BACKGROUND: The COVID-19 pandemic and associated changes in school learning model reshaped students' lives and may have impacted sexual behaviors and healthcare access. METHODS: We used a difference-in-differences (DID) approach to compare changes in sexual behaviors, HIV/STI testing, and STI diagnosis rates from 2019 to 2021 between jurisdictions where high school was primarily virtual versus in-person for the 2020-2021 school year. We used behavioral data from local jurisdictions administering Youth Risk Behavior Survey and reported chlamydia and gonorrhea diagnosis rates for 15-19-year-olds in corresponding counties from AtlasPlus. Learning model was defined using the COVID-19 School Data Hub, school/governmental policies, news, or other documentation. We used survey-weighted logistic regression for behavioral outcomes and Poisson regression for diagnosis rates. DID estimates were parameterized as the interaction between year and learning model. RESULTS: Twenty-four local jurisdictions (16 virtual, 8 in-person) were included. Compared to in-person learning, virtual learning was significantly associated with a relative increase in condom use from 2019 to 2021 [DID odds ratio (DID-OR) = 1.42, 95%CI = 1.12-1.79] and relative decreases in STI testing [DID-OR = 0.75, 95%CI = 0.59-0.96], chlamydia diagnoses [DID incidence rate ratio (DID-IRR) = 0.86, 95%CI = 0.84-0.88], and gonorrhea diagnoses [DID-IRR = 0.83, 95%CI = 0.79-0.87]. Learning model was not significantly associated with changes in sexual intercourse ever or in past 3 months, multiple sex partners in past 3 months, alcohol/drug use before last sex, or ever HIV testing. CONCLUSIONS: Efforts are needed to maintain access to sexual health services during and after public health emergencies involving schools and increase STI testing access for students, especially those who attended school virtually.

This study aims to understand availability of school-based infectious disease surveillance data (e.g., COVID-19 cases, student absences) based on experiences during the COVID-19 pandemic using a national sample of public K-12 schools (n = 1,602). Based on surveys administered to school administrators throughout the 2021-2022 school year, we found high levels of missingness data for school-level COVID-19 cases, quarantines, and student absenteeism, increasing missingness over time, and variations in missingness by school characteristics (e.g., school size) and protocols (e.g., having a school-based system to report at-home COVID-19 tests). For the same sample of schools, using data requests to health departments, we found similarly high levels of missingness of school-level COVID-19 case data and varying approaches in data collection. Developing nationally standardized case definitions-and systems to surveil or collect and monitor school-based infectious disease outcomes early in a public health emergency-may be helpful in producing actionable data.

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.

Adverse childhood experiences (ACEs) are preventable, potentially traumatic events occurring before age 18 years. Data on ACEs among adolescents in the United States have primarily been collected through parent report and have not included important violence-related ACEs, including physical, sexual, and emotional abuse. This report presents the first national prevalence of self-reported ACEs among U.S. high school students aged <18 years, estimates associations between ACEs and 16 health conditions and risk behaviors, and calculates population-attributable fractions of ACEs with these conditions and behaviors using cross-sectional, nationally representative 2023 Youth Risk Behavior Survey data. Exposures were lifetime prevalence of individual (emotional, physical, and sexual abuse; physical neglect; witnessed intimate partner violence; household substance use; household poor mental health; and incarcerated or detained parent or guardian) ACEs and cumulative ACEs count (zero, one, two or three, or four or more). Health conditions and risk behaviors included violence risk factors, substance use, sexual behaviors, weight and weight perceptions, mental health, and suicidal thoughts and behaviors. Bivariate analyses assessed associations between individual and cumulative ACEs and demographics. Adjusted prevalence ratios assessed associations between cumulative ACEs and health conditions and risk behaviors, accounting for demographics. Population-attributable fractions were calculated to determine the potential reduction in health conditions and risk behaviors associated with preventing ACEs. ACEs were common, with approximately three in four students (76.1%) experiencing one or more ACEs and approximately one in five students (18.5%) experiencing four or more ACEs. The most common ACEs were emotional abuse (61.5%), physical abuse (31.8%), and household poor mental health (28.4%). Students who identified as female; American Indian or Alaska Native; multiracial; or gay or lesbian, bisexual, questioning, or who describe their sexual identity in some other way experienced the highest number of ACEs. Population-attributable fractions associated with experiencing ACEs were highest for suicide attempts (89.4%), seriously considering attempting suicide (85.4%), and prescription opioid misuse (84.3%). ACEs are prevalent among students and contribute substantially to numerous health conditions and risk behaviors in adolescence. Policymakers and public health professionals can use these findings to understand the potential public health impact of ACEs prevention to reduce adolescent suicidal behaviors, substance use, sexual risk behaviors, and other negative health conditions and risk behaviors and to understand current effects of ACEs among U.S. high school students.

Adolescents' sexual consent behaviors are critical for developing healthy sexual relationships and preventing experiences of sexual violence. This report uses 2023 Youth Risk Behavior Survey data to describe prevalence of asking for sexual consent verbally at last sexual contact among U.S. high school students. Differences in prevalence of asking for sexual consent verbally by sex, age, race and ethnicity, sexual identity, sex of sexual contacts, and gender identity were examined. Differences in asking for sexual consent verbally also were examined by experiences of sexual violence and sexual behaviors. Sex-stratified logistic regression analyses were performed to determine the association between asking for sexual consent verbally with experiences of sexual violence and sexual behaviors. In addition, data were analyzed using adjusted logistic regression models controlling for age, race and ethnicity, and sexual identity. Among high school students who reported ever having sexual contact, 79.8% reported asking for sexual consent verbally at last sexual contact. A lower percentage of female students (74.5%) reported asking for sexual consent verbally than male students (84.6%). In adjusted sex-stratified analyses, female students who asked for sexual consent verbally had higher prevalence of ever having had sexual intercourse. Male students who asked for sexual consent verbally had higher prevalence of ever having had sexual intercourse and being currently sexually active. Female and male students who asked for sexual consent verbally had higher prevalence of having first sexual intercourse before age 13 and using condoms. In addition, female students who asked for sexual consent verbally during last sexual intercourse had lower prevalence of using alcohol or drugs at last sexual intercourse. Public health researchers and practitioners, health care providers, schools, and youth-serving organizations can use these findings to better understand high school students' verbal sexual consent, improve complex measurement of consent-seeking behaviors, and guide multicomponent sexual health and violence prevention efforts across various settings.

PURPOSE: Data on adverse childhood experiences (ACEs) among teens is collected using a single informant, a parent-proxy, or teen self-report. Little is known about alignment between these approaches. METHODS: Surveys were administered online to teens ages 15-17 and their parents (n=522 dyads) using the AmeriSpeak panel. We present descriptive statistics on the prevalence and measures agreement for 18 ACEs based on teen self-report and parent-proxy report. We fit multivariable models examining associations between teen and household demographic characteristics and discordance in ACE report. RESULTS: Based on teen-self report and parent-proxy report, cumulative and individual ACE prevalence was overall similar. However, discordance was found in individual ACE reports within teen-parent dyads (discordance ranged: 2.9% - 21.2%). Lowest agreement was among ACEs related to abuse, neglect, and violence victimization and highest among household challenges. Furthermore, parent-teen dyads with LGB+ youth (vs. heterosexual) and Black, Hispanic, and multiracial or another race (vs. White) youth were more likely to have discordant responses among several ACEs. CONCLUSIONS: Surveillance and programmatic efforts should consider the type of ACE and the reporter when using data to inform prevention strategies. Teen self-report for abuse, neglect, and violence victimization and community challenges ACEs are particularly important to capture.

School meals play a vital role in supporting student health. Access to school meals was disrupted during COVID-19-related school closures, impacting student nutritional intake and household food insecurity. Data from the National School COVID-19 Prevention Study Survey and school staff focus groups were used to examine challenges to school meal provision in K-12 public schools. Data were analyzed using R and MAXQDA. Survey data indicated that most schools served breakfast and lunch in the cafeteria or classroom during the 2021-2022 school year. City schools were less likely to experience challenges with receiving the foods and supplies needed for school meal programs. Qualitative data revealed that school meal participation increased during the COVID-19 pandemic, however schools encountered challenges when implementing the program including staff shortages and supply chain issues. Findings from this study can help strengthen the K-12 school meal system to equitably serve students in future public health emergencies.

BACKGROUND: Population-level monitoring of adolescent mental health is a critical public health activity used to help define local, state, and federal priorities. The Youth Risk Behavior Surveillance System includes a single-item measure of experiences of sadness or hopelessness as an indicator of risk to mental health. In 2021, 42% of high school students reported having felt sad or hopeless for 2 weeks or more during the past 12 months. The high prevalence of US high school students with this experience has been highlighted in recent studies and media reports. OBJECTIVE: This study seeks to examine associations between this single-item measure of experiences of sadness or hopelessness with other indicators of poor mental health including frequent mental distress and depressive symptoms. METHODS: We analyzed survey data from a national sample of 737 adolescents aged 15-19 years as a part of the Teen and Parent Surveys of Health. Participants were recruited from AmeriSpeak, a probability-based panel designed to be representative of the US household population. Feeling sad or hopeless was operationalized as a "yes" response to the item, "During the past 12 months, did you ever feel so sad or hopeless almost every day for 2 weeks or more in a row that you stopped doing some usual activities?" Unadjusted and adjusted prevalence ratios (aPRs) were calculated to examine associations between the single-item measure of having felt sad or hopeless almost every day for 2 weeks with moderate to severe depressive symptoms, frequent mental distress, and functional limitation due to poor mental health. Adjusted models controlled for age, race and ethnicity, sex assigned at birth, and sexual identity. RESULTS: Overall, 17.3% (unweighted: 138/735) of adolescents reported that they felt sad or hopeless for 2 weeks or more during the past 12 months, 30.2% (unweighted: 204/716) reported moderate to severe depressive symptoms, 18.4% (unweighted: 126/732) reported frequent mental distress, and 15.4% (unweighted: 107/735) reported functional limitation due to poor mental health. After adjusting for demographics, adolescents who reported that they felt sad or hopeless for 2 weeks or more were 3.3 times as likely to report moderate to severe depressive symptoms (aPR 3.28, 95% CI 2.39-4.50), 4.8 times as likely to indicate frequent mental distress (aPR 4.75, 95% CI 2.92-7.74), and 7.8 times as likely to indicate mental health usually or always interfered with their ability to do things (aPR 7.78, 95% CI 4.88-12.41). CONCLUSIONS: Associations between having felt sad or hopeless for 2 weeks or more and moderate to severe depressive symptoms, frequent mental distress, and functional limitation due to poor mental health suggest the single-item indicator may represent relevant symptoms associated with poor mental health and be associated with unmet health needs. Findings suggest the single-item indicator provides a population-level snapshot of adolescent experiences of poor mental health.

PURPOSE: Examine how school-based COVID-19 prevention strategy implementation varied over time, including by local characteristics. METHODS: School administrators (n=335) from a nationally representative sample of K-12 public schools completed four surveys assessing COVID-19 prevention strategies at two-month intervals between October 2021 and June 2022. We calculated weighted prevalence estimates by survey wave. Generalized estimating equations (GEE) were used to model longitudinal changes in strategy implementation, accounting for school and county covariates. RESULTS: Opening doors/windows, daily cleaning, and diagnostic testing were reported by ≥50% of schools at each survey wave. Several strategies were consistently implemented across the 2021-2022 school year (i.e., daily cleaning, opening doors and windows, diagnostic testing) while other strategies increased initially and then declined (i.e., contact tracing, screening testing, on-campus vaccination) or declined consistently throughout the school year (i.e., mask requirement, classroom distancing, quarantine). Although longitudinal changes in strategy implementation did not vary by school characteristics, strategy implementation varied by urban-rural classification and school level throughout the school year. CONCLUSIONS: Strategies that were consistently implemented throughout the school year were also reported by a majority of schools, speaking toward their feasibility for school-based infection control and prevention and potential utility in future public health emergencies.

The COVID-19 pandemic impacted school-based delivery of special educational supports and therapeutic services. This study describes student receipt of school-based supports/services and parent satisfaction by instruction modalities during the 2020-2021 academic year in the United States. Data were collected through the COVID Experiences Survey from parents of children ages 5-12 years, administered using NORC's AmeriSpeak panel. Most parents reported satisfaction with supports (88.4%) and services (93.2%). Dissatisfaction with special education supports and therapeutic services was more common among parents whose children received supports/services virtually than in person (special educational supports: aOR=12.00, 95% CI [1.49-96.89], p=0.020; therapeutic services: aOR=15.76, 95% CI [1.01-245.40], p=0.049). These findings suggest opportunities to improve design and delivery of online special education supports and therapeutic services as well as emergency preparedness by considering the needs of students with disabilities and their families.

PURPOSE: Transgender youths (those whose gender identity differs from their sex assigned at birth) experience stigma and discrimination that can place them at increased risk for poor health outcomes compared with cisgender youths (those whose gender identity aligns with their sex assigned at birth). Limited population-based data exist on disparities among transgender and cisgender youths. METHODS: We examined differences in experiences of violence, substance use, mental health, suicide, sexual behavior, unstable housing, parental monitoring, and school connectedness among 98,174 transgender and cisgender high school students using data from 18 states that included an item to assess transgender identity on their 2021 Youth Risk Behavior Survey. RESULTS: Overall, 2.9% of students identified as transgender and 2.6% questioned whether they were transgender. Among transgender students, 71.5% reported that their mental health was not good, 32.3% had attempted suicide, and 29.0% experienced sexual violence. Transgender students were more likely than cisgender students to report experiences of violence, substance use, poor mental health, suicide risk, some sexual risk behaviors, and unstable housing, and were less likely to report feeling connected to others at school. CONCLUSIONS: Interventions that can address the causes of these adverse outcomes and promote the health and wellbeing of transgender youths are warranted.

PURPOSE: The COVID-19 pandemic disrupted pediatric health care in the United States, and this disruption layered on existing barriers to health care. We sought to characterize disparities in unmet pediatric health care needs during this period. METHODS: We analyzed data from Wave 1 (October through November 2020) and Wave 2 (March through May 2021) of the COVID Experiences Survey, a national longitudinal survey delivered online or via telephone to parents of children aged 5 through 12 years using a probability-based sample representative of the US household population. We examined 3 indicators of unmet pediatric health care needs as outcomes: forgone care and forgone well-child visits during fall 2020 through spring 2021, and no well-child visit in the past year as of spring 2021. Multivariate models examined relationships of child-, parent-, household-, and county-level characteristics with these indicators, adjusting for child's age, sex, and race/ethnicity. RESULTS: On the basis of parent report, 16.3% of children aged 5 through 12 years had forgone care, 10.9% had forgone well-child visits, and 30.1% had no well-child visit in the past year. Adjusted analyses identified disparities in indicators of pediatric health care access by characteristics at the level of the child (eg, race/ethnicity, existing health conditions, mode of school instruction), parent (eg, childcare challenges), household (eg, income), and county (eg, urban-rural classification, availability of primary care physicians). Both child and parent experiences of racism were also associated with specific indicators of unmet health care needs. CONCLUSIONS: Our findings highlight the need for continued research examining unmet health care needs and for continued efforts to optimize the clinical experience to be culturally inclusive.

Preventing unintended pregnancy and sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infection, among adolescents is a public health priority. This report presents prevalence estimates for condom and contraceptive use among sexually active U.S. high school students from the 2019 Youth Risk Behavior Survey. Behaviors examined included any condom use, primary contraceptive method use, and condom use with a more effective contraceptive method, all reported at last sexual intercourse. Analyses were limited to sexually active students (i.e., those who had sexual intercourse with one or more persons during the 3 months before the survey). Except for any condom use, students reporting only same-sex sexual contact were excluded from analyses. Weighted prevalence estimates were calculated, and bivariate differences in prevalence were examined by demographic characteristics (sex, race/ethnicity, and grade) and other sexual risk behaviors (age of sexual initiation, previous 3-month and lifetime number of sex partners, and substance use before last sexual intercourse). Nationwide, 27.4% of high school students reported being sexually active (n = 3,226). Among sexually active students who reported having had sexual contact with someone of the opposite sex (n = 2,698), most students (89.7%) had used a condom or a primary contraceptive method at last sexual intercourse. Prevalence of any condom use at last sexual intercourse was 54.3%, and condoms were the most prevalent primary contraceptive method (43.9% versus 23.3% for birth control pills; 4.8% for intrauterine device [IUD] or implant; and 3.3% for shot, patch, or ring). Approximately 9% had used condoms with an IUD, implant, shot, patch, ring, or birth control pills. Using no pregnancy prevention method was more common among non-Hispanic black (23.2%) and Hispanic (12.8%) students compared with non-Hispanic white students (6.8%); compared with Hispanic students, using no pregnancy prevention method was more common among non-Hispanic black students. Prevalence of condom use was consistently lower among students with other sexual risk behaviors. Results underscore the need for public health professionals to provide quality sexual and reproductive health education and clinical services for preventing unintended pregnancy and STDs/HIV and decreasing disparities among sexually active youths.

Disproportionate rates of sexually transmitted diseases (STDs), including HIV, and unintended pregnancy among adolescents persist and might have been affected by the COVID-19 pandemic. This study uses 2019 and 2021 data from the nationally representative Youth Risk Behavior Surveys to characterize changes in sexual behaviors and receipt of sexual and reproductive health services among U.S. high school students before and during the pandemic. Outcomes included HIV testing (lifetime), STD testing (past 12 months), condom use (last sexual intercourse), and primary contraceptive method used to prevent pregnancy (last sexual intercourse). Except for HIV testing, all analyses were limited to currently sexually active students. Weighted prevalence and 95% CIs of outcomes for 2019 and 2021 were calculated for each year by demographics (sex [female or male], age, and race and ethnicity) and sex of sexual contacts (opposite sex only, both sexes, same sex only). For each year, pairwise t-tests with Taylor series linearization were used to identify demographic differences among outcomes. Across years, change in prevalence of outcomes was assessed by using absolute and relative measures of association overall and by demographics. During 2019-2021, the prevalence of HIV testing decreased by 3.68 percentage points, from 9.4% to 5.8%. Among sexually active students, prevalence of STD testing decreased by 5.07 percentage points, from 20.4% to 15.3%. Among sexually active students reporting opposite sex or both sexes sexual contact, intrauterine device or implant use at last sexual intercourse increased by 4.11 percentage points, from 4.8% to 8.9%, and no contraceptive method use increased by 2.74 percentage points, from 10.7% to 13.4%. Because of disruptions throughout the pandemic, results underscore the importance of improving access to a range of health services for adolescents and improving STD/HIV and unintended pregnancy prevention.

PURPOSE: Examine children's mental health symptoms, including changes during the COVID-19 pandemic. METHODS: The COVID Experiences Surveys, designed to be representative of the U.S. household population, were administered online to parents of children aged 5-12 years (Wave 1, Oct-Nov 2020, n=1561; Wave 2, March-May 2021, n=1287). We modeled changes in children's symptoms of anxiety, depression, and psychological stress and examined associations between demographic characteristics, COVID-19 related experiences, and protective factors with symptoms across both waves using generalized estimating equations. RESULTS: Based on parent-report, children's symptoms of anxiety and depression decreased from W1 to W2 (Δ t-score anxiety = -1.8 [95% CI: -2.5, -1.0]; Δ t-score depression = -1.0 [CI: -1.7, -0.3]). Psychological stress remained consistent. Across waves, older children and children with an emotional, mental, developmental, behavioral, physical, or medical condition were more likely to have specific poor mental health symptoms. Poor mental health symptoms were more likely among children with several contextual stressors (e.g., economic stress, parental emotional strain) and less likely among children with protective factors (e.g., daily routines, neighborhood cohesion). CONCLUSIONS: Establishing programs that support mental health, improving access to mental health services, and fostering collaborations to advance children's mental health is important.

To meet the educational needs of students, most schools in the United States (U.S.) reopened for in-person instruction during the 2021-2022 school year implementing a wide range of COVID-19 prevention strategies (e.g., mask requirements). To date, there have been limited studies examining facilitators and barriers to implementing each of the recommended COVID-19 prevention strategies in schools. Twenty-one semistructured interviews were conducted with public school staff from across the U.S. responsible for overseeing prevention strategy implementation. MAXQDA was used for thematic analysis. Findings identified key facilitators including utilizing Centers for Disease Control and Prevention guidance and district policies to guide decision-making at the school level, possessing financial resources to purchase supplies, identifying key staff for implementation, and having school health services infrastructure in place. Key barriers included staff shortages, limited resources, and community opposition. Findings from this study provide important insight into how schools can prepare for future public health emergencies.

OBJECTIVE: The authors sought to explore the availability of mental health supports within public schools during the COVID-19 pandemic by using survey data from a nationally representative sample of U.S. K-12 public schools collected in October-November 2021. METHODS: The prevalence of 11 school-based mental health supports was examined within the sample (N=437 schools). Chi-square tests and adjusted logistic regression models were used to identify associations between school-level characteristics and mental health supports. School characteristics included level (elementary, middle, or high school), locale (city, town, suburb, or rural area), poverty level, having a full-time school nurse, and having a school-based health center. RESULTS: Universal mental health programs were more prevalent than more individualized and group-based supports (e.g., therapy groups); however, prevalence of certain mental health supports was low among schools (e.g., only 53% implemented schoolwide trauma-informed practices). Schools having middle to high levels of poverty or located in rural areas or towns and elementary schools and schools without a health infrastructure were less likely to implement mental health supports, even after analyses were adjusted for school-level characteristics. For example, compared with low-poverty schools, mid-poverty schools had lower odds of implementing prosocial skills training for students (adjusted OR [AOR]=0.49, 95% CI=0.27-0.88) and providing confidential mental health screening (AOR=0.42, 95% CI=0.22-0.79). CONCLUSIONS: Implementation levels of school-based mental health supports leave substantial room for improvement, and numerous disparities existed by school characteristics. Higher-poverty areas, schools in rural areas or towns, and elementary schools and schools without a health infrastructure may require assistance in ensuring equitable access to mental health supports.

During the COVID-19 pandemic, US schools have been encouraged to take a layered approach to prevention, incorporating multiple strategies to curb transmission of SARS-CoV-2. Using survey data representative of US public K-12 schools (N = 437), we determined prevalence estimates of COVID-19 prevention strategies early in the 2021-22 school year and describe disparities in implementing strategies by school characteristics. Prevalence of prevention strategies ranged from 9.3% (offered COVID-19 screening testing to students and staff) to 95.1% (had a school-based system to report COVID-19 outcomes). Schools with a full-time school nurse or school-based health center had significantly higher odds of implementing several strategies, including those related to COVID-19 vaccination. We identified additional disparities in prevalence of strategies by locale, school level, and poverty. Advancing school health workforce and infrastructure, ensuring schools use available COVID-19 funding effectively, and promoting efforts in schools with the lowest prevalence of infection prevention strategies are needed for pandemic preparedness.

Improving ventilation has been one of several COVID-19 prevention strategies implemented by kindergarten through grade 12 (K-12) schools to stay open for safe in-person learning. Because transmission of SARS-CoV-2 occurs through inhalation of infectious viral particles, it is important to reduce the concentration of and exposure time to infectious aerosols (1-3). CDC examined reported ventilation improvement strategies among U.S. K-12 public school districts using telephone survey data collected during August-December 2022. Maintaining continuous airflow through school buildings during active hours was the most frequently reported strategy by school districts (50.7%); 33.9% of school districts reported replacement or upgrade of heating, ventilation, and air conditioning (HVAC) systems; 28.0% reported installation or use of in-room air cleaners with high-efficiency particulate air (HEPA) filters; and 8.2% reported installation of ultraviolet (UV) germicidal irradiation (UVGI) devices, which use UV light to kill airborne pathogens, including bacteria and viruses. School districts in National Center for Education Statistics (NCES) city locales, the West U.S. Census Bureau region, and those designated by U.S. Census Bureau Small Area Income Poverty Estimates (SAIPE) as high-poverty districts reported the highest percentages of HVAC system upgrades and HEPA-filtered in-room air cleaner use, although 28%-60% of all responses were unknown or missing. Federal funding remains available to school districts to support ventilation improvements. Public health departments can encourage K-12 school officials to use available funding to improve ventilation and help reduce transmission of respiratory diseases in K-12 settings.

BACKGROUND: Students with special education needs or underlying health conditions have been disproportionately impacted (e.g., by reduced access to services) throughout the COVID-19 pandemic. OBJECTIVE: This study describes challenges reported by schools in providing services and supports to students with special education needs or underlying health conditions and describes schools' use of accessible communication strategies for COVID-19 prevention. METHODS: This study analyzes survey data from a nationally representative sample of U.S. K-12 public schools (n=420, February-March 2022). Weighted prevalence estimates of challenges in serving students with special education needs or underlying health conditions and use of accessible communication strategies are presented. Differences by school locale (city/suburb vs. town/rural) are examined using chi-square tests. RESULTS: The two most frequently reported school-based challenges were staff shortages (51.3%) and student compliance with prevention strategies (32.4%), and the two most frequently reported home-based challenges were the lack of learning partners at home (25.5%) and lack of digital literacy among students' families (21.4%). A minority of schools reported using accessible communications strategies for COVID-19 prevention efforts, such as low-literacy materials (7.3%) and transcripts that accompany podcasts or videos (6.7%). Town/rural schools were more likely to report non-existent or insufficient access to the internet at home and less likely to report use of certain accessible communication than city/suburb schools. CONCLUSION: Schools might need additional supports to address challenges in serving students with special education needs or with underlying health conditions and improve use of accessible communication strategies for COVID-19 and other infectious disease prevention.

Effective COVID-19 prevention in kindergarten through grade 12 (K-12) schools requires multicomponent prevention strategies in school buildings and school-based transportation, including improving ventilation (1). Improved ventilation can reduce the concentration of infectious aerosols and duration of potential exposures (2,3), is linked to lower COVID-19 incidence (4), and can offer other health-related benefits (e.g., better measures of respiratory health, such as reduced allergy symptoms) (5). Whereas ambient wind currents effectively dissipate SARS-CoV-2 (the virus that causes COVID-19) outdoors,* ventilation systems provide protective airflow and filtration indoors (6). CDC examined reported ventilation improvement strategies among a nationally representative sample of K-12 public schools in the United States using wave 4 (February 14-March 27, 2022) data from the National School COVID-19 Prevention Study (NSCPS) (420 schools), a web-based survey administered to school-level administrators beginning in summer 2021.(†) The most frequently reported ventilation improvement strategies were lower-cost strategies, including relocating activities outdoors (73.6%), inspecting and validating existing heating, ventilation and air conditioning (HVAC) systems (70.5%), and opening doors (67.3%) or windows (67.2%) when safe to do so. A smaller proportion of schools reported more resource-intensive strategies such as replacing or upgrading HVAC systems (38.5%) or using high-efficiency particulate air (HEPA) filtration systems in classrooms (28.2%) or eating areas (29.8%). Rural and mid-poverty-level schools were less likely to report several resource-intensive strategies. For example, rural schools were less likely to use portable HEPA filtration systems in classrooms (15.6%) than were city (37.7%) and suburban schools (32.9%), and mid-poverty-level schools were less likely than were high-poverty-level schools to have replaced or upgraded HVAC systems (32.4% versus 48.8%). Substantial federal resources to improve ventilation in schools are available.(§) Ensuring their use might reduce SARS-CoV-2 transmission in schools. Focusing support on schools least likely to have resource-intensive ventilation strategies might facilitate equitable implementation of ventilation improvements.

OBJECTIVES: National guidelines call for annual testing for certain sexually transmitted infections (STIs) among specific adolescent populations, yet we have limited population-based data on STI testing prevalence among adolescents. With inclusion of a new item in the 2019 national Youth Risk Behavior Survey, we provide generalizable estimates of annual STI testing among sexually active high school students. METHODS: We report weighted prevalence estimates of STI testing (other than HIV) in the past 12 months among sexually active students (n = 2501) and bivariate associations between testing and demographic characteristics (sex, age, race and ethnicity, sexual identity, and sex of sexual contact). Multivariable models stratified by sex and adjusted for demographics examine the relationships between testing and sexual behaviors (age of initiation, number of sex partners, condom nonuse at last sexual intercourse, and substance use at last sexual intercourse). RESULTS: One-fifth (20.4%) of sexually active high school students reported testing for an STI in the previous year. A significantly higher proportion of female (26.1%) than male (13.7%) students reported testing. Among female students, prevalence differed by age (15 years = 12.6%, age 16 = 22.8%, age 17 = 28.5%, or 18 years = 36.9%). For male students, there were no differences by demographic characteristics, including sexual identity, but most sexual risk behaviors were associated with increased likelihood of STI testing (adjusted prevalence ratios ranging from 1.48 to 2.47). CONCLUSIONS: Low prevalence of STI testing suggests suboptimal adherence to national guidelines, particularly for sexually active adolescent females and young men who have sex with men who should be tested for Chlamydia and gonorrhea annually.

PURPOSE: To examine the association between state laws protecting lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) students and school districts' recommendations or requirements for establishing gay-straight alliances (GSAs) in schools. Beginning in fall 2013, 19 state education agencies (SEAs) engaged in HIV/STI and pregnancy prevention activities in "priority" school districts. SEAs provided support to priority districts to require or recommend GSAs in their schools. METHODS: This study used semi-annually collected program evaluation data and state law data from the Gay, Lesbian, and Straight Education Network. We assessed whether increases in the percentage of priority districts recommending or requiring schools to provide GSAs varied by the presence of nondiscrimination or enumerated antibullying laws with a difference-in-difference design. RESULTS: States with nondiscrimination laws began with more priority districts recommending or requiring schools to provide GSAs (52.5%) compared to states without laws (47.5%). We found a significant interaction (p < .01) between increases in the percentage of priority districts recommending or requiring a GSA and having a state nondiscrimination law. Across the first 3 years of program implementation, there was a 30% increase (p < .01) in priority districts recommending or requiring schools to provide GSAs in states with nondiscrimination laws, compared to a 12% increase (p < .01) in states without laws. There was no significant interaction between states with enumerated antibullying laws and districts recommending or requiring a GSA. DISCUSSION: State LGBTQ nondiscrimination laws for students may facilitate school district support of GSAs, which may decrease health risks among LGBTQ youth.

INTRODUCTION: Given mixed findings regarding the relationship between long-acting reversible contraception and condom use, this systematic review and meta-analysis synthesizes studies comparing sexually transmitted infection‒related outcomes between users of long-acting reversible contraception (intrauterine devices, implants) and users of moderately effective contraceptive methods (oral contraceptives, injectables, patches, rings). METHODS: MEDLINE, Embase, PsycINFO, Global Health, CINAHL, Cochrane Library, and Scopus were searched for articles published between January 1990 and July 2018. Eligible studies included those that (1) were published in the English language, (2) were published in a peer-reviewed journal, (3) reported empirical, quantitative analyses, and (4) compared at least 1 outcome of interest (condom use, sexual behaviors other than condom use, sexually transmitted infection‒related service receipt, or sexually transmitted infections/HIV) between users of long-acting reversible contraception and users of moderately effective methods. In 2020, pooled ORs were calculated for condom use, chlamydia/gonorrhea infection, and trichomoniasis infection; findings for other outcomes were synthesized qualitatively. The protocol is registered on the International Prospective Register of Systematic Reviews (CRD42018109489). RESULTS: A total of 33 studies were included. Long-acting reversible contraception users had decreased odds of using condoms compared with oral contraceptive users (OR=0.43, 95% CI=0.30, 0.63) and injectable, patch, or ring users (OR=0.58, 95% CI=0.48, 0.71); this association remained when limited to adolescents and young adults only. Findings related to multiple sex partners were mixed, and only 2 studies examined sexually transmitted infection testing, reporting mainly null findings. Pooled estimates for chlamydia and/or gonorrhea were null, but long-acting reversible contraception users had increased odds of trichomoniasis infection compared with oral contraceptive users (OR=2.01, 95% CI=1.11, 3.62). DISCUSSION: Promoting condom use specifically for sexually transmitted infection prevention may be particularly important among long-acting reversible contraception users at risk for sexually transmitted infections, including adolescents and young adults.

PURPOSE: This study examined associations between student sexual behaviors and both school-level socioeconomic status and metropolitan status. METHODS: National Youth Risk Behavior Survey data from 2017 (N = 14,765, response rate = 60%) and 2019 (N = 13,677, 60%) were combined. School-level socioeconomic status (low-, mid-, and high-poverty based on the percentage of students eligible for free or reduced-price meals) and metropolitan status (urban, suburban/town, or rural) were identified for students attending public high schools. Sexual behaviors included currently sexually active, four or more lifetime sexual partners, condom use during the last sexual intercourse, hormonal birth control use during the last sexual intercourse, condom and hormonal birth control use during the last sexual intercourse, and drank alcohol or used drugs before the last sexual intercourse. Adjusted prevalence ratios were calculated using logistic regression models, controlling for sex, race/ethnicity, and grade. RESULTS: Compared to students attending low-poverty schools, high-poverty school students were significantly more likely to be currently sexually active (adjusted prevalence ratio = 1.4 [95% confidence interval = 1.1-1.8]) and have four or more lifetime sexual partners (1.6 [1.0-2.5]), but were significantly less likely to have drank alcohol or used drugs before the last sexual intercourse (.7 [.5-.9]) and have used hormonal birth control during the last sexual intercourse (.7 [.6-1.0]). Compared to students attending rural schools, urban school students were significantly less likely to be currently sexually active (.8 [.7-.9]) and have four or more lifetime sexual partners (.7 [.5-.9]). CONCLUSIONS: School-level socioeconomic status and metropolitan status were associated with differential risk in sexual behaviors.

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.

PURPOSE: Transgender populations experience health inequities that underscore the importance of ensuring access to high quality care. We thematically summarize the health care experiences of transgender youth living in the southeast United States to identify potential barriers and facilitators to health care. DESIGN AND METHODS: Transgender youth recruited from community settings in an urban area of the southeast United States participated in individual interviews (n = 33) and focus groups (n = 9) about protective factors. We conducted a thematic analysis of data from 42 participants who described their experiences seeking and receiving health care. RESULTS: Participants reported a wide range of gender identities. The individual interview sample was majority Black (54.5%) and the mean age was 21.7 years and focus group participants were all white and the mean age was 16.8 years. Participants described numerous barriers to health care, including limited availability of gender affirming care, logistical challenges, such as gatekeeping and cost, concerns about confidentiality in relation to sexual behavior and gender identity, and inadequate cultural competency among providers regarding gender-affirming care. Facilitators included intake procedures collecting chosen pronouns and names and consistent use of them by providers, and open communication, including active listening. CONCLUSIONS: Findings underscore the need for a multi-component approach to ensure both transgender- and youth-friendly care. PRACTICE IMPLICATIONS: Providers and office staff may benefit from transgender cultural competency trainings. In addition, clinic protocols relating to confidentiality and chosen name and pronoun use may help facilitate access to and receipt of quality care.

PURPOSE: To synthesize the diverse body of literature on sexual and gender minority youth (SGMY) and sexual health education. METHODS: We conducted a systematic search of the literature on SGMY and sexual health education, including SGMY perspectives on sexual health education, the acceptability or effectiveness of programs designed for SGMY, and SGMY-specific results of sexual health education programs delivered to general youth populations. RESULTS: A total of 32 articles were included. Sixteen qualitative studies with SGMY highlight key perspectives underscoring how youth gained inadequate knowledge from sexual health education experiences and received content that excluded their identities and behaviors. Thirteen studies examined the acceptability or effectiveness of sexual health interventions designed for SGMY from which key characteristics of inclusive sexual health education relating to development, content, and delivery emerged. One study found a sexual health education program delivered to a general population of youth was also acceptable for a subsample of sexual minority girls. CONCLUSIONS: Future research on SGMY experiences should incorporate populations understudied, including younger adolescents, sexual minority girls, and transgender persons. Further, the effectiveness of inclusive sexual health education in general population settings requires further study.

Transgender youth are more likely than cisgender youth to report health risks related to violence victimization, substance use, mental health, and sexual health. Parental support may help foster resilience and better health outcomes among this population. However, limited research has characterized parental support among transgender youth. To address this gap, we conducted a thematic analysis of 33 in-depth interviews with transgender youth. We coded interviews using the dimensions of the social support framework (i.e., emotional, instrumental, appraisal, and informational) as well as inductive codes to identify emergent themes. Almost all participants described some form of general parental support (e.g., expressions of love, housing, advice, and affirmation). Parental support specific to gender identity was also noted (e.g., emotional support for coming out as transgender and chosen name and pronoun use) but was more limited. Parents may benefit from resources and programming to promote acceptance and gender-affirming behaviors.

Objectives. To examine the association between school-level poverty status and students’ persistent feelings of sadness or hopelessness, suicidality, and experiences with violence victimization among U.S. high school students. Methods. Public schools captured in the 2015 and 2017 national Youth Risk Behavior Surveys were categorized as high-, mid-, or low-poverty based on the percentage of students eligible for free or reduced-price meals (N=29,448). Results. Students in high-poverty schools were significantly more likely than students in low-poverty schools to experience persistent feelings of sadness or hopelessness, experience suicidal thoughts and attempts, not go to school because of safety concerns, be threatened or injured with a weapon on school property, be bullied on school property, be physically forced to have sexual intercourse, and be victims of sexual and physical dating violence. Conclusions. School and community approaches to address suicide and violence victimization may be especially important for students living in poverty.