Intersectional Differences in Protective School Assets by Sexuality, Gender, Race/Ethnicity, and Socioeconomic Status.

BACKGROUND: School assets-such as connectedness, caring relationships with adults, high behavioral expectations from adults, and meaningful participation-are associated with positive outcomes for adolescents. However, little is known about how school assets differ among adolescents with intersecting marginalized identities. METHODS: We used the 2013-2014 California Healthy Kids Survey (N = 320,462 students) to examine differences in school assets with respect to sexuality, gender, race/ethnicity, and socioeconomic status using adjusted multilevel linear regression models. RESULTS: Sexual minority, gender minority, racial/ethnic minority, and low socioeconomic status adolescents had significantly lower protective school assets. For all outcomes, the differences between sexual minority and heterosexual adolescents were more pronounced among nontransgender girls than nontransgender boys; however, these differences were not consistently present among racial/ethnic minority students. For school connectedness and meaningful participation, differences for racial/ethnic minorities versus white adolescents were more pronounced among nontransgender girls than nontransgender boys. Differences between transgender adolescents and nontransgender boys were more pronounced for white adolescents compared to some other racial/ethnic minority students. Overall, adolescents with certain multiple marginalized identities had lower school assets. CONCLUSIONS: Interventions are needed to strengthen school assets among marginalized students, thereby helping mitigate health and education inequities.

Sexual Orientation-Based Alcohol, Tobacco, and Other Drug Use Disparities: The Protective Role of School-Based Health Centers.

This study investigated whether the presence of school-based health centers (SBHCs) was associated with six substance use behaviors among sexual minority youth (SMY) and their heterosexual peers. Data from the 2015 Oregon Healthy Teens Survey, including 13,608 11th graders in 137 schools (26 with SBHCs) were used in the current study. Multilevel logistic regression analyses were performed. Results revealed significant SBHC by SMY status interactions indicating a relatively lower likelihood of past 30-day alcohol use (23%), binge drinking (43%), use of e-cigarettes (22%), marijuana (44%), and unprescribed prescription drugs (28%) among SMY in SBHC schools compared with non-SMY at SBHC schools. Furthermore, SMY in SBHC schools reported lower likelihood of aforementioned substance use behaviors than SMY attending non-SBHC schools. Conversely, no differences in these outcomes were observed for non-SMY in SBHC and non-SBHC schools. Findings from this study suggest SBHCs may help to mitigate substance use disparities among marginalized populations, such as SMY.

Sexual Orientation-Based Depression and Suicidality Health Disparities: The Protective Role of School-Based Health Centers.

This study's purpose was to examine whether school-based health centers (SBHCs) support mental health indicators among sexual minority youth (SMY). Data came from the 2015 Oregon Healthy Teens Survey with 13,608 11th graders in 137 public high schools in Oregon. Regression results revealed significant SBHC by SMY status interactions indicating relative reductions in likelihood of depressive episodes (30%), suicidal ideation (34%), and suicide attempts (43%) among SMY in schools with SBHCs. SMY students in SBHC schools reported lower likelihood of a past-year depressive episode, suicidal ideation, and suicide attempt versus those attending non-SBHC schools. Conversely, no differences in these outcomes were observed for non-SMY by SBHC status. SBHCs may help reduce mental health disparities among SMY, a marginalized, underserved population.

School-based health services and educational attainment: Findings from a national longitudinal study.

This study examined whether availability and use of different types of school-based health services (SBHS) during adolescence were associated with educational attainment in adulthood. Data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) were analyzed in 2018 to assess relationships between different types of SBHS provided by schools and use of SBHS among adolescents in 1995, and educational attainment in young adulthood (2001-02) and later adulthood (2008). Multi-level linear regression models included SBHS such as providing immunizations, physical exams and emotional counseling at the school level, and receiving a school-based physical exam, emotional counseling or family planning counseling at the individual level, with other school and individual characteristics included as covariates. At the school level, providing immunizations in 1995 was associated with higher educational attainment in 2001-02 and 2008. Providing physical exams and physical fitness/recreation centers also were marginally associated with higher educational attainment in 2001-02 and 2008, respectively. At the individual level, receiving a physical exam at school in 1995 was associated with higher educational attainment in 2001-02, while receiving emotional counseling at school was inversely associated with educational attainment in 2008. None of the other types of SBHS at the school or individual level were associated with later educational attainment. This study suggests that preventive SBHS such as immunizations, physical exams and physical fitness/recreation centers may contribute to academic achievement and higher educational attainment during young and later adulthood.

"It just depends on the environment": Patterns and decisions of substance use and co-use by adolescents.

This study used rich qualitative data to examine the role that social and physical contexts play in decision-making related to simultaneous use of alcohol and marijuana among adolescents. In-depth, semi-structured interviews were conducted with 13 adolescents who used alcohol and marijuana within several hours of each other. Decisions about whether to use alcohol and marijuana simultaneously as well as use patterns (e.g. the sequence in which substances were used) were informed by the context and the desired effect of the substance(s). Also, simultaneous alcohol and marijuana use was described as occurring in multiple contexts, both destination and transitional. Interventions designed to reduce simultaneous alcohol and marijuana use could benefit from paying attention to substance use contexts.

School-Based Health Centers and School Connectedness.

BACKGROUND: Improvements in health behaviors and academic outcomes have been associated with school-based health centers (SBHCs). However, underlying mechanisms for these associations have been largely unexamined, particularly among lower-income youth. The current study examines the relationship between SBHCs and school connectedness and whether this relationship differs by youths' socioeconomic status (SES). METHODS: Student-level cross-sectional data from 503 traditional high schools in California were analyzed using multilevel regression models. California Healthy Kids Survey 2013-2014 data included information on 3 dimensions of school connectedness and demographic characteristics including SES as measured by parental education. School-level demographic data was gathered from publicly available sources. RESULTS: Although no significant relationship between SBHCs and any of the school connectedness dimensions emerged, there were significant cross-level interactions between SBHCs and parent education. SBHCs were more positively associated with school connectedness (adult caring, adult expectations, and meaningful participation) among lower SES students compared to students with higher SES. CONCLUSIONS: SBHCs may be particularly effective in affecting school connectedness among lower income youth populations. This has wide ranging implications with regards to planning (eg, careful selection of where SBHCs can be most effective), and future research (eg, examining the effectiveness of specific SBHC strategies that support connectedness).

Cognitive precursors to adolescents' reproductive health: Exploring the role of school-based health services.

The goal of this study was to examine associations between the number of school-based health services (SBHS) provided and the cognitive precursors to adolescents' reproductive health, including birth control self-efficacy, motivation to use birth control, attitudes toward birth control, and contraception knowledge. Further, this study examined whether these associations varied by adolescents' age, gender, socioeconomic status (SES), and race/ethnicity. Data were drawn from two waves of Add Health, a longitudinal survey of a nationally representative sample of U.S. adolescents (1994-96). Results from hierarchical linear regression models indicated that the number of SBHS interacted with adolescents' age to predict birth control self-efficacy, such that a greater number of SBHS were associated with greater birth control self-efficacy among 15-year-old adolescents. Findings also indicated that a greater number of SBHS were associated with lower reported birth control motivation. Although access to a greater number of health services in school settings had some effect, study findings suggest that simply increasing the number or range of health services provided may not be the most effective method for supporting diverse adolescents' reproductive health. This information is important for schools as it highlights the need for SBHS to be health outcome specific and can be used to inform initiatives related to adolescents' reproductive health.

Perceived Access and Parental Monitoring as Moderators of Impulsivity and Marijuana Use Among Adolescents.

The social and political climate regarding marijuana use has been changing in the US over the past decade. Research suggests that many adolescents report relatively easy access to marijuana and perceptions that recreational use involves minimal harm despite a growing body of research implicating the deleterious effects of use on cognitive and psychological development. Not surprisingly, prevalence rates have been rising in recent years, making it important to identify risk and protective factors associated with adolescent marijuana use. We tested a 3-way interaction model designed to (a) examine the relationship between behavioral impulsivity and marijuana use in adolescents, and (b) evaluate the roles of perceived access and parental monitoring as moderators of this relationship. High school students (N = 498, M age  = 15.7, 53% female, 77% White) completed an anonymous self-report assessment examining substance use, perceived access, and psychosocial factors related to substance use (i.e., behavioral impulsivity and parental monitoring). Results indicated that higher levels of impulsivity, greater access, and reduced parental monitoring were related to marijuana use. Significant moderating effects were found for perceived access and parental monitoring, such that use was greater for adolescents who perceived that marijuana was easier to acquire and for those with lower levels of parental monitoring. Among individuals with greater levels of impulsivity, parental monitoring reduced the impact of perceived access. Overall, results highlight risk and protective factors related to adolescent marijuana use and indicate that parental monitoring can be an effective means for reducing consumption.

Providing Culturally Competent Care for LGBTQ Youth in School-Based Health Centers: A Needs Assessment to Guide Quality of Care Improvements.

School-based health centers (SBHCs) can take specific steps to provide culturally competent care for lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth, potentially impacting well-being. A needs assessment survey was conducted among a convenience sample of SBHC administrators and medical directors to assess climates and actions supportive of LGBTQ quality medical care. Half (53%) of the SBHCs surveyed ( N = 66) reviewed print materials for negative LGBTQ stereotypes, and 27.3% conducted exhaustive materials review. Regional differences were detected: 46.2% of Southern SBHCs conducted any materials review compared to 91.3% in the West and all in the East and Midwest (χ2, p < .001). In the last academic year, 45.5% conducted no medical provider trainings, and 54.5% conducted no general staff trainings on providing care for LGBTQ youth. On intake forms, 85.4% included preferred names, but only 23.5% included preferred pronoun. There are significant gaps in the extent to which SBHCs provide culturally competent care. These findings can guide future training and advocacy.

School-based mental health services, suicide risk and substance use among at-risk adolescents in Oregon.

This study examined whether an increase in the availability of mental health services at school-based health centers (SBHCs) in Oregon public schools was associated with the likelihood of suicidal ideation, suicide attempts and substance use behaviors among adolescents who experienced a depressive episode in the past year. The study sample included 168 Oregon public middle and high schools and 9073 students who participated in the Oregon Healthy Teens Survey (OHT) in 2013 and 2015. Twenty-five schools had an SBHC, and 14 of those schools increased availability of mental health services from 2013 to 2015. The OHT included questions about having a depressive episode, suicidal ideation, attempting suicide in the past year, and substance use behaviors in the past 30days. Multi-level logistic regression analyses were conducted in 2017 to examine associations between increasing mental health services and the likelihood of these outcomes. Analysis results indicated that students at SBHC schools that increased mental health services were less likely to report any suicidal ideation [odds ratio (OR) (95% C.I.)=0.66 (0.55, 0.81)], suicide attempts [OR (95% C.I.)=0.71 (0.56, 0.89)] and cigarette smoking [OR (95% C.I.)=0.77 (0.63, 0.94)] from 2013 to 2015 compared to students in all other schools. Lower frequencies of cigarette, marijuana and unauthorized prescription drug use were also observed in SBHC schools that increased mental health services relative to other schools with SBHCs. This study suggests that mental health services provided by SBHCs may help reduce suicide risk and substance use behaviors among at-risk adolescents.

The Effects of Gender- and Sexuality-Based Harassment on Lesbian, Gay, Bisexual, and Transgender Substance Use Disparities.

PURPOSE: We tested three competing models about whether gender- and sexuality-based harassment at school have nonindependent, additive, or interactive effects on adolescents' electronic cigarette use (i.e., vaping), cigarette smoking, alcohol use, and heavy episodic drinking (HED). We also tested whether harassment mediated substance use disparities between lesbian, gay, bisexual, transgender (LGBT) adolescents and their cisgender heterosexual peers. METHODS: We analyzed cross-sectional data from the 2013-2014 California Healthy Kids Survey, including 316,766 students in grades 7, 9, and 11 from more than 1,500 middle and high schools. We used logistic regression models and interaction terms to estimate associations of past-year gender- and sexuality-based harassment at school on past-month substance use, and the Karlson-Holm-Breen method to test whether harassment mediated LGBT disparities in substance use. RESULTS: Vaping, smoking, drinking, HED, and gender- and sexuality-based harassment were higher for transgender adolescents than for cisgender males and females, and for adolescents who were lesbian, gay, or bisexual only versus heterosexual only. Gender- and sexuality-based harassments were independently associated with greater odds of using each substance in every grade. These two types of harassment had positive interactions with each other for vaping in grade 11, smoking in grade 11, and HED in grades 9 and 11. Gender- and sexuality-based harassment significantly mediated many of the LGBT disparities in substance use. CONCLUSIONS: Gender- and sexuality-based harassment at school independently or interactively produced LGBT disparities in substance use. Reducing these types of discrimination in schools will likely mitigate these disparities.

Oregon School-Based Health Centers and Sexual and Contraceptive Behaviors Among Adolescents.

This study investigated the association between school-based health centers (SBHCs) and sexual behavior and contraceptive use among 11th graders. The sample included 134 high schools (27 schools with SBHCs) and 11,840 students who participated in the 2015 Oregon Healthy Teens Survey. Multilevel logistic regressions found positive associations between SBHC presence and healthy sexual behavior ( OR = 1.23, p < .05) and contraceptive use ( OR = 1.31, p < .01). Associations were stronger at schools with at least 50% of students receiving free or reduced price lunch. Among SBHC schools, prescribing and dispensing contraceptives onsite was positively related to contraceptive use among students who had sex within the past 3 months ( OR = 1.77, p < .01). Findings suggest that exposure to SBHCs in general, and availability of specific reproductive health services, may be effective population-based strategies to support healthy sexual behaviors among youth.

School-Based Health Centers, Depression, and Suicide Risk Among Adolescents.

INTRODUCTION: This study examined whether increasing availability of mental health services at school-based health centers in Oregon public schools would be associated with a decrease in the likelihood of depressive episodes and suicide risk among adolescents. METHODS: The study included 168 Oregon public schools that participated in the Oregon Healthy Teens Survey in 2013 and 2015. Twenty-five schools had a school-based health center, and 14 of those schools increased the availability of mental health services from 2013 to 2015. The Oregon Healthy Teens Survey included questions about having a depressive episode, suicidal ideation, and attempting suicide in the past year. Multilevel logistic regression analyses were conducted in 2017 to examine associations between increasing mental health services and the likelihood of past year depressive episodes, suicidal ideation, and suicide attempts. Analyses also compared student subgroups defined by demographic characteristics (e.g., gender). RESULTS: Students at school-based health center schools that increased availability of mental health services were less likely to report depressive episodes (OR=0.88, p<0.01), suicidal ideation (OR=0.84, p<0.01), and suicide attempts (OR=0.82, p<0.01) from 2013 to 2015 compared with all other schools. Significant risk reductions in past year depressive episodes and suicidal ideation were also observed in school-based health center schools that increased availability of mental health services relative to other schools with school-based health centers. No significant differences were observed for student demographic subgroups. CONCLUSIONS: This study suggests that increasing availability of school-based mental health services can help to reduce depressive episodes and suicide risk among adolescents.

Adolescent drinking in different contexts: What behaviors do parents control?

Previous research suggests that the context in which drinking occurs contribute to specific alcohol-related problems. In the current study we assessed how often adolescents attended different contexts in which they could drink, how often they drank in those contexts, and whether drinking patterns and parental monitoring were related to alcohol use in those contexts. We collected survey data from 1,217 adolescents 15-18 years of age in 24 midsized California cities. Measures included past-year frequencies of attending and drinking in restaurants, bars/nightclubs, and outdoor places, typical hours spent at home (i.e., own home or someone else's home), perceptions of parental control and disclosure to parents about free time activities, and demographics. Multilevel zero-inflated negative binomial models were used to assess associations between drinking patterns, parental control, and disclosure and frequency of attending and drinking in specific contexts. There were large variations in attending contexts in which drinking could take place. More frequent drinking was related to less time spent at home, while heavier drinking was associated with more time spent at home. Parental control was related to less frequent attendance at bars/nightclubs, and disclosure to less frequent involvement in outdoor activities and spending more time at home. Among drinkers, frequencies of attendance were strongly related to frequencies of drinking in all contexts except the home. Parental control and disclosure were related to more frequent drinking at restaurants and exposure to bars/nightclubs and drinking at outdoor activities. Parental monitoring may reduce exposure to risks by shifting adolescent contexts for alcohol use.

School-Based Health Centers and Adolescent Substance Use: Moderating Effects of Race/Ethnicity and Socioeconomic Status.

BACKGROUND: School-based health centers (SBHCs) have been associated with many positive health and academic outcomes. The current study extends previous research and examines possible differences in the association between SBHC exposure and adolescent alcohol, tobacco, and other drug use by race/ethnicity, sex, and socioeconomic status (SES). METHODS: California Healthy Kids Survey data from 504 traditional high schools in California were linked with publicly available data on SBHCs and school demographics. Multilevel logistic regression analyses were conducted controlling for school and individual characteristics. RESULTS: Significant interactions suggest that SBHC exposure was inversely associated with past 30-day alcohol use, binge drinking, and cigarette and e-cigarette use among African American youth and negatively associated with cigarette and marijuana use among Asian youth, relative to whites. There was also a significant interaction between SBHC exposure and parent education for past 30-day alcohol use and binge drinking. No significant sex interactions were observed. CONCLUSIONS: SBHC exposure appears to be inversely related to substance use among youth in some ethnic minority groups and youth of lower SES. This may have implications regarding SBHC placement and investment. Additional research is necessary to understand the mechanisms through which SBHCs may influence adolescent substance use and other health behaviors.

Adolescents, alcohol, and marijuana: Context characteristics and problems associated with simultaneous use.

We investigated contexts of simultaneous use of alcohol and marijuana and the impact of simultaneous use on problems among adolescents. Ecological momentary assessment data were obtained over two weekends from 150 adolescents in California (47% female, M age=16.36years), using smartphone surveys administered early and late in the evening and again the following morning. We assessed whether, in what context, and with whom adolescents drank alcohol and used other substances over 3 evening hours. We assessed problems they experienced each evening on the following morning. Results showed that greater adult supervision in every context was associated with a 55% lower risk of simultaneous use (RRR=0.45, p≤.05). Contexts with no other underage drinkers were associated with 99% lower risk of simultaneous use (RRR=0.01, p≤.005). Each occasion of simultaneous use was related to 110% increase in the number of problems (IRR=2.10, p≤.005), with 83%, 221% and 311% greater odds of violence (OR=1.83, p≤.05), driving under the influence or riding with a drunk driver (OR=3.21, p≤.05), or being drunk (OR=4.11, p≤.005). Additional analyses showed that these problems may be attributed largely to the alcohol consumed in each context. Results demonstrate that it is essential to consider situational and social characteristics of substance use contexts to better understand adolescent simultaneous use of alcohol and drugs and problems.

Deficits in young men's knowledge about accessing sexual and reproductive health services.

OBJECTIVE: The current study aimed to examine (1) gender differences in college students' knowledge of sexual and reproductive health care (K-SRHC) service access points, and (2) the relationship between demographic and psychosocial factors and college students' overall K-SRHC service access points. METHODS AND PARTICIPANTS: Self-report online surveys were administered to 18- and 19-year-old college students from a northern California public university (N = 183; 39.9% men; 32.2% Latino). RESULTS: Women reported higher overall K-SRHC service access point scores than men. Findings indicated that gender and family planning self-efficacy were the strongest correlates of K-SRHC service access points. Men with a regular source of health care had higher K-SRHC service access points than men without. CONCLUSIONS: Results suggest that college men need additional education about how to access sexual and reproductive health services to support their own and their partner's health.

Reproductive Health Services: Barriers to Use Among College Students.

The objective of the current study was to explore demographic, financial, and psychosocial barriers associated with the use/non-use of reproductive health (RH) services. The sample included 212 college students (60 % female) aged 18-19 from a Northern California public university. In October, 2014, students took an on-line survey with questions on knowledge, access, barriers, and use of different RH services and settings. Findings indicated that college students were more likely to visit a primary care setting and/or school-based setting for their RH care. Sexual intercourse was the strongest correlate of having received RH care in the past year, followed by gender, social disapproval, and knowledge of available services. Analyses stratified by gender found a similar pattern among females. However, the only significant predictor among males was knowledge of available services. These finding highlight universities as uniquely positioned to reduce perceived barriers to accessing RH services by making use of technology, promoting health and wellness centers, and providing/adding sexual and reproductive information to general education classes.

Identifying Strategies to Limit Youth Drinking in the Home.

OBJECTIVE: The present study aims to better understand the situational, contextual, and social event-level characteristics that contribute to youth drinking behavior in the home. METHOD: We used survey data from 1,217 adolescents (15-18 years, 47.7% female) living in 24 midsized, noncontiguous California cities. The study focused on those who reported at least one drink during their last drinking occasion at home or a friend's home (n = 336). We obtained data about total drinks at last event as well as contextual and situational characteristics at last event, including adult presence, number of people present, participant's home or friend's home, ease of alcohol access, and gender ratio. We also gathered information on individual-level characteristics such as past-year drinking behavior, perceived drinking norms, age, ethnicity, and gender. Multilevel Poisson regression models were used to analyze the data. RESULTS: Among the full sample, the number of people at the event and the perceived ease of access were positively associated with an increase in number of drinks consumed. Among females, having a responsible adult present was associated with consuming fewer drinks. Among males, having more boys at the event was related to consuming fewer drinks, whereas increased perceived access to alcohol was positively associated with consuming more drinks. CONCLUSIONS: Parents may be able to manage or manipulate the home drinking environment to reduce heavy drinking and alcohol-related problems. Future research is needed to explore additional contextual factors that may enable or inhibit heavy drinking.

School-Based Health Centers' Presence: The Role of School and Community Factors.

INTRODUCTION: School-based health centers (SBHCs) offer an efficient mechanism for delivering health services to large numbers of underserved youth; however, their availability varies across communities. Data on sociocontextual variables were analyzed to investigate factors that inhibit and facilitate SBHCs. METHODS: Secondary data from 2012 to 2015 state databases were linked to examine the association between SBHCs' presence in California high schools and demand, resource, and political conservatism at the school and community levels that may influence where SBHCs are located and the number of provided health services. Data were analyzed in 2015 using hierarchical binary and Poisson models. RESULTS: Presence of a local non-school-based family planning clinic was the strongest correlate of SBHC presence. School size, percentage non-white, and percentage receiving free or reduced-price lunches were positively associated with SBHC presence. Percentage who voted Republican in the 2012 general election and teen pregnancy rates were negatively associated with SBHC presence. None of the predictors were associated with number of services provided by SBHCs. CONCLUSIONS: School and community factors appear to play a role in supporting or impeding the establishment of SBHCs. In addition to variables tapping communities' need for and resources available to support SBHCs, political conservatism appears to affect SBHC availability. SBHC advocates can use this information to understand where opportunities for growth might exist, identify collaborative partners, and prepare for challenges to supporting new SBHCs. Researchers may also use this information in evaluation studies to control for school-level confounders and develop appropriate comparison samples through matching procedures.