The Emergence of Spatial Clustering in Medical Vaccine Exemptions Following California Senate Bill 277, 2015-2018.

Objectives. To understand how the elimination of nonmedical vaccine exemptions through California Senate Bill 277 (SB277) may have resulted in increased spatial clustering of medical exemptions.Methods. We used spatial scan statistics and negative binomial regression models to examine spatial clustering in medical vaccine exemptions in California kindergartens from 2015 to 2018.Results. Spatial clustering of medical exemptions across schools emerged following SB277. Clusters were located in similar geographic areas to previous clusters of nonmedical vaccine exemptions, suggesting a spatial association between high nonmedical exemption prevalence and increasing rates of medical exemptions. Regression results confirmed this positive association at the local level. The sociodemographic characteristics of the neighborhoods in which schools were located explained some, but not all, of the positive spatial associations between exemptions before and after SB277.Conclusions. Elimination of nonmedical vaccine exemptions via SB277 may have prompted some parents to instead seek medical exemptions to required school vaccines. The spatial association of these 2 types of exemptions has implications for maintaining pockets of low vaccine compliance and increased disease transmission.

Time trends in the prevalence of breastfeeding among schoolchildren from public and private schools in Florianópolis, Southern Brazil: From 2002 to 2013.

OBJECTIVE: To describe breastfeeding trends from 2002 to 2012/2013, and to investigate whether breastfeeding practices differ between mothers of children in public and private schools. METHODS: Data were obtained from three school-based cross-sectional studies conducted with 7 to 10 years old children. The total sample was 7264 individuals. Data related to breastfeeding were analyzed descriptively and compared using the chi-square test for heterogeneity or trend. RESULTS: In the 10-year period was observed a decrease in the total percentage of schoolchildren who were not breastfed (12.9%-10.5%) and an increase in the percentage of schoolchildren breastfed for >12 months (23.9%-36.7%). In public schools, the increase of breastfeeding for >12 months was independent of maternal age and years of schooling. In private schools, the increase was observed for schoolchildren born to older mothers and to more educated mothers, although the highest percentage was observed for schoolchildren born to less educated mothers. CONCLUSIONS: The results confirm the complexity of determining breastfeeding behaviors, and understanding these dynamics is fundamental to develop and improve programs and actions aimed at encouraging, supporting, and protecting breastfeeding. However, strategies developed in Brazil during the first decade of the 21st century should explain the increase of proportion of breastfed children for more than 12 months, and the concomitant decrease of never breastfeed children in the city of Florianopolis (Southern Brazil).

Adolescent Physical Activity at Public Schools, Private Schools, and Homeschools, United States, 2014.

INTRODUCTION: Physical activity overall and during school-related opportunities among homeschool adolescents are poorly documented. METHODS: We used data from the National Cancer Institute's Family Life, Activity, Sun, Health, and Eating (FLASHE) study, a national sample of parent-child dyads. We examined reported frequency of physical activity in middle-school and high-school respondents (N = 1,333). We compared the overall physical activity by school type (ie, public school, private school, and homeschool), compared school-related contexts (eg, recess, physical education [PE] class), and tested for level of physical activity by school for those reporting PE. RESULTS: Middle-school homeschool adolescents reported less physical activity during school hours compared with public school, but not private school, adolescents. Physical activity was not different by school type for out of school or weekends. Physical activity of high-school homeschool adolescents was not different from that of high-school adolescents at traditional schools; homeschool adolescents in both middle and high school reported less physical activity in PE compared with public and private school adolescents. Other school-related contexts of physical activity were not different by school type. More homeschool students reported not having PE (middle school, 54.8%; high school, 57.5%) compared with public (middle school, 18.7%; high school, 38.0%) or private schools (middle school, 13.5%; high school, 41.5%). CONCLUSION: Homeschool adolescents in middle school reported less physical activity compared with middle-school adolescents in traditional schools during school hours, likely because of having fewer PE classes and less physical activity during PE.

Recovery High School Attendance Effects on Student Delinquency and Substance Use: the Moderating Role of Social Problem Solving Styles.

Recovery high schools (RHSs) provide educational programming and therapeutic support services for young people in recovery from substance use disorders (SUDs). The objectives of this study were to examine whether students with SUDs who attended RHSs report less delinquency and substance use than students with SUDs who attended non-RHSs, and how students' social problem solving styles might moderate those associations. Participants were students from a longitudinal quasi-experimental study of adolescents who enrolled in high schools after receiving treatment for SUDs. The propensity-score balanced sample included 260 adolescents (143 in RHSs, 117 in non-RHSs) enrolled in schools in Minnesota, Wisconsin, or Texas (M age = 16; 83% White; 44% female). Negative binomial regression models were used to compare delinquency and substance use outcomes for RHS and non-RHS students at 6-month and 12-month follow-ups. The results indicated that students attending RHSs after discharge from SUD treatment reported less frequent delinquent behavior while intoxicated, and fewer days of substance use relative to students attending non-RHSs. Negative problem solving styles moderated the effect of RHS attendance on substance use outcomes, with RHSs providing minimal beneficial effects for those students endorsing maladaptive problem solving styles. We conclude that RHSs offer a promising continuing care approach for adolescents in recovery from SUD problems, but may vary in their effectiveness for students with impulsive, careless, or avoidant problem solving styles.

Using polytomous latent class analysis to compare patterns of substance use and co-occurring health-risk behaviors between students in alternative and mainstream high schools.

INTRODUCTION: Alternative high school (AHS) students, an understudied and underserved population, experience educational, social, and health disparities relative to students in mainstream high schools. Disparities in single types of substance use are particularly high, yet no known studies have compared patterns of substance use or relationships between these patterns and other health-risk behaviors between AHS and mainstream high schools. METHODS: Using data from the Texas Alternative School Health Survey (n = 515; mean age 17.1 years, 49% male, 59% Hispanic, 23% White, 15% Black) and the Texas Youth Risk Behavior Survey (n = 2,113; mean age 16 years, 47% male, 64% Hispanic, 22% White, 7% Black), we used latent class analyses to compare patterns of substance use in AHSs and mainstream high schools. We used latent class regression to examine relationships between patterns of substance use and involvement in other health-risk behaviors in each school setting. RESULTS: Students in AHSs and mainstream high schools had similar patterns of substance use, and youth in higher risk categories engaged in higher levels of other health-risk behaviors. A substantially greater proportion of AHS students, however, fell into the moderate and high use categories, in support of continuing disparities for AHS students. CONCLUSIONS: Additional support is needed in AHSs to address the prevalence of high-risk patterns of substance use and associated health-risk behaviors. For example, ongoing public health surveillance is needed in AHSs, just as is done in mainstream high schools, to monitor trends in substance use and impact of policies and interventions.

Reaching High-Need Youth Populations With Evidence-Based Sexual Health Education in California.

OBJECTIVES: To explore the programmatic reach and experience of high-need adolescents who received sexual health education in 3 distinct implementation settings (targeted-prevention settings, traditional schools, and alternative schools) through a statewide sexual health education program. METHODS: Data are from youth surveys collected between September 2013 and December 2014 in the California Personal Responsibility Education Program. A sample of high-need participants (n = 747) provided data to examine the impact of implementation setting on reach and program experience. RESULTS: Implementation in targeted-prevention settings was equal to or more effective at providing a positive program experience for high-need participants. More than 5 times as many high-need participants were served in targeted-prevention settings compared with traditional schools. Reaching the same number of high-need participants served in targeted-prevention settings over 15 months would take nearly 7 years of programming in traditional schools. CONCLUSIONS: To maximize the reach and experience of high-need youth populations receiving sexual health education, state and local agencies should consider the importance of implementation setting. Targeted resources and efforts should be directed toward high-need young people by expanding beyond traditional school settings.

Education, school type and screen time were associated with overweight and obesity in 2930 adolescents.

AIM: This cross-sectional study analysed the influence of socio-economic factors on screen time, overweight and obesity. METHODS: We asked adolescents aged 10, 14 and 17 from 10 school types in urban and rural regions in Upper Austria to complete questionnaires from December 2012 to February 2013. Their parents were also asked to complete questionnaires. RESULTS: The questionnaires were completed by 2930 adolescents and 2209 parents. Total weekend screen time was significantly associated with a higher body mass index (BMI) in 10-year-old boys (p < 0.005) and 10-year-old girls (p = 0.002), and there were significant associations between higher BMI and television time and longer weekend video game use in subjects aged 10 and 14. Higher education levels were associated with shorter daily video game use and longer computer use. Males (p < 0.0001) and adolescents from immigrant families (p < 0.0001) reported longer screen times at all ages. Lower parental education and higher parental BMI correlated significantly with longer screen time and BMI in the youngest age group. CONCLUSION: The greatest weight problems were in younger adolescents, despite shorter screen times, and boys and adolescents from immigrant families reported the longest screen times. Prevention strategies need to start early.

School climate and physical adolescent relationship abuse: Differences by sex, socioeconomic status, and bullying.

Little is known about the association between school climate and adolescent relationship abuse (ARA). We used 2011-2012 data from surveys of California public school students (in the United States of America) who were in a dating relationship in the last year (n = 112 378) to quantify the association between different school climate constructs and physical ARA. Fifty-two percent of students were female, and all students were in 9th or 11th grade (approximately ages 14-17). Over 11% of students reported experiencing physical ARA in the last year. Increased school connectedness, meaningful opportunities for participation, perceived safety, and caring relationships with adults at school were each significantly associated with lower odds of physical ARA. Increased violence victimization and school-level bullying victimization were associated with higher odds of physical ARA. These school climate-ARA associations were significantly moderated by student sex, school socioeconomic status, and school-level bullying victimization. School climate interventions may have spillover benefits for ARA prevention.

A cross-sectional observation on habitual non-alcoholic beverage consumption among adolescents from four Irish post-primary schools.

OBJECTIVE: No up-to-date data on the dietary intake of Irish adolescents are available. The aim of the present pilot study was to obtain and compare cross-sectional information on habitual adolescent beverage consumption between four distinct post-primary schools in the Republic of Ireland, in 2014-2015. DESIGN: A cross-sectional observation study. A beverage consumption questionnaire was used to obtain data on beverage intake and influences on consumption. SETTING: Four post-primary mixed-sex schools in Ireland representing the following school classifications were selected for the study: urban fee-paying, urban disadvantaged, rural fee-paying and rural disadvantaged. SUBJECTS: Students (n 761) aged 12-18 years. RESULTS: Data were analysed by Kruskal-Wallis (non-parametric) ANOVA to compare the distribution of beverage consumption across the schools. Water was the most highly consumed beverage among students from all four schools (median 1425 ml/d). Students from urban and rural disadvantaged schools reported a significantly higher volume of carbonated beverage intake than students from fee-paying schools. Students from an urban disadvantaged school also reported a significantly higher volume of carbonated beverage and energy drink intake compared with the other three schools. Students from an urban fee-paying school reported the highest consumption of water, while rural disadvantaged school students were the biggest consumers of tea and milk. CONCLUSIONS: Significant differences in beverage consumption (ml/d) were reported by adolescents from four schools in Ireland. Surveillance on current beverage consumption trends among adolescents is vital to guide policies and interventions, and for appropriate targeting of resources.

Bullying among immigrant and non-immigrant early adolescents: School- and student-level effects.

We examined the association between school immigrant concentration and bullying among immigrant and non-immigrant early adolescents, and identified potential explanatory factors. First generation immigrant students had reduced odds of victimization and perpetration in schools with high (20-60%), compared to low, levels of immigrant concentration. Second generation immigrant students had reduced odds of ethnic/racial victimization in moderately concentrated schools; while non-immigrants had increased odds in the same schools. Non-white students had increased odds of ethnic/racial victimization compared to White students. While students' sense of school belonging and perceived teacher cultural sensitivity were negatively associated with bullying, they did not account for the differential associations noted above. Results demonstrate the importance of immigrant density as a protective school characteristic for immigrant and ethnic minority youth. Additional social processes operating in schools that may explain bullying behaviors among immigrant and non-immigrant youth should be explored to inform programs for promoting inclusion in schools.

Approaches to education provision for mobile pastoralists.

Experiences of mobile pastoralists often attest to a wide range of contradictions about the presumed advantages of formal education. While effort to 'reach' pastoralists has intensified under the global Education for All movement, there remain considerable difficulties in finding ways to make formal education relate to pastoralist livelihoods and complement endogenous knowledge. This paper examines how these dynamics play out across models of formal and non-formal education service provision, and identifies innovations that offer promising ways forward: Alternative Basic Education, Open and Distance Learning, and Pastoralist Field Schools.

Les expériences rapportées par les pasteurs nomades témoignent souvent de contradictions diverses concernant les avantages présumés de l'éducation formelle. Les efforts visant à proposer une offre adaptée aux pasteurs se sont intensifiés dans le cadre du mouvement de l'Éducation pour tous mais se heurtent à la difficulté d'élaborer des solutions d'éducation formelle en lien avec les moyens de subsistance du pastoralisme et complétant les savoirs endogènes. L'auteur examine l'évolution de ces dynamiques dans différents modèles d'offres d'éducation formelle et non formelle et identifie trois champs d'innovation qui lui paraissent prometteurs pour l'avenir : l'Enseignement élémentaire alternatif, l'apprentissage ouvert et à distance et les écoles pastorales de terrain.

La experiencia de los grupos pastorales nómadas suele evidenciar muy diversas contradicciones que ponen en tela de juicio las presuntas ventajas de la educación formal. Como parte del movimiento mundial en pro de la Educación para Todos se han redoblado esfuerzos para «llegar¼ a los grupos de pastores, pero aun así subsisten considerables dificultades a la hora de encontrar fórmulas para impartirles una enseñanza que guarde relación con sus medios de sustento y venga a completar los conocimientos endógenos. La autora examina el modo en que esta dinámica se articula con los modelos de prestación de servicios educativos formales y no formales y describe innovaciones que abren vías prometedoras: la educación básica alternativa, el aprendizaje abierto y a distancia o las escuelas de campo pastorales.

Private schooling and admission to medicine: a case study using matched samples and causal mediation analysis.

BACKGROUND: Are applicants from private schools advantaged in gaining entry to degrees in medicine? This is of international significance and there is continuing research in a range of nations including the USA, the UK, other English-speaking nations and EU countries. Our purpose is to seek causal explanations using a quantitative approach. METHODS: We took as a case study admission to medicine in the UK and drew samples of those who attended private schools and those who did not, with sample members matched on background characteristics. Unlike other studies in the area, causal mediation analysis was applied to resolve private-school influence into direct and indirect effects. In so doing, we sought a benchmark, using data for 2004, against which the effectiveness of policies adopted over the past decade can be assessed. RESULTS: Private schooling improved admission likelihood. This did not occur indirectly via the effect of school type on academic performance; but arose directly from attending private schools. A sensitivity analysis suggests this finding is unlikely to be eliminated by the influence of an unobserved variable. CONCLUSIONS: Academic excellence is not a certain pathway into medicine at university; yet applying with good grades after attending private school is more certain. The results of our paper differ from those in an earlier observational study and find support in a later study. Consideration of sources of difference from the earlier observational study suggest the causal approach offers substantial benefits and the consequences in the causal study for gender, ethnicity, socio-economic classification and region of residence provide a benchmark for assessing policy in future research.

Impact of rurality on the oral health status of 6-year-old children from central Chile: the EpiMaule study.

INTRODUCTION: The aim of this study was the assessment of dental caries and the gingival status of 6-year-old children living in the Maule region, Chile's most rural region, and to determine if rurality was related to a higher prevalence of oral conditions. METHODS: A representative sample of 485 children aged 6 years was examined using WHO methods. Children were chosen from schools belonging to urban and rural districts of the region. Caries status was obtained by deft (decayed, extracted, filled teeth), DMFT (decayed, missing, filled teeth) and SiC (Significant Caries) indexes. To assess gingival health status, the oral hygiene (OHI) and the gingival index (GI) were used. Urban and rural children data were compared using student's t-test at p < 0.05. RESULTS: Overall caries prevalence was 80.62%. Rural children showed higher prevalence (p < 0.0001) than urban 6-year-olds, with 88.3% and 69.9%, respectively. The deft (decayed, extracted, filled teeth) index was 4.63 for the region, with 5.74 for rural and 3.09 for urban districts (p < 0.05). The SiC index was 10.23 for rural and 7.13 for urban children (p < 0.05). Mean OHI score was 1.44, but rural children had higher OHI: 1.49 compared with 1.37 for urban 6-year-olds (p < 0.0001). The GI of the region was 1.37, but no differences were detected between rural and urban children (p < 0.05). CONCLUSIONS: Children from the Maule region in Chile have a severely deteriorated oral health, higher than Chile's mean. Rural are significantly more affected than urban children. A special focus on rural communities when designing oral health policies is strongly suggested.

Early childhood malaria prevention and children's patterns of school leaving in the Gambia.

BACKGROUND: Early childhood malaria is often fatal, but its impact on the development and education of survivors has not received much attention. Malaria impacts cognitive development in a number of ways that may impact later educational participation. AIMS: In this study, we examine the long-term educational effects of preventing early childhood malaria. Does intermittent preventive treatment (IPT) during early childhood reduce the risk of dropout? If so, does this effect vary by school type - government school versus madrassa? SAMPLE: We use data from a 2001 follow-up of a 1985-1987 malaria prevention randomized controlled trial in the Gambia. The sample consists of 562 youth born between 1981 and 1986. METHODS: We use discrete-time survival analysis to identify the impact of the intervention on dropout risk over time. RESULTS: We find that IPT has a positive impact on dropout for government school students, but not for madrassa attendees. The difference was striking: in government schools, the odds of dropout in the treatment group were one third of those in the control group. CONCLUSIONS: Our findings suggest that preventing early childhood malaria may reduce dropout at a relatively low cost. In this intervention, the drugs cost less than one dollar per year per child. While IPT is no longer practised in many countries due to concerns over drug resistance, these results support the conclusion that any type of effective malaria control programme protecting young children, such as consistent and correct use of bed nets, could improve educational attainment in areas where malaria is prevalent.

Migration background is associated with caries in Viennese school children, even if parents have received a higher education.

BACKGROUND: A low level of education and the migration background of parents are associated with the development of caries in children. The aim of this study was to evaluate whether a higher educational level of parents can overcome risks for the development of caries in immigrants in Vienna, Austria. METHODS: The educational level of the parents, the school type, and the caries status of 736 randomly selected twelve-year-old children with and without migration background was determined in this cross sectional study. In children attending school in Vienna the decayed, missing, and filled teeth (DMFT) index was determined. For statistical analysis, a mixed negative-binomial-model was used. RESULTS: The caries status of the children with migration background was significantly worse compared to that of the native Viennese population. A significant interaction was found between migration background and the educational level of the parents (p = 0.045). No interaction was found between the school type and either the migration background (p = 0.220) or the education level of the parents (p = 0.08). In parents with a higher scholarly education level, migration background (p < 0.01) and school type (p = 0.018) showed an association with DMFT values. In parents with a low education level, however, migration background and school type had no significant association with DMFT values. CONCLUSION: These data indicate that children with a migration background are at higher risk to acquire caries than other Viennese children, even when the parents have received a higher education.

Executive functions and behavioral problems in deaf and hard-of-hearing students at general and special schools.

In this study, behavioral problems of deaf and hard-of-hearing (D/HH) school-aged children are discussed in the context of executive functioning and communicative competence. Teachers assessed the executive functions of a sample of 214 D/HH students from general schools and schools for the deaf, using a German version of the Behavior Rating Inventory of Executive Functions (BRIEF-D). This was complemented by a questionnaire that measured communicative competence and behavioral problems (German version of the Strengths and Difficulties Questionnaire; SDQ-D). The results in nearly all the scales show a significantly higher problem rate for executive functions in the group of D/HH students compared with a normative sample of hearing children. In the D/HH group, students at general schools had better scores on most scales than students at schools for the deaf. Regression analysis reveals the importance of executive functions and communicative competence for behavioral problems. The relevance of the findings for pedagogical work is discussed. A specific focus on competencies such as self-efficacy or self-control in educational concepts for D/HH students seems to be necessary in addition to extending language competencies.

Difference in children's gross motor skills between two types of preschools.

The purpose of this study was to assess the influence of preschool type (public vs private) on motor skill performance in 239 (121 boys, 118 girls) preschool children ages 3 to 6.5 yr. Preschoolers were tested on 12 fundamental motor skills from the Test of Gross Motor Development-Second Edition and 11 anthropometrics (body height, weight, Body Mass Index, waist and hip girths, and body segment lengths). Analysis of variance controlled for anthropometrics and age indicated that children from private preschools performed better on locomotor skills than those from public preschools. However, no difference was found in object control skills. The results suggest that performance of locomotor skills by preschool children is affected by their schools' physical environment.

Acceptability and attractiveness of intra- and extra-oral orthodontic appliances.

OBJECTIVES: To evaluate the acceptability of different intra-oral and extra-oral orthodontic appliances, to rank orthodontic appliances from the most to the least attractive and to investigate the factors that may affect the acceptance of orthodontic treatment. SUBJECTS: A random sample of 800 students (schoolchildren and university students) were invited to participate in this study and a total of 688 students were included (86%). METHODS: A self-administrated structured questionnaire was constructed for the purpose of this study. RESULTS: More than one-half in each age group (53%) claimed that they would accept to have orthodontic treatment. Acceptance of the different orthodontic appliances was affected by gender, age and type of school. Removable appliance was reported as the most acceptable and facemask was reported as the least acceptable orthodontic appliances. Majority of subjects ranked ceramic and facemask appliances as the most and the least attractive orthodontic appliances, respectively. The predictor variables for the acceptance of orthodontic treatment were perceived demand for orthodontic treatment, perceived positive effect of orthodontic treatment and expected benefits from orthodontic treatment. CONCLUSIONS: Removable appliance was the most acceptable orthodontic appliance whereas ceramic appliance was ranked as the most attractive one. Facemask was the least acceptable and the least attractive option.

Relationship between obesity/overweight status, sugar consumption and dental caries among adolescents in South India.

OBJECTIVE: To evaluate the relationship between obesity/overweight status, sugar consumption and dental caries among adolescents in Udupi District, India. METHODS: Study population consisted of 463 school children aged between 13 and 15 years. Information on age, sex, type of school attending and frequency of sugar consumption per day was recorded by a structured self-administered questionnaire. Body mass index (BMI) (height in metres and weight in kilograms) and caries measurements (DMFT) were taken by a trained recorder according to standard criteria. RESULTS: Majority of the children were having low normal weight, with 18.6% in overweight and 3.5% in obese groups. There was a significant difference in the frequency of sugar consumption between the BMI groups. Obese group of children had more caries than the overweight and low-normal-weight children. Correlation analysis showed significant positive relation with BMI, decayed teeth and DMFT. Regression analysis showed that caries experience had a significant association with male sex (OR = 2.09, CI = 1.01-4.33), overweight/obese (OR = 3.68, CI = 1.79-7.56) and frequency of sugar consumption more than once per day (OR = 3.13, CI = 1.25-7.85). CONCLUSION: There was a significant association between overweight/obesity and caries experience among school children of Udupi District. Obesity and dental caries have common risk determinants and require a comprehensive multidisciplinary approach to paediatric patients by both medical and dental healthcare professionals.

Do schools differ in suicide risk? The influence of school and neighbourhood on attempted suicide, suicidal ideation and self-harm among secondary school pupils.

BACKGROUND: Rates of suicide and poor mental health are high in environments (neighbourhoods and institutions) where individuals have only weak social ties, feel socially disconnected and experience anomie - a mismatch between individual and community norms and values. Young people spend much of their time within the school environment, but the influence of school context (school connectedness, ethos and contextual factors such as school size or denomination) on suicide-risk is understudied. Our aim is to explore if school context is associated with rates of attempted suicide and suicide-risk at age 15 and self-harm at age 19, adjusting for confounders. METHODS: A longitudinal school-based survey of 1698 young people surveyed when aged 11, (primary school), 15 (secondary school) and in early adulthood (age 19). Participants provided data about attempted suicide and suicide-risk at age 15 and deliberate self-harm at 19. In addition, data were collected about mental health at age 11, social background (gender, religion, etc.), and at age 15, perception of local area (e.g. neighbourhood cohesion, safety/civility and facilities), school connectedness (school engagement, involvement, etc.) and school context (size, denomination, etc.). A dummy variable was created indicating a religious 'mismatch', where pupils held a different faith from their school denomination. Data were analysed using multilevel logistic regression. RESULTS: After adjustment for confounders, pupils attempted suicide, suicide-risk and self-harm were all more likely among pupils with low school engagement (15-18% increase in odds for each SD change in engagement). While holding Catholic religious beliefs was protective, attending a Catholic school was a risk factor for suicidal behaviours. This pattern was explained by religious 'mismatch': pupils of a different religion from their school were approximately 2-4 times more likely to attempt suicide, be a suicide-risk or self-harm. CONCLUSIONS: With several caveats, we found support for the importance of school context for suicidality and self-harm. School policies promoting school connectedness are uncontroversial. Devising a policy to reduce risks to pupils holding a different faith from that of their school may be more problematic.