Disparities in Unmet Health Care Needs Among US Children During the COVID-19 Pandemic.

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.

Disparities in Implementing COVID-19 Prevention Strategies in Public Schools, United States, 2021-22 School Year.

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.

Ventilation Improvements Among K-12 Public School Districts - United States, August-December 2022.

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.

Facilitators and Barriers to Implementing COVID-19 Prevention Strategies in K-12 Public Schools.

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.

Ventilation Improvement Strategies Among K-12 Public Schools - The National School COVID-19 Prevention Study, United States, February 14-March 27, 2022.

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.

Alignment of PrEP use and sexual behavior over four months among men who have sex with men in the southern United States.

Unlike antiretrovirals for HIV treatment, pre-exposure prophylaxis (PrEP) does not require continual adherence to be fully effective; rather, PrEP adherence is important only in the context of episodes of sexual risk. Therefore, studies of PrEP adherence and persistence must incorporate contemporaneous measurement of sexual behavior. Short, frequent surveys of PrEP use and sexual behavior allow for the measurement of the alignment between PrEP use and sexual behavior. We assessed the feasibility of using biweekly PrEP use and sexual behavior questionnaires to measure adherence and persistence on PrEP over a period of four months. We also measured the alignment of PrEP use and condomless anal sex. PrEP-using MSM in the southern US were recruited using online advertisements. Participants completed a baseline survey followed by brief surveys every two weeks for 16 weeks to report their PrEP use and sexual behavior over the preceding two-week period. Study retention was high: 91% of participants completed the baseline and final survey and, overall, 86% of study surveys were completed. Self-reported PrEP adherence and persistence were high, but instances of PrEP non-adherence were observed to frequently overlap with episodes of condomless anal sex. The most prominent reasons cited for missing PrEP doses were being too busy, not having PrEP on hand, and not being sexually active. Completing short, biweekly surveys of PrEP use and sexual behavior is feasible and acceptable to MSM in the southern US. Future studies should investigate incorporating biomarker measurements to validate self-reported adherence.

Demographic and behavioral characteristics of urban and non-urban PrEP-using MSM in the South.

Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention intervention; however, most studies of PrEP adherence and persistence among men who have sex with men (MSM) have been conducted with MSM who live in urban areas. The experiences of PrEP-using MSM in non-urban areas might differ due to increased barriers to culturally competent care. We examined similarities and differences among urban and non-urban PrEP-using MSM in the southern United States, the region with the highest number of annual HIV diagnoses. We surveyed a total of 78 (n = 25 non-urban, n = 53 urban) PrEP-using MSM. Self-reported adherence was high across all participants. No differences were observed with respect to PrEP persistence, source of PrEP, or reasons for PrEP initiation. Fewer non-urban than urban men reported STI testing in the past 12 months. Overall, we observed few differences comparing urban and non-urban PrEP-using MSM. Additional studies are needed to describe differences in PrEP initiation comparing urban and non-urban MSM.

Association of Children's Mode of School Instruction with Child and Parent Experiences and Well-Being During the COVID-19 Pandemic - COVID Experiences Survey, United States, October 8-November 13, 2020.

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.

Differences in PrEP Awareness, Discussions with Healthcare Providers, and Use Among Men Who Have Sex with Men in the United States by Urbanicity and Region: A Cross-sectional Analysis.

Pre-exposure prophylaxis (PrEP) is a highly effective HIV prevention intervention and is critical to the Ending the HIV Epidemic strategy. Most PrEP research has been conducted among urban populations; less is known about PrEP awareness, willingness to use, and actual use among rural and suburban populations. We examined these PrEP indicators by United States region and urbanicity among men who have sex with men who responded to the 2019 cycle of the American Men's Internet Survey. Rural and suburban men were less likely than urban men to be aware of PrEP, to have discussed PrEP with a healthcare provider in the past 12 months, and to have ever used PrEP. Smaller differences were observed across regions. Notably, willingness to use PrEP was similar across region and urbanicity. Additional work will be needed to increase PrEP awareness and access among rural and suburban populations.

"We Deserve Care and we Deserve Competent Care": Qualitative Perspectives on Health Care from Transgender Youth in the Southeast United States.

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.

School Climate Among Transgender High School Students: An Exploration of School Connectedness, Perceived Safety, Bullying, and Absenteeism.

This study used self-administered survey data from seven high schools in Florida with a majority Black and/or Hispanic sample to examine transgender students' perceptions and experiences related to school climate in comparison to cisgender students. Using propensity score matching, a matched analytic sample was created of transgender and cisgender students (n = 542, including 186 transgender youth). Adjusted weighted logistic regression models indicated that transgender students were significantly more likely to report ever being bullied at school, being bullied in the past 3 months, and not going to school ≥3 days during the past 30 days. Transgender students were significantly less likely to report feeling safe at school and having positive perceptions of all five school connectedness items compared to cisgender students. Recent bullying experiences moderated the association between transgender status and past month absences. Findings can inform potential roles for school nurses in improving school climate for transgender youth.

Substance use, violence experiences, and mental health issues: are these health risks associated with HIV testing among sexually experienced U.S. high school students?

HIV testing is a critical strategy for prevention of HIV yet testing among sexually experienced adolescents is sub-optimal. The purpose of this study is to examine associations between risk behaviors and experiences related to substance use, violence, and mental health and suicide and receipt of testing. We analyzed cross-sectional data from the 2017 national Youth Risk Behavior Survey, a nationally representative sample of U.S. high school students in grades 9-12. Analyses were limited to sexually experienced participants (n = 5192). Measures included nine indicators related to substance use, violence, and mental health and suicide. Unadjusted and adjusted prevalence ratios were calculated for each indicator to examine associations with testing. Adjusted models controlled for same-sex sexual behavior, sexual risk, and demographic characteristics. Prevalence of HIV testing was 17.2%. In adjusted models, forced sexual intercourse, injection drug use, other illicit drug use, and persistent feelings of sadness or hopelessness were associated with a higher likelihood of testing. Prevalence of HIV testing in this sexually experienced sample was low. Some behaviors and experiences that may be indicative of HIV risk, including sexual dating violence and prescription opioid misuse, were not associated with testing.

Adverse Childhood Experiences and the Presence of Cancer Risk Factors in Adulthood: A Scoping Review of the Literature From 2005 to 2015.

Exposure to Adverse Childhood Experiences (ACEs) is associated with a host of harmful outcomes, including increased risk for cancer. A scoping review was conducted to gain a better understanding of how ACEs have been studied in association with risk factors for cancer. This review includes 155 quantitative, peer-reviewed articles published between 2005 and 2015 that examined associations between ACEs and modifiable cancer risk factors, including alcohol, environmental carcinogens, chronic inflammation, sex hormones, immunosuppression, infectious agents, obesity, radiation, ultraviolet (UV) radiation, and tobacco, among U.S. adults. This review highlights the growing body of research connecting ACEs to cancer risk factors, particularly alcohol, obesity, and tobacco. Fewer studies investigated the links between ACEs and chronic inflammation or infectious agents. No included publications investigated associations between ACEs and environmental carcinogens, hormones, immunosuppression, radiation, or ultraviolet radiation. Mitigating the impact of ACEs may provide innovative ways to effect comprehensive, upstream cancer prevention.

Sexual Risk Behavior Differences Among Sexual Minority High School Students - United States, 2015 and 2017.

Sexual minority youths (i.e., those identifying as gay, lesbian, bisexual, or another nonheterosexual identity or reporting same-sex attraction or sexual partners) are at higher risk than youths who are not sexual minority youth (nonsexual minority youth) for negative health behaviors and outcomes, including human immunodeficiency virus (HIV) infection, other sexually transmitted diseases (STDs), pregnancy (1),* and related sexual risk behaviors (2). Less is known about sexual risk behavior differences between sexual minority youth subgroups. This is the first analysis of subgroup differences among sexual minority youths using nationally representative Youth Risk Behavior Survey (YRBS) data. CDC analyzed pooled data from the 2015 and 2017 cycles of the national YRBS, a cross-sectional, school-based survey assessing health behaviors among U.S. students in grades 9-12. Analyses examined differences in eight sexual risk behaviors between subgroups of sexual minority youths and nonsexual minority youths, as well as within sexual minority youths. Logistic regression models controlling for race/ethnicity and grade found that bisexual females and "not sure" males reported higher prevalences for many behaviors than did heterosexual students. For behavior-based subgroups, the largest number of differences were seen between students who had sexual contact with both sexes compared with students with only opposite-sex sexual contact. Findings highlight subgroup differences within sexual minority youths that could inform interventions to promote healthy behavior.

Violence Victimization, Substance Use, and Suicide Risk Among Sexual Minority High School Students - United States, 2015-2017.

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

Mental health outcomes among Arab refugees, immigrants, and U.S. born Arab Americans in Southeast Michigan: a cross-sectional study.

BACKGROUND: Arab refugees and immigrants living in the United States may be exposed to political, economic, social, and environmental stressors that may affect their mental health. Yet, little is known regarding mental health outcomes among Arab Americans. The purpose of this study was to measure depression and anxiety levels among Arabs in Southeast Michigan and determine whether these levels differ by resident status: refugee, immigrant, or U.S. born. METHODS: We conducted a cross-sectional study in a convenience sample of 275 adults who self-identify as Arab living in Southeast Michigan. Participants were recruited from a non-profit health and social services organization between August-November 2015. Data were collected via self-administered questionnaires, using standardized instruments to assess depression and anxiety symptoms. RESULTS: All three resident groups exhibited high mean levels of depression and anxiety. Refugees reported higher levels of depression and anxiety than either immigrants or U.S. born Arab Americans. After adjustment for sociodemographics, differences between U.S. born Arab Americans and refugees were statistically significant for depression (b = 2.84; 95% CI: 0.21, 5.47), but not for anxiety. Refugees had significantly higher depression scores (b = 3.18, 95% CI: 1.52, 4.84) and anxiety scores (b = 1.31, 95% CI: 0.11, 2.50) than immigrants. Those reporting political violence and religious persecution as reasons for immigration had the highest levels of depression and anxiety. CONCLUSIONS: This convenience sample of Arab Americans reported high levels of depression and anxiety symptoms. Refugees appear to have poorer mental health outcomes than either immigrants or U.S.-born Arab Americans.

Receipt of and Satisfaction with School-based and Virtual Special Education Supports and Therapeutic Services During the COVID-19 Pandemic.

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.

Disparities in behaviors and experiences among transgender and cisgender high school students - 18 U.S. states, 2021.

PURPOSE: Transgender youth (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 youth (those whose gender identity aligns with their sex assigned at birth). Limited population-based data exist on disparities among transgender and cisgender youth. 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.

A longitudinal analysis of COVID-19 prevention strategies implemented among US K-12 public schools during the 2021-2022 school year.

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.

Disparities in the Implementation of School-Based Mental Health Supports Among K-12 Public Schools.

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.