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Addressing HIV/Sexually Transmitted Diseases and Pregnancy Prevention Through Schools: An Approach for Strengthening Education, Health Services, and School Environments That Promote Adolescent Sexual Health and Well-Being

      Abstract

      Adolescents’ health behaviors and experiences contribute to many outcomes, including risks for HIV, other sexually transmitted diseases, and unintended pregnancy. Public health interventions and approaches addressing risk behaviors or experiences in adolescence have the potential for wide-reaching impacts on sexual health and other related outcomes across the lifespan, and schools are a critical venue for such interventions. This paper describes a school-based program model developed by the Centers for Disease Control and Prevention’s Division of Adolescent and School Health for preventing HIV/sexually transmitted diseases, unintended pregnancy, and related health risk behaviors and experiences among middle and high school students. This includes a summary of the theoretical and evidence base that inform the model, and a description of the model’s activities, organized into three key strategies (sexual health education, sexual health services, and safe and supportive environments) and across three cross-cutting domains (strengthening staff capacity, increasing student access to programs and services, and engaging parent and community partners). The paper also outlines implications for adolescent health professionals and organizations working across schools, clinics, and communities, to address and promote adolescent sexual health and well-being.

      Keywords

      Implications and Contribution
      This paper describes a school-based, theory- and research-driven program model developed by the Centers for Disease Control and Prevention’s Division of Adolescent and School Health for preventing HIV/sexually transmitted diseases, unintended pregnancy, and related health outcomes among U.S. adolescents. It includes strategies, activities, and key implementation considerations for adolescent health professionals.
      See Related Editorial on p.521
      Youth’s experiences and behaviors during adolescence impact their current health and set the stage for their health into adulthood [
      Centers for Disease Control and Prevention
      Youth risk behavior survey data summary & trends report 2009–2019.
      ]. Experiences and behaviors during childhood and adolescence greatly influence longer term health and wellbeing [
      • Braveman P.
      • Barclay C.J.P.
      Health disparities beginning in childhood: A life-course perspective.
      ,
      • Wethington E.
      An overview of the life course perspective: Implications for health and nutrition.
      ] including sexual health-related outcomes [
      • Wickrama T.
      • Merten M.J.
      • Wickrama K.J.S.
      Early socioeconomic disadvantage and young adult sexual health.
      ], which makes adolescence a critical time for health interventions. Sexual risk behavior in adolescence contributes to unintended pregnancy, risk for HIV, and other sexually transmitted diseases (STDs) [
      Centers for Disease Control and Prevention
      Youth risk behavior survey data summary & trends report 2009–2019.
      ]. Although prevalence of most sexual risk behaviors and experiences among adolescents in the U.S. has decreased from 2009 to 2019 [
      Centers for Disease Control and Prevention
      Youth risk behavior survey data summary & trends report 2009–2019.
      ], STD rates among U.S. youth aged 15-19 have increased from 2014 to 2018 [
      • Bowen V.B.
      • Braxton J.
      • Davis D.W.
      • et al.
      Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2018.
      ]. Although it is estimated that youth ages 15-24 make up just over one quarter of the sexually active population, youth in this age group account for half of the 20 million new sexually transmitted infections that occur in the U.S. each year [
      • Bowen V.B.
      • Braxton J.
      • Davis D.W.
      • et al.
      Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2018.
      ]. Adolescents are identified as a particularly high-risk group for STDs due in part to the barriers they may face accessing STD prevention and management services (e.g., inability to pay, lack of transportation, confidentiality concerns with parents/guardians). Other health behaviors such as high-risk substance use, victimization from violence, and poor mental health and suicide-related experiences are shown to co-occur with and contribute to risk for HIV/STDs and unintended pregnancy among adolescents [
      Centers for Disease Control and Prevention
      Youth risk behavior survey data summary & trends report 2009–2019.
      ]. Recent trend data from 2009 to 2019 illustrate that several violence victimization, mental health, and suicide-related behaviors and experiences among U.S. adolescents have grown worse [
      Centers for Disease Control and Prevention
      Youth risk behavior survey data summary & trends report 2009–2019.
      ].
      Given the prevalence of such behaviors and experiences, public health professionals must identify opportunities to effectively reach adolescents with the knowledge, skills, services, and support they need to enhance their health behaviors and outcomes. Fortunately, schools are particularly well-suited for improving the health trajectories of adolescents, including reducing risk behaviors, for three main reasons. First, each year schools serve more than 56 million U.S. youth across key years of their social, physical, and intellectual development [
      National Center for Education Statistics
      Fast facts: Back to school statistics.
      ,
      National Center for Education Statistics
      The condition of education: Elementary and secondary enrollment.
      ]. Second, schools often have both internal staff (e.g., health educators, school counselors, nurses) and partners in the community (e.g., health and mental health providers) with knowledge of health risk and protective behaviors and have infrastructure to support a varied set of public health interventions and approaches. Third, schools provide a venue for direct health education for students, through designated health curricula, courses, or content integrated across multiple subject areas. Finally, many schools offer a range of health services, connect students to health and social services outside of the school, provide opportunities for reaching and engaging parents, and help students develop connectedness with peers and adults [
      • Steiner R.J.
      • Sheremenko G.
      • Lesesne C.
      • et al.
      Adolescent connectedness and adult health outcomes.
      ].
      The Centers for Disease Control and Prevention’s (CDC) Division of Adolescent and School Health (DASH) has worked for over three decades with education and public health agencies, national nongovernmental organizations, youth-serving organizations, and families and communities to support healthy behaviors among youth. Over the past 10 years, DASH has worked with these partners to develop and refine a school-based model to prevent HIV, other STDs, unintended pregnancies, and related risk behaviors among adolescents and to help them become healthy, successful adults [
      Centers for Disease Control and Prevention
      Division of adolescent and school health. The path forward: DASH strategic plan.
      ,
      Centers for Disease Control and Prevention
      PS18-1807 program guidance: Guidance for school-based HIV/STD prevention (component 2) recipients of PS18-1807.
      ]. This school-based program model is currently being funded and implemented among 28 local education agencies (LEAs) (school districts) and LEA consortia (groups of LEAs collaboratively working with CDC funding) across the U.S., reaching approximately two million middle and high school students. This translates to approximately 8% of all U.S. middle and high school students [
      National Center for Education Statistics
      Enrollment in public elementary and secondary schools, by level and grade: Selected years, fall 1980 through fall 2029.
      ]. Research on previous iterations of the model indicates that it has been effective in decreasing adolescent sexual risk behaviors (e.g., ever having sex, having four or more sexual partners), violence victimization, and substance use [
      • Barrios L.C.
      • Underwood J.M.
      • McManus T.
      • et al.
      Impact of an education agency-based program on adolescent health risk and protective behaviors.
      ,
      Centers for Disease Control and Prevention
      CDC's adolescent and school health program protecting our nation's youth from HIV, STDs and pregnancy.
      ].
      In this paper, we present the theoretical foundations that informed this school-based program model, and describe the strategies, domains, and activities that make up the model for preventing HIV/STDs, unintended pregnancy, and related risk behaviors among adolescents. Finally, we offer considerations for adolescent health professionals, working with and in schools, who wish to implement these strategies to promote health and wellbeing among their students.

      Theoretical Foundation

      Behavioral and social science theories offer a foundation for understanding the kinds of strategies that are likely to improve knowledge and behavior change related to sexual health [
      • Glanz K.
      • Bishop D.B.
      The role of behavioral science theory in development and implementation of public health interventions.
      ]. Ecological Systems Theory and associated ecological perspectives on health promotion suggest that behavior change is most likely when interventions are designed to affect individual, organizational, and environmental factors linked to the desired behavior [
      • Bronfenbrenner U.
      The ecology of human development.
      ,
      • Sallis J.F.
      • Owen N.
      • Fisher E.
      • et al.
      Ecological models of health behavior..
      ,
      Centers for Disease Control and Prevention
      The social-ecological model: A framework for prevention.
      ]. Ecological Systems Theory considers the interaction between the individual and the settings in which they are nested to be fundamental in human development and behavior change. For example, a student’s ability to learn and acquire skills for avoiding risky health behavior may be a consequence not only of the instruction they receive, but also the extent to which they feel safe and connected to their teachers and peers in the classroom and in school [
      • Bronfenbrenner U.
      The ecology of human development.
      ]. Although a variety of other behavior theories inform individual elements within the program model, these ecological perspectives formed the primary theoretical foundation for the program. They offer an ideal framework for considering the key needs and opportunities for implementing a school-based program, where schools have the opportunity to impact individual behaviors and are also connected to and dependent on community and societal factors. In line with the ecological perspectives, the school-based HIV/STD, unintended pregnancy, and related risk behavior prevention program model is grounded in the perspective that sexual health promotion and risk reduction approaches may be most effective when activities to improve individual level knowledge and skills are combined with additional activities that address relationship (e.g., parent-child communication), community (e.g., availability of sexual health services [SHS] and positive youth development [PYD] opportunities), and societal (e.g., policy) level factors [
      • Shoveller J.A.
      • Johnson J.L.
      • Savoy D.M.
      • et al.
      Preventing sexually transmitted infections among adolescents: An assessment of ecological approaches and study methods.
      ,
      • Salazar L.F.
      • Bradley E.L.
      • Younge S.N.
      • et al.
      Applying ecological perspectives to adolescent sexual health in the United States: Rhetoric or reality?.
      ,
      • DiClemente R.J.
      • Salazar L.F.
      • Crosby R.A.
      A review of STD/HIV preventive interventions for adolescents: Sustaining effects using an ecological approach.
      ,
      • Ivankovich M.B.
      • Fenton K.A.
      • Douglas Jr., J.M.
      Considerations for national public health leadership in advancing sexual health.
      ].

      Program Model: Strategies, Domains, and Activities

      As shown in Figure 1, the school-based HIV/STD, unintended pregnancy, and related risk behavior prevention program model relies on a program lead in each LEA to champion and coordinate activities. The program model is organized into three strategy areas: sexual health education (SHE), SHS, and safe and supportive environments (SSE). These strategies and their associated activities are described in detail later in this section.
      Figure thumbnail gr1
      Figure 1School-based program model developed by the Centers for Disease Control and Prevention’s Division of Adolescent and School Health for preventing HIV/STDs, unintended pregnancy, and related health risk behaviors and experiences among adolescents. STD = sexually transmitted disease.
      The model also includes three domains, or types of work, that are integrated within and across each of the three strategies (SHE, SHS, and SSE) (Figure 1). These domains represent key opportunities for interventions that can help shape or influence students’ health and behaviors, including (1) strengthening staff capacity [
      • Kirby D.
      • Laris B.
      • Rolleri L.
      ,
      • Riley M.
      • Patterson V.
      • Lane J.C.
      • et al.
      The adolescent champion model: Primary care becomes adolescent-centered via targeted quality improvement.
      ,
      • Kosciw J.G.
      • Palmer N.A.
      • Kull R.M.
      • et al.
      The effect of negative school climate on academic outcomes for LGBT youth and the role of in-school supports.
      ]; (2) increasing student access to programs and services [
      • Dittus P.J.
      • De Rosa C.J.
      • Jeffries R.A.
      • et al.
      The project connect health systems intervention: Linking sexually experienced youth to sexual and reproductive health care.
      ,
      • Saewyc E.M.
      • Konishi C.
      • Rose H.A.
      • et al.
      School-based strategies to reduce suicidal ideation, suicide attempts, and discrimination among sexual minority and heterosexual adolescents in Western Canada.
      ]; and (3) engaging parent and community partners [
      • Wight D.
      • Fullerton D.
      A review of interventions with parents to promote the sexual health of their children.
      ,
      • Dittus P.J.
      Promoting adolescent health through triadic interventions.
      ]. Strengthening staff capacity refers to improving self-efficacy, knowledge and skills, and behaviors of school staff (e.g., teachers, nurses, administrators) in delivering health promotion strategies for adolescents through tailored professional development and training experiences. Increasing student access to programs and services involves ensuring access to and receipt of health education, resources, initiatives, and services both within the school and community. Finally, engaging parent and community partners is an important part of effectively and sustainably implementing school-based health promotion strategies. Work in this domain is designed to incorporate key stakeholders into intervention activities; for example, connecting students with PYD programs in the community and supporting parents and caregivers to engage in positive parenting practices. Taken together, these strategies, domains, and implementation activities are believed to influence student health and behaviors.
      Across the program model as a whole, activities from these three domains are designed to impact a set of short-term and intermediate outcomes designed to move the longer-term outcomes of delayed onset of sexual activity, decreased sex without a condom, increased contraceptive use, decreased risk behaviors that place adolescents at higher risk of adverse health outcomes (e.g., substance use, violence, and poor mental health), reduced HIV and other STD infection, decreased unintended pregnancy rates, and increased student academic success. The full set of outcomes, with short-term outcomes organized by strategy focus, are provided in Table 1.
      Table 1Short-term, intermediate, and long-term outcomes for the activities recommended for the school-based program model developed by the Center for Disease Control and Prevention’s Division of Adolescent and School Health for preventing HIV/STDs and unintended pregnancy and related health risk behaviors and experiences among adolescents
      Strategy areaShort-term outcomesIntermediate outcomesLong-term outcomes
      Sexual health education
      • Teacher ability to teach sexual health education effectively
      • Student receipt of effective sexual health education
      • Student knowledge, skills, and behaviors to avoid and reduce sexual risk behaviors
      • Student awareness of sexual health services needs and services
      • Student HIV testing
      • Student STD testing
      • Student reproductive healthcare visits
      • Access to confidential SHS in accordance with state laws
      • Parental monitoring
      • Parent/student communication about sexual health information and services
      • Student connectedness to school
      • Delayed onset of sexual activity
      • Decreased sex without a condom
      • Increased use of contraceptives
      • Decreased risk behaviors that place adolescents at higher risk of adverse health outcomes including substance use, violence, and mental illness
      • Reduced HIV infection and other STDs
      • Decreased unintended pregnancy rates
      • Increased student academic success
      Sexual health services
      • Access to on-site and off-site sexual health services
      • Delivery of on-site sexual health services
      • Referrals for sexual health services to community providers
      Safe and supportive environments
      • Teacher implementation of best classroom management practices for safe and supportive environments
      • Student participation in positive youth development activities
      Note: Some intermediate and long-term outcomes are linked to multiple strategy areas (e.g., “student awareness of sexual health services needs and services” is an intermediate outcome linked to both sexual health education and sexual health services strategy areas and activities.
      SHS = sexual health services; STD = sexually transmitted disease.

      Sexual health education

      SHE, as part of a comprehensive health education curricula framework, uses a systematic, evidence-informed approach to equip youth with functional information and skills needed to prevent or reduce HIV/STDs, and unintended pregnancy. Grounded in theorical and scientific evidence as well as practice-based guidance, SHE emphasizes planned, sequential learning across grades pre-kindergarten to 12th by using medically accurate, developmentally appropriate, and culturally driven learning strategies, content, and skills [
      Guidelines for Comprehensive Sexuality Education
      Kindergarten-12th grade.
      ]. Research suggests that effective school health education programs are associated with reductions in adolescent risk behaviors and improved academic performance [
      • Rasberry C.N.
      • Tiu G.F.
      • Kann L.
      • et al.
      Health-related behaviors and academic achievement among high school students—United States, 2015.
      ,
      • Basch C.E.
      Healthier students are better learners: A missing link in school reforms to close the achievement gap.
      ]. Well-designed and implemented school-based HIV/STDs prevention programs can decrease sexual risk behaviors among school age youth, including delaying first sexual intercourse, reducing the number of sex partners, decreasing the number of times adolescents have unprotected sex, and increasing condom use [
      • Mavedzenge S.N.
      • Luecke E.
      • Ross D.A.
      Effective approaches for programming to reduce adolescent vulnerability to HIV infection, HIV risk, and HIV-related morbidity and mortality: A systematic review of systematic reviews.
      ,
      • Chin H.B.
      • Sipe T.A.
      • Elder R.
      • et al.
      The effectiveness of group-based comprehensive risk-reduction and abstinence education intervention to prevent or reduce the risk of adolescent pregnancy, human immunodeficiency virus, and sexually transmitted infections.
      ]. The school-based program model promotes a range of activities that support and strengthen SHE in schools. This includes activities that strengthen teachers’ ability to deliver sexual health effectively, increase students’ access and receipt of effective SHE, and engage parents and communities in the selection, implementation, and improvement of SHE in schools as outlined in Table 2.
      Table 2Activities for local education agencies to support HIV, other STD, and pregnancy prevention
      StrategyDomainActivity
      Sexual health educationStrengthening staff capacityIdentify and approve a list of instructional competencies to be demonstrated by those teaching skill-based health and sexual health education in middle and high school
      Develop and implement a technical assistance plan that incorporates teacher observation, coaching, peer mentoring, and other methods to improve an individual teacher’s sexual health education instruction
      Provide training at the local education agency once per year to ensure school health and sexual health education teachers have content knowledge, comfort, and instructional competencies to effectively implement approved school health and sexual health education instructional programs
      Increasing student access to programs and servicesEstablish, adopt, and implement a skill-based health education course requirement, which includes sexual health education content, for all students attending middle and high schools in the district
      Develop and approve a health education scope and sequence that delineates sexual health education learning outcomes for all students in middle and high schools in the district
      Develop, revise, or select a sexual health education instructional program consistent with the approved scope and sequence (referenced above), and inclusive of instructional lessons, student learning activities, resources, and student assessment
      Develop, revise, or select health education instructional programs for students in elementary grades that align with the priorities for health education and sexual health education established in the health education scope and sequence
      Incorporate specific changes to existing instructional programs to better meet the needs of LGBTQ adolescents
      Strengthen student assessment instruments to more accurately assess student mastery of health education knowledge and skills
      Develop, update, and foster use of teaching tools and resources (e.g., lesson pacing guide, specific lesson plans) for teachers to continuously improve delivery of the identified sexual health education instructional program
      Engaging parents and community partnersEstablish and maintain a School Health Advisory Council that regularly provides district-level advice and guidance to improve health and sexual health education programs for students and health and sexual health education instruction for staff
      Integrate strategies to actively engage parents in sexual health education instructional programs
      SHSStrengthening staff capacityProvide training and professional development to school and/or health service staff to support SHS activities annually
      Increasing student access to programs and servicesAssess district and priority school capacity to implement activities to increase student access to SHS
      Incorporate skill-based instruction to students on accessing school-based and community SHS into sexual health education lessons annually
      Increase student access to and use of SHS through either on-site provision or referral to community-based sexual health providers depending on district/schools’ health services infrastructure. For on-site health services, improve student use and quality of SHS provided by School-Based Health Centers. For referral-based health services, establish or improve use of a referral system to link sexually active students to community providers for SHS by using the referral system toolkit to implement the seven core components of a referral system
      Implement school-wide, student-planned marketing campaigns that promote recommended health services for teens and selected school SHS programs
      Conduct school-based STD screening events.
      Implement or improve a condom availability program
      Engaging parents and community partnersDisseminate SHS-related materials for parents
      Safe and supportive environmentsStrengthening staff capacityProvide professional development to teachers on classroom management annually
      Provide professional development to all school staff on supporting LGBTQ adolescents annually
      Increasing student access to programs and servicesImplement mentoring, service learning, and/or other positive youth development programs for students, and/or connect students to such community-based programs
      Establish or enhance student-led clubs that support LGBTQ adolescents (often known as Gay-Straight Alliances or Genders and Sexualities Alliances)
      Engaging parents and community partnersDisseminate resources to parents/caregivers on parental monitoring and parent-adolescent communication (generally and specifically about sex)
      Disseminate resources specifically relevant to parents of LGBTQ students
      Implement and/or connect parents to skill-building parenting programs
      LGBTQ = lesbian, gay, bisexual, transgender, and questioning; SHS = sexual health services; STD = sexually transmitted disease.
      In addition to curricular content and skills needed to address adolescent sexual health outcomes, quality SHE also requires well-trained and supported teachers who can create safe and inclusive learning environments and are skilled in effective pedagogy. Research suggests that teachers’ instructional competency (i.e., essential knowledge and skills) is key to improved delivery [
      • Darling-Hammond L.
      Teacher quality and student achievement.
      ,
      • Palardy G.J.
      • Rumberger R.W.
      Teacher effectiveness in the first grade: The importance of background qualifications, attitudes, and instructional practices for student learning.
      ,
      • Marzano R.J.
      What works in schools: Translating research into action.
      ,
      • Stronge J.H.
      • Ward T.J.
      • Grant L.W.
      What makes good teachers good? A cross-case analysis of the connection between teacher effectiveness and student achievement.
      ]. For example, studies demonstrate that higher levels of student achievement are associated with teachers using a variety of teaching strategies (e.g., instructional differentiation), demonstrating organization, fostering safe classroom environments, setting clear expectations for learning and behavior, exhibiting enthusiasm for the content, building relationships with students, and treating students with care, fairness, and respect [
      • Darling-Hammond L.
      Teacher quality and student achievement.
      ,
      • Palardy G.J.
      • Rumberger R.W.
      Teacher effectiveness in the first grade: The importance of background qualifications, attitudes, and instructional practices for student learning.
      ,
      • Marzano R.J.
      What works in schools: Translating research into action.
      ,
      • Allington R.L.
      What I've learned about effective reading instruction : From a decade of studying exemplary elementary classroom teachers.
      ,
      • McColsky W.
      • Stronge J.
      • Ward T.
      • et al.
      ]. One effective strategy for strengthening teacher instructional competency is through professional development. Data suggest improvements in teachers’ implementation of classroom instruction [
      • Clayton H.B.
      • Brener N.D.
      • Barrios L.C.
      • et al.
      Professional development on sexual health education is associated with coverage of sexual health topics.
      ,
      • Kealey K.A.
      • Peterson Jr., A.V.
      • Gaul M.A.
      • et al.
      Teacher training as a behavior change process: Principles and results from a longitudinal study.
      ,
      • Pateman B.
      • Grunbaum J.A.
      • Kann L.
      Voices from the field—a qualitative analysis of classroom, school, district, and state health education policies and programs.
      ] and increases in time teachers spend teaching health topics, as well as their self-efficacy toward teaching [
      • Telljohann S.K.
      • Everett S.A.
      • Durgin J.
      • et al.
      Effects of an inservice workshop on the health teaching self-efficacy of elementary school teachers.
      ,
      • Levenson-Gingiss P.
      • Hamilton R.
      Evaluation of training effects on teacher attitudes and concerns prior to implementing a human sexuality education program.
      ], following professional development training [
      • Kirby D.
      Emerging answers 2007: Research findings on programs to reduce teen pregnancy and sexually transmitted diseases.
      ]. Furthermore, research on mentoring programs, a specialized approach to professional development, has been linked to positive effects on instructional delivery, including teaching strategies and classroom management, and student achievement among beginning teachers [
      • Ingersoll R.M.
      • Strong M.
      The impact of induction and mentoring programs for beginning teachers: A critical review of the research.
      ,
      • Darling-Hammond L.
      Keeping good teachers: Why it matters, what leaders can do.
      ,
      • Heider K.L.
      Teacher isolation: How mentoring programs can help.
      ]. Given this, the program model supports several activities to strengthen staff capacity for teaching SHE; these range from identifying and approving teacher instructional competencies, to providing annual training and support through activities such as observation, coaching, and mentoring. All related activities are described in greater detail in Table 2.
      The program model also includes several activities to increase student access to and receipt of quality SHE, including establishing a scope and sequence (S&S), implementing skill-based health education course requirements, selecting or developing instructional programs that meet the sexual health needs of lesbian, gay, bisexual, transgender, and questioning (LGBTQ) adolescents, and other activities described in Table 2. Improving student access to and receipt of quality SHE curriculum is necessary in order for adolescents to practice, adopt, and maintain skills and behaviors that prevent or reduce HIV/STDs and unintended pregnancy, among other outcomes. Several key characteristics are associated with effective curricula including sequential implementation across grade levels (i.e., kindergarten to 12th); use of content that is medically accurate, developmentally appropriate, and culturally inclusive; an emphasis on skill building; use of relevant and engaging instructional tools, delivery by qualified and trained teachers; focus on developing and practicing healthy behaviors within safe school environments; and integrating family and community partners [
      • Chin H.B.
      • Sipe T.A.
      • Elder R.
      • et al.
      The effectiveness of group-based comprehensive risk-reduction and abstinence education intervention to prevent or reduce the risk of adolescent pregnancy, human immunodeficiency virus, and sexually transmitted infections.
      ,
      • Kirby D.B.
      • Laris B.
      • Rolleri L.A.
      Sex and HIV education programs: Their impact on sexual behaviors of young people throughout the world.
      ,
      • Tortolero S.R.
      • Markham C.M.
      • Fleschler Peskin M.
      • et al.
      It’s your game. Keep it real: Delaying sexual behavior with an effective middle school program.
      ,
      • Coyle K.K.
      • Kirby D.B.
      • Marín B.V.
      • et al.
      Draw the line/respect the line: A randomized trial of a middle school intervention to reduce sexual risk behaviors.
      ,
      • Sikkema K.J.
      • Anderson E.S.
      • Kelly J.A.
      • et al.
      Outcomes of a randomized, controlled community-level HIV prevention intervention for adolescents in low-income housing developments.
      ,
      • Jemmott J.B.
      • Jemmott L.S.
      • Fong G.T.
      Efficacy of a theory-based abstinence-only intervention over 24 months: A randomized controlled trial with young adolescents.
      ,
      • Villarruel A.M.
      • Jemmott J.B.
      • Jemmott L.S.
      A randomized controlled trial testing an HIV prevention intervention for Latino youth.
      ,
      • Denford S.
      • Abraham C.
      • Campbell R.
      • et al.
      A comprehensive review of reviews of school-based interventions to improve sexual-health.
      ].
      Effective planning in health education can accelerate student learning and achievement, and education plans or resources which frame curricula are critical to successful implementation [
      • English F.
      Deciding what to teach and test: Developing, aligning, and leading the curriculum.
      ]. Research from curriculum planning and instruction describes S&S charts and similar unit/lesson planning documents as effective resources for assessing, planning, and designing instruction [
      • Fodor J.
      • Dalis G.
      • DGiarratano Russell S.
      Designing and implementing mathematics instruction for students with diverse learning needs.
      ,
      • Hale J.
      A guide to curriculum mapping: Planning, implementing, and sustaining the process.
      ]. One essential planning resource is the health education S&S [
      Centers for Disease Control and Prevention
      Developing a scope and sequence for sexual health education.
      ], a document outlining the breadth and arrangement of key health topics and concepts across grade levels (scope), and the logical progression of essential health knowledge, skills, and behaviors to be addressed at each grade level (sequence) from pre-kindergarten to the 12th grade [
      Centers for Disease Control and Prevention
      Developing a scope and sequence for sexual health education.
      ].
      Moreover, to reach public health priorities outlined by the U.S. Department of Health and Human Services’ Healthy People 2030 initiative, improvements in the number of schools that provide health education on sexual health topics including HIV/STDs and unintended pregnancy prevention is needed through policy implementation and monitoring. Specifically, attention to state or local policies, laws, or mandates shaping course requirements and instructional time for SHE must be addressed and strengthened to ensure program sustainability [
      • Hall K.S.
      • Sales J.M.
      • Komro K.A.
      • et al.
      The state of sex education in the United States.
      ,

      Centers for Disease Control and Prevention. Results from the school health policies and practices study 2014. Atlanta, GA; 2015. p. 60–74.

      ]. School Health Advisory Councils (SHACs) can play an important role in assessing and prioritizing the SHE needs in their district and work with school boards to approve and implement evidence-based curricula [
      • Hernandez B.F.
      • Peskin M.
      • Shegog R.
      • et al.
      Choosing and maintaining programs for sex education in schools.
      ,
      • Hernandez B.F.
      • Peskin M.F.
      • Shegog R.
      • et al.
      iCHAMPSS: usability and psychosocial impact for increasing implementation of sexual health education.
      ].
      Parents and community partners are essential in supporting and engaging in SHE. Data show that most U.S adults and parents support SHE delivered through schools [
      • Barr E.M.
      • Moore M.J.
      • Johnson T.
      • et al.
      New evidence: Data documenting parental support for earlier sexuality education.
      ,
      • Tortolero S.R.
      • Johnson K.
      • Peskin M.
      • et al.
      Dispelling the myth: What parents really think about sex education in schools.
      ], and as such, their support can be leveraged to aid its implementation. Through roles on an SHAC or similar school-based decision-making team/committee, parents and community partners can also be directly involved in making recommendations on sexual health curricula, services, and policies or practices that promote the health of all students and staff [
      • Howell K.
      Establishing and maintaining school health advisory councils: A how-to manual for local educational agencies.
      ,
      • Marx E.
      • Wooley S.F.
      ,
      American Cancer Society
      Promoting healthy youth, schools, and communities: A guide to community-school health Councils.
      ,
      • Wyche J.
      • Nicholson L.
      • Lawson E.
      • et al.
      Schools and health: Our nation’s investment.
      ]. Furthermore, when SHE programs are designed to facilitate students’ engagement with their parents, through take-home assignments or activities, research shows improvements in parent-adolescent communication as well as parental monitoring, both of which are linked to lower sexual risk behavior among youth [
      • Wight D.
      • Fullerton D.
      A review of interventions with parents to promote the sexual health of their children.
      ]. The school-based program model describes various implementation activities to increase parent and community partner engagement in SHE (Table 2).

      Sexual health services

      Preventive sexual health services are important, and school and community-level sexual health promotion activities can include those to increase student access to specific services like HIV and STD testing and contraception and condom provision, as well as more broad preventive measures like conducting sexual risk assessments, creating adolescent-friendly clinical environments, and providing counseling about preventive behaviors [
      Centers for Disease Control and Prevention
      What works: Sexual health services.
      ]. Quality adolescent SHS can help reduce adolescents’ risk behavior and prevent negative sexual health outcomes like unintended pregnancy, STDs, and HIV [
      • Hagan J.F.
      • Shaw J.S.
      • Duncan P.M.
      Bright futures: Guidelines for health supervision of infants, children, and adolescents.
      ,
      United States Preventive Services Task Force
      ,
      • Alderman E.M.
      AMA Guidelines for Adolescent Preventive Services (GAPS): recommendations and rationale.
      ]. Despite national guidelines and recommendations for routine provision of SHS for adolescents [
      • Hagan J.F.
      • Shaw J.S.
      • Duncan P.M.
      Bright futures: Guidelines for health supervision of infants, children, and adolescents.
      ,
      • Gavin L.
      • Moskosky S.
      • Carter M.
      • et al.
      Providing quality family planning services: Recommendations of CDC and the US Office of Population Affairs.
      ,
      • Gavin L.
      Update: Providing quality family planning services—recommendations from CDC and the US Office of Population Affairs, 2015.
      ,
      • Curtis K.M.
      US selected practice recommendations for contraceptive use, 2016.
      ,
      • Workowski K.A.
      • Bolan G.A.
      Sexually transmitted diseases treatment guidelines, 2015.
      ,
      • DiNenno E.A.
      • Prejean J.
      • Irwin K.
      • et al.
      Recommendations for HIV screening of gay, bisexual, and other men who have sex with men—United States, 2017.
      ,
      • Marcell A.V.
      • Burstein G.R.
      Sexual and reproductive health care services in the pediatric setting.
      ], many young people do not have preventive care visits [
      • Irwin C.E.
      • Adams S.H.
      • Park M.J.
      • et al.
      Preventive care for adolescents: Few get visits and fewer get services.
      ,
      • Edman J.C.
      • Adams S.H.
      • Park M.J.
      • et al.
      Who gets confidential care? Disparities in a national sample of adolescents.
      ]. Even among those who do, missed opportunities for SHS are common. For instance, confidentiality and developmentally appropriate care are critical to adolescent SHS [
      • Brittain A.W.
      • Williams J.R.
      • Zapata L.B.
      • et al.
      Confidentiality in family planning services for young people: A systematic review.
      ,
      • Reddy D.M.
      • Fleming R.
      • Swain C.
      Effect of mandatory parental notification on adolescent girls’ use of sexual health care services.
      ,
      • Thomas N.
      • Murray E.
      • Rogstad K.
      Confidentiality is essential if young people are to access sexual health services.
      ,
      • Jones R.K.
      • Purcell A.
      • Singh S.
      • et al.
      Adolescents’ reports of parental knowledge of adolescents’ use of sexual health services and their reactions to mandated parental notification for prescription contraception.
      ,
      • Thrall J.S.
      • McCloskey L.
      • Ettner S.L.
      • et al.
      Confidentiality and adolescents’ use of providers for health information and for pelvic examinations.
      ,
      • Peralta L.
      • Deeds B.G.
      • Hipszer S.
      • et al.
      Barriers and facilitators to adolescent HIV testing.
      ], yet young people do not often receive time alone with their provider [
      • Edman J.C.
      • Adams S.H.
      • Park M.J.
      • et al.
      Who gets confidential care? Disparities in a national sample of adolescents.
      ,
      • Bravender T.
      • Lyna P.
      • Tulsky J.A.
      • et al.
      Physicians’ assurances of confidentiality and time spent alone with adolescents during primary care visits.
      ] and report concerns about the confidentiality of their care [
      • Tylee A.
      • Haller D.M.
      • Graham T.
      • et al.
      Youth-friendly primary-care services: How are we doing and what more needs to be done?.
      ]. These issues may contribute to low SHS use among adolescents and provide an opportunity for educating parents and caregivers on the importance of adolescents having time alone with healthcare providers. As outlined in Table 2, the school-based program model includes activities that improve school and health services staff’s ability to support SHS, increase student access and use of SHS, and strengthen communication about SHS with parents and caregivers.
      Findings from a previous iteration of the CDC-funded program model suggest that school staff, including health services staff, need training to improve their self-efficacy and comfort providing or referring students to SHS [
      • Rasberry C.N.
      • Liddon N.
      • Adkins S.H.
      • et al.
      The importance of school staff referrals and follow-up in connecting high school students to HIV and STD testing.
      ]. Furthermore, professional development trainings have been shown to change school staff’s beliefs and self-efficacy for addressing sexuality topics with their students in the classroom, and these trainings may also better help staff identify student sexual health needs and connect students to services. Trainings to develop staff comfort, capacity, and expertise in best practices and core areas of adolescent sexual health have improved clinical services, including in school-based health centers (SBHCs) [
      • Riley M.
      • Patterson V.
      • Lane J.C.
      • et al.
      The adolescent champion model: Primary care becomes adolescent-centered via targeted quality improvement.
      ]. Professional development is also a key component of quality improvement programs and interventions for health clinic and school health staff [
      Centers for Disease Control and Prevention
      Project connect implementation guide.
      ]. Building on this, DASH’s program model supports schools to provide training and professional development to school and/or health service staff annually to help support their other SHS activities (Table 2).
      In addition, the program model developed by DASH supports a full range of activities—from direct provision of onsite SHS to helping students learn about, find, and connect to services in the community—to increase students’ access to SHS (Table 2). Researchers have explored several ways schools can directly increase students’ access to important SHS. For example, schools with clinical infrastructure such as SBHCs can directly provide a range of comprehensive health services to adolescents; SBHCs can be particularly useful for their ability to reach underserved populations [
      • Mason-Jones A.J.
      • Crisp C.
      • Momberg M.
      • et al.
      A systematic review of the role of school-based healthcare in adolescent sexual, reproductive, and mental health.
      ] and their provision of confidential services such as SHS [
      • Gustafson E.M.
      History and overview of school-based health centers in the US.
      ,
      • Coyne-Beasley T.
      • Ford C.A.
      • Waller M.W.
      • et al.
      Sexually active students’ willingness to use school-based health centers for reproductive health care services in North Carolina.
      ]. Schools that cannot provide SHS on school grounds can establish processes to link students to adolescent-friendly providers in the community. This has been found effective in several studies. For example, one recent study found that high school students in a large Florida school district were more likely to get tested for HIV or STDs when referred by school staff [
      • Rasberry C.N.
      • Liddon N.
      • Adkins S.H.
      • et al.
      The importance of school staff referrals and follow-up in connecting high school students to HIV and STD testing.
      ]. Similarly, another school-based referral program, Project Connect, found an increase in sexually active students’ receipt of sexual and reproductive health services following a program in which school nurses referred students to clinics providing quality adolescent SHS in the community [
      • Dittus P.J.
      • De Rosa C.J.
      • Jeffries R.A.
      • et al.
      The project connect health systems intervention: Linking sexually experienced youth to sexual and reproductive health care.
      ,
      • Dittus P.J.
      • Harper C.R.
      • Becasen J.S.
      • et al.
      Structural intervention with school nurses increases receipt of sexual health care among male high school students.
      ,
      • Loosier P.S.
      • Doll S.
      • Lepar D.
      • et al.
      Effectiveness of an adaptation of the project connect health systems intervention: Youth and clinic-level findings.
      ]. Even schools that do not typically provide SHS onsite may be able to implement school-based STD screening programs, which have been conducted in school districts across the U.S. and have been found feasible and efficient for identifying students with STDs and treating them quickly [
      Centers for Disease Control and Prevention
      PS18-1807 program guidance: Guidance for school-based HIV/STD prevention (component 2) recipients of PS18-1807.
      ]. In one recent study, a school-based STD screening program was associated with sustained reduction of the prevalence of Chlamydia among adolescents [
      • Dunville R.
      • Peterson A.
      • Liddon N.
      • et al.
      Sustained reduction in Chlamydia infections following a school-based screening: Detroit, 2010–2015.
      ].
      Research also provides examples of other school-based efforts to increase students’ access to services and lower risk behaviors. For example, condom availability programs (CAPs) can increase condom use among students and may be particularly effective for adolescents who exhibit greater risk behaviors (i.e., report earlier initiation of sex, frequent sex, more sex partners). Studies have found these students more likely to have used a CAP-provided condom than students with less risk behavior [
      • Blake S.M.
      • Ledsky R.
      • Goodenow C.
      • et al.
      Condom availability programs in Massachusetts high schools: Relationships with condom use and sexual behavior.
      ,
      • Kirby D.
      • Brener N.
      • Brown N.
      • et al.
      The impact of condom distribution in Seattle schools on sexual behavior and condom use.
      ,
      • Schuster M.A.
      • Bell R.M.
      • Berry S.H.
      • et al.
      Students’ acquisition and use of school condoms in a high school condom availability program.
      ]. In addition, schools can raise student awareness and encourage use of needed SHS through both skill-based education on where and how to access SHS, as well as campaigns to promote SHS. Both approaches can help ensure students know where to find services, which is important given that research shows awareness of clinic locations is a key factor related to adolescents’ use of SHS [
      • Hubley J.
      Interventions targeted at youth aimed at influencing sexual behavior and AIDS/STDs.
      ]. A recent review of sexual health campaigns found that several resulted in increases in STI testing and condom use [
      • Friedman A.L.
      • Kachur R.E.
      • Noar S.M.
      • et al.
      Health communication and social marketing campaigns for sexually transmitted disease prevention and control: What is the evidence of their effectiveness?.
      ]. One recent pilot test of an adapted “GYT: Get Yourself Tested” social marketing campaign implemented in a high school was linked to increased HIV and STD testing at a local clinic and student awareness of services [
      • Liddon N.
      • Carver L.
      • Robin L.
      • et al.
      Schools to clinics: Connecting students to STD/HIV service providers using GYT social marketing campaign.
      ].
      In addition to helping students access services through direct provision of services or referral to community-based providers, schools can also help increase adolescents’ access to services by engaging their parents in ways that may support their access to needed services. Although research is clear that adolescents need access to confidential services, researchers have also advocated for involving parents in some aspects of adolescent clinical care [
      • Dittus P.J.
      Promoting adolescent health through triadic interventions.
      ,
      • Ford C.A.
      • Davenport A.F.
      • Meier A.
      • et al.
      Partnerships between parents and health care professionals to improve adolescent health.
      ]. As an example, in the Project Connect intervention, school-distributed resources for parents were associated with increased parental monitoring and communication [
      • Dittus P.J.
      • Harper C.R.
      • Hoo E.
      • et al.
      The Project Connect parental monitoring intervention: Population-level effects on adolescent perceptions of parental enforcement of family rules. 2015.
      ], which has been linked to reduced risk behavior among adolescents [
      • Markham C.M.
      • Lormand D.
      • Gloppen K.M.
      • et al.
      Connectedness as a predictor of sexual and reproductive health outcomes for youth.
      ]. Similar dissemination of SHS-related materials for parents is one of the strategies for parent engagement that is supported in the program model developed by DASH (Table 2).

      Safe and supportive environments

      SSE is a strategy that focuses on promoting school and family-level protective factors [
      • DiClemente R.J.
      • Salazar L.F.
      • Crosby R.A.
      • et al.
      Prevention and control of sexually transmitted infections among adolescents: The importance of a socio-ecological perspective—a commentary.
      ]. The three specific protective factors DASH’s SSE activities target are school connectedness, parental monitoring, and parent-adolescent communication (both generally and specifically about sex), which each promote behaviors that reduce HIV and other STDs among young people (e.g., delayed sexual initiation or condom use) [
      • Rasberry C.N.
      • Tiu G.F.
      • Kann L.
      • et al.
      Health-related behaviors and academic achievement among high school students—United States, 2015.
      ,
      • Markham C.M.
      • Lormand D.
      • Gloppen K.M.
      • et al.
      Connectedness as a predictor of sexual and reproductive health outcomes for youth.
      ,
      • Frieden T.R.
      A framework for public health action: The health impact pyramid.
      ,
      • Dittus P.J.
      • Michael S.L.
      • Becasen J.S.
      • et al.
      Parental monitoring and its associations with adolescent sexual risk behavior: A meta-analysis.
      ,
      • Ethier K.A.
      • Harper C.R.
      • Hoo E.
      • et al.
      The longitudinal impact of perceptions of parental monitoring on adolescent initiation of sexual activity.
      ] and promote positive sexual health outcomes long-term as well [
      • Dittus P.J.
      • Harper C.R.
      • Hoo E.
      • et al.
      The Project Connect parental monitoring intervention: Population-level effects on adolescent perceptions of parental enforcement of family rules. 2015.
      ,
      • Markham C.M.
      • Lormand D.
      • Gloppen K.M.
      • et al.
      Connectedness as a predictor of sexual and reproductive health outcomes for youth.
      ]. School connectedness, parental monitoring, and parent-adolescent communication are also linked to reductions in behaviors and experiences associated with adolescent sexual risk (e.g., substance use, violence victimization, and perpetration) [
      • DiClemente R.J.
      • Salazar L.F.
      • Crosby R.A.
      • et al.
      Prevention and control of sexually transmitted infections among adolescents: The importance of a socio-ecological perspective—a commentary.
      ] and increases in behaviors and experiences known to be protective against sexual risk (e.g., academic achievement) [
      • Mavedzenge S.N.
      • Luecke E.
      • Ross D.A.
      Effective approaches for programming to reduce adolescent vulnerability to HIV infection, HIV risk, and HIV-related morbidity and mortality: A systematic review of systematic reviews.
      ]. Consistent with ecological systems theory, this strategy not only directly contributes to HIV and other STD prevention, but also establishes a context necessary for other prevention approaches (such as SHE and SHS) to be effective [
      • Rasberry C.N.
      • Tiu G.F.
      • Kann L.
      • et al.
      Health-related behaviors and academic achievement among high school students—United States, 2015.
      ,
      • Markham C.M.
      • Lormand D.
      • Gloppen K.M.
      • et al.
      Connectedness as a predictor of sexual and reproductive health outcomes for youth.
      ,
      • Frieden T.R.
      A framework for public health action: The health impact pyramid.
      ,
      • Dittus P.J.
      • Michael S.L.
      • Becasen J.S.
      • et al.
      Parental monitoring and its associations with adolescent sexual risk behavior: A meta-analysis.
      ,
      • Ethier K.A.
      • Harper C.R.
      • Hoo E.
      • et al.
      The longitudinal impact of perceptions of parental monitoring on adolescent initiation of sexual activity.
      ,
      • Hawkins J.D.
      • Kosterman R.
      • Catalano R.F.
      • et al.
      Effects of social development intervention in childhood 15 years later.
      ,
      • Resnick M.D.
      • Bearman P.S.
      • Blum R.W.
      • et al.
      Protecting adolescents from harm: Findings from the national longitudinal study on adolescent health.
      ]. The school-based program model includes activities that strengthen teachers’ ability to create safe and supportive classroom environments for all students, connect youth with PYD programs and activities, and communicate with parents about ways to monitor and communicate effectively with their teens.
      One key programmatic activity for increasing school connectedness is leveraging professional development of school staff to improve the school environment. Effective class management has been linked to greater school connectedness [
      • McNeely C.A.
      • Nonnemaker J.M.
      • Blum R.W.
      Promoting school connectedness: Evidence from the national longitudinal study of adolescent health.
      ,
      • Hawkins J.D.
      • Guo J.
      • Hill K.G.
      • et al.
      Long-term effects of the Seattle social development intervention on school bonding trajectories.
      ] as well as improved effectiveness of classroom-based interventions, such as SHE [
      • Marzano R.J.
      • Marzano J.S.
      • Pickering D.J.
      ]. However, teachers need foundational skills to be able to ensure effective classroom management [
      • Marzano R.J.
      • Marzano J.S.
      • Pickering D.J.
      ] and have reported a need for trainings to gain strategies for this [
      ]. Specifically, training staff on classroom management and addressing the needs of students at disproportionate risk for negative school climate experiences, such as LGBTQ adolescents, can be particularly important. Many health and education organizations identify professional development for school staff as a best practice to improve school connectedness and safety for LGBTQ adolescents specifically [
      • Kosciw J.G.
      • Palmer N.A.
      • Kull R.M.
      • et al.
      The effect of negative school climate on academic outcomes for LGBT youth and the role of in-school supports.
      ]. Due to social stigma, LGBTQ students are more likely to report experiencing violence at school and having lower school connectedness when compared to their non-LGBTQ peers [
      • Rasberry C.N.
      • Lesesene C.
      • Herbert A.
      • et al.
      Factors associated with school connectedness for sexual minority youth.
      ,
      • Toomey R.B.
      • Russell S.T.
      The role of sexual orientation in school-based victimization: A meta-analysis.
      ], and professional development designed to improve school staff’s understanding of and ability to support LGBTQ adolescents has shown effectiveness in changing school staff’s beliefs and self-efficacy in supporting these students [
      • Greytak E.A.
      • Kosciw J.G.
      • Boesen M.J.
      Educating the educator: Creating supportive school personnel through professional development.
      ,
      • Kull R.M.
      • Kosciw J.G.
      • Greytak E.A.
      Preparing school counselors to support LGBT youth: The roles of graduate education and professional development.
      ].
      Beyond staff trainings, student programs such as mentoring, service learning, and other PYD programs can also increase school connectedness as part of the SSE strategy. Mentoring and service-learning [
      • Plourde K.F.
      • Ippoliti N.B.
      • Nanda G.
      • et al.
      Mentoring interventions and the impact of protective assets on the reproductive health of adolescent girls and young women.
      ,
      • O'Donnell L.
      • Stueve A.
      • O'Donnell C.
      • et al.
      Long-term reductions in sexual initiation and sexual activity among urban middle schoolers in the reach for health service learning program.
      ], and PYD programs more generally have shown a range of benefits across a variety of health and academic outcomes [
      • Ciocanel O.
      • Power K.
      • Eriksen A.
      • et al.
      Effectiveness of positive youth development interventions: A meta-analysis of randomized controlled trials.
      ,
      • Gavin L.E.
      • Catalano R.F.
      • David-Ferdon C.
      • et al.
      A review of positive youth development programs that promote adolescent sexual and reproductive health.
      ,
      • Shepherd J.
      • Kavanagh J.
      • Picot J.
      • et al.
      The effectiveness and cost-effectiveness of behavioural interventions for the prevention of sexually transmitted infections in young people aged 13-19: A systematic review and economic evaluation.
      ]. For example, gay-straight alliances or genders and sexualities alliances (GSAs), which incorporate key principles of PYD, are associated with lower rates of risk behaviors associated with sexual health (e.g., violence victimization, alcohol use, illicit drug use, prescription drug misuse, suicidal behavior) among both LGBTQ and heterosexual adolescents [
      • Saewyc E.M.
      • Konishi C.
      • Rose H.A.
      • et al.
      School-based strategies to reduce suicidal ideation, suicide attempts, and discrimination among sexual minority and heterosexual adolescents in Western Canada.
      ,
      • Heck N.C.
      • Livingston N.A.
      • Flentje A.
      • et al.
      Reducing risk for illicit drug use and prescription drug misuse: High school gay-straight alliances and lesbian, gay, bisexual, and transgender youth.
      ,
      • Coulter R.W.
      • Birkett M.
      • Corliss H.L.
      • et al.
      Associations between LGBTQ-affirmative school climate and adolescent drinking behaviors.
      ].
      Schools can also positively influence protective factors within the family environment, including parent-adolescent communication and parental monitoring [
      • Dittus P.J.
      • Michael S.L.
      • Becasen J.S.
      • et al.
      Parental monitoring and its associations with adolescent sexual risk behavior: A meta-analysis.
      ,
      • Widman L.
      • Choukas-Bradley S.
      • Noar S.M.
      • et al.
      Parent-adolescent sexual communication and adolescent safer sex behavior: A meta-analysis.
      ,
      • Laird R.D.
      • Criss M.M.
      • Pettit G.S.
      • et al.
      Parents’ monitoring knowledge attenuates the link between antisocial friends and adolescent delinquent behavior.
      ,
      • Stattin H.
      • Kerr M.
      Parental monitoring: A reinterpretation.
      ,
      • Kerr M.
      • Stattin H.
      What parents know, how they know it, and several forms of adolescent adjustment: Further support for a reinterpretation of monitoring.
      ]. Schools can influence these family-level protective factors by providing information to parents that can help improve their parenting practices [
      • Dittus P.J.
      • Harper C.R.
      • Hoo E.
      • et al.
      The Project Connect parental monitoring intervention: Population-level effects on adolescent perceptions of parental enforcement of family rules. 2015.
      ], implementing or connecting parents to relevant parenting programs in the community [
      • Santa Maria D.
      • Markham C.
      • Bluethmann S.
      • et al.
      Parent-based adolescent sexual health interventions and effect on communication outcomes: A systematic review and meta-analyses.
      ,
      • Sutton M.Y.
      • Lasswell S.M.
      • Lanier Y.
      • et al.
      Impact of parent-child communication interventions on sex behaviors and cognitive outcomes for black/African-American and Hispanic/Latino youth: A systematic review, 1988-2012.
      ,
      • Stanton B.
      • Cole M.
      • Galbraith J.
      • et al.
      Randomized trial of a parent intervention: Parents can make a difference in long-term adolescent risk behaviors, perceptions, and knowledge.
      ,
      • Hadley W.
      • Brown L.K.
      • Barker D.
      • et al.
      Work it out together: Preliminary efficacy of a parent and adolescent DVD and workbook intervention on adolescent sexual and substance use attitudes and parenting behaviors.
      ], or engaging parents through designated activities built into students’ curriculum or activities, such as SHE programs that include activities designed to help parents build their capacity to talk to their teens about sex [
      • Wang B.
      • Stanton B.
      • Deveaux L.
      • et al.
      The impact of parent involvement in an effective adolescent risk reduction intervention on sexual risk communication and adolescent outcomes.
      ]. In implementing this aspect of the program model, DASH has focused on dissemination of existing resources to parents that support parent adolescent communication and parental monitoring, such as CDC’s resources on positive parenting practices [
      Division of Adolescent and School Health
      Positive parenting practices.
      ].

      Considerations for Adolescent Health Professionals and Organizations

      The above school-based model of HIV/STD, unintended pregnancy, and related risk prevention and its activities were developed to highlight evidence-based ways to impact adolescent health outcomes via school settings. In line with leading educational frameworks (e.g., the Whole School, Whole Community, Whole Child model) [
      • Lewallen T.C.
      • Hunt H.
      • Potts-Datema W.
      • et al.
      The whole school, whole community, whole child model: A new approach for improving educational attainment and healthy development for students.
      ], activities are situated within a social ecological framework that moves beyond solely individual, student-level intervention points to address multi-level intervention opportunities through activities designed to impact individual students and school staff, their relationships, and their broader communities, all of which are interdependent and must be addressed to improve health [
      • Bronfenbrenner U.
      The ecology of human development.
      ,
      • Sallis J.F.
      • Owen N.
      • Fisher E.
      • et al.
      Ecological models of health behavior..
      ]. Such a model requires collaborations between LEAs and adolescent health organizations in the community. For example, referring students outside of the school for SHS requires the presence of adolescent-friendly health service providers in the community [
      • Dittus P.J.
      • De Rosa C.J.
      • Jeffries R.A.
      • et al.
      The project connect health systems intervention: Linking sexually experienced youth to sexual and reproductive health care.
      ,
      • Dittus P.J.
      • Harper C.R.
      • Becasen J.S.
      • et al.
      Structural intervention with school nurses increases receipt of sexual health care among male high school students.
      ,
      • Loosier P.S.
      • Doll S.
      • Lepar D.
      • et al.
      Effectiveness of an adaptation of the project connect health systems intervention: Youth and clinic-level findings.
      ]. Adolescent health professionals can partner with their local educational leaders to implement the SHE, SHS, and SSE activities described above, and can also provide other cross-cutting implementation support. This includes developing and implementing relevant school health policies and staff professional development; raising awareness of students, parents, and community members; and establishing evaluation programs to monitor the implementation and impact of activities.
      Many school districts are already leading school-based models of HIV/STD, unintended pregnancy, and related risk prevention that include collaborative partnerships with local health providers and adolescent health practitioners. For example, as a key part of their implementation of the program model described in this paper, education agencies funded through CDC-DASH (a full list of CDC-DASH funded partners is available at: https://www.cdc.gov/healthyyouth/partners/funded_locals.htm) work to foster collaborative partnerships, including those with local health departments and community clinics, as well as national, state, and local agencies and organizations that serve adolescent populations more broadly. Education agencies leverage funding through mechanisms such as government, private, or corporate grants or in-kind labor, materials, or other resources to maximize project outcomes through strategic partnerships. Other school districts may organically rely on such partnerships through recognition of need and the mutual goal of promoting adolescent health. There may also be potential for such a school-based model to be initiated and coordinated by others in the community such as a local health department or other adolescent health services organization, in partnership with LEAs.
      There are many ways that adolescent health professionals and other community partners can support the specific school-based activities outlined above. For example, schools can establish and maintain an active SHAC or similar advisory council that includes community representatives to link schools to community resources, inform SHE curriculum, and support all sexual health promotion activities more broadly. Community providers and health departments can also provide clinical and population health expertise to advise school leaders on issues such as reporting requirements and maintaining patient confidentiality for sensitive services. Health departments are often experienced in community outreach and engagement [
      National Association of County & City Health Officials
      The role of local health departments in advancing adolescent HIV and STI prevention efforts through school-based programs.
      ] and the provision of clinical services for students, either on school property or off site. Community providers can provide schools with a place to refer students for youth-friendly prevention resources and services. Local providers may also enhance classroom-based lessons and other school programs to prevent HIV, other STDs, and teen pregnancy. As respected health experts, providers are also uniquely positioned to influence parents and community members which can result in greater awareness and buy-in for sexual health promotion within communities [
      • Epstein J.L.
      School, family, and community partnerships: Preparing educators and improving schools.
      ,
      • Gerne K.
      • Epstein J.
      The power of partnerships: School, family, and community collaborations to improve children’s health.
      ,
      Centers for Disease Control and Prevention
      Promoting adolescent health through school-based HIV/STD prevention and school-based surveillance.
      ,
      • Landis S.
      • Janes C.
      The Claxton Elementary School Health Program: Merging perceptions and behaviors to identify problems.
      ]. Finally, youth-serving community organizations are critical partners for schools as they often lead or provide substantial support for the implementation of programs that strengthen safe, supportive environments for students including mentoring, service learning, and PYD programs within communities. For example, community-based organizations that provide support for LGBTQ youth can support schools in establishing or strengthening their GSAs by providing professional development to staff advisors and linking adolescents with resources and services. Many of the strategies and activities of this program model may have broad utility and could be applied in schools or school districts as feasible and appropriate.
      LEAs, schools, and other organizations engaged in the promotion of school-based adolescent sexual health can find more information on the program model at the CDC/DASH Healthy Youth website [
      Centers for Disease Control and Prevention
      Adolescent and school health.
      ], including detailed descriptions of all recommended activities in the program model as well as a variety of resources to aid school districts in their implementation efforts [
      Centers for Disease Control and Prevention
      PS18-1807 program guidance: Guidance for school-based HIV/STD prevention (component 2) recipients of PS18-1807.
      ]. As more adolescent health organizations or LEAs adopt, implement, and evaluate the strategies and activities of this school-based program model, evidence for preventing HIV/STDs, and unintended pregnancy among adolescents effectively, equitably, and sustainably will grow and improve our ability to improve the health and wellbeing of all youth.

      Acknowledgments

      The authors would like to thank Riley Steiner for her significant contributions to conceptualizing the program model framework, leadership in developing the guidance for the safe and supportive environments strategy, suggestion to disseminate the program model to a broad adolescent health audience, and helpful review of this manuscript. The authors would also like to thank Adriane King and Valerie Sims for their contributions to development of the SSE guidance. Finally, the authors would like to thank Sanjana Pampati for her research assistance in developing the program guidance.

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      Linked Article

      • Advancing Sexual and Reproductive Health Education—Pursuing the Long Arc of Justice
        Journal of Adolescent HealthVol. 70Issue 4
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          Since 1988, the Centers for Disease Control and Prevention's (CDC) Division of Adolescent and School Health has been instrumental in our country's efforts to promote “environments where youth can gain fundamental health knowledge and skills, establish healthy behaviors, and connect to health services to prevent HIV, sexually transmitted diseases (STDs), and unintended pregnancy.” Through its commitment to “translating science into innovative programs and tools,” CDC helps the country implement effective programs and practice standards that shape the field more broadly [1].
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