596 Although teen pregnancy, defined by the US Centers for Disease Control and Prevention as pregnancies between the ages of 15 and 19, has declined in the US over recent years to 16.7 births per 1000 girls, it continues to represent an enormous risk factor for poorer economic, educational, and health outcomes, both for the teen and the baby.1 Sexually transmitted infections (STIs) also continue to be a concern among this age group, with nearly half of the 26 million new STIs reported each year occurring in young people aged 15 to 24.2 To mitigate this problem, the US Department of Health and Human Services (USDHHS) provides funding to organizations and communities to prevent teen pregnancy and sexually transmitted infections (STIs). Unfortunately, reviews of the evaluations of these programs show limited positive impacts on pregnancy, sexual delay, and STI prevention methods or contraceptive use.3,4 Juras et al4 conducted a meta-analysis of 34 of the 43 adolescent pregnancy prevention program evaluations funded by the USDHHS between 2010 and 2016. On average, the programs showed small, statistically non-significant improvements in sexual risk behaviors and in pregnancy and STI Kayla Knopp, University of California San Diego School of Medicine, San Diego, CA, United States. Galena K. Rhoades, Research Professor, Department of Psychology, University of Denver, Denver, CO, United States. Lisa A. Rue, Senior Advisor for Adolescent and Behavioral Health at cliexa, Denver, CO, United States. Michael A. Floren, Assistant Professor of Data Analytics, Department of Finance, Economics and Data Analytics, University of North Alabama, Florence, AL, United States. Kiley M. Floren, Director of Evaluation Services at Practical Statistics, Florence, AL, United States. Correspondence Dr Knopp; [email protected] Messaging Considerations in Teen Pregnancy and Sexually Transmitted Infection Prevention

Objective: Teen pregnancy and sexually transmitted infection (STI) prevention are top public health goals. Despite decades of research, programs to prevent adverse sexual health outcomes among adolescents show limited effectiveness in broad dissemination. In the current study, we aimed to identify understudied factors that may impact effectiveness of teen pregnancy and STI prevention (TPP) programs, with goals of informing innovation in program development and outlining future research priorities. Methods: A panel of experts in TPP programs generated a list of understudied constructs in evaluation research, distilled to 3 considerations regarding messaging: single versus multiple messages, adverse effects of safety messages, and sociocultural context. We conducted an exploratory search of published literature in health promotion fields targeted toward messaging strategies, and we synthesized information from relevant empirical and review papers. Results: Limited evidence was found suggesting multiple messages or adverse message impacts are likely to impair TPP program effectiveness overall, although both may emerge in certain contexts and populations. In contrast, considerable evidence highlighted the importance of cultural context and individual differences. Conclusions: Effective TPP program messaging should be consistent, tailored, and systemic. Future research should evaluate these messaging strategies to determine whether they may enhance program impacts.

The Impact of COVID-19 on Pre-K-12 Students and Staff in a Mid-sized Metropolitan Area

Objective: During fall 2020, schools used a variety of learning modes based on anticipated risk of viral transmission within schools. Methods: De-identified SARS-CoV-2 data from 11 school districts in the Wichita, Kansas metropolitan area from August 1 to November 15, 2020, was collated for analysis. The Sedgwick County Health Department (SCHD) and Kansas Department of Health and Environment (KDHE) databases were accessed for community-level and contact tracing data. Results: Altogether, 13,573 staff and 54,479 students receiving full or partial on-site (hybrid) education were included. Few students (1.4%) or staff (4.7%) tested positive for SARSCoV- 2. District rates varied from 0.1% to 3.3% in students and 0.7% to 8.7% in staff. Students in grades 9-12 had a higher rate of positive tests and cases were more likely linked to school-based exposure. Staff rate by grade level did not show an identifiable trend; staff rates were higher in nonattendance centers. Conclusions: Low SARS-CoV-2 student case rates suggests on-site learning formats may be appropriate. School trends reflected community rate reinforcing that communitylevel interventions are necessary to decrease transmission. As new variants arise, transmission characteristics must be studied. Health and education partnership is important to ensure the greatest well-being for students and staff.

Hallways to Health: School Health Beyond School-Based Health Center Walls

Objective: In this paper, we describe the implementation and outcomes of an initiative that engaged school-based health centers (SBHCs) in a learning community to create programmatic and policy school health changes beyond the health center walls. Methods: Sixty respondents completed impact surveys and 13 coalitions completed progress reports to document schoolwide wellness efforts and outcomes in stakeholder engagement, student healthy eating and active living, student social and emotional wellness, and school staff wellness. Results: Respondents reported pre- to post-intervention improvements in stakeholder engagement, including school administration promotion of school health policies (from 64% to 95%), and teacher participation in SBHC sponsored activities (from 63% to 98%). They reported schoolwide policy and programmatic achievements including increased opportunities for physical activity for students during school hours (from 55% to 85%), access to behavioral health counseling and support services to all students, either on-site or through referrals (from 62% to 89%), and offering healthy food or nutrition education to staff (from 10% to 73%). Conclusions: SBHC staff, school employees, and community members can work collaboratively to assess student physical and mental health needs, and develop and implement school policies and programs beyond the clinic walls.

That Pop-Up Restaurant: Innovation in a Summer Feeding Program

Objective: That Pop-Up Restaurant Summer Food Service Program (SFSP) was a federally reimbursed program that first served healthy meals to families in a rural Kansas community during the summer of 2017. The program aimed to empower communities to address child hunger by reducing stigma concerning food assistance and providing high-quality, nutritious meals to families. This pilot was developed to increase low utilization rates of summer feeding programs. Methods: An ecological approach was implemented to engage students and families. Program innovations included an open menu ordering format with paid adult meals and proper food storage while maintaining USDA’s nutritional requirements. Additionally, the menu options exceeded fruit and vegetable requirements. Results: On average, 9.6% of youth who participated in the free and reduced-price lunch programs participated daily in summer nutrition during the 2016-2017 school year (FRAC, 2019). Comparatively, That Pop-Up Restaurant’s pilot had over 25% of eligible youth participate in the program one or more times. Conclusions: That Pop-Up Restaurant summer food service program showed promising results for the target population and program developers aim to replicate the program in various communities.

Perceived Barriers to and Recommendations for Cessation among Poly-tobacco-using Young Adults

Objective: Young adult tobacco users are at an increased risk for using non-cigarette tobacco products and have high poly-use rates. We interviewed poly-tobacco-using young adults from an urban community to explore characteristics associated with their poly-tobacco use, perceived barriers to tobacco cessation, and recommendations for and interest in cessation programs. Methods: We conducted 17 focus group discussions with 97 poly-tobacco-using young adults. Interviews were analyzed using framework analysis and quantitative surveys were analyzed using descriptive statistics. Results: All participants reported a history of tobacco product poly-use, and 85% reported poly-use in the past 30 days. Study results indicate that this population faces multiple barriers to cessation (eg, influence of social network, easy access, anxiety management, belief in self-control, boredom), but that there is interest in utilizing mobile-based interventions and social media for cessation attempts, ultimately allowing them to manage cessation in their own time, and in a way that is more fitting with their lifestyle. Conclusions: To work toward eliminating tobacco-related cancer disparities, we must understand social and environmental factors that influence tobacco use among underserved populations so that primary prevention strategies to prevent smoking initiation may be implemented. Equally important are secondary prevention strategies that develop more targeted, effective smoking cessation interventions.

Barriers and Diabetes Care Quality in Public Schools in the United States

Objective: In this study, we examined the influence of multi-level barriers on school diabetes care quality. Methods: We administered an online survey to nurses in Missouri K-12 schools (N = 245). We assessed 57 potential barriers in 5 domains (at individual, school, community, social/ cultural, and political/economic levels). We developed 38 criteria for care quality based on the National Institute of Diabetes and Digestive and Kidney Diseases’ school diabetes care guidelines. We carried out structural equation modeling to examine the effect of barriers on school diabetes care quality. Results: School nurses’ heavy workloads, teachers’/parents’ lack of training/knowledge on evidence-based practices, and lack of funding from government, districts, and schools serving disadvantaged or rural populations were among the key barriers to school diabetes care. Deficiencies in care quality were identified in areas including knowledge/training, communication, school policies, resources and environment, physical activity engagement among students with diabetes, school nurses’ diabetes management practices, and trained diabetes practitioners’ responsibilities. School diabetes care barriers, overall, were inversely associated with care quality; one standard deviation increase in the barriers was associated with a 0.163 (95% confidence interval = 0.002- 0.324) standard-deviation decrease in care quality. Conclusions: Multi-level policy interventions are called upon to address these barriers to improve care quality and ensure the healthy growth of students with diabetes.

A Content Analysis of Implementation Strategies Chosen by Virginia School Nutrition Directors

Objective: School-based interventions are common approaches to address childhood obesity; however, there is little understanding of strategies that can foster their implementation into schools. In this study, we aimed to identify goals and the specific strategies selected by school nutrition directors (SNDs) in Virginia to execute school-based interventions. Methods: Between 2018 and 2019, SNDs in Virginia participated in Team Nutrition workshops through which they created action plans. We carried out a content analysis of 132 action plans collected from 100 school divisions. We developed codes deductively and inductively. The codes captured plan completion, goals, and strategies. Each plan was independently coded by 2 coders. Results: Action plans included 1.2 goals (SD = 0.54) and 3.9 strategies per goal (SD = 2.1). Goals were most commonly related to improving menus or increasing participation in the school meal programs. The strategies varied based on the goals. However, obtaining buy-in from school personnel and students was the most commonly included goal (64.4%) across plans. The level of action plan completion decreased with each subsequent section of the worksheet. Conclusions: Emerging patterns identified in this study suggest SNDs’ strategy selection is based on goals and that trainings should be tailored to promote the development of skills required to execute optimal strategies.

Reduction in Pediatric Emergency Department Admissions during Lockdown: Just Fear of COVID-19?

Objective: Italy was the first European nation to undergo a general lockdown as a means of containing the COVID-19 pandemic. In that period, a significant reduction in pediatric accesses to emergency rooms (ERs) was reported. In this study, we evaluated whether, in addition to the fear of infection, the reduced ER visits were also an indirect indicator of reduced incidence of common seasonal viruses. Methods: Sales data for pediatric formulations of antipyretics and probiotics from 27 pharmacies were evaluated, during March-May 2020, and compared to sales during the same period in 2019. Pediatric accesses in the emergency department (ED) also were evaluated. Results: The median number of antipyretics and probiotics sold per pharmacy was respectively 152 (IQR = 144) and 55 (IQR = 52) in 2019; during the same period of 2020 it was 77.5 (IQR = 60) (p < .001) and 27 (IQR = 44) (p < .05). In the March-May period of 2019, the number of pediatric accesses was 1004, whereas in the same period of 2020 it was 143, a reduction of 85.76% (p < .001). Conclusions: We found a statistically significant reduction in pediatric admissions to the ED during the lockdown, but that this reduction could largely be due to a reduction in seasonal viral disease as an effect of social distancing, mask use, and frequent hand-washing, as mandated by healthcare dispositions.

Salad Bar Use among Middle School Children in a Socio-economically Disadvantaged Rural County

Objective: Our objective in this study was to inform policymakers if including a salad bar in school cafeterias in the district would serve all subgroups of students equally. Methods: A salad bar was implemented during the 2016-2017 academic year in a rural low-income county middle-school. Halfway through, a “healthy lifestyle” educational campaign was presented. Students’ gender, race, and body mass index (BMI) were recorded along with their choice of daily lunch item. Results: Overall, 528 middle schoolers participated in this program. Students opted to consume salad for approximately 5.73 days out of the 123 days that salad was served. The educational campaign had no effect on salad bar use. There was no gender difference in frequency of salad bar use. African- American students consumed significantly more salad than Hispanic students, and marginally more salad than white students. Students classified as normal weight (by BMI percentile) chose the salad bar option more frequently than obese students. Conclusions: Salad bar was the least popular food choice, and popularity of the salad bar decreased over time. The educational campaign designed to increase salad bar use had no effect. These results can help guide future interventions in low-income rural communities.

Effective Elements of School-based Provision for the Promotion of Healthy Lifestyles: A European Delphi Study

Objective: Schools can serve as settings for promoting their student health, although it is necessary to identify the key elements of provision to leverage change. This study’s objective was to develop a Europe-based list of the elements of learning and health support systems judged by a group of experts to be most effective in influencing school student healthy lifestyles education. Methods: A 3-stage Delphi study involving a group of 18 Europe-based subject specialists was used to articulate shared expert opinions on the main research question: what are the most effective elements of learning and health support systems influencing school students’ healthy lifestyles education? Over 3 rounds of data-gathering, experts were asked to assess the effectiveness of 25 specific elements. Results: The 3 rounds resulted in the following ranked list: Physical Education (PE), Staff Professional Development, Healthy School Policies, Active Recess, Family & Community Engagement, Healthy Eating, Physical Activity in Classroom Lessons, and Active Transport. Conclusions: Cautious of overly generalizing from the results, we suggest the findings offer useful information for evidence-based programs, as well as future research that explores the necessary components of health promotion in schools.