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Assessment of Exposure to High-Performing Schools and Risk of Adolescent Substance UseA Natural Experiment

Educational Objective To review if exposure to high-performing school environments is associated with a reduction in risky health behaviors for low-income minority high school students.
1 Credit CME
Key Points

Question  Is exposure to high-performing school environments associated with a reduction in risky health behaviors for low-income minority high school students?

Findings  In this natural experiment of 1270 students who applied via admissions lotteries to high-performing public charter schools in low-income minority communities in Los Angeles, California, lottery winners had lower marijuana misuse scores, fewer marijuana-using peers, less truancy, greater teacher support for college, more orderly school environments, and less school mobility and spent more time studying than lottery losers.

Meaning  School environments may influence risky health behaviors and constitute an important prevention tool and target for addressing the social determinants of health.


Importance  Although school environments are thought to influence health behaviors, experimental data assessing causality are lacking, and which aspects of school environments may be most important for adolescent health are unknown.

Objective  To test whether exposure to high-performing schools is associated with risky adolescent health behaviors.

Design, Setting, and Participants  This natural experiment used admission lotteries, which mimic random assignment, to estimate the association of school environments and adolescent health. A survey of 1270 students who applied to at least 1 of 5 high-performing public charter schools in low-income minority communities in Los Angeles, California. Schools had an academic performance ranked in the top tertile of Los Angeles County public high schools, applicants outnumbered available seats by at least 50, and an admissions lottery was used. Participants included lottery winners (intervention group [n = 694]) and lottery losers (control group [n = 576]) from the end of 8th grade and beginning of 9th grade through the end of 11th grade. Intention-to-treat (ITT) and instrumental variable techniques estimated the association of winning the lottery and attending high-performing schools with health behaviors and whether the association varied by sex. Data were collected from March 11, 2013, through February 22, 2017, and analyzed from October 1, 2017, through July 1, 2018.

Exposures  Schools were considered high performing if they placed in the top tercile of public high schools in LA County on 2012 state standardized tests. Most students attended that same school for 3 years (9th-11th grades).

Main Outcomes and Measures  Primary self-reported outcomes were 30-day and high-risk self-reported marijuana use. Additional health outcomes included 30-day alcohol use, alcohol misuse, ever being in a fight, ever having sex, and past-year delinquency. Potential intermediate factors (time studying, truancy, school mobility, school culture, school order, teacher support for college, and proportion of substance-using peers in students’ social networks) were also examined.

Results  Among the 1270 participating students (52.6% female; mean [SD] age at enrollment, 14.3 [0.5] years), ITT analysis showed that the intervention group reported less marijuana misuse than the control group (mean marijuana misuse score, 0.46 vs 0.71), as well as fewer substance-using peers (9.6% vs 12.7%), more time studying (mean, 2.63 vs 2.49 hours), less truancy (84.3% vs 77.3% with no truancy), greater teacher support for college (mean scores, 7.20 vs 7.02), more orderly schools (mean order score, 7.06 vs 6.83), and less school mobility (21.4% vs 28.4%) (all P < .05). Stratified analyses suggest that among boys, intervention participants had significantly lower marijuana use (mean misuse score, 0.43 vs 0.88; difference, −0.45; 95% CI, −0.78 to −0.13) and alcohol misuse (mean misuse score, 0.52 vs 0.97; difference, −0.44; 95% CI, −0.80 to −0.09) scores compared with control participants, whereas no significant health outcomes were noted for girls.

Conclusions and Relevance  This natural experiment provides evidence that school environments can improve risky behaviors for low-income minority adolescents.

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Article Information

Accepted for Publication: July 6, 2018.

Corresponding Author: Rebecca N. Dudovitz, MD, MS, Department of Pediatrics and Children’s Discovery and Innovation Institute, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Room 12-358 CHS, Mail Code 175217, Los Angeles, CA 90095 (rdudovitz@mednet.ucla.edu).

Published Online: October 29, 2018. doi:10.1001/jamapediatrics.2018.3074

Correction: This article was corrected on March 22, 2021, to fix errors in the Methods section and in Figure 1.

Author Contributions: Dr Dudovitz had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Dudovitz, Chung, Wong.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Dudovitz, Shoptaw, Wong.

Critical revision of the manuscript for important intellectual content: Chung, Reber, Kennedy, Tucker, Shoptaw, Dosanjh, Wong.

Statistical analysis: Reber, Wong.

Obtained funding: Chung, Wong.

Administrative, technical, or material support: Dudovitz, Kennedy, Dosanjh, Wong.

Supervision: Wong.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by grants RO1 DA033362 and 1K23DA040733-01A1 from the National Institute on Drug Abuse, National Institutes of Health (NIH); grant UL1TR001881 from the NIH National Center for Advancing Translational Science, Clinical and Translational Science Institute (CTSI), UCLA; and the Lincy Foundation through the UCLA CTSI Healthy Neighborhood Schools Initiative.

Role of the Funder/Sponsor: The sponsor had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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