such as greater numbers of partners, condom non-use, teen pregnancy, and STI (1-3). More work is needed to understand the reasons for these decreases and to ensure that they continue.

PURPOSE: The objective of this study was to examine the relationship between school involvement and connectedness with measures of sexual risk, substance use, and experience of violence among students who had sexual contact with the same sex or with both sexes. METHODS: A sample of middle school and high school students who participated in a study conducted in a large urban school district were selected based on their reported experience of having initiated sexual activity with same-sex partners. In classroom-based surveys, we assessed self-reported involvement in school-based activities and feelings of school connectedness, as well as self-reported sexual risk, substance use, and experience of violence. RESULTS: Significant protective associations were found between school involvement and lifetime alcohol and marijuana use, and between school connectedness and ever having been in a fight, feeling safe at school, and drug use other than marijuana (all p < .05). CONCLUSIONS: Findings suggest that efforts to increase school involvement and connectedness provide a starting point for addressing significant health and safety concerns among students with same-sex sexual activity.

PURPOSE: Adolescent males are less likely to receive health care and have lower levels of sexual and reproductive health (SRH) knowledge than adolescent females. The purpose of this study was to determine if a school-based structural intervention focused on school nurses increases receipt of condoms and SRH information among male students. METHODS: Interventions to improve student access to sexual and reproductive health care were implemented in six urban high schools with a matched set of comparison schools. Interventions included working with school nurses to improve access to sexual and reproductive health care, including the provision of condoms and information about pregnancy and sexually transmitted disease prevention and services. Intervention effects were assessed through five cross-sectional yearly surveys, and analyses include data from 13,740 male students. RESULTS: Nurses in intervention schools changed their interactions with male students who visited them for services, such that, among those who reported they went to the school nurse for any reason in the previous year, those in intervention schools reported significant increases in receipt of sexual health services over the course of the study compared with students in comparison schools. Further, these results translated into population-level effects. Among all male students surveyed, those in intervention schools were more likely than those in comparison schools to report increases in receipt of sexual health services from school nurses. CONCLUSIONS: With a minimal investment of resources, school nurses can become important sources of SRH information and condoms for male high school students.

Studies have shown links between educational outcomes such as letter grades, test scores, or other measures of academic achievement, and health-related behaviors. However, as reported in a 2013 systematic review, many of these studies have used samples that are not nationally representative, and quite a few studies are now at least 2 decades old (1). To update the relevant data, CDC analyzed results from the 2015 national Youth Risk Behavior Survey (YRBS), a biennial, cross-sectional, school-based survey measuring health-related behaviors among U.S. students in grades 9-12. Analyses assessed relationships between academic achievement (i.e., self-reported letter grades in school) and 30 health-related behaviors (categorized as dietary behaviors, physical activity, sedentary behaviors, substance use, sexual risk behaviors, violence-related behaviors, and suicide-related behaviors) that contribute to leading causes of morbidity and mortality among adolescents in the United States (5). Logistic regression models controlling for sex, race/ethnicity, and grade in school found that students who earned mostly A's, mostly B's, or mostly C's had statistically significantly higher prevalence estimates for most protective health-related behaviors and significantly lower prevalence estimates for most health-related risk behaviors than did students with mostly D's/F's. These findings highlight the link between health-related behaviors and education outcomes, suggesting that education and public health professionals can find their respective education and health improvement goals to be mutually beneficial. Education and public health professionals might benefit from collaborating to achieve both improved education and health outcomes for youths.

PURPOSE: The association between parental monitoring and adolescent behavior is well established. Past research suggests that parents monitor adolescent activities through parental control, solicitation of information, and youth disclosure, which increase parents' knowledge of youth activity leading to decreased risk behavior. However, there is mixed evidence of the impact of these efforts on sexual behavior. We examined these strategies from the adolescent perspective and assessed their impact on the initiation of sexual activity across the transition from middle school to high school. METHODS: Analyses include 533 primarily Latino adolescents, who had not yet had sex in eighth grade and were surveyed yearly through 10th grade. RESULTS: Adolescents who in eighth grade reported greater parental knowledge and more family rules about dating were less likely to initiate sex between eighth and 10th grade. Exchange of information, through parental solicitation and youth disclosure, and parental control, through rules about friends and dating, as well as maternal relationship satisfaction were significant predictors of parental knowledge. There were no gender differences in the impact of dating rules and parental knowledge on sexual initiation, but the paths to acquiring knowledge did differ by gender. CONCLUSIONS: Results suggest that parental monitoring at earlier ages has an impact on sexual initiation. Effective monitoring is an active process within a family that includes setting boundaries and exchanging information. Interventions that encourage family rules, provide strategies for improving parental solicitation of information, and increase youth disclosure by enhancing the maternal-child relationship may be more likely to impact sexual initiation.

CONTEXT: Lesbian, gay, and bisexual (LGB) populations experience significant health inequities in preventive behaviors and chronic disease compared with non-LGB populations. OBJECTIVES: To examine differences in physical activity and diet by sexual orientation and sex subgroups and to assess the influences of home and neighborhood environments on these relationships. DESIGN: A population-based survey conducted in 2013-2014. SETTING: A stratified, simple, random sample of households in 20 sites in the United States. PARTICIPANTS: A total of 21 322 adult LGB and straight-identified men and women. OUTCOME MEASURES: Any leisure-time physical activity in the past month; physical activity 150 min/wk or more; daily frequency of consumption of vegetables, fruit, water, and sugar-sweetened beverages; and the number of meals prepared away from home in the past 7 days. RESULTS: Physical activity and diet varied by sexual orientation and sex; differences persisted after adjusting for sociodemographic factors and household and community environments. Bisexual men reported a higher odds of engaging in frequent physical activity than straight men (odds ratio [OR] = 3.10; 95% confidence interval [CI], 1.57-6.14), as did bisexual women compared with straight women (OR = 1.84; 95% CI, 1.20-2.80). LGB subgroups reported residing in more favorable walking and cycling environments. In contrast, gay men and lesbian and bisexual women reported a less favorable community eating environment (availability, affordability, and quality of fruit and vegetables) and a lower frequency of having fruit or vegetables in the home. Lesbian women reported lower daily vegetable consumption (1.79 vs 2.00 mean times per day; difference = -0.21; 95% CI, -0.03 to -0.38), and gay men reported consumption of more meals prepared away from home (3.17 vs 2.63; difference = 0.53; 95% CI, 0.11-0.95) than straight women and men, respectively. Gay men and lesbian and bisexual women reported a higher odds of sugar-sweetened beverage consumption than straight men and women. CONCLUSIONS: Findings highlight opportunities for targeted approaches to promote physical activity and mitigate differences in diet to reduce health inequities.

PROBLEM: Although substantial progress has been made in improving the health of persons in the United States, serious problems remain to be solved. Life expectancy is increasing, and the rates of the leading causes of death are improving in many cases; however, numerous indicators (i.e., measures of observed or calculated data on the status of a condition) of the health and safety of the U.S. population remain poor. This report reviews population health in the United States and provides an assessment of recent progress in meeting high-priority health objectives. The health status indicators described in this report were selected because of their direct relation to the leading causes of death and other substantial sources of morbidity and mortality and should be the focus of prevention efforts. REPORTING PERIOD COVERED: Data are reported starting in 2005 (or the earliest available year since 2005) through the current data year. Because data sources and specific indicators vary regarding when data are available, the most recent year for which data are available might range from 2010 to 2013. DESCRIPTION OF THE SYSTEM: Data were obtained from 17 CDC surveys or surveillance systems and three non-CDC sources to provide a view of this particular point of time in the nation's health and trends in recent years. Data from the following CDC surveillance systems and surveys were used: Behavioral Risk Factor Surveillance System (BRFSS); Emerging Infections Program/Active Bacterial Core surveillance (EIP/ABCs); Foodborne Diseases Active Surveillance Network (FoodNet); Internet Panel Surveys: Influenza Vaccination Coverage Among Health-Care Personnel and Influenza Vaccination Coverage Among Pregnant Women; National Ambulatory Medical Care Survey (NAMCS); National Health and Nutrition Examination Survey (NHANES); National Health Interview Survey (NHIS); National Healthcare Safety Network (NHSN); National HIV Surveillance System; National Hospital Discharge Survey (NHDS); National Immunization Survey (NIS); National Immunization Survey-Teen (NIS-Teen); National Notifiable Disease Surveillance System (NNDSS); Nationally Notifiable STD Surveillance; National Vital Statistics System (NVSS); and Youth Risk Behavior Surveillance System (YRBSS). Three non-CDC sources were used: the Alcohol and Tobacco Tax and Trade Bureau Monthly Statistical Releases; the National Highway Traffic Safety Administration Fatality Analysis Reporting System (FARS); and the Substance Abuse and Mental Health Services Administration's National Survey on Drug Use and Health (NSDUH). RESULTS: Since 2005, life expectancy at birth in the U.S. has increased by 1 year; however, the number of persons who died prematurely was relatively constant. The years of potential life lost declined for eight of the 10 leading causes of death. Age-adjusted rates declined among all leading causes except deaths attributable to Alzheimer's disease and suicide, although the numbers of deaths increased for most causes. Heart disease, stroke, and deaths attributed to motor-vehicle injuries demonstrated notable declines since 2005. Numbers and rates increased for both Alzheimer's disease and suicide. The number of deaths from drug poisoning increased by approximately 11,000, and the number of deaths among older adults caused by falls increased by approximately 7,000. Risk and protective factors for these leading causes of death also showed mixed progress. Current smoking among adults remained stable at approximately 25% while smoking among youths declined to a record low of 15.7%. Obesity rates remained level at approximately 35% for adults and approximately 17% for youths. Approximately 21% of adults met recommended levels of physical activity, consistent with results recorded in the 3 previous years. Control of blood pressure and cholesterol increased to 46.3% and 29.5%, respectively. During the 2012-13 influenza season, vaccination rates reached highs of 72.0% for health-care personnel, 56.6% for children aged <17 years, 50.5% for pregnant women, and 41.5% for persons aged >18 years. Other important measures of the health of the U.S. population also varied. Rates of foodborne illness varied from year to year, with average annual increases for Salmonella and Salmonella serotype Enteritidis. Listeria rates were stable in recent years at 0.26 cases per 100,000 population. Shiga toxin-producing E. coli (STEC) O157 increased during the past 3 years to a rate of 1.15 cases per 100,000 population, even though the annual change for the study period noted an average decline overall. Health-care-associated infections declined, on average, for central-line associated bloodstream infections (CLABSI), surgical site infections (SSI), and Methicillin-resistant Staphylococcus aureus (MRSA) infection. The percentage of persons living with HIV who know their serostatus increased to 84.2%, but trends fluctuated for the number of new HIV infections and the rate of HIV transmission among adolescents and adults. Chlamydia rates increased by an average of 3.3% per year for persons aged 15-19 years and by 4.9% per year for women aged 20-24 years. The number of new cases of hepatitis C and hepatitis C-associated deaths increased by an average of 6.4% and 6.0% per year. Indictors of maternal and child health all improved, including historically low rates of infant mortality (6.1 per 1,000 live births) and teen births (26.6 per 1,000 female population). The percentage of infants breastfed at 6 months increased to 49.4%. Among children aged 19-35 months, 70.4% received the set of universally recommended vaccines, an increase of 2.9% from the previous year. INTERPRETATION: The findings in this report indicate that progress has been steady but slow for many of the priority health issues in the United States. The age-adjusted rates for most of the leading causes of death are declining, but in some cases, the number of deaths is increasing, in part reflecting the growing U.S. population. Several protective factors that have registered substantial average increases (e.g., physical activity among adults, high blood pressure control, and human papillomavirus vaccination among adolescent females) have stalled in recent years. Many protective factors, even those with impressive relative gains, still represent only a minority of the U.S. population (e.g., control of high cholesterol at 29.5%). More data are needed to properly interpret fluctuating trends, such as those observed with the number of HIV infections and HIV transmission rates. Finally, some indicators of disease that appear to be increasing, such as chlamydia and hepatitis C, reflect increased efforts to engage in targeted screening but also suggest that the actual burden of infection is much greater than the reported data alone indicate. PUBLIC HEALTH ACTION: Although not all-inclusive, this compilation highlights important health concerns, points to areas in which important success has been achieved, and highlights areas in which more effort is needed. By tracking progress, public health officials, program managers, and decision makers can better identify areas for improvement and institute policies and programs to improve health and the quality of life.

PURPOSE: To evaluate a health systems intervention to increase adolescents' receipt of high-quality sexual and reproductive health care services. METHODS: Quasi experimental design. Twelve high schools in a large public school district were matched into pairs. Within each pair, schools were assigned to condition so that no control school shared a geographic border with an intervention school. Five yearly surveys (T1, T2, ..., T5) were administered from 2005 to 2009 (N = 29,823) to students in randomly selected classes in grades 9-12. Community-based providers of high-quality sexual and reproductive health care services were listed on a referral guide for use by school nurses to connect adolescents to care. RESULTS: Statistically significant effects were found for intervention school females on three outcomes, relative to controls. Relative to T1, receipt of birth control in the past year was greater at T4 (adjusted odds ratio [AOR] = 1.85; 95% confidence interval [CI], 1.09-3.15) and T5 (AOR = 2.22; 95% CI, 1.32-3.74). Increases in sexually transmitted disease testing and/or treatment in the past year were greater in T1-T3 (AOR = 1.78; 95% CI, 1.05-3.02), T1-T4 (AOR = 1.73; 95% CI, 1.01-2.97), T1-T5 (AOR = 1.97; 95% CI, 1.17-3.31), and T2-T5 (AOR = 1.76; 95% CI, 1.06-2.91). Increases in ever receiving an HIV test were greater in T1-T4 (AOR = 2.14; 95% CI, 1.08-4.26). Among males, no intervention effects were found. CONCLUSIONS: A school-based structural intervention can improve female adolescents' receipt of services.

PURPOSE: We conducted an intervention to improve the implementation of a high school condom availability program, and evaluated its effect on students' awareness of the program and acquisition of condoms. METHODS: Twelve public high schools in the Los Angeles, CA area participated, half each in the intervention and control conditions. Project staff facilitated intervention schools' self-assessment of compliance with the school district's condom availability policy, creating an action plan by determining which mandatory program elements were lacking and identifying steps to improve compliance. Staff provided technical assistance and follow-up to assist schools in improving program implementation. From 2005 to 2009 (T1-T5), 29,823 students were randomly selected by classroom and they completed surveys. We tested for changes in students' awareness and acquisition of condoms over time between conditions using mixed model logistic regression analyses. Records of condom orders by schools also were reviewed. RESULTS: Awareness increased significantly among intervention versus control participants from T1 to T3 (adjusted odds ratio [AOR]: 1.28; 95% confidence interval [CI]: 1.01, 1.62), T4 (AOR: 2.17; 95% CI: 1.70, 2.76), and T5 (AOR: 2.78; 95% CI: 2.18, 3.56). Acquisition of condoms increased significantly among intervention versus control participants from T1 to T4 (AOR: 1.69; 95% CI: 1.23, 2.32) and T5 (AOR: 1.81; 95% CI: 1.32, 2.49). Results were similar across gender and different levels of sexual experience. Orders of condoms increased markedly in intervention schools by T5. CONCLUSIONS: Feasible minor enhancements to condom availability program implementation improved program delivery, resulting in increased student awareness of the program and acquisition of condoms.

PURPOSE: The current analyses compared receipt of reproductive health care, contraceptive use, and screening for sexually transmitted diseases (STD) among adolescents who are sexually experienced, with or without access to a school clinic. METHODS: A total of 12 urban California high schools, selected from areas with high teen pregnancy and STD rates, half with school-based health centers (SBHCs), participated in an intervention study designed to improve sexual health among adolescents. Of the participating students, 44% indicated that they had ever had intercourse and were included in these analyses. RESULTS: Access to an SBHC did not influence receipt of reproductive health care for either males or females and did not influence contraceptive use, either hormonal or condoms, for males. For females, however, those with access to an SBHC had increased odds of having received pregnancy or disease prevention care (adjusted odds ratio [AOR] = 1.45, 95% confidence interval [CI] = 1.16-1.80), having used hormonal contraceptives at last sex (AOR = 1.68, 95% CI = 1.24-2.28), and were more likely to have ever been screened for an STD (AOR = 1.85, 95% CI = 1.43-2.40). Also among female students, those with access to an SBHC were more likely to have used emergency contraception at last sex (AOR = 2.1, 95% CI = 1.08-4.22). CONCLUSION: Although access to an on-site clinic does not seem to lead to increases in all types of reproductive care in the population as a whole, sexually active females are more likely to have received more specific care and to have used hormonal contraceptives if their school has an SBHC.

BACKGROUND: Research has suggested the importance of pregnancy desire in explaining pregnancy risk behavior among adolescent females. Much of the literature, however, uses cross-sectional study designs to examine this relationship. Because bias may strongly influence these results, more prospective studies are needed to confirm the relationship between pregnancy desire and pregnancy incidence over time. METHODS: Nonpregnant adolescents aged 14- to 19 years (n = 208) completed baseline interviews and interviews every 6 months thereafter for 18 months. Logistic regression was used to examine demographic and psychosocial correlates of pregnancy desire. Cox regression analysis was used to determine whether pregnancy desire predicted pregnancy incidence over time after controlling for potential confounders. RESULTS: Twenty-four percent of participants either desired pregnancy or were ambivalent toward pregnancy in the next year. Pregnancy desire was associated with older age, relationship duration of <6 months, and greater perceived stress. After accounting for potential confounders, pregnancy desire doubled the risk of becoming pregnant over the 18-month follow-up period (relative risk, 2.00; 95% confidence interval [CI], 0.99-4.02). Additionally, a heightened risk for pregnancy was found among those who expressed some desire for pregnancy and who were not in school compared with those who expressed no desire for pregnancy and who were in school (relative risk, 4.84; 95% CI, 1.21-19.31). CONCLUSION: Our analysis reinforces the importance of evaluating pregnancy desire among sexually active adolescent females. Interventions should target young women in new romantic relationships and who are not in school to improve pregnancy prevention efforts. Additionally, improving coping abilities may help to reduce feelings of pregnancy desire among adolescent females.

Relationships influence sexual risk and maternal-child health. Few studies have assessed relationship dissolution and its association with sexually transmitted diseases (STD) among adolescent parents. Our study aimed to describe relationship dissolution among 295 parenting and non-parenting adolescents over an 18-month period and how it related to STD incidence. Results showed that nonparenting adolescents in a relationship with someone other than their baby's father were more likely to have a relationship dissolution over an 18-month period compared to those in a relationship with the baby's father (OR = 1.69, P < .05). Parenting adolescents who ended their relationship with their baby's father were 3 times more likely to get an STD over the course of the study compared to parenting adolescents who remained with their baby's father (39% vs. 13%). Comparatively, nonparenting adolescents who ended their relationship were only 1.4 times more likely to get an STD compared to nonparenting adolescents who remained with their partner (44% vs. 32%). Our results suggest that prevention programs that incorporate male partners and components that strengthen relationship skills may reduce HIV/STD risk and help adolescents adapt during times of transition such as parenthood. (PsycINFO Database Record (c) 2010 APA, all rights reserved) (journal abstract).

CONTEXT: Early sexual initiation is associated with elevated teenage pregnancy and STD risk, yet little is known about the prevalence and correlates of sexual behavior among young adolescents. Better information is needed to guide interventions to prevent early sexual debut. METHODS: Data from a 2005 survey of 4,557 sixth-, seventh- and eighth-grade students at 14 urban public schools in Southern California were analyzed using chi-square tests and logistic regression, to identify correlates of oral sex, intercourse and both. RESULTS: Overall, 9% of youth had ever had sexual intercourse, and 8% had had oral sex. Three percent reported having had oral sex only, 4% intercourse only and 5% both. Among those who reported intercourse, 69% had used a condom at last intercourse, and 43% had had multiple partners. Being male, being black and having at least one friend who had ever been involved in a pregnancy were positively associated with having had intercourse only and both intercourse and oral sex (odds ratios, 1.7–4.2). Being in eighth grade, expecting to have intercourse in the next six months and currently having a boyfriend or girlfriend were positively associated with all three outcomes (2.1–7.2). Intercourse and oral sex were highly correlated. CONCLUSIONS: Interventions addressing oral sex, intercourse and multiple partners should begin before sixth grade and continue throughout the middle school years. Health professionals should target adolescent risk reduction counseling toward males, blacks, youth with a boyfriend or girlfriend, and those with a friend who has been involved in a pregnancy.