The Journal of School Nursing2024, Vol. 40(5) 536–546© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221120437journals.sagepub.com/home/jsn
Abstract
School nurses are critical components of school-based interdisciplinary teams supporting student behavioral health. The purpose of the present study is to understand the extent to which school nurses in New Mexico across grade levels manage emergencies related to behavioral health, violence, and trauma. The study also seeks to identify which topics the school nurses received continuing education (CE) for, and which topics they consider to be important to their practice. Analyses of 2019 statewide survey data show a considerable number of school nurses in New Mexico provide management for behavioral health, violence, and trauma-related emergencies, and nurses in secondary schools are significantly more likely than nurses in primary schools to report managing these emergencies and to have received CE on behavioral health topics. Our findings reaffirm the essential role of school nurses in addressing emergent student health issues and underscore the need for practice- and competency-based behavioral health CE opportunities.
Keywordsbehavioral health, emergency management, continuing education, school health, school nurses, violence, trauma
School-aged youth are impacted by a wide-range of behavioral health challenges and schools and school nurses are consistently recognized as critical to promoting student wellbeing through education, assessment and identification of concerns, intervention, and referral to appropriate supports (Bohnenkamp et al., 2015, 2018; Cowell, 2019; Kolbe, 2019; Langer et al., 2015; NASN, 2021, 2022a; Ravenna & Cleaver, 2015). An estimated 13% to 20% of children are living with a mental, emotional, or behavioral disorder (Ghandour et al., 2019). Population-based surveys in the US have shown that suicidality is a particularly alarming concern among high school aged youth, with nearly 9% in 2019 reporting they attempted suicide at least once in their lives (Ivey-Stephenson et al., 2020). Use of substances such as alcohol, tobacco, marijuana, and other illicit drugs (DuPont et al., 2018); child abuse, neglect, and maltreatment (Zeanah & Humphreys, 2018); and experiences of violence, bullying, and assault (Espelage & Hong, 2019; Johns et al., 2020; Pontes et al., 2018) are all considerable challenges faced by school-aged youth in the US, and ones that school-based health and educational professionals address every day.
As part of interdisciplinary teams, school nurses are part of the invaluable front line for supporting youth behavioral health and often are both an entry point and a coordinator of children’s continuum of care. It is estimated that school nurses spend a third of their time focused on behavioral health (Foster et al., 2005). The primary care and referrals they provide spans from supporting adolescent dating violence victims (Khubchandani et al., 2013), to dealing with alcohol use (Lunstead et al., 2017), to managing the impacts of mental illness (Smith & Bevan, 2020). Nurses also play a key role in identifying and referring youth in crisis, including initial psychological evaluations, referrals to emergency departments, and collaborations with emergency services response teams (Grudnikoff et al., 2015; Muller et al., 2021). Beyond their role in identification, treatment, and referral to services, school nurses also educate not only young people but also other school staff and adult guardians on important behavioral health issues like adolescent relationship abuse and child maltreatment (Haas, 2020; Jordan et al., 2017; Raible et al., 2017). Nurses have also been identified as promising leaders for school-based behavioral health interventions including for substance use (Pbert et al., 2011), mental health (Drake et al., 2015; Muggeo et al., 2017; Stallard et al., 2008; Turner & Mackay, 2015), and changing school climates and cultures to promote health equity (Willging et al., 2016).
During the ongoing COVID-19 pandemic, children and adolescents’ behavioral and mental health have deteriorated (Meherali et al., 2021; Nearchou et al., 2020). A recent systematic review found that young people under the age of 19 showed more depressive and anxious symptoms compared to pre-pandemic, and older children, girls, young people with neuro-diversities, and those living with chronic physical conditions were more likely to report negative mental health outcomes (Samji et al., 2022). School nurses play a vital role in addressing pandemic-related stressors tied to these increased incidence rates as well as identifying and responding to emergencies (McIntosh et al., 2022; Rothstein & Olympia, 2020; Williams et al., 2021).
Despite the continued and increasing importance of school nurses in addressing behavioral and mental health of children, many still feel under prepared for such a role (Hoskote et al., 2023; Muggeo & Ginsburg, 2019). Continuing education (CE) for school nurses is a practical and ethical imperative for providing care responsive to the needs of student populations, including behavioral and mental health (NASN, 2022b).
The purpose of the present study is to understand the extent to which school nurses in New Mexico are managing emergencies related to behavioral health, violence, and trauma. Further, this paper examines whether or not school nurses in New Mexico have received CE on behavioral health, violence, or trauma-related topics, and how important they consider those topics to be to their practice, while attending to potential differences across grade levels served.
Data for the current study are drawn from the 2019 New Mexico School Nurse Workforce Survey, which collected information on the responsibilities of school nurses, their work environments, and their needs and educational priorities. This workforce survey has been conducted every five years since 2009. The sampling frame included all school nurses currently working in a public school district, public state or local charter, nonpublic, Bureau of Indian Education or tribally controlled school. The roster of school nurses was developed in collaboration with the New Mexico Department of Health, New Mexico Public Education Department, and schools and school districts. Potential respondents were emailed an invitation to participate with a survey link. Participants were provided with a $5 gift card as incentive for completing the survey. Of the 520 potential respondents, 320 completed the survey for a response rate of 61.5%. Study procedures were approved by the Pacific Institute for Research and Evaluation Office of Research Integrity and Compliance, the University of New Mexico Human Research Protections Office, and relevant school district research review boards.
Demographic and workplace characteristics measured include age, gender identity, ethnicity, race, sexual orientation, education level, years of experience, type of school(s) served, zip code/geographical area of employment, and number of school campuses served. Respondents were also asked to indicate which grade levels they served. Answer choices included preschool/pre-k/early intervention, elementary school, middle school, and high school, and respondents could select all grade levels that apply.
The provision of emergency management was assessed by asking respondents to indicate if they had provided emergency management for a list of situations during the previous school year. Emergencies were categorized into behavioral health, violence or trauma, and medical emergencies. Behavioral health emergencies included those related to alcohol or substance use, overdose, depression, self-injurious behavior, and suicidality. A subcategory of behavioral health emergencies concerning violence and trauma included bullying, child abuse or neglect, dating violence, human trafficking, sexual abuse or assault, and violence at school. Medical emergencies included abdominal pain, altered mental states, asthma, injury, respiratory distress, seizure, and severe allergic reaction.
Respondents were asked to indicate topics they had received CE for in the past three years and to rate the importance to school nurse practice of the list of CE topics. To rate the importance of topics, respondents could choose between “not important,” “somewhat important,” and “very important.” CE topics were categorized as related to behavioral health, violence or trauma, medical, and school climate and culture. Behavioral health, violence/trauma, and medical categories included topics related to the types of emergencies identified above. School climate and culture included topics relevant to the social and emotional culture and social climate of schools. Medical emergencies and medical CE topics are chiefly included as a comparison point for the reported rates of behavioral health emergencies and CE topics.
This analysis focused on the provision of emergency management for behavioral health emergencies and the receipt and perceived importance of CE on related topics. For examining the demographics of our sample, we have included all survey respondents. For all other analyzes we have included only those that worked in elementary and lower grades (herein referred to a “primary schools”) and those that worked in middle schools and/or higher grades (herein referred to as “secondary schools”). Those that worked with multiple grade levels across the elementary and middle school grades were excluded to allow for comparison of the experiences of school nurses working with these two distinct student populations.
We used SPSS 27.0 to analyze the data (IBM, 2020). We conducted descriptive analyzes to assess the demographic and workplace characteristics of school nurses. We conducted bivariate analyzes to compare emergencies managed and CE received and perceived as very important by grade levels served (primary only versus secondary only). Finally, we conducted bivariate analyzes to compare CE received on specific topics between school nurses who had and had not managed specific emergencies. Chi-square and Fisher’s exact tests (for variables with small cell sizes) were used to determine statistical significance without controlling for other variables. Differences were considered statistically significant when p-values were less than .05.
Most school nurse respondents working in New Mexico schools are non-Hispanic, heterosexual, white women who are at least 50 years old (Table 1). A little over a quarter identify as Hispanic (28.6%) and five percent as Native American. Most respondents (70.8%) hold a bachelor’s degree or higher and 41.9% have five or more years of experience as a school nurse. The sample included school nurses who served primary schools only (44.4%) and nurses who worked with secondary schools only (26.1%). The remaining 29.5% of respondents worked in multiple grade levels, either across school campuses or within one school.
Almost all school nurses who responded to the survey had provided emergency management for medical emergencies in the prior year, including for injuries (89.4%), asthma (75.3%), altered mental states (56.3%), and respiratory distress (54.4%). Nearly two thirds reported providing emergency management for behavioral health and violence or trauma-related emergencies in the 2018–2019 school year (Table 2). More than half of school nurses reported having provided emergency management for suicidality, self-injurious behavior, and child abuse or neglect. Other commonly cited emergencies included depression (42.6%) and violence at school (48.9%). The least cited behavioral health and violence or trauma-related emergencies included human trafficking (1.8%) dating violence (4.4%), sexual abuse or assault (14.3%), and overdose (15.6%).
Significant differences exist between the experiences of school nurses that served primary schools only and those that served secondary schools only (Table 2). School nurses who served secondary schools were significantly more likely to report having provided management for any behavioral health emergency in the previous year and were more likely to report each specific behavioral health emergency including suicidality, depression, selfinjurious behavior, overdose, and alcohol or substance use. There was not a significant difference by grade level in reporting having to manage any violence/trauma related emergency. However, when looking at specific violence/trauma emergencies, primary school nurses were significantly more likely to say they managed a child abuse emergency and those serving secondary schools were more likely to say they had addressed dating violence, human trafficking, sexual abuse or assault, and violence at school. Bullying was the only violence/trauma emergency for which there was not a significant difference between grade levels served. There was also not a significant difference by grade level in reporting having to manage any medical emergency, however nurses working with secondary schools were more likely to report they had provided emergency management for altered mental states, injury or trauma, respiratory distress, and seizure.
Survey respondents were asked topics for which they had received CE in the past three years. Table 3 presents the proportions of school nurses who reported having received CE on various subjects. The topics are organized into four broad categories: behavioral health, school climate and culture, trauma or violence, and medical CE. Across almost all topics, nurses that served secondary schools reported having received more CE than those working in primary school contexts.
Significantly more nurses working in secondary schools reported having received CE on most of the behavioral health topics, including alcohol/substance use (89.5%, p < .001), depression/mood disorders (81.6%, p < .001), suicide risk assessment and screening (82.9%, p = .012), suicide prevention (89.5%, p < .001), tobacco use (50.0%, p = .009), and vaping (61.8%, p = .002). Mental Health First Aid was the only behavioral health topic for which there was not a significant difference according to grade level.
Among school climate and culture topics, significantly more secondary school nurses reported having received CE bullying prevention (78.9%, p = .018) and social climate policies and practices (47.4%, p = .003). No difference was found for having received CE on changing the social and emotional culture of schools.
School nurses working in secondary schools were also more likely to report having received CE on child abuse or neglect (89.5%, p = .007) and dating violence (34.2%, p = .002). No significant difference was found for other violence and trauma CE topics, including human trafficking, sexual assault or abuse, or violence at school.
Medical topics for which significantly more secondary school nurses reported having received CE included asthma (85.5%, p = .027); anaphylaxis (77.6%, p = .018); diabetes (86.7%, p = .012); immunizations (86.8%, p = .026); lesbian, gay, and bisexual (LGB) student health (73.3%, p = .001); and transgender student health (60.5%, p = .002).
School nurse participants were also asked to rate CE topics in importance to their practice as a school nurse from “not important,” to “somewhat important,” to “very important.” Table 3 shows the proportions of school nurses who indicated CE topics as “very important.” Of the 25 topic choices in the survey, a majority of school nurses across both grade levels indicated that 16 were very important to their practice, including CE on depression/mood disorders, mental health first aid, suicide risk assessment and screening, suicide prevention, vaping, bullying prevention, changing the social and emotional culture of school, social climate policies and procedures, child abuse or neglect, sexual abuse or assault, violence at school, asthma, anaphylaxis, diabetes, immunizations, and seizure management. Among the behavioral health topics, significantly more nurses serving secondary schools said CE on alcohol and substance use (89.5%, p < .001), suicide prevention (92.0%, p = .009), tobacco use (68.0%, p < .001), and vaping (88.0%, p < .001) was “very important” to their practice. There were no significant differences among any of the school climate and culture topics.
Among the trauma and violence CE topics, school nurses in secondary schools were more likely to report dating violence (74.7%, p < .001) as very important. School nurses working in primary schools were significantly more likely to say that CE on child and abuse or neglect (95.5%, p = .001) was very important to their practice. No significant differences were found for other violence and trauma CE topics.
Of the medical CE topics, significantly more school nurses in secondary schools identified LGB student health (60.8%, p = .034), reproductive health (62.7%, p = .006), and transgender student health (65.3%, p = .004) as very important. Significantly more school nurses working in primary schools identified asthma (97.0%, p < .001) and oral health (50.4%, p = .010) as very important topics.
Table 4 shows the proportions of school nurses who had received CE on behavioral health topics among those who had provided management of specific behavioral health emergencies. In general, the findings show that most school nurses who had managed any of the behavioral health emergencies had received CE directly relevant to those emergencies. For example, 89.9% of those school nurses who had managed an alcohol or substances use related emergency and 90.5% of those who had managed an overdose emergency in the previous school year had received CE on alcohol or substance use in the past three years.
High proportions of nurses who had managed emergencies related to suicidality, depression, or self-injurious behavior had received CE related to suicide prevention and mental health. More than two thirds of school nurses who had managed a depression-related emergency, two thirds of those who had managed a self-injurious behavior emergency and a little less than two thirds who had managed an emergency related to suicidality had received CE on depression and mood disorders. In terms of suicidality specifically, 85.6% of those who had managed an emergency related to suicidality had received CE on suicide risk assessment and screening and 82.63% had received CE on suicide prevention. More than half of those nurses who had managed emergencies related to overdose (76.2%), depression (71.4%), suicidality (70.7%), self-injurious behavior (70.1%), or alcohol or substance use (69.9%) had been trained in Mental Health First Aid in the past three years. Smaller proportions of nurses who had managed behavioral health emergencies had also recently engaged in education on LGB student health, transgender student health, or other school culture or policy-focused CE topics.
School nurses in New Mexico also appear to have received CE on topics relevant to the violence and trauma related emergencies they had managed (Table 5). A large majority of those who had managed a bullying emergency (79.7%), a child abuse or neglect emergency (82.6%), or a dating violence emergency (75.0%), had received CE on those respective topics. All nurses who had reported managing a human trafficking emergency also said they had received CE on human trafficking. More than half of nurses who had managed an emergency related to violence at school (53.8%) and more than half of those who had managed an emergency related to sexual abuse or assault (59.0%) had also received CE on those respective topics.
Using data from the 2019 NM School Nurse Workforce survey, this study examined the rates of behavioral health emergencies managed, CE received, and ratings of CE topic importance. Overall, findings indicate high levels of behavioral health emergency management by school nurses in New Mexico, including a high amount even in elementary school settings. The differences in the number of nurses in upper and lower grades reporting having provided emergency management for behavioral health concerns, specifically for mental health concerns, aligns with previous research indicating that the chances of youth encountering these types of challenges increases with age (Angelakis et al., 2020; Ghandour et al., 2019; Henderson et al., 2021). However, the numbers for nurses working with younger populations cannot be discounted. Almost a quarter of nurses working in primary school settings said that they had provided emergency management for a student dealing with depression, a third for self-injurious behavior, and more than a third for suicidality. This is worrisome considering that there are very few evidence-based, school-based suicide prevention programs aimed at this younger population, nor ones that strategically make use of the school nurse (Guo & Harstall, 2002; Pestaner et al., 2019). The number of nurses serving lower grades indicating that they had received CE focused on suicide prevention or suicide risk assessment and screening was significantly lower than those in secondary schools.
Specifically related to suicide, in comparison to a previous survey of the New Mexico school nurse workforce, there appears to be some important differences. A report published on the 2009 survey showed that 40.8% of secondary school nurses in New Mexico had provided emergency management for suicide and 72.4% had received CE on the topic in the last five years (Ramos et al., 2013). There appears to be an important increase in the number of school nurses reporting providing emergency management for suicide in the 2019 survey (75.3% secondary school nurses), but also an increase in the number of nurses reporting they had received training on the topic (89.5% of secondary school nurses). These changes signal an important shift in the mental health emergencies experience by young people and managed by school nurses, as well as the responding shifts in the preparation of the school nurse workforce to better handle suicide-related emergencies. While the data explored here are pre-pandemic, given recent research examining the increase in prevalence of mental health challenges like depression and anxiety, it is likely that school nurses will also experience more frequent management of behavioral and mental health conditions and emergencies during the pandemic (McIntosh et al., 2022; Meherali et al., 2021; Nearchou et al., 2020; Samji et al., 2022).
A potentially surprising finding is the number of school nurses in secondary schools that had provided management for child abuse and neglect related emergencies. Even though nurses in lower grades were statistically more likely to report having managed these types of emergencies, nearly 60% of those working in secondary schools reported handling child abuse or neglect in their practice. A majority of nurses across all grade levels had received CE on child abuse and neglect and considered it “very important” to their practice. Continued education in this topic area is important both for building the capacity of school nurses across all grades to recognize and intervene in child abuse and neglect emergencies, but also to educate other school professionals on the signs and proper responses to suspected child abuse and neglect (Jordan et al., 2017). Especially in the context of the pandemic, where channels of communication have shifted, the role of school nurses in educating others in the school community to recognize and respond has been particularly critical to ensuring that the safety-net function of schools is sustained (Haas, 2020; Jordan et al., 2017).
While most school nurses that had dealt with any of the emergencies listed in Tables 4 and 5 had received CE on those topics, none of the intersections indicate 100% congruence between emergencies managed and the CE school nurses had received in the past three years. For topics such as suicide prevention, risk assessment and screening, and Mental Health First Aid, it is recommended that staff are trained at least every two to three years (Institute, 2022; Wellbeing, 2022; Zero Suicide). A large majority of nurses that had managed emergencies related to suicide, depression, and self-injurious behavior had recently received training on suicide prevention, risk, and assessment, however fewer had received specialized training on depression or self-injurious behaviors, or Mental Health First Aid which would have potentially addressed all mental health topics. Bolstering education specific to mental health emergencies, given their prevalence within school nurse practice and school nurses’ role in crisis response, is an important area for school nursing leadership to consider improvements (Smith & Bevan, 2020). Further, paying close attention to the experiences on school nurses can inform for which areas CE should be offered. For example, only about half of school nurses that had managed violence at school had recently received CE on that topic and a little over half that managed an emergency dealing with sexual abuse or assault had received CE on that topic. These gaps may indicate an area for future CE engagements.
In planning, delivering, and selecting CE opportunities, it is important to maintain an eye toward health equity and ensure school nurses are trained to respond to the specific needs of subgroups of students. For example, between a little more than half to two-thirds of school nurses who had managed emergencies related to bullying and violence at school had received CE on lesbian, gay, bisexual, or transgender student health—groups of students who are disproportionately impacted by bullying and victimization (Johns et al., 2020). Further, in general school nurses in our sample were more likely to receive CE on LGBTQ student populations if they worked in secondary schools, however the behavioral health disparities these populations face are likely to have already been taking shape since a younger age; meaning that interventions at middle and high school levels supportive of LGBTQ+ students are more likely to mitigate the impact of already established behavioral health challenges rather than preventing them (Fish, 2020; Martin-Storey & Fish, 2019; Mittleman, 2019). Early education for school nurses on the needs of LGBTQ+ students could mean earlier intervention in behavioral patterns and experiences that contribute to health disparities.
Few school nurses across all grade levels had received CE related to changing the social and emotional culture of schools or on social climate policies and practices. These two topical areas are related to important parts of school nurse practice—addressing health equity, addressing social determinants of health, leading policy development and implementation, as well as systems-level leadership (“Framework for twenty-first Century School Nursing Practice™: Clarifications and Updated Definitions,” 2020). School nurses play not only a valuable role as part of a school behavioral health team, but as leaders within schools that can enact and support systemic change. The social and emotional culture of schools bolstered by policies and practices at the school, district, and state level have direct linkages to student health and academic outcomes, particularly for populations experiencing health disparities. CE for school nurses should include education on these topics as well as leadership development to support their confident and active participation in improving school environments.
This study has a few limitations. The data used is cross-sectional, drawn from a single state, and the survey was conducted prior to the pandemic. However, given the strong response rate, large sample size, and our sampling frame that included the entire census of school nurses in the state as identified by the New Mexico Department of Health, New Mexico Public Education Department, and school districts, we believe this study provides valuable insight into the role of school nurses supporting student behavioral health. Future studies should take into consideration other factors like geographic context and dynamics like frequency of emergencies managed to further understand the role of the school nurse in providing a critical safety net for student behavioral health.
Our findings underscore the importance of the school setting and school nurses in particular in the early identification of many behavioral health concerns for youth. During the COVID-19 pandemic, school nurses played an essential role in maintaining safe school environments, continuing to provide school nursing services, and attending to the increasing needs of students, staff, and community members, including behavioral health needs (Chardavoyne & Olympia, 2020; Combe, 2020; Henderson et al., 2020; Kunz et al., 2021; O’Shea et al., 2021; Rothstein & Olympia, 2020). The physical absence of many students from school campuses, potentially increased psychological distress (Chadi et al., 2022) as well as prevented schools and school nurses from serving as a prevention mechanism for concerns like child abuse or neglect (Nguyen, 2021).
To meet the complex behavioral health needs of students, school nurses must have access to high quality professional development. The National Association of School Nurses’ (NASN) Code of Ethics states it is the responsibility of the school nurse to maintain competency and pursue personal and professional growth (NASN, 2022b). Accessing, undertaking, and putting into practice up-to-date CE is both a practical need and an ethical obligation for school nurses. School nurses have access to training specific to behavioral health such as Mental Health Training Intervention for Health Providers in School (MH-TIPS) and Child Anxiety Learning Modules (CALM), accessible through the NASN; school nurses in New Mexico have access to Mental Health First Aid, suicide prevention, nonviolent crisis intervention, and trauma sensitive schools trainings through the NM Department of Health Office of School and Adolescent Health; and many other resources are available through the National Alliance on Mental Health, the Substance Abuse and Mental Health Services Administration, and the Centers for Disease Control and Prevention. However, gaps in school nurse preparation in some behavioral health topics, such as mental health promotion, may exist and therefore pose a barrier to optimizing their effectiveness in supporting whole student health and academic outcomes (Anttila et al., 2020; Bohnenkamp et al., 2015; Muggeo & Ginsburg, 2019; Ravenna & Cleaver, 2015; Turner & Mackay, 2015). Especially in the new territory of navigating student wellbeing within a pandemic, CE on how to respond to increased student mental health need is critical, as school nurses are often best positioned within schools to investigate, interpret, communicate, and use new information and best practices (McIntosh et al., 2022).
Two key elements of CE, in addition to providing a knowledge base focused on behavioral health, could help bolster school nurse practice. First, survey assessments like the one in this study can provide insight into the emergencies that school nurses are facing and the education they have recently received to help prepare them for intervening and managing emergencies. This kind of data may help dispel possible incorrect assumptions about the types of behavioral health concerns school nurses address at different grade levels, such as child abuse and neglect still being a considerable issue in upper grade and suicide-related emergencies occurring in younger student populations. With this knowledge, school health leadership can help funnel appropriate resources and educational opportunities to those school nurses who may be in need of specific topical support. At the same time, in states like New Mexico where CE is required for RN licensure, but exact CE topics are self-chosen, school health leadership may use emergency management data to stress the importance of seeking out behavioral health CE for school nurses.
Second, competency-based CE may be particularly valuable to the professional development of school nurses when it comes to behavioral health. Competency-based education stresses the development and application of the knowledge, skills, and attitudes required of school nurses to provide safe school nursing (Shin & Roh, 2020). This approach integrates a recognition and strong emphasis on the ways in which health knowledge is combined with communication skills, program planning, coordination of care, and other more complex on-the-ground realities of school contexts (Wolf, 2022). Competency-based CE can help school nurses stay informed of new or improved methods for addressing behavioral health, including evidence-based mental health programing or the use of Narcan to intervene in overdose emergencies.
Finally, school nurses should avail themselves of educational opportunities specifically concerning leadership development and health equity. Combining needs-based and competencybased education alongside professional development that supports school nurses in taking active leadership for programmatic and policy-change has the potential to shift the social and emotional environment of schools in ways that prevent many behavioral health concerns and promote resilience for all young people, including those at highest risk.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the New Mexico Department of Health, Office of School and Adolescent Health.
Daniel Shattuck https://orcid.org/0000-0003-4689-863X
Mary M. Ramos https://orcid.org/0000-0002-5260-7395
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Daniel Shattuck, PhD, is an Associate Research Scientist at the Pacific Institute for Research and Evaluation Southwest Center.
Rachel Sebastian, MA, is an Associate Research Scientist at the Pacific Institute for Research and Evaluation Southwest Center.
Kim Zamarin, MPH, is Program Director and Evaluator at the Pacific Institute for Research and Evaluation Southwest Center.
Susan Acosta, RN, BS, is the School Health Consultant for the New Mexico Department of Health Office of School and Adolescent Health.
Mary M. Ramos, MD, MPH, is an Associate Professor at the University of New Mexico School of Medicine, Department of Pediatrics, Division of Adolescent Medicine.
1 Pacific Institute for Research and Evaluation—Southwest, 851 University Boulevard, Albuquerque, NM, USA
2 New Mexico Department of Health, Office of School and Adolescent Health, Albuquerque, NM, USA
3 Department of Pediatrics, University of New Mexico, MSC11-6145, 1 University of New Mexico, Albuquerque, NM, USA
Corresponding Author:Daniel Shattuck, PhD, Pacific Institute for Research and Evaluation—Southwest, 851 University Boulevard, SE, Suite 101, Albuquerque, NM 87106, USA.Email: dshattuck@pire.org
