School Teachers' Perceptions of Adolescent Human Papillomavirus (HPV) Vaccination: A Systematic Review.

School nurses are uniquely positioned to educate students about immunizations, including human papillomavirus (HPV) vaccination, but schools are often without a nurse for different reasons. In lieu of nurses, teachers who closely interact with students and are traditionally well-trusted by parents may be able to communicate about HPV vaccination, alleviating parental vaccine hesitancy. This systematic review explores school teachers' perspectives on adolescent HPV vaccination and factors influencing their willingness to make vaccine recommendations. We searched three databases with appropriate medical subject headings and keywords to identify relevant studies. We reviewed fifteen studies and provided an extensive summary and a comparison of the results across the studies. Teachers had low to moderate levels of HPV knowledge with low self-efficacy to counsel parents about the HPV vaccine and expressed concerns about the vaccine condoning adolescent sexual activity, vaccine side effects, and parental disapproval. Nonetheless, some teachers showed interest in learning about vaccine effectiveness in preventing HPV-associated cancers and wanted guidance on vaccine communication with parents, viewing schools as adequate venues to promote and deliver HPV vaccines. Schools should consider educating teachers on HPV and HPV vaccination, with a focus on effective vaccine communication practices to increase adolescent HPV vaccine uptake.

Lessons Learned from All for Them: Best Practices for a Cross-Collaboration Approach to HPV Vaccination in Public Schools.

The Community Preventive Services Task Force endorses vaccination programs in schools to increase access to vaccinations. However, implementing a school-based approach requires substantial coordination, planning, and resources. All for Them (AFT) is a multilevel, multicomponent approach to increase HPV vaccination among adolescents attending public schools in medically underserved areas in Texas. AFT comprised a social marketing campaign, school-based vaccination clinics, and school nurse continuing education. Process evaluation metrics and key informant interviews to understand experiences with AFT program implementation informed lessons learned. Lessons emerged in six domains: strong champion, school-level support, tailored and cost-effective marketing approaches, mobile provider collaboration, community presence, and crisis management. Strong support at district and school levels is vital for gaining principal and school nurse buy-in. Social marketing strategies are integral to program implementation and should be adjusted to maximize their effectiveness in motivating parents to vaccinate children against HPV, which also can be achieved through increased community presence of the project team. Preparing contingency plans and flexibility within the program can facilitate appropriate responses to provider restrictions in mobile clinics or in the event of unforeseen crises. These important lessons can offer useful guidelines for the development of prospective school-based vaccination programs.

School Parent Attitudes and Perceptions Relating to Animals, Animal-Assisted Interventions, and the Support of Children's Mental Health.

Growing awareness of the negative effects of trauma has led San Antonio, TX, school districts to expand efforts that can help mitigate these effects and support mental health. Given the literature around the psychological benefits of human-animal interactions, the concept of incorporating animals in treatments or interventions is not a new one. While schools have begun considering or utilizing animal-assisted interventions (AAIs), there have been limited efforts to understand existing perceptions relating to animals and AAIs among school parents in this Hispanic community. To address this gap, a cross-sectional study consisting of a 34-item survey was conducted to explore attitudes, knowledge, and perceptions relating to animals (i.e., pets), AAIs, and the need for supporting young children's mental health among parents. A total of 187 surveys from two school districts were completed and utilized for analysis. The study's findings demonstrate that parents acknowledged the importance of addressing mental health issues early on and were aware of the health benefits human-animal interactions can provide. Furthermore, parents had positive attitudes toward pets and positive perceptions toward AAIs in schools. Some implementation concerns were expressed relating to safety and well-being. Overall, these findings suggest there is existing parent support in using AAIs as a trauma-informed strategy and school innovation.

Assessing associations between insecure income and US workers' health: An IPUMS-MEPS analysis.

Gig economy compensation policy initiatives, such as California Prop 22, are increasing the number of US workers receiving piece rate pay (PRP) and other forms of insecure income. However, there is limited evidence about how this trend affects people's health. Using data from the 2008-19 IPUMS Medical Expenditure Panel Survey (MEPS), we examined associations between insecure compensation and US adults' self-reported overall health as well as psychological distress. We report significant associations with three types of insecure income - PRP, hourly, and daily pay - on overall health and psychological distress. These effects were robust to adjustment for suspected confounders, but point estimates suggested that the effect of each type of non-salary compensation differed by sex, level of education, income level, and health insurance coverage. These findings warrant policy makers' consideration as they balance the purported benefits of gig economy non-salary compensated work with implications for workers' health.

Exploring School Staff Perceptions Relating to Animals and Their Involvement in Interventions to Support Mental Health.

Given the growing awareness of the health benefits of human-animal interactions, the use of animal-assisted interventions (AAIs) in educational settings has increased over the years. While many school districts are now considering or utilizing AAIs, the literature investigating AAI-related perceptions among school stakeholders is limited with previous studies focusing on evaluating specific programs. To address this gap, a qualitative exploratory study was conducted using semi-structured interviews with school staff in the San Antonio, TX community. A total of 11 interviews were completed with staff serving preschool and elementary school age children. Data collected from interviews were analyzed using thematic analysis. Findings demonstrated that participating staff had some knowledge of the potential benefits of human-animal interactions and perceived the involvement of animals in interventions to be beneficial to children's emotions and social-emotional skills. While perceptions of AAIs were generally positive, concerns around children's safety and well-being were expressed as potential barriers in the adoption of AAIs in schools. These findings are preliminary and provide a segue to future research that can help expand our understanding of how school staff perceive AAIs, their impact on children's mental health, their compatibility with school values, and their advantage relative to other interventions.

Understanding implementation strategies to support classroom-based physical activity approaches in elementary schools: A qualitative study.

BACKGROUND: Classroom-based physical activity approaches can improve children's physical activity levels during school. However, the implementation of these approaches remains a challenge. The purpose of this study was to examine implementation strategies to support the delivery of classroom-based physical activity approaches from the perspectives of elementary school staff. METHODS: We conducted individual interviews with elementary school staff from a mid-sized school district in Texas. Interviews lasted approximately 60 min and were audio recorded and transcribed for analyses. We used directed content analysis and an iterative categorization approach to identify emerging themes related to implementation strategies. RESULTS: We interviewed 15 participants (4 classroom teachers, 4 physical education teachers, 3 assistant principals, and 4 principals) about implementation strategies supporting classroom-based physical activity approaches. Four prominent themes related to implementation strategies emerged: 1) the role of program champions, 2) the use and function of staff training, 3) the importance of strategic planning, and 4) the use of positive reinforcements to support implementation. CONCLUSIONS: Results highlight the need for multiple implementation strategies to support the delivery of classroom-based physical activity approaches. Results also highlight potential mechanisms through which the implementation strategies operate. This information is valuable to future planning efforts for classroom-based physical activity approaches.

Adolescent Dating Violence Prevention Program for Early Adolescents: The Me & You Randomized Controlled Trial, 2014-2015.

Objectives. To test the efficacy of Me & You, a multilevel technology-enhanced adolescent dating violence (DV) intervention, in reducing DV perpetration and victimization among ethnic-minority early adolescent youths. We assessed secondary impact for specific DV types and psychosocial outcomes.Methods. We conducted a group-randomized controlled trial of 10 middle schools from a large urban school district in Southeast Texas in 2014 to 2015. We used multilevel regression modeling; the final analytic sample comprised 709 sixth-grade students followed for 1 year.Results. Among the total sample, odds of DV perpetration were lower among intervention students than among control students (adjusted odds ratio = 0.46; 95% confidence interval = 0.28, 0.74). Odds of DV victimization were not significantly different. There were significant effects on some specific DV types.Conclusions. Me & You is effective in reducing DV perpetration and decreasing some forms of DV victimization in early middle-school ethnic-minority students.

Replication of It's Your Game Keep It Real! in Southeast Texas.

Despite the recent efforts of the Office of Adolescent Health to replicate programs with demonstrated efficacy, there are still few evidence-based HIV, sexually transmitted infection (STI), and teen pregnancy prevention programs that have been replicated in "real-world" settings. To test the effectiveness of It's Your Game…Keep It Real! (IYG), an evidence-based STI and pregnancy prevention program for middle schools, the curriculum was implemented by teachers in urban and suburban middle schools in Southeast Texas from 2012 to 2015. IYG was evaluated using a group-randomized wait-list controlled effectiveness trial design in which 20 middle schools in nine urban and suburban school districts in Southeast Texas were randomized equally, using a multi-attribute randomization protocol, to either the intervention condition (received IYG) (n = 10 schools comprising 1936 eligible seventh graders) or the comparison condition (received usual care) (n = 10 schools comprising 1825 eligible seventh graders). All students were blinded to condition prior to administering the baseline survey. The analytic sample comprised 1543 students (n = 804, intervention; n = 739, comparison) who were followed from baseline (seventh grade) to the 24-month follow-up (ninth grade). Multilevel regression analyses were conducted to assess behavioral and psychosocial outcomes at follow-up. There were no significant differences in initiation of vaginal or oral sex between study conditions at follow-up. However, at 12-month follow-up, compared with students in the comparison condition, students in the intervention condition reported increased knowledge, self-efficacy, and perceived favorable norms related to HIV/STIs, condoms, and/or abstinence; decreased intentions to have sex; and increased intentions to use birth control. Knowledge outcomes were statistically significant at 24-month follow-up. This IYG effectiveness trial did not replicate the behavioral effects of the original IYG efficacy trials. However, it adds to the growing literature on the replication of evidence-based programs, and underscores the need to better understand how variations in implementation, setting, and measurement affect the behavioral impact of such programs.Clinical trial registration clinicaltrials.gov (NCT03533192).

Racial/ethnic disparities in health-related quality of life and health status across pre-, early-, and mid-adolescence: a prospective cohort study.

PURPOSE: To examine (1) racial/ethnic disparities in health-related quality of life (HRQOL) and overall health status among Black, Latino, and White youth during adolescence; (2) whether socioeconomic status (SES) and family contextual variables influence disparities; and (3) whether disparities are consistent from pre- to early- to mid-adolescence. METHODS: A population sample of 4823 Black (1755), Latino (1812), and White (1256) youth in three US metropolitan areas was prospectively assessed in a longitudinal survey conducted on three occasions, in 5th, 7th, and 10th grades, when youth reported their HRQOL using the PedsQL™ short-form Total, Physical and Psychosocial scales and youth and parents separately reported on youth's overall health status. Parents reported their education and household income to index SES, family structure, and use of English at home. RESULTS: Based on analysis conducted separately at each grade, marked racial/ethnic disparities were observed across all measures of HRQOL and health status, favoring White and disfavoring Black, and especially Latino youth. More strongly present in 5th and 7th grade, HRQOL disparities decreased by 10th grade. Most disparities between White and Black youth disappeared when adjusting for SES. However, even after adjusting for SES, family structure, and English use, overall health status disparities disfavoring Latino youth remained across all three assessments. CONCLUSIONS: Racial/ethnic disparities in adolescent HRQOL and health are substantial. These disparities appear consistent from pre- to early-adolescence but diminish for HRQOL by mid-adolescence. As disparities appear influenced by SES and other family contextual variables differently in different racial/ethnic groups, efforts to reduce health disparities in youth should address culturally specific conditions impinging on health.

Self-reporting discrepancies of bullying victimization and perpetration measures.

PURPOSE: To evaluate the relationship between sociodemographics and the prevalence of bullying victimization and perpetration using single-item and multiple-item measures. METHODS: Longitudinal survey data were obtained from 4297 children at fifth, seventh, and tenth grade in three U.S. cities. Bullying victimization and perpetration were measured in two ways: 1) a single-item recall measure; and 2) a separate multiple-item measure using specific behaviors indicating bullying victimization and perpetration. Multilevel logistic regression modeled the relationship between sociodemographics and bullying, stratified by measurement type. RESULTS: In fifth grade, 4% of children were identified as victims using the single-item approach but not the multiple-item approach, 27% were identified as victims using the multiple-item approach but not the single-item approach, and 17% were identified as victims using both approaches. For perpetration, 3% were identified using the single-item approach but not the multiple-item approach, 18% were identified using the multiple-item and not the single-item approach, and 4% were identified using both approaches. The odds of victimization were significantly lower in seventh and tenth grades than in fifth grade using both approaches. The single-item odds of perpetration were significantly lower in tenth grade than fifth grade, but the multiple-item odds of perpetration significantly increased over time. CONCLUSIONS: Bullying prevalence rates are sensitive to the structure of measures. Future research should identify whether these differences reflect a lack of awareness of types of bullying and/or cognitive variability in answering sensitive survey questions.

Mechanisms and Frequency of Violent Injuries Among Victims and Perpetrators of Bullying.

PURPOSE: This article aims to (1) evaluate whether bullying typology predicts violent injury; (2) longitudinally examine whether violent injury trajectories differ across bullying typology as children age; and (3) longitudinally determine whether children who consistently reported perpetration or victimization (i.e., reported bullying at fifth, seventh, and 10th grade) were different from children who inconsistently reported perpetration or victimization. METHODS: Longitudinal data were obtained from 4,297 children at three waves (fifth, seventh, and 10th grade) in three United States communities. Children were categorized into four mutually exclusive bullying typologies: neither victim nor perpetrator; victim only; perpetrator only; victim-perpetrator. Children self-reported mechanisms of violent injuries that needed medical attention in the past year. Regression models were used to evaluate the relationship between bullying group and the likelihood of violent injury over time. RESULTS: Seventeen percent (n=857) of children in fifth grade reported a violent injury. Prevalence of overall violent injuries, and specifically firearm and knife injuries, increased over time. Children who reported perpetration in the absence of victimization were at increased odds for violent injury (adjusted odds ratio = 1.41, 95% confidence interval: 1.24, 1.60) compared with children who reported neither victimization nor perpetration, while children who reported victimization in the absence of perpetration were at decreased odds (adjusted odds ratio=.84, 95% confidence interval: .73, .97). A significant linear dose-response relationship was observed between duration of bullying perpetration and violent injury. CONCLUSIONS: The relationship between bullying perpetration and violent injury over time was strong. Future research should investigate potential mediating behaviors, such as weapon access, which might explain the observed relationship.

Racial disparities in fifth-grade sun protection: Evidence from the Healthy Passages study.

BACKGROUND/OBJECTIVES: Despite rising skin cancer rates in children, multiple studies reveal inadequate youth sun-protective behavior (eg, sunscreen use). Using Healthy Passages data for fifth-graders, we set out to determine sunscreen adherence in these children and investigated factors related to sunscreen performance. METHODS: Survey data were collected from 5119 fifth-graders and their primary caregivers. Logistic regression was used to assess associations between sunscreen adherence and performance of other preventive health behaviors (eg, flossing, helmet use) and examine predictors of sunscreen adherence. Analyses were repeated in non-Hispanic black, Hispanic, and non-Hispanic white subgroups. RESULTS: Five thousand one hundred nineteen (23.4%) children almost always used sunscreen, 5.9% of non-Hispanic blacks (n = 1748), 23.7% of Hispanics (n = 1802), and 44.8% of non-Hispanic whites (n = 1249). Performing other preventive health behaviors was associated with higher odds of sunscreen adherence (all P < .001), with the greatest association with flossing teeth (odds ratio = 2.41, 95% confidence interval = 1.86-3.13, P < .001). Factors for lower odds of sunscreen adherence included being male and non-Hispanic black or Hispanic and having lower socioeconomic status. School-based sun-safety education and involvement in team sports were not significant factors. CONCLUSION: Our data confirm low use of sun protection among fifth-graders. Future research should explore how public health success in increasing prevalence of other preventive health behaviors may be applied to enhance sun protection messages. Identifying risk factors for poor adherence enables providers to target patients who need more education. Improving educational policies and content in schools may be an effective way to address sun safety.

Unequal interactions: Examining the role of patient-centered care in reducing inequitable diffusion of a medical innovation, the human papillomavirus (HPV) vaccine.

RATIONALE: Studies of inequities in diffusion of medical innovations rarely consider the role of patient-centered care. OBJECTIVE: We used uptake of the human papillomavirus (HPV) vaccine shortly after its licensing to explore the role of patient-centered care. METHODS: Using a longitudinal multi-site survey of US parents and adolescents, we assessed whether patient-centered care ratings might shape racial/ethnic and socioeconomic gaps at two decision points in the HPV vaccination process: (1) Whether a medical provider recommends the vaccine and (2) whether a parent decides to vaccinate. RESULTS: We did not find evidence that the association of patient-centeredness with vaccination varies by parent education. In contrast, parent ratings of providers' patient-centeredness were significantly associated with racial/ethnic disparities in parents' reports of receiving a HPV vaccine recommendation from a provider: Among parents who rate patient-centered care as low, white parents' odds of receiving such a recommendation are 2.6 times higher than black parents' odds, but the racial/ethnic gap nearly disappears when parents report high patient-centeredness. Moderated mediation analyses suggest that patient-centeredness is a major contributor underlying vaccination uptake disparities: Among parents who report low patient-centeredness, white parents' odds of vaccinating their child are 8.1 times higher than black parents' odds, while both groups are equally likely to vaccinate when patient-centeredness is high. CONCLUSION: The results indicate that patient-centered care, which has been a relatively understudied factor in the unequal diffusion of medical innovations, deserves more attention. Efforts to raise HPV vaccination rates should explore why certain patient groups may be less likely to receive recommendations and should support providers to consistently inform all patient groups about vaccination.

iCHAMPSS: Usability and Psychosocial Impact for Increasing Implementation of Sexual Health Education.

INTRODUCTION: Diffusion of sexual health evidence-based programs (EBPs) in schools is a complex and challenging process. iCHAMPSS ( CHoosing And Maintaining effective Programs for Sex education in Schools) is an innovative theory- and Web-based decision support system that may help facilitate this process. The purpose of this study was to pilot-test iCHAMPSS for usability and short-term psychosocial impact. METHOD: School district stakeholders from across Texas were recruited ( N = 16) and given access to iCHAMPSS for 3 weeks in fall 2014. Pre- and posttests were administered to measure usability parameters and short-term psychosocial outcomes. Data were analyzed using descriptive statistics and the Wilcoxon signed-rank test. RESULTS: Most participants reported that iCHAMPSS was easy to use, credible, helpful, and of sufficient motivational appeal. iCHAMPSS significantly increased participants' self-efficacy to obtain approval from their board of trustees to implement a sexual health EBP. Positive, though nonsignificant, trends included increased knowledge to locate EBPs, skills to prioritize sexual health education at the district level, and ability to choose an EBP that best meets district needs. CONCLUSIONS: iCHAMPSS is an innovative decision support system that could accelerate uptake of EBPs by facilitating diffusion and advance the field of dissemination and implementation science for the promotion of sexual health EBPs.

The Association Between Familial Homelessness, Aggression, and Victimization Among Children.

PURPOSE: The purpose of this study was to evaluate the relationship between the number of periods children were exposed to familial homelessness and childhood aggression and victimization. METHODS: Survey data were obtained from 4,297 fifth-grade children and their caregivers in three U.S. cities. Children and primary caregivers were surveyed longitudinally in 7th and 10th grades. Family homelessness, measured at each wave as unstable housing, was self-reported by the caregiver. Children were categorized into four mutually exclusive groups: victim only, aggressor only, victim-aggressor, and neither victim nor aggressor at each time point using validated measures. Multinomial, multilevel mixed models were used to evaluate the relationship among periods of homelessness and longitudinal victimization, aggression, and victim aggression compared to children who were nonvictims and nonaggressors. RESULTS: Results suggest that children who experienced family homelessness were more likely than domiciled children to report aggression and victim aggression but not victimization only. Multivariate analyses suggested that even brief periods of homelessness were positively associated with aggression and victim aggression (relative to neither) compared to children who were never homeless. Furthermore, childhood victimization and victim aggression significantly decreased from 5th grade to 10th grade while aggression significantly increased in 10th grade. CONCLUSIONS: Children who experienced family homelessness for brief periods of time were significantly more likely to be a victim-aggressor or aggressor compared to those who were never homeless. Prevention efforts should target housing security and other important factors that may reduce children's likelihood of aggression and associated victimization.

Firearm Ownership and Acquisition Among Parents With Risk Factors for Self-Harm or Other Violence.

OBJECTIVE: Recent policy initiatives aiming to reduce firearm morbidity focus on mental health and illness. However, few studies have simultaneously examined mental health and behavioral predictors within families, or their longitudinal association with newly acquiring a firearm. METHODS: Population-based, longitudinal survey of 4251 parents of fifth-grade students in 3 US metropolitan areas; 2004 to 2011. Multivariate logistic models were used to assess associations between owning or acquiring a firearm and parent mental illness and substance use. RESULTS: Ninety-three percent of parents interviewed were women. Overall, 19.6% of families reported keeping a firearm in the home. After adjustment for confounders, history of depression (adjusted odds ratio [aOR], 1.36; 95% confidence interval [CI], 1.04-1.77), binge drinking (aOR 1.75; 95% CI, 1.14-2.68), and illicit drug use (aOR 1.75; 95% CI, 1.12-2.76) were associated with a higher likelihood of keeping a firearm in the home. After a mean of 3.1 years, 6.1% of parents who did not keep a firearm in the home at baseline acquired one by follow-up and kept it in the home (average annual likelihood = 2.1%). No risk factors for self-harm or other violence were associated with newly acquiring a gun in the home. CONCLUSIONS: Families with risk factors for self-harm or other violence have a modestly greater probability of having a firearm in the home compared with families without risk factors, and similar probability of newly acquiring a firearm. Treatment interventions for many of these risk factors might reduce firearm-related morbidity.

Relationship Between Adolescent Report of Patient-Centered Care and of Quality of Primary Care.

OBJECTIVE: Few studies have examined adolescent self-report of patient-centered care (PCC). We investigated whether adolescent self-report of PCC varied by patient characteristics and whether receipt of PCC is associated with measures of adolescent primary care quality. METHODS: We analyzed cross-sectional data from Healthy Passages, a population-based survey of 4105 10th graders and their parents. Adolescent report of PCC was derived from 4 items. Adolescent primary care quality was assessed by measuring access to confidential care, screening for important adolescent health topics, unmet need, and overall rating of health care. We conducted weighted bivariate analyses and multivariate logistic regression models of the association of PCC with adolescent characteristics and primary care quality. RESULTS: Forty-seven percent of adolescents reported that they received PCC. Report of receiving PCC was associated with high quality for other measures, such as having a private conversation with a clinician (adjusted odds ratio [aOR] 2.2; 95% confidence interval [CI] [1.9, 2.6]) and having talked about health behaviors (aOR 1.6; 95% CI 1.4, 1.8); it was also associated with lower likelihood for self-reported unmet need for care (aOR 0.8; 95% CI 0.7, 0.9) and having a serious untreated health problem (aOR 0.4; 95% CI 0.3, 0.5). CONCLUSIONS: Many adolescents do not report receiving PCC. Adolescent-reported PCC positively correlates with measures of high-quality adolescent primary care. Our study provides support for using adolescent-report of PCC as a measure of adolescent primary care quality.

Gender role orientation is associated with health-related quality of life differently among African-American, Hispanic, and White youth.

PURPOSE: This study examined the association between gender role orientation (GRO) and health-related quality of life (HRQOL) in youth, and how this relationship may differ between males and females as well as among African-American, White, and Hispanic individuals. GRO has been reported to influence serious health outcomes including cancer, heart disease, mental illness, and mortality rates. However, few studies have examined the link between GRO and health outcomes for children, even though gender identity is formed in childhood. METHODS: Data were examined from 4824 participants in the Healthy Passages™ project, a population-based survey of fifth-grade children in three US metropolitan areas. Children reported their own HRQOL using the PedsQL and degree of female, male, and androgynous GRO using the Children's Sex Role Inventory. RESULTS: Based on structural equations analysis, male GRO was positively associated with HRQOL for all racial/ethnic groups, regardless of sex, whereas female GRO was associated with better HRQOL for Hispanic and White females and poorer HRQOL for Hispanic males. Androgynous GRO was associated with better HRQOL among Hispanic and White females, but not males nor African-Americans of either sex. CONCLUSIONS: Racial/ethnic differences emerged for female and androgynous, but not male, GROs. Hispanic males are the only group for which GRO (female) was associated with poorer HRQOL. Future research should find ways to help youth overcome negative effects on health from gender beliefs and behavior patterns with sensitivity to racial/ethnic membership.

Daily violent video game playing and depression in preadolescent youth.

Most studies on the impact of playing violent video games on mental health have focused on aggression. Relatively few studies have examined the relationship between playing violent video games and depression, especially among preadolescent youth. In this study, we investigated whether daily violent video game playing over the past year is associated with a greater number of depressive symptoms among preadolescent youth, after controlling for several well-known correlates of depression among youth. We analyzed cross-sectional data collected from 5,147 fifth-grade students and their primary caregivers who participated in Wave I (2004-2006) of Healthy Passages, a community-based longitudinal study conducted in three U.S. cities. Linear regression was conducted to determine the association between violent video game exposure and number of depressive symptoms, while controlling for gender, race/ethnicity, peer victimization, witnessing violence, being threatened with violence, aggression, family structure, and household income level. We found that students who reported playing high-violence video games for ≥2 hours per day had significantly more depressive symptoms than those who reported playing low-violence video games for <2 hours per day (p<0.001). The magnitude of this association was small (Cohen's d=0.16), but this association was consistent across all racial/ethnic subgroups and among boys (Cohen's d values ranged from 0.12 to 0.25). Our findings indicate that there is an association between daily exposure to violent video games and number of depressive symptoms among preadolescent youth. More research is needed to examine this association and, if confirmed, to investigate its causality, persistence over time, underlying mechanisms, and clinical implications.

Tobacco use and smoking intentions among U.S. fifth-grade students.

PURPOSE: To identify the risk and protective factors for cigarette smoking and future intentions among racially/ethnically diverse preadolescent children. METHODS: We analyzed data from 5,119 fifth-grade children and their parents living in three U.S. metropolitan areas. Using the multivariate logistic regression models, we examined how cigarette smoking and intentions to smoke within 1 year are associated with (1) number of friends who smoke, (2) parental disapproval of smoking, (3) parental communication about not smoking, (4) performance in school, and (5) educational aspirations. RESULTS: Twenty-nine percent of the children were black, 44% were Hispanic, 22% were white, and 5% were of another race/ethnicity. Mean age was 11.1 years. The prevalence of ever smoking a cigarette among black, Hispanic, and white children was 9.8%, 5.6%, and 4.9%, respectively. In adjusted analyses, children were more likely to have smoked a cigarette if their friends smoked (adjusted odds ratio [aOR] 5.1, 95% confidence interval [CI] 3.8-6.9), they frequently had trouble with schoolwork (aOR 2.1, 95% CI 1.5-3.1), or their parents were not college graduates (aOR 2.0, 95% CI 1.2-3.5 for high school graduate). They were less likely to have smoked cigarettes if their parents disapproved of smoking (aOR .3, 95% CI .1-.6). Parental communication (aOR .1, 95% CI .0-.6) and disapproval (aOR .2, 95% CI .1-.7) had protective associations for future intentions among children who had ever and had never smoked, respectively. CONCLUSIONS: Fifth-graders share many of the same risk factors for smoking identified in older adolescents, some of which are modifiable. Antismoking policies and programs should be designed for preadolescents as well as adolescents, and campaigns targeting parents should place greater emphasis on communication and expressed disapproval of smoking.