Readiness to implement screening, brief intervention, and referral to treatment in school-based health centers.

The purpose of this study was to evaluate the readiness of a university-based school-based health center (SBHC) program to implement the screening, brief intervention, and referral to treatment (SBIRT) model. We completed preimplementation surveys and interviews with providers, staff, and administrators at participating SBHCs (N = 19) to measure current protocols for and barriers to addressing adolescent substance use and barriers and facilitators to implementing SBIRT. We used the R = MC2 heuristic (readiness equals motivation, general organizational capacity, and innovation-specific capacity) to interpret findings from the data. Using the R = MC2 heuristic, we identified factors that may aid implementation, including the prioritization of substance use and a supportive organizational culture, as well as potential barriers, including competing high-priority health issues and a lack of resources for innovation. This study contributes to the emerging literature on the implementation of the SBIRT model with adolescents and in SBHCs and demonstrates the practical applicability of the R = MC2 heuristic for assessing implementation readiness. SBHCs are ideal locations for addressing substance use but SBHC providers also face unique challenges when implementing the SBIRT model.

School Nursing Workforce Differences Between Urban and Non-Urban Areas: Implications for School Health Services and Equity.

The professional experiences of school nurses who work outside of urban areas are not often described. We used data from a 2019 statewide survey of school nurses to describe differences between the urban and non-urban (urban cluster and rural) school nurse workforce in New Mexico. Non-urban school nurses were twice as likely as urban nurses to provide clinical services to multiple school campuses (P < .001) and more likely to serve both elementary and secondary school settings (P = .002). They were less likely than urban school nurses to be bachelor's prepared, or to have received recent continuing education on diabetes (P < .001), reproductive health (P = 0.02), LGBQ+ and transgender student health (P < .001, for each), and suicide risk assessment and screening (P = .012). Our findings underscore concerns about geographic differences in the school nursing workforce in terms of educational preparation and student access that could potentially limit the school nurse role in advancing child health equity.

School Nurse Management of Behavioral Health, Violence, and Trauma-Related Emergencies: Findings from a Statewide Survey.

School nurses are critical components of school-based interdisciplinary teams supporting student behavioral health. The purpose of the present study is to understand the extent to which school nurses in New Mexico across grade levels manage emergencies related to behavioral health, violence, and trauma. The study also seeks to identify which topics the school nurses received continuing education (CE) for, and which topics they consider to be important to their practice. Analyses of 2019 statewide survey data show a considerable number of school nurses in New Mexico provide management for behavioral health, violence, and trauma-related emergencies, and nurses in secondary schools are significantly more likely than nurses in primary schools to report managing these emergencies and to have received CE on behavioral health topics. Our findings reaffirm the essential role of school nurses in addressing emergent student health issues and underscore the need for practice- and competency-based behavioral health CE opportunities.

Associations Between Maternity Care Practices and 2-Month Breastfeeding Duration Vary by Race, Ethnicity, and Acculturation.

Objectives This study examines the associations between specific maternity care practices and breastfeeding duration for Spanish-speaking Hispanic, English-speaking Hispanic, non-Hispanic Native American, and non-Hispanic White women. Methods We analyzed data from the 2012-2014 New Mexico Pregnancy Risk Assessment Monitoring System. We used survey language as a proxy measure of acculturation and categorized women as Spanish-speaking Hispanic, English-speaking Hispanic, non-Hispanic Native American, and non-Hispanic White. We conducted bivariate analyses to compare rates of breastfeeding at 2 months and experiences of maternity care practices and logistic regression analysis to estimate the effects of these practices on breastfeeding duration for each group. Results Hispanic women were less likely than non-Hispanic women to breastfeed for at least 2 months (67.9% vs. 76.6%; p = 0.000); however, this varied significantly by acculturation level: 78.1% of Spanish-speaking Hispanic women compared to 66.1% of English-speaking Hispanic women breastfed for at least 2 months (p = 0.000). The effects of specific maternity care practices on duration varied across groups. Among non-Hispanic White, Native American, and English-speaking Hispanic women, breastfeeding while at the hospital had the strongest effect (AOR 2.09, 95% CI 1.67-2.61; AOR 2.71, 95% CI 2.08-3.52; and AOR 1.99, 95% CI 1.76-2.25, respectively). Among Spanish-speaking Hispanic women, being encouraged to breastfeed on demand had the strongest effect (AOR 5.179, 95% CI 3.86-6.94). Conclusions for Practice The effects of maternity care practices on breastfeeding duration vary by race, ethnicity, and acculturation level. Health care systems must acknowledge the diversity of their patient populations when seeking to develop and implement breastfeeding-friendly practices.

A clinical instrument to guide brief interventions for adolescents with substance use concerns.

BACKGROUND: Adolescent substance use is an important public health problem in New Mexico and the United States. The New Mexico Department of Health school-based health centers (SBHCs) universally administer a validated screen, the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble), for adolescent substance use concerns; however, quality assurance efforts revealed that SBHC providers needed more information at the point of screening to initiate brief interventions for students with positive CRAFFT screens. The CHISPA (Cocaine, Heroin, IV drugs, Synthetic pot, Pot, Alcohol) was developed to gather specific information on recent substance use experience to guide brief interventions. This paper describes the development and initial reliability and validity of data obtained using the CHISPA instrument. METHODS: In 2015, 99 high school-aged SBHC users in Albuquerque, New Mexico, completed the CRAFFT and CHISPA twice over 2 weeks using standard test-retest methods. Using the CHISPA, students reported for the prior 3 months substances used, frequency of use, and signs of addiction or acute danger (adverse events). RESULTS: Retest reliability for the CRAFFT score was 0.82. CHISPA retest reliabilities were 0.75 for alcohol use; 0.91 for having used any substances; 0.92 for number of substances used; 0.81 for frequency of substance use; and 0.79 for number of adverse events. CRAFFT scores correlated with CHISPA measures of number of substances used at 0.62; with frequency of substance use at 0.58; and with number of adverse events at 0.64. CONCLUSIONS: CHISPA measures show preliminary evidence of reliability and validity. SBHC providers and other providers in primary care settings who use the CRAFFT screen may benefit from using the CHISPA to define recent substance use experience to guide brief interventions for adolescents with substance use concerns. The CHISPA instrument is currently being tested in electronic form in selected SBHCs in the state of New Mexico.

Adolescent substance use: Assessing the knowledge, attitudes, and practices of a school-based health center workforce.

BACKGROUND: Recent attention has focused on the potential for school-based health centers (SBHCs) to provide access points for adolescent substance use care. In 2015, the University of New Mexico began screening, brief intervention, and referral to treatment (SBIRT) training for providers at New Mexico Department of Health (NMDOH)-funded SBHCs across the state. This study assesses baseline knowledge, attitudes, and practices of the New Mexico SBHC provider workforce regarding adolescent substance use and provision of services. METHODS: In early 2015, the NMDOH administered an SBHC provider workforce survey (N = 118) and achieved a 44.9% response rate. This descriptive analysis includes all survey respondents who self-identified as a primary care or behavioral health provider in an SBHC serving middle or high school students (n = 52). RESULTS: Among respondents, the majority (57.7%) were primary care providers, including nurse practitioners, physicians, and physician assistants. The remaining 42.3% of respondents were master's-level behavioral health providers. Only 44.2% of providers reported practicing the full SBIRT model at their SBHC, and 21.2% reported having received continuing education on SBIRT within the previous 3 years. Most respondents, 84.6%, agreed that it is the responsibility of SBHC providers to screen students for substance use using a standardized tool, and 96.2% agreed that it is the responsibility of the SBHC provider to assess for students' readiness to change. A majority reported self-efficacy in helping students achieve change in their alcohol use, illicit drug use, and prescription drug misuse: 73.1%, 65.4%, and 63.5%, respectively. CONCLUSIONS: These results suggest that SBIRT training for New Mexico SBHC providers is timely. The authors identified gaps between recommended SBIRT practices and SBIRT delivery as well as discrepancies between reported provider self-efficacy and actual implementation of the SBIRT model. Further study will determine the effectiveness of efforts to address substance use and implement SBIRT in SBHCs.

Outer-context determinants on the implementation of school-based interventions for LGBTQ+ adolescents.

Background: Schools are critical venues for supporting LGBTQ+ youth well-being. Implementing LGBTQ-supportive practices can decrease experiences of stigmatization, discrimination, and victimization that lead to adverse mental health outcomes like anxiety, depression, and suicidality. However, schools are also subject to a wide range of outer-context pressures that may influence their priorities and implementation of LGBTQ-supportive practices. We assessed the role of emergent outer-context determinants in the context of a 5-year cluster randomized controlled trial to study the implementation of LGBTQ-supportive evidence-informed practices (EIPs) in New Mexico high schools. Method: Using an iterative coding approach, we analyzed qualitative data from annual interviews with school professionals involved in EIP implementation efforts. Results: The analysis yielded three categories of outer-context determinants that created challenges and opportunities for implementation: (a) social barriers related to heterocentrism, cisgenderism, and religious conservatism; (b) local, state, and national policy and political discourse; and (c) crisis events. Conclusions: By exploring the implications of outer-context determinants for the uptake of LGBTQ-supportive practices, we demonstrate that these elements are dynamic-not simply reducible to barriers or facilitators-and that assessing outer-context determinants shaping implementation environments is crucial for addressing LGBTQ health equity.

High schools are critical to supporting youth who identify as lesbian, gay, bisexual, transgender, and queer or of other diverse sexualities and gender identities (LGBTQ+). The use of supportive practices in schools can help reduce experiences of stigmatization, discrimination, and victimization that lead to negative mental health outcomes like anxiety, depression, and suicidality. However, schools' ability to implement new practices is heavily influenced by forces stemming from their surrounding communities and broader society. These outer-context factors and their impact on implementation are generally understudied compared to factors considered to be squarely a part of schools. This article examines the role of outer-context factors, such as structurally-based social barriers, policy and political discourse, and crisis events, on the implementation of six evidence-informed practices (EIPs) intended to make schools safer and more supportive of LGBTQ+ youth. We find that while stigma, politics, and crises can undermine efforts within schools to improve their support and services, these same factors sometimes create opportunities, including renewed interest or urgency for addressing student needs. This article encourages implementation science researchers and practitioners to think through and plan for the ways that outer-context factors impact schools and other institutional settings, including using adaptable implementation frameworks and multilevel implementation strategies.

Associations Between Nonsuicidal Self-Injury and School-Based Health-Promotive Factors for Sexual and Gender Minority Youth and Their Peers.

Purpose: The purpose of this study was to identify associations between school-based, health-promotive factors and nonsuicidal self-injury (NSSI) for sexual and gender minority youth and their heterosexual and cisgender peers. Methods: Using data from the 2019 New Mexico Youth Risk and Resiliency Survey (N = 17,811) and multilevel logistic regression to account for school-based clustering, we compared the effect of four school-based health-promotive factors on NSSI for stratified samples of lesbian/gay, bisexual, and gender-diverse (hereafter, gender minority [GM]) youth. Interactions were examined to evaluate the impact of school-based factors on NSSI for lesbian/gay, bisexual, (compared with heterosexual) and GM (compared with cisgender) youth. Results: Stratified analyses showed that three school-based factors (adult at school who listens, adult at school who believes they will be successful, clear school rules) were associated with lower odds of reporting NSSI for lesbian/gay and bisexual youth, but not GM youth. Interaction effects showed that lesbian/gay youth demonstrated greater reductions in odds of NSSI when reporting school-based supports compared with heterosexual youth. Associations between school-based factors and NSSI were not significantly different for bisexual compared with heterosexual youth. GM youth appear to experience no health-promotive effect on NSSI of school-based factors. Conclusions: Our findings underscore the potential of schools to provide supportive resources that reduce the odds of NSSI for most youth (i.e., heterosexual and bisexual youth), but are particularly effective in reducing NSSI among lesbian/gay youth. However, more study is needed to understand the potential impact of school-based health-promotive factors on NSSI for GM youth.

Positive Trends in School-Based Practices to Support LGBTQ Youth in the United States Between 2010 and 2018.

PURPOSE: The present study tests the hypothesis that there has been a significant increase in the implementation of six LGBTQ-supportive school practices in US states between 2010 and 2018. METHODS: Data were drawn from the publicly available School Health Profiles reports published by the Centers for Disease Control and Prevention, Division of Adolescent and School Health. We conducted unadjusted linear regression models separately for each practice to examine state-specific linear trends in the percentage of secondary schools reportedly engaging in six LGBTQ-supportive practices across all 50 states. In addition, we conducted an unadjusted linear regression on the trend to estimate changes in the median percentage of schools across all states engaging in each of the six practices through time. RESULTS: In 2010, 5.7% of schools reported implementing all six practices, which increased to 15.3% in 2018. In the period from 2010 to 2018, the implementation of four of six key practices increased significantly in more than half of US states. Most states experienced a mix of either increases in practices or no change in practice prevalence, with no state experiencing a significant decrease. DISCUSSION: There have been significant gains in the percentage of schools implementing LGBTQ-supportive practices. Yet, despite increases in the examined practices, the median percentage of schools in the United States that implement all six remains low. There is considerable room to improve on the use of these practices in schools across the United States, including increased attention to the quality of implementation and the barriers and facilitators to their instantiation.

Immigration status, acculturation, and dating violence risk for Hispanic adolescent girls in New Mexico.

Little data exist on dating violence experienced by immigrant Hispanic adolescents. The present study examined the relationships between immigration status, language spoken at home, and dating violence experienced by Hispanic adolescent girls in New Mexico. Data from the 2007 New Mexico Youth Risk and Resiliency Surveys were analyzed. Adjusted logistic regression analyses were conducted among the full sample of Hispanic females (N = 3,412) and among strata based on immigration status. Immigrant Hispanic girls were as likely as non-immigrant Hispanic girls to have experienced dating violence in the prior year (P = 0.93). Among immigrant Hispanic girls, those who were Non-English-dominant were one-fourth as likely to have experienced dating violence as those immigrant girls who were English-dominant (aOR 0.27 [95% CI 0.08-0.87]). Among US-born Hispanic girls, those who were Non-English-dominant were less likely to have experienced dating violence; however, this value did not reach statistical significance (aOR 0.65 [95% CI 0.33-1.27]). Past sexual experience was a significant risk factor for dating violence for US-born Hispanic girls (aOR 4.99 [95% CI 3.18-7.83]) but not for immigrant Hispanic girls (aOR 1.66 [95% CI 0.63-4.43]). Immigrant status was not found to be protective against dating violence for New Mexico Hispanic girls. However, those immigrant girls who were less acculturated in terms of language used at home were found to have only a quarter of the risk of dating violence as those more acculturated. The use of heritage language by immigrant Hispanic girls may be a protective factor against dating violence. Further studies are indicated to confirm this finding.

Amplification of school-based strategies resulting from the application of the dynamic adaptation process to reduce sexual and gender minority youth suicide.

BACKGROUND: Evidence-informed practices (EIPs) are imperative to increase school safety for lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) students and their peers. Recently, the Expert Recommendations for Implementing Change (ERIC), a taxonomy of discrete implementation strategies used in health care settings, was adapted for schools. The School Implementation Strategies, Translating the ERIC Resources (SISTER) resulted in 75 discrete implementation strategies. In this article, we examine which SISTER strategies were used to implement six EIPs to reduce suicidality among LGBTQ high school students. We applied the dynamic adaptation process (DAP), a phased, data-driven implementation planning process, that accounts for adaptation while encouraging fidelity to the core elements of EIPs. METHODS: Qualitative data derived from 36 semi-structured interviews and 16 focus groups conducted with school professionals during the first of a 3-year effort to implement EIPs in 19 high schools. We undertook iterative comparative analysis of these data, mapping codes to the relevant domains in the SISTER. We then synthesized the findings by creating a descriptive matrix of the SISTER implementation strategies employed by schools. RESULTS: We found that 20 SISTER strategies were encouraged under the DAP, nine of which were amplified by school personnel. Nine additional SISTER strategies not specifically built into the DAP were implemented independently by school personnel, given the freedom the DAP provided, resulting in a total of 29 SISTER strategies. CONCLUSION: This study offers insight into how schools select and elaborate implementation strategies. The DAP fosters freedom to expand beyond study-supported strategies. Qualitative data illuminate motives for strategy diversification, such as improving EIP fit. Qualitative methods allow for an in-depth illustration of the strategies that school personnel enacted in their efforts to implement the EIPs. We discuss the utility of the DAP in supporting EIP implementation to reduce disparities for LGBTQ students. PLAIN LANGUAGE ABSTRACT: Implementation science is, in part, concerned with implementation strategies, which are actions made to bridge implementation gaps between evidence-informed practices and the contexts in which practices are to be used. Implementation experts compiled a list of strategies for promoting the use of new practices in school settings. The authors of this article examine which implementation strategies in this list were promoted by the research team and which were employed independently by school personnel. Our results illustrate how school personnel applied strategies based on the conditions and needs of their individual schools. These results will contribute to knowledge about implementation strategies and improve readiness by building in strategies implementation teams will use. The authors conducted interviews and focus groups with school personnel involved in implementing six evidence-informed practices for reducing suicidality and other negative outcomes for lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) high school students. Findings are from the end of the first year of implementation and provide a glimpse into how and why certain implementation strategies were employed by school personnel to facilitate adoption of the practices. Findings describe how they applied these strategies in communities where LGBTQ people were marginalized and where anti-LGBTQ stigma influenced policies and resulted in barriers to implementation. This article contributes to efforts to identify and tailor implementation strategies that can encourage the use of evidence-informed practices to improve the well-being of LGBTQ youth and other health disparity populations.

Inspections of hand washing supplies and hand sanitizer in public schools.

Hand washing and hand antisepsis are proven infection control measures in the school setting, yet barriers such as lack of soap, paper towels, and hand sanitizer can hinder compliance. This pilot study measured the prevalence of hand cleaning supplies in public schools. Ten school districts (93 schools) participated in school nurse inspections. In November 2008, 90 schools (97%) reported their inspection results. Among 697 total bathrooms, 88.8% had soap and 91.7% had paper towels or hand dryers. Hand sanitizer was reported in 1.2% of bathrooms and 15.2% of cafeterias. No difference was observed between boys' and girls' bathrooms, or primary and secondary schools, in the prevalence of soap or paper towels/hand dryers. Hand washing supplies were generally available in public school bathrooms. Alcohol-based hand sanitizer in school bathrooms was reported occasionally and should be discouraged. Hand sanitizer in a supervised setting, the school cafeteria, was not often reported and should be promoted.

Missed Opportunities in the Outpatient Pediatric Setting to Support Breastfeeding: Results From a Mixed-Methods Study.

INTRODUCTION: Outpatient pediatric providers play a crucial role in the promotion of breastfeeding. We conducted a mixed methods study to measure provider knowledge, attitudes, and current practices around breastfeeding counseling. METHOD: In New Mexico in 2016 and 2017, we conducted a knowledge, attitudes, and practice survey of outpatient pediatric providers (i.e., nurse practitioners, physicians, and physician assistants) and conducted focus groups with outpatient pediatric providers. RESULTS: Seventy-seven providers responded to the survey, and 17 participated in three focus groups. Fewer than half of providers surveyed reported asking how long mothers plan to breastfeed at initial well-baby examinations. One quarter of participants (28.2%) erroneously reported that hepatitis C was an absolute contraindication to breastfeeding. Just half of respondents had received continuing education within the past 3 years about managing common breastfeeding problems. DISCUSSION: We identified missed opportunities for outpatient pediatric providers to support breastfeeding and a need for continuing provider education.

Epidemic dengue and dengue hemorrhagic fever at the Texas-Mexico border: results of a household-based seroepidemiologic survey, December 2005.

A dengue-2 epidemic causing dengue hemorrhagic fever (DHF) occurred in the contiguous border cities of Matamoros, Tamaulipas (Mexico), and Brownsville, TX, in 2005. In December, we conducted a household-based epidemiologic survey to determine the incidence and seroprevalence of dengue infection among Matamoros and Brownsville residents and to identify risk factors associated with infection. Antibodies to dengue were measured in 273 individuals. The estimated incidence of recent dengue infection was 32% and 4% among Matamoros and Brownsville participants, respectively. The estimated prevalence of past dengue infection was 77% and 39% among Matamoros and Brownsville participants, respectively. The Breteau index was 28 in Matamoros and 16 in Brownsville, reflecting an abundant winter population of Aedes mosquitoes. Discarded waste tires and buckets were the two largest categories of infested containers found in both cities. Our results underscore the risk for epidemic dengue and DHF in the Texas-Mexico border region.

Factors Impacting Implementation of Evidence-Based Strategies to Create Safe and Supportive Schools for Sexual and Gender Minority Students.

PURPOSE: The Centers for Disease Control and Prevention recommends six evidence-based strategies to improve safety and support for sexual and gender minority (SGM) youth in U.S. schools. However, only a small minority of schools implement all strategies. This study draws on implementation science to assess contextual challenges to strategy implementation. METHODS: Semistructured interviews were conducted with at least two stakeholders at each of 42 high schools in New Mexico. Interviews consisted of open-ended questions centered on attitudes toward, access to, and availability of school and community supports for SGM youth, school policies, and practices, and organizational factors believed to impact implementation. Transcripts were imported into NVivo 11 for iterative coding and qualitative analysis. RESULTS: We identified eleven overarching sets of factors related to the preparedness of schools to implement the evidence-based strategies: (1) political climate; (2) community context; (3) community resources; (4) policies and practices; (5) staff knowledge and exposure to SGM issues; (6) training deficits; (7) prevalence of neutrality discourses suggesting SGM students should not be singled out for "special treatment" or intervention; (8) student attitudes and support; (9) de facto safe spaces; (10) health education curricula; and (11) pragmatic considerations, such as time, staff turnover, and workloads. Key factors believed to hinder implementation included lack of resources, staffing concerns, and knowledge deficits. CONCLUSIONS: These results can be used to inform the development of implementation strategies to modify school health systems from within to best support evidence-based practices for SGM youth and other stigmatized populations.

Measuring Unmet Needs for Anticipatory Guidance Among Adolescents at School-Based Health Centers.

PURPOSE: Our previously validated Youth Engagement with Health Services survey measures adolescent health care quality. The survey response format allows adolescents to indicate whether their needs for anticipatory guidance were met. Here, we describe the unmet needs for anticipatory guidance reported by adolescents and identify adolescent characteristics related to unmet needs for guidance. METHODS: We administered the survey in 2013-2014 to 540 adolescents who used school-based health centers in Colorado and New Mexico. A participant was considered to have unmet needs for anticipatory guidance if they indicated that guidance was needed on a given topic but not received or guidance was received that did not meet their needs. We calculated proportions of students with unmet needs for guidance and examined associations between unmet needs for guidance and participant characteristics using the chi-square test and logistic regression. RESULTS: Among participants, 47.4% reported at least one unmet need for guidance from a health care provider in the past year. Topics with the highest proportions of adolescents reporting unmet needs included healthy diet (19.5%), stress (18.0%), and body image (17.0%). In logistic regression modeling, adolescents at risk for depression and those with minority or immigrant status had increased unmet needs for guidance. Adolescents reporting receipt of patient-centered care were less likely to report unmet needs for guidance. CONCLUSIONS: The Youth Engagement with Health Services survey provides needs-based measurement of anticipatory guidance received that may support targeted improvements in the delivery of adolescent preventive counseling. Interventions to improve patient-centered care and preventive counseling for vulnerable youth populations may be warranted.

Implementing school nursing strategies to reduce LGBTQ adolescent suicide: a randomized cluster trial study protocol.

BACKGROUND: Reducing youth suicide in the United States (U.S.) is a national public health priority, and lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) youth are at elevated risk. The Centers for Disease Control and Prevention (CDC) endorses six evidence-based (EB) strategies that center on meeting the needs of LGBTQ youth in schools; however, fewer than 6 % of U.S. schools implement all of them. The proposed intervention model, "RLAS" (Implementing School Nursing Strategies to Reduce LGBTQ Adolescent Suicide), builds on the Exploration, Preparation, Implementation, and Sustainment (EPIS) conceptual framework and the Dynamic Adaptation Process (DAP) to implement EB strategies in U.S. high schools. The DAP accounts for the multilevel context of school settings and uses Implementation Resource Teams (IRTs) to facilitate appropriate expertise, advise on acceptable adaptations, and provide data feedback to make schools implementation ready and prepared to sustain changes. METHODS/DESIGN: Mixed methods will be used to examine individual, school, and community factors influencing both implementation process and youth outcomes. A cluster randomized controlled trial will assess whether LGBTQ students and their peers in RLAS intervention schools (n = 20) report reductions in suicidality, depression, substance use, bullying, and truancy related to safety concerns compared to those in usual care schools (n = 20). Implementation progress and fidelity for each EB strategy in RLAS intervention schools will be examined using a modified version of the Stages of Implementation Completion checklist. During the implementation and sustainment phases, annual focus groups will be conducted with the 20 IRTs to document their experiences identifying and advancing adaptation supports to facilitate use of EB strategies and their perceptions of the DAP. DISCUSSION: The DAP represents a data-informed, collaborative, multiple stakeholder approach to progress from exploration to sustainment and obtain fidelity during the implementation of EB strategies in school settings. This study is designed to address the real-world implications of enabling the use of EB strategies by school nurses with the goal of decreasing suicide and youth risk behaviors among LGBTQ youth. Through its participatory processes to refine and sustain EB strategies in high schools, the RLAS represents a novel contribution to implementation science. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02875535.

A Statewide Profile of Frequent Users of School-Based Health Centers: Implications for Adolescent Health Care.

BACKGROUND: The purpose of this study is to describe patterns of care and service use among adolescent school-based health center (SBHC) users in New Mexico and contrast patterns and services between frequent and infrequent users. METHODS: Medical claims/encounter data were analyzed from 59 SBHCs located in secondary schools in New Mexico during the 2011-2012 school year. We used Pearson's chi-square test to examine the differences between frequent (≥ 4 visits/year) and infrequent users in their patterns of SBHC care, and we conducted logistic regression to examine whether frequent use of the SBHC predicted receipt of behavioral, reproductive, and sexual health; checkup; or acute care services. RESULTS: Most of the 26,379 adolescent SBHC visits in New Mexico were for behavioral health (42.4%) and reproductive and sexual health (22.9%). Frequent users have greater odds of receiving a behavioral, reproductive, and sexual health; and acute care visit than infrequent users (p < .001). American Indians, in particular, have higher odds of receiving behavioral health and checkup visits, compared with other races/ethnicities (p < .001). CONCLUSIONS: SBHCs deliver core health care services to adolescents, including behavioral, reproductive, and checkup services, to high need populations. American-Indian youth, more than their peers, use SBHCs for behavioral health and checkups.