Health risk behaviors of Texas students attending dropout prevention/recovery schools in 1997

School-Level Efforts to Address Sexual Health and Risky Sexual Behavior Among Students in Texas Alternative High Schools

We compared sexual/reproductive health services and sexuality education topics provided in Texas alternative high schools (AHSs) with the prevalence of sexual risk behaviors among students in AHS. Using cross-sectional data from convenience samples of 14 principals, 14 lead health educators, and 515 students, we calculated descriptive statistics for 20 services and 15 sexuality education topics provided by AHSs and seven sexual risk behaviors among students in AHS. AHSs provided few sexual/reproductive health services and limited educational content, despite high levels of sexual risk taking among students. For example, no AHSs taught students about proper condom use, yet 84% of students have had sex. Findings provide preliminary evidence of unmet needs for school-based sexual/reproductive health services and comprehensive sexuality education in AHS settings. Future investigation with larger, representative samples is needed to assess the provision of sexual/reproductive health services and sexuality education in AHSs and monitor sexual risk behaviors in the AHS population.

Poly-substance use and sexual risk behaviours: a cross-sectional comparison of adolescents in mainstream and alternative education settings

BACKGROUND

Surveys of young people under-represent those in alternative education settings (AES), potentially disguising health inequalities. We present the first quantitative UK evidence of health inequalities between AES and mainstream education school (MES) pupils, assessing whether observed inequalities are attributable to socioeconomic, familial, educational and peer factors.

METHODS

Cross-sectional, self-reported data on individual- and poly-substance use (PSU: combined tobacco, alcohol and cannabis use) and sexual risk-taking from 219 pupils in AES (mean age 15.9 years) were compared with data from 4024 pupils in MES (mean age 15.5 years). Data were collected from 2008 to 2009 as part of the quasi-experimental evaluation of Healthy Respect 2 (HR2).

RESULTS

AES pupils reported higher levels of substance use, including tobacco use, weekly drunkenness, using cannabis at least once a week and engaging in PSU at least once a week. AES pupils also reported higher levels of sexual health risk behaviours than their MES counterparts, including: earlier sexual activity; less protection against sexually transmitted infections (STIs); and having 3+ lifetime sexual partners. In multivariate analyses, inequalities in sexual risk-taking were fully explained after adjusting for higher deprivation, lower parental monitoring, lower parent-child connectedness, school disengagement and heightened intentions towards early parenthood among AES vs MES pupils. However, an increased risk (OR = 1.73, 95% CI 1.15, 2.60) of weekly PSU was found for AES vs MES pupils after adjusting for these factors and the influence of peer behaviours.

CONCLUSION

AES pupils are more likely to engage in health risk behaviours, including PSU and sexual risk-taking, compared with MES pupils. AES pupils are a vulnerable group who may not be easily targeted by conventional population-level public health programmes. Health promotion interventions need to be tailored and contextualised for AES pupils, in particular for sexual health and PSU. These could be included within interventions designed to promote broader outcomes such as mental wellbeing, educational engagement, raise future aspirations and promote resilience.

Recovery schools for improving behavioral and academic outcomes among students in recovery from substance use disorders: a systematic review

This Campbell systematic review examines the effects of recovery schools on student behavioral and academic outcomes, compared to the effects of non-recovery schools. The review summarizes evidence from one quasi-experimental study (with a total of 194 participants) that had potential serious risk of bias due to confounding. Sizable portions of youth are in recovery from substance use disorders, and many youth will return to use after receiving substance use treatment. Youth spend most of their waking hours at school, and thus schools are important social environments for youth in recovery from substance use disorders. Recovery schools have been identified as educational programs that may help support youth in recovery from substance use disorders. This review focused on two types of recovery schools: RHSs, which are schools that award secondary school diplomas and offer a range of therapeutic services in addition to standard educational curricula; and CRCs, which offer therapeutic and sober support services on college campuses. This review looked at whether recovery schools (RHSs or CRCs) affect academic success and substance use outcomes among students, compared to similar students who are not enrolled in recovery schools.

Plain language summary

There is insufficient evidence to know whether recovery high schools and collegiate recovery communities are effective: Evidence that recovery high schools (RHSs) may improve academic and substance use outcomes is based on the findings from a single study with a serious risk of bias.The review in brief: Very limited evidence addresses the effectiveness of recovery high schools (RHSs). There is no rigorous evidence on the effectiveness of collegiate recovery communities (CRCs).It is unclear whether CRCs are effective in promoting academic success and reducing substance use among college students.What is the aim of this review?: This Campbell systematic review examines the effects of recovery schools on student behavioral and academic outcomes, compared to the effects of non-recovery schools. The review summarizes evidence from one quasi-experimental study (with a total of 194 participants) that had potential serious risk of bias due to confounding.What are the main findings of this review?: Sizable portions of youth are in recovery from substance use disorders, and many youth will return to use after receiving substance use treatment. Youth spend most of their waking hours at school, and thus schools are important social environments for youth in recovery from substance use disorders. Recovery schools have been identified as educational programs that may help support youth in recovery from substance use disorders.This review focused on two types of recovery schools: RHSs, which are schools that award secondary school diplomas and offer a range of therapeutic services in addition to standard educational curricula; and CRCs, which offer therapeutic and sober support services on college campuses.This review looked at whether recovery schools (RHSs or CRCs) affect academic success and substance use outcomes among students, compared to similar students who are not enrolled in recovery schools.What studies are included?: The included study of recovery high schools used a controlled quasi-experimental pretest-posttest design and reported on the following outcomes: grade point average, truancy, school absenteeism, alcohol use, marijuana use, other drug use, and abstinence from alcohol/drugs. The included study focused on a sample of U.S. high school students. There were no eligible studies of CRCs.What do the findings of this review mean?: Findings from this review indicate insufficient evidence on the effects of recovery schools on student well-being. Although there is some indication RHSs may improve academic and substance use outcomes, this is based on the findings from a single study. There is no available evidence on the effects of CRCs.No strong conclusions can be drawn at this time, given the lack of available evidence on RHSs and CRCs, and the serious risk of bias in the one RHS study included in the review. The evidence from this review suggests there is a clear need for additional rigorous evaluations of recovery school effects prior to widespread implementation.How up-to-date is this review?: The review authors searched for studies until September 2018. This Campbell systematic review was published in 2018.

Executive Summary/Abstract

BACKGROUND: Substance use disorders (SUDs) among youth are a major public health problem. In the United States, for example, the incidence of SUDs increases steadily after age 12 and peaks among youth ages 18-23 (White, Evans, Ali, Achara-Abrahams, & King, 2009). Although not every youth who experiments with alcohol or illicit drugs is diagnosed with an SUD, approximately 7-9% of 12-24 year olds in the United States were admitted for public SUD treatment in 2013 (Substance Abuse and Mental Health Services Administration [SAMHSA], 2016). Recovery from an SUD involves reduction or complete abstinence of use, defined broadly as "voluntarily sustained control over substance use, which maximises health and wellbeing and participation in the rights, roles and responsibilities of society" (UK Drug Policy Commission, 2008). However, SUDs are often experienced as chronic conditions; among youth who successfully complete substance use treatment, approximately 45-70% return to substance use within months of treatment discharge (Anderson, Ramo, Schulte, Cummins, & Brown, 2007; Brown, D'Amico, McCarthy, & Tapert, 2001; Ramo, Prince, Roesch, & Brown, 2012; White et al., 2004). Thus, multiple treatment episodes and ongoing recovery supports after treatment are often necessary to assist with the recovery process (Brown et al., 2001; Ramo et al., 2012; White et al., 2004).Success and engagement at school and in postsecondary education are critical to healthy youth development. For youth in recovery from SUDs, school attendance, engagement, and achievement build human capital by motivating personal growth, creating new opportunities and social networks, and increasing life satisfaction and meaning (Keane, 2011; Terrion, 2012; 2014). Upon discharge from formal substance use treatment settings, schools become one of the most important social environments in the lives of youth with SUDs. Healthy school peer environments can enable youth to replace substance use behaviors and norms with healthy activities and prosocial, sober peers. Conversely, many school environments may be risky for youth in recovery from SUDs due to perceived substance use among peers, availability of drugs or alcohol, and substance-approving norms on campus (Centers for Disease Control [CDC], 2011; Spear & Skala, 1995; Wambeam, Canen, Linkenbach, & Otto, 2014).Given the many social and environmental challenges faced by youth in recovery from substance use, recovery-specific institutional supports are increasingly being linked to educational settings. The two primary types of education-based continuing care supports for youth in recovery, defined under the umbrella term of "recovery schools" for this review, are recovery high schools (RHSs) and collegiate recovery communities (CRCs). RHSs are secondary schools that provide standard high school education and award secondary school diplomas, but also include therapeutic programming aimed at promoting recovery (e.g., group check-ins, community service, counseling sessions). CRCs also provide recovery oriented support services (e.g., self-help groups, counseling sessions, sober dorms) for students, but are embedded within larger college or university settings. The primary aims of RHSs and CRCs are to promote abstinence and prevent relapse among students, and thus ultimately improve students' academic success.OBJECTIVES: This review summarized and synthesized the available research evidence on the effects of recovery schools for improving academic success and behavioural outcomes among high school and college students who are in recovery from substance use. The specific research questions that guided the review are as follows: 1. What effect does recovery school attendance (versus attending a non-recovery or traditional school setting) have on academic outcomes for students in recovery from substance use? Specifically (by program type): a. For recovery high schools: what are the effects on measures of academic achievement, high school completion, and college enrolment?b. For collegiate recovery communities: what are the effects on measures of academic achievement and college completion?2. What effect does recovery school attendance have on substance use outcomes for students in recovery from substance use? Specifically, what are the effects on alcohol, marijuana, cocaine, or other substance use?3. Do the effects of recovery schools on students' outcomes vary according to the race/ethnicity, gender, or socioeconomic status of the students?4. Do the effects of recovery schools on students' outcomes vary according to existing mental health comorbidity status or juvenile justice involvement of the students? SEARCH METHODS: We aimed to identify all published and unpublished literature on recovery schools by using a comprehensive and systematic literature search. We searched multiple electronic databases, research registers, grey literature sources, and reference lists from prior reviews; and contacted experts in the field.SELECTION CRITERIA: Studies were included in the review if they met the following criteria:Types of studies: Randomized controlled trial (RCT), quasi-randomized controlled trial (QRCT), or controlled quasi-experimental design (QED).Types of participants: Students in recovery from substance use who were enrolled part-time or full-time in secondary (high school) or postsecondary (college or university) educational institutions.Types of interventions: Recovery schools broadly defined as educational institutions, or programs at educational institutions, developed specifically for students in recovery and that address recovery needs in addition to academic development.Types of comparisons: Traditional educational programs or services that did not explicitly have a substance use recovery focus.Types of outcome measures: The review focused on primary outcomes in the following two domains: academic performance (e.g., achievement test scores, grade-point average, high school completion, school attendance, college enrolment, college completion) and substance use (alcohol, marijuana, cocaine, heroin, stimulant, mixed drug use, or other illicit drug use). Studies that met all other eligibility criteria were considered eligible for the narrative review portion of this review even if they did not report outcomes in one of the primary outcome domains.Other criteria: Studies must have been reported between 1978 and 2016. The search was not restricted by geography, language, publication status, or any other study characteristic.DATA COLLECTION AND ANALYSIS: Two reviewers independently screened all titles and abstracts of records identified in the systematic search. Records that were clearly ineligible or irrelevant were excluded at the title/abstract phase; all other records were retrieved in full-text and screened for eligibility by two independent reviewers. Any discrepancies in eligibility assessments were discussed and resolved via consensus. Studies that met the inclusion criteria were coded by two independent reviewers using a structured data extraction form; any disagreements in coding were resolved via discussion and consensus. If members of the review team had conducted any of the primary studies eligible for the review, external and independent data collectors extracted data from those studies. Risk of bias was assessed using the ROBINS-I tool for non-randomized study designs (Sterne, Higgins, & Reeves, 2016).Inverse variance weighted random effects meta-analyses were planned to synthesize effect sizes across studies, as well as heterogeneity analysis, subgroup analysis, sensitivity analysis, and publication bias analysis. However, these synthesis methods were not used given that only one study met the inclusion criteria for the review. Instead, effect sizes (and their corresponding 95% confidence intervals) were reported for all eligible outcomes reported in the study.RESULTS: Only one study met criteria for inclusion in the review. This study used a QED to examine the effects of RHSs on high school students' academic and substance use outcomes. No eligible studies examining CRCs were identified in the search.The results from the one eligible RHS study indicated that after adjusting for pretest values, students in the RHS condition reported levels of grade point averages (= 0.26, 95% CI [-0.04, 0.56]), truancy (= 0.01, 95% CI [-0.29, 0.31]), and alcohol use (= 0.23, 95% CI [-0.07, 0.53]) similar to participants in the comparison condition. However, students in the RHS condition reported improvements in absenteeism (= 0.56, 95% CI [0.25, 0.87]), abstinence from alcohol/drugs (OR = 4.36, 95% CI [1.19, 15.98]), marijuana use (= 0.51, 95% CI [0.20, 0.82]), and other drug use (= 0.45, 95% CI [0.14, 0.76]).Overall, there was a serious risk of bias in the one included study. The study had a serious risk of bias due to confounding, low risk of bias due to selection of participants into the study, moderate risk of bias due to classification of interventions, inconclusive risk of bias due to deviations from intended interventions, inconclusive risk of bias due to missing data, moderate risk of bias in measurement of outcomes, and low risk of bias in selection of reported results.AUTHORS' CONCLUSIONS: There is insufficient evidence regarding the effectiveness of RHSs and CRCs for improving academic and substance use outcomes among students in recovery from SUDs. Only one identified study examined the effectiveness of RHSs. Although the study reported some beneficial effects, the results must be interpreted with caution given the study's potential risk of bias due to confounding and limited external validity. No identified studies examined the effectiveness of CRCs across the outcomes of interest in this review, so it is unclear what effects these programs may have on students' academic and behavioral outcomes.The paucity of evidence on the effectiveness of recovery schools, as documented in this review, thus suggest the need for caution in the widespread adoption of recovery schools for students in recovery from SUDs. Given the lack of empirical support for these recovery schools, additional rigorous evaluation studies are needed to replicate the findings from the one study included in the review. Furthermore, additional research examining the costs of recovery schools may be needed, to help school administrators determine the potential cost-benefits associated with recovery schools.

Methods Matter: Tracking Health Disparities in Alternative High Schools

Alternative high school (AHS) students are at-risk for school dropout and engage in high levels of health-risk behaviors that should be monitored over time. They are excluded from most public health surveillance efforts (e.g., Youth Risk Behavior Survey; YRBS), hindering our ability to monitor health disparities and allocate scarce resources to the areas of greatest need. Using active parental consent, we recruited 515 students from 14 AHSs in Texas to take a modified YRBS. We calculated three different participation rates, tracked participation by age of legal consent (≥18 and <18 years), and identified other considerations for obtaining quality data. Being required to use active consent resulted in a much lower cooperation rate among students <18 years (32%) versus those who were ≥18 years and could provide their own consent (57%). Because chronic truancy is prevalent in AHS students, cooperation rates may be more accurate than participation rates based off of enrollment or attendance. Requiring active consent and not having accurate participation rates may result in surveillance data that are of disparate quality. This threatens to mask the needs of AHS students and perpetuate disparities because we are likely missing the highest-risk students within a high-risk sample and cannot generalize findings.

Tobacco, Alcohol, and other Drug use among High-Risk Young People: A Five-Year Longitudinal Study from Adolescence to Emerging Adulthood

The present study described the prevalence of adult role taking and substance use among individuals attending alternative high schools, who were followed for five years to early emerging adulthood (n = 848). Psychosocial factors at baseline and adult role taking at the follow-up were examined as correlates of substance use during emerging adulthood. At this stage of life, 74% of subjects were employed, 30% were married or engaged, and 43% had at least one child. One third of subjects were daily cigarette smokers, and 24% had used marijuana in the past 30 days. Forty-seven percent had experienced negative consequences of alcohol or drug use in the last year. The most consistent positive predictors of substance use in emerging adulthood were male gender and previous drug use. Addiction concern was a consistent negative predictor. After controlling for baseline psychosocial variables, attending school and being married at the five-year follow-up were negative correlates of both personal consequences and problems related to alcohol or drug use.

Health risk behavior pattern among students from Cartagena, Colombia: prevalence and associated variables

The aim of the study was to determine the prevalence and variables associated with the pattern of risky health behavior (PRHB) among adolescent students in Cartagena, Colombia. A cross-sectional study was designed to investigate PRHB in a random cluster sample of students from middle and high schools. The associations were adjusted by logistic regression. A total of 2,625 students participated in this research, with ages from 10 to 20 years, mean=13.8 years (SD=2.0), and 54.3% were women. A total of 332 students reported PRHB (12.7%, 95%CI 11.4-14.0). Age over 15 years (OR=2.19, 95%CI 1.72-2.79), not being heterosexual (OR=1.98, 95%CI 1.36-2.87), poor/mediocre academic performance (OR=1.87, 95%CI 1.47-2.38), family dysfunction (OR=1.78, 95%CI 1.40-2.28) and male gender (OR=1.58, 95%CI 1.24-2.01) were associated with PRHB. One in every eight students presented a PRHB. It is important to pay greater attention to students who are over 15 years of age, male, not heterosexual, with a poor/mediocre academic performance and a dysfunctional family.

Interventions to reduce sexual risk behaviors among youth in alternative schools: a randomized controlled trial

PURPOSE

This paper presents results from a randomized controlled trial that assessed the short- and longer-term impact of a skills-based HIV/STI/pregnancy prevention curriculum, service learning, and the combination.

METHODS

The study featured a four-arm experimental design involving 47 classrooms (765 youth) from continuation high schools. Classrooms were randomly assigned to one of four conditions: (1) HIV/STI/pregnancy prevention curriculum only; (2) service learning only; (3) HIV/STI/pregnancy prevention curriculum plus service learning; or (4) an attention control curriculum. Students completed 3 surveys over 18 months. Multi-level analysis was used to adjust for the correlation among students within the same classroom and school, and the correlation of repeated measurements.

RESULTS

Participants were 53% male (mean age: 16.2 years). The majority of youth reported being Hispanic/Latino or African-American (37.9% and 22.3%, respectively). Students in the HIV/STI/pregnancy prevention curriculum condition were less likely to have vaginal intercourse without a condom in the 3 months prior to the survey [odds ratio (OR) = .58, p = .04]; these effects diminished by final follow-up. The program also significantly reduced students' exposure to risky situations. These changes were not significant in the service learning only or combined intervention conditions relative to control.

CONCLUSION

This study is one of a few controlled studies of HIV/STI and pregnancy prevention programs in continuation settings, and suggests the curriculum was effective in changing selected risk behaviors in the short term.

Predicting high risk adolescents' substance use over time: the role of parental monitoring

We examined whether parental monitoring at baseline predicted subsequent substance use in a high-risk youth population. Students in 14 alternative high schools in Washington State completed self-report surveys at three time points over the course of 2 years. Primary analyses included 1,423 students aged 14-20 who lived with at least one parent or step-parent at baseline. Using hierarchical linear modeling, we found that high parental monitoring at baseline predicted significantly less use of alcohol, marijuana, downers, cocaine, PCP, LSD, and prescription drugs and drinking to intoxication at the first posttest. Approximately 1 year later, high parental monitoring at baseline predicted significantly less use of alcohol, cocaine, prescription drugs, uppers, and ecstasy and drinking to intoxication. Study results suggest that parental monitoring serves as a protective factor, even for high-risk alternative high school students. Including a parental monitoring component may increase the effectiveness of traditional drug prevention programs.

Comparison of health-risk behaviors among students attending alternative and traditional high schools in Minnesota

Previous research, over a decade old, suggests students attending alternative high schools (AHS) engage in high levels of health-risk behaviors. Data from the 2007 Minnesota Student Survey for students attending AHS (n = 2,847) and traditional high schools (THS; n = 87,468) were used for this cross-sectional analysis to compare prevalence estimates, adjusted for age, race/ethnicity, and free and reduced lunch, for 28 health-risk behaviors. Students attending AHS were significantly more likely than students attending THS to report engaging in all behaviors related to unintentional injury and violence, tobacco use, alcohol and other drug use, and sexual activity, and were significantly less likely to report participating in physical activity, including sports teams. Students attending AHS continue to engage in high levels of health-risk behaviors as compared to their peers in THS. Updated national prevalence data were needed, as well as studies examining the role of protective factors in the lives of students attending AHS.

Health behaviors and mental health of students attending alternative high schools: a review of the research literature

PURPOSE

The purpose of this review is to describe current knowledge about health-risk behaviors and mental health among alternative high school students.

CONCLUSIONS

Substance use, diet and/or physical activity, sexual-risk behaviors, mental health, and violence were reviewed. Students were described as marginalized youth facing significant social environmental challenges. Findings from 43 studies published from 1997-2010 suggested a high prevalence of health-risk behaviors among alternative high school students. Very few studies were conducted by nurse researchers. Suggestions for future research include addressing social environmental factors, resiliency, and emotional/mental health outcomes.

PRACTICE IMPLICATIONS

Alternative high schools offer a venue to conduct research and implement nursing interventions with high-risk, yet resilient, youth.

Substance use and dietary practices among students attending alternative high schools: results from a pilot study

Background

Substance use and poor dietary practices are prevalent among adolescents. The purpose of this study was to examine frequency of substance use and associations between cigarette, alcohol and marijuana use and selected dietary practices, such as sugar-sweetened beverages, high-fat foods, fruits and vegetables, and frequency of fast food restaurant use among alternative high school students. Associations between multi-substance use and the same dietary practices were also examined.

Methods

A convenience sample of adolescents (n = 145; 61% minority, 52% male) attending six alternative high schools in the St Paul/Minneapolis metropolitan area completed baseline surveys. Students were participants in the Team COOL (Controlling Overweight and Obesity for Life) pilot study, a group randomized obesity prevention pilot trial. Mixed model multivariate analyses procedures were used to assess associations of interest.

Results

Daily cigarette smoking was reported by 36% of students. Cigarette smoking was positively associated with consumption of regular soda (p = 0.019), high-fat foods (p = 0.037), and fast food restaurant use (p = 0.002). Alcohol (p = 0.005) and marijuana use (p = 0.035) were positively associated with high-fat food intake. With increasing numbers of substances, a positive trend was observed in high-fat food intake (p = 0.0003). There were no significant associations between substance use and fruit and vegetable intake.

Conclusions

Alternative high school students who use individual substances as well as multiple substances may be at high risk of unhealthful dietary practices. Comprehensive health interventions in alternative high schools have the potential of reducing health-compromising behaviors that are prevalent among this group of students. This study adds to the limited research examining substance use and diet among at-risk youth.

Trial registration number

ClinicalTrials.gov: NCT01315743

Project success' effects on substance use-related attitudes and behaviors: a randomized controlled trial in alternative high schools

Using a randomized controlled effectiveness trial, we examined the effects of Project SUCCESS on a range of secondary outcomes, including the program's mediating variables. Project SUCCESS, which is based both on the Theory of Reasoned Action and on Cognitive Behavior Theory, is a school-based substance use prevention program that targets high-risk students. We recruited two groups of alternative high schools in successive academic years, and randomly assigned schools in each group to either receive the intervention (n = 7) or serve as a control (n = 7). Students completed surveys prior to and following the administration of the program, and again 1 year later. Although participation in Project SUCCESS significantly increased students' perceptions of harm resulting from alcohol and marijuana use, students in the control group reported greater increases in peer support. We also found conflicting evidence in two opposing trends related to students' perceptions of the prevalence and acceptability of substance use. Therefore, the effects of Project SUCCESS on substance use-related beliefs and behaviors must be considered mixed.

Project SUCCESS' effects on the substance use of alternative high school students

Project SUCCESS is a selective and indicated substance use prevention program that targets high risk students in secondary school settings. We evaluated the effects of Project SUCCESS on adolescents' substance use immediately following program implementation, and again one year later. Two successive cohorts of alternative high schools were randomly assigned to an intervention or control group, yielding seven schools per condition. Main outcomes included 30-day use of alcohol, marijuana, and illegal drugs excluding marijuana, and drinking to intoxication. We conducted exploratory analyses on 30-day cigarette use. Using Hierarchical Linear Modeling, we found that students in the control schools reported significantly less use of illegal drugs excluding marijuana than those in the intervention group at the first posttest; however, this effect did not persist one year later. There were no other outcome effects of even a marginal nature. While results of this study do not provide evidence of Project SUCCESS' effectiveness, students' program exposure was low. It is possible that Project SUCCESS would perform better in schools with higher and more regular rates of attendance.

Sexual abuse and sexual risk behavior: beyond the impact of psychiatric problems

OBJECTIVE

This study examined the association between sexual abuse (SA) and sex risk in girls and boys placed in alternative and therapeutic school settings while controlling for psychiatric problems.

METHOD

Adolescents were recruited from alternative and therapeutic schools. Youth completed audio computer-assisted self-interviews assessing childhood abuse, sexual behaviors, sexual attitudes, and psychiatric symptoms.

RESULTS

Of the 162 youth with available data, 23% reported a moderate or severe SA history. After controlling for gender and the presence of a psychiatric diagnosis, youth with a SA history were significantly more likely to have engaged in sex, had sex in the last 90 days, and engaged in unprotected sex. Adolescents with a history of SA also endorsed fewer advantages of using condoms.

CONCLUSIONS

SA is uniquely associated with sexual behavior and attitudes even when adjusting for the presence of a psychiatric diagnosis. These data have implications for interventions for those with SA histories.

Should we ask our Children about Sex, Drugs and Rock & Roll?: Potentially Harmful Effects of Asking Questions About Risky Behaviors

Research shows that asking questions can fundamentally change behavior. We review literature on this question-behavior effect, which demonstrates that asking questions changes both normal and risky behaviors. We discuss potential explanations for the effect and review recent findings that reveal interesting moderators of the influence of questions on behavior. We then highlight the potential impact of the question-behavior effect in an important public health context: screening adolescents for risky behavior. While medical guidelines emphasize the importance of asking adolescents questions about substance (drug, alcohol) use and sexual behaviors, research on the question-behavior effect suggests that asking adolescents about risky behaviors has the potential to increase the frequency with which they engage in these behaviors. We argue that the act of screening or measuring risky behavior is potentially counterproductive. We emphasize the importance of interventions beyond screening, and suggest ways in which screening can be carried out to minimize its impact. In short, asking questions about behaviors can change behavior, and asking questions about risky behaviors may itself be a risky undertaking.

Safer choices 2: rationale, design issues, and baseline results in evaluating school-based health promotion for alternative school students

BACKGROUND

Students attending 'alternative' high schools form relatively small, highly mobile high-risk populations, presenting challenges for the design and implementation of HIV-, other STI-, and pregnancy-prevention interventions. This paper describes the rationale, study design, and baseline results for the Safer Choices 2 program.

STUDY DESIGN

Modified group-randomized intervention trial with cross-over of schools but not of students. The study cohort was defined a priori as those who completed the baseline measures and were still enrolled at the time of first follow-up. DESIGN RESULTS: Of 940 students initially enrolled in the study, 711 (76%) formed the study cohort. There were significant demographic differences between those included and those excluded from the study cohort in sex, age, sexual experience, experience with pregnancy, drug use, and some psychosocial measures. There were no significant differences between the intervention and control groups within the study cohort. The only significant difference between those students excluded from the intervention group and those excluded from the control group was reported age at first intercourse. BASELINE DATA RESULTS: Students (n=940) enrolled were predominately African-American (29.7%) and Hispanic (61.3%); 57.3% were female; 66% had ever had sex; and reported drug use in the previous 30 days ran from 4.3% (cocaine) to 26.9% (marijuana). Of the 627 sexually experienced, 41.8% reported their age at first intercourse as 13 years or younger; 28.5% reported ever being or having gotten someone pregnant; 74% reported sex in the past 3 months. Of the 464 sexually active in the last 3 months, 55.4% reported unprotected intercourse and 31.3% reported using drugs beforehand.

CONCLUSION

The cross-over design will provide a rigorous test of the intervention; however, loss to follow-up of this population can result in some selection bias. Students attending dropout prevention and recovery schools are at high risk for HIV, STIs, and pregnancy, and are in need of interventions.

All4You! A randomized trial of an HIV, other STDs, and pregnancy prevention intervention for alternative school students

This study evaluated All4You!, a theoretically based curriculum designed to reduce sexual risk behaviors associated with HIV, other STDs, and unintended pregnancy among students in alternative schools. The study featured a randomized controlled trial involving 24 community day schools in northern California. A cohort of 988 students was assessed four times during an 18-month period using a self report questionnaire. At the 6-month follow-up, the intervention reduced the frequency of intercourse without a condom during the previous 3 months, the frequency of intercourse without a condom with steady partners, and the number of times students reported having intercourse in the previous 3 months. It also increased condom use at last intercourse. These behavioral effects were no longer statistically significant at the 12- and 18-month follow-ups. The All4You! intervention was effective in reducing selected sexual risk behaviors among students in alternative school settings; however, the effects were modest and short term.

Using intervention mapping to adapt an effective HIV, sexually transmitted disease, and pregnancy prevention program for high-risk minority youth

Although many programs have been developed to reduce adolescent pregnancy and sexually transmitted diseases (STDs) (including HIV), with some showing promise in reducing sexual risk-taking behavior, little guidance has been given as to how to adapt existing interventions to new communities. When adapting a program, effective elements deemed necessary to change behaviors need to be preserved, while cultural competence and relevance for the new population must be considered in creating new elements. To address these needs, the authors describe the application of a systematic process, intervention mapping (IM), to adapt a theory-based, multicomponent HIV, STD, and pregnancy prevention program titled Safer Choices to a new target population, at-risk youth attending alternative schools and at risk of dropping out. IM is a detailed process that provides planners with a systematic method for decision making in each phase of developing or adapting an intervention to influence changes in behavior and environmental conditions.

Integrating service learning into a curriculum to reduce health risks at alternative high schools

Service learning has been identified as a promising approach to reduce sexual risk behavior, among other outcomes. This study used qualitative data analysis to offer suggestions for optimally integrating service learning into a program to reduce sexual risks among alternative school students. Data were collected from student participants in the All4You! Project using classroom materials, focus groups, and individual interviews. Project educators and project staff also provided data through summary forms and field notes. Qualitative data analysis revealed 5 strategies for creating positive service experiences for alternative school students: (1) find appropriate service-learning sites, (2) create staff support, (3) maintain appropriate student participation and behavior; (4) enhance student reflection on service-learning experiences, and (5) address students' self-images.

A drop-out prevention program for high-risk inner-city youth

Inner-city youth are at high risk for dropping out of high school. Within this article, risk factors associated with dropout and strategies for effective prevention and intervention are reviewed. An example of a school-based drop-out prevention program is highlighted. The FUTURES Program is a school-based drop-out prevention program designed to address the needs of high-risk youth through smaller classes, character development, career preparation, case management/mentoring, positive incentives, and access to mental health services. Components of the program are described in detail and data evaluating the effectiveness of the program are presented. Directions for the future development of programs and conducting research to prevent dropout by inner-city youth are discussed.

Reduction in sexual risk behaviors and infection rates among African Americans and Mexican Americans

BACKGROUND

Project SAFE, a gender- and culture-specific cognitive-behavioral intervention, was one of the few interventions to have demonstrated a significant reduction in sexually transmitted infections in a randomized, controlled trial.

GOAL

We evaluated intervention efficacy in 379 Mexican Americans and 170 African Americans; and in a subset of 477 women, explored ethnic differences in the relationships over time between attitudes/beliefs about relationships, reported sexual behavior, and infection.

STUDY DESIGN

Women were questioned intensively at baseline, 6, and 12 months. We used stratified analyses and multivariate regression to evaluate ethnic differences and the role of behavior in explaining ethnic differences in infection.

RESULTS

African Americans had higher overall infection rates (29.0% vs. 18.3%) than Mexican Americans, but the intervention efficacy was similar (odds ratios, 0.58 and 0.54, respectively). African Americans reported more douching after sex, less mutual monogamy, and more rapid partner turnover. However, Mexican Americans appeared slightly more likely to have sex with an untreated partner, and there was no difference in risky sex. African Americans reported greater difficulty finding partners and reported attitudes more compatible with nonmonogamy.

CONCLUSIONS

Despite substantial ethnic differences in attitudes/beliefs, behaviors, and infection rates, the intervention had a comparable impact on both Mexican American and African American.

Drug Use Among Texas Alternative School Students: Findings from Houston's Safer Choices 2 Program

Self-report drug use data were collected from 494 alternative school students, grades seven through 12, surveyed through the Safer Choices 2 study in Houston, Texas. Data were collected between October 2000 and March 2001 via audio-enabled laptop computers equipped with headphones. Twenty-eight percent of the sample reported past-month marijuana use, and 10% reported past-month opiate/codeine use. Males were almost twice as likely as females to have used cocaine during the past month, and over four times as likely to have used opiates/codeine during the past month. Students 16 years and older and were twice as likely to have ever used cocaine and opiates/codeine than students under 16 years. Latinos were 10 times more likely than Blacks to have ever used cocaine; Blacks were twice as likely as Latinos to have used opiates/codeine during the past month. Males were twice as likely as females to have tried "fry," a new street drug made of tobacco or marijuana mixed with embalming fluid and PCP. These new drug trends are startling because they indicate a potential for long-term treatment services for abusers.

Gender differences in the consequences of a coercive sexual experience among adolescents attending alternative schools

Of 490 middle and high school students attending alternative schools who participated in this study, 18.2% of females and 6.7% of males reported a past unwanted sexual experience. Relative to nonabused subjects, female and male adolescents who reported a forced sexual experience were more likely to exhibit externalizing problems such as sexual risk behaviors and internalizing problems such as depression and suicidal thoughts in the past two weeks. Females with a history of a coercive sexual experience also had increased odds of drug and alcohol use, and violence-related behaviors. The magnitude of these associations ranged from a twofold increase to a tenfold increase. Controlling for ethnicity, family income, and family support had less impact on the strength of associations between a forced sexual experience and sexual risk behaviors for females than for males. A forced sexual experience remained significantly associated with depression for females and suicidal thoughts for males. Alcohol use in the past 30 days was the only substance use-related problem that remained significant for females. Violence-related behaviors did not remain significant in the presence of control variables for females. Interventions focusing on adolescents with a history of a coercive sexual experience in general, and in alternative schools in particular, are suggested by these results. More research focusing on the differential impact of a coercive sexual experience on males and females is crucial.

Lifetime inhalant use among alternative high school students in Texas: prevalence and characteristics of users

This cross-sectional study describes the prevalence of lifetime inhalant use and identifies demographic, psychosocial, and other risk behavior characteristics of students reporting lifetime inhalant use. The sample consisted of 354 students attending alternative high schools (dropout prevention/recovery schools) in Texas. The prevalence of lifetime inhalant use was 27.7%. After controlling for potentially confounding factors, students reporting lifetime inhalant use were less likely to be financially supported by their parents/guardians, more likely to use alcohol/tobacco, marijuana, and cocaine, and more likely to carry weapons and consider suicide. Study results may allow school officials, parents, researchers, and health care providers to gain a better understanding of inhalant use among students at risk for dropping out of school, a group which has not been extensively studied by previous researchers.

Comparison of health-risk behaviours among students in alternative high schools from New Zealand and the USA

OBJECTIVES

To describe the prevalence of health-risk behaviours of New Zealand alternative education students, and to compare these behaviours to similar students in the USA.

METHODS

Thirty-six alternative education schools in the northern region of New Zealand were surveyed. A total of 269 students completed a youth health questionnaire using laptop computers. These data were compared to data from an equivalent population of alternative education students in the USA.

RESULTS

Alternative education students from New Zealand and the USA engage in similar high levels of health-risk behaviours. Female students in New Zealand are at particularly high risk of poor health and social outcomes due to high levels of alcohol and marijuana use, driving under the influence of alcohol and high prevalence of risky sexual behaviours. Such health-risk behaviours place alternative education students at greater risk of some of the leading causes of morbidity and mortality in both youth and adult populations.

CONCLUSIONS

Findings from the present study support the need for specific health policies and programmes for alternative high school students. Providers of New Zealand alternative education should be aware that female students are at particularly high risk of many health-risk behaviours.

The relationship between sexual abuse and drug use: findings from Houston's Safer Choices 2 program

Self-report drug use data were collected from 282 female alternative school students surveyed through the Safer Choices 2 study in Houston, Texas. Data collection took place between October 2000 and March 2001 via audio-enabled laptop computers equipped with headphones. Logistic regression analyses indicated that sexual abuse history was significantly associated with lifetime use (OR = 1.9, p < or = 0.05). While the relationships tested in this study are exploratory, they provide evidence for an important connection between sexual abuse and substance use among female alternative school students.

Violent behavior among urban youth attending alternative schools

This study described violent behavior and aggression among youth attending alternative schools, and examined sociodemographic factors associated with such violence. The study involved 494 students attending 10 alternative schools in Houston, Texas. Data were collected between November 2000 and February 2001 by audio-enabled laptop computers equipped with headphones. Students self-reported an average of 11.8 aggressive acts during the week prior to the survey. Students reported a 30-day weapon carrying prevalence of 22.7%; 30-day gun carrying prevalence of 11.1%; 30-day knife or club prevalence of 17.2%; 12-month fighting prevalence of 50.6%; and 12-month prevalence of injuries due to fighting of 6.5%. Association between demographic variables, self-reported aggressive behavior, and other forms of aggression was examined using multivariate logistic regression. Students were divided into four mutually exclusive violence-related categories: no fighting and no weapon (referent), fighting only, carrying weapon only, fighting and weapon carrying. Student aggression was significantly associated with fighting and weapon carrying, with incremental increases at each level (OR 1.1 per unit of increase, 95% CI 1.1-1.2) and in presence of the covariates. Among Houston's alternative school students, the prevalence of violent behavior (weapon carrying, gun carrying, knife or club carrying, fighting, and treatment by a doctor or nurse for injuries) is higher compared to regular high school students. Aggression related strongly to weapon carrying and fighting in the sample. Data indicate alternative school youth urgently need prevention and treatment programs to help them live in safer environments.

Prevalence of health-related behaviors among alternative high school students as compared with students attending regular high schools

PURPOSE

To provide national data on health-risk behaviors of students attending alternative high schools and compare the prevalence of these risk behaviors with data from the 1997 national Youth Risk Behavior Survey.

METHODS

The national Youth Risk Behavior Survey uses a three-stage cluster sampling design. Data were collected from 8918 students in alternative high schools in 1998 (ALT-YRBS) and 16,262 students in regular high schools in 1997 (YRBS). The health-risk behaviors addressed include behaviors that contribute to unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors, unhealthy dietary behaviors, and physical inactivity. A weighing factor was applied to each student record to adjust for nonresponse and varying probabilities of selection. SUDAAN was used to compute 95% confidence intervals, which were considered significant if the 95% confidence intervals did not overlap.

RESULTS

Students attending alternative high schools were at significantly greater risk than students in regular high schools for violence-related injury; suicide; human immunodeficiency virus infection or other sexually transmitted diseases; pregnancy; and development of chronic disease related to tobacco use, unhealthy dieting practices, and lack of vigorous activity.

CONCLUSIONS

Many students in alternative high schools are at risk for both acute and chronic health problems. Because these youth are still in a school setting, alternative high schools are in a unique position to provide programs to help decrease the prevalence of risk-taking behaviors.

Substance use on school property among students attending alternative high schools in the United States

We analyzed nationally representative data from the 1998 National Alternative High School Youth Risk Behavior Survey, conducted by the Centers for Disease Control and Prevention, to determine the prevalence of substance use on school property among alternative high school students in the United States, to describe the characteristics of students who use substances on school property, and to examine the interrelationships of substance-use behaviors. During the 30 days preceding the survey, nearly 48 percent of students used at least one substance on school property and 17 percent used more than one substance on school property. Males were more likely than females and white students were more likely than black or Hispanic students to have used substances on school property. The results of this and other studies suggest that school administrators, public health practitioners, and policy makers should work to improve strategies for reducing substance use in this heterogeneous, hard-to-reach population.

Cultural, social, and intrapersonal factors associated with substance use among alternative high school students

The purpose of this study was to identify cultural, social, and intrapersonal factors associated with tobacco, alcohol, and illicit drug use among students attending dropout prevention/recovery high schools. Four mutually exclusive categories of substance use were used as outcome measures, and religiosity, educational achievement, educational aspiration, family caring, others caring, self-esteem, optimism, coping, depression, loneliness, and self-efficacy were used as predictor variables. In the final multivariate model more family caring and loneliness were inversely associated with marijuana use; young age, more family caring, less coping ability, church attendance, and low educational aspirations were significantly associated with cocaine use. This study demonstrates the importance of health education and health promotion programs for students attending alternative high schools which include prevention of initiation, as well as treatment.

Youth risk behavior surveillance. National Alternative High School Youth Risk Behavior Survey, United States, 1998

Alternative high schools serve approximately 280,000 students nationwide who are at high risk for failing or dropping out of regular high school or who have been expelled from regular high school because of illegal activity or behavioral problems. Such settings provide important opportunities for delivering health promotion education and services to these youth and young adults. However, before this survey, the prevalence of health-risk behaviors among students attending alternative high schools nationwide was unknown. The Youth Risk Behavior Surveillance System (YRBSS) monitors the following six categories of priority health-risk behaviors among youth and young adults: behaviors that contribute to unintentional and intentional injuries; tobacco use; alcohol and other drug use; sexual behaviors that contribute to unintended pregnancy and sexually transmitted diseases (STDs) (including human immunodeficiency virus [HIV] infection); unhealthy dietary behaviors; and physical inactivity. The national Alternative High School Youth Risk Behavior Survey (ALT-YRBS) is one component of the YRBSS; it was conducted in 1998 to measure priority health-risk behaviors among students at alternative high schools. The 1998 ALT-YRBS used a three-stage cluster sample design to produce a nationally representative sample of students in grades 9-12 in the United States who attend alternative high schools. The school response rate was 81.0%, and the student response rate was 81.9%, resulting in an overall response rate of 66.3%. This report summarizes results from the 1998 ALT-YRBS. The reporting period is February-May 1998. In the United States, 73.6% of all deaths among youth and young adults aged 10-24 years results from only four causes--motor vehicle crashes, other unintentional injuries, homicide, and suicide. Results from the 1998 ALT-YRBS demonstrate that many students at alternative high schools engage in behaviors that increase their likelihood of death from these four causes. During the 30 days preceding the survey, 51.9% had ridden with a driver who had been drinking alcohol, 25.1% had driven a vehicle after drinking alcohol, 32.9% had carried a weapon, 64.5% had drunk alcohol, and 53.0% had used marijuana. During the 12 months preceding the survey, 15.7% had attempted suicide, and 29.0% had rarely or never worn a seat belt. Substantial morbidity among school-aged youth and young adults also results from unintended pregnancies and STDs, including HIV infection. ALT-YRBS results indicate that in 1998, a total of 87.8% of students at alternative high schools had had sexual intercourse, 54.1% of sexually active students had not used a condom at last sexual intercourse, and 5.7% had ever injected an illegal drug. Among adults aged > or = 25 years, 66.5% of all deaths result from two causes--cardiovascular disease and cancer. Most risk behaviors associated with these causes of death are initiated during adolescence. In 1998, a total of 64.1% of students at alternative high schools had smoked cigarettes during the 30 days preceding the survey, 38.3% had smoked a cigar during the 30 days preceding the survey, 71.2% had not eaten > or = 5 servings of fruits and vegetables during the day preceding the survey, and 81.0% had not attended physical education (PE) class daily. Comparing ALT-YRBS results with 1997 national YRBS results demonstrates that the prevalence of most risk behaviors is higher among students attending alternative high schools compared with students at regular high schools. Some risk behaviors are more common among certain sex and racial/ethnic subgroups of students. ALT-YRBS data can be used nationwide by health and education officials to improve policies and programs designed to reduce risk behaviors associated with the leading causes of morbidity and mortality among students attending alternative high schools.