Consent Form Return Research Articles

Parent Engagement with a School-Based Health Center Consent Process Predicts Student Attendance and School Transition.

School-based health centers (SBHCs) fill critical pediatric health care access gaps but typically require parental consent for enrollment. Families' responses to SBHC consent form outreach efforts may reflect broader school engagement. This study investigated whether SBHC consent form return predicted subsequent chronic absenteeism and school transition, indicators of student and family school engagement. Multivariable logistic regression was used to compare the odds of being chronically absent or transitioning out of a US elementary/middle school (n=1917) during 2015-2016 and 2016-2017 for those who declined SBHC enrollment or did not return a consent form, compared to those who enrolled. Compared to enrolled students, those who declined had 78% lower odds of chronic absenteeism [95% CI: 0.09, 0.54]. Families who did not respond had 2.8 times greater odds of their student transitioning out of school [95% CI: 2.15, 3.58] but were no more likely to be chronically absent. Consent form return may predict aspects of broader students and family school engagement.

Teacher and school staff perspectives on their role in school-based vision programs

ObjectiveSchool-based vision programs (SBVPs) are one approach to increase access to vision care by providing vision screenings, eye examinations, and eyeglasses directly in schools. Few studies report on the perspectives of teachers and staff, who are important stakeholders, on SBVPs. We examined teacher and staff perspectives on their involvement in SBVPs. DesignQualitative study using focus groups. ParticipantsTeachers and staff at Baltimore and Chicago public schools served by SBVPs between 2016 and 2018. MethodsWe conducted 21 semistructured focus groups with 117 teachers and staff in 10 Baltimore and 11 Chicago public preK–12 schools that participated in SBVPs. Sessions were recorded, transcribed, and coded using inductive thematic analysis. ResultsParticipants identified 2 main themes regarding teacher and staff involvement in SBVPs: (i) program outreach, including using multiple communication modalities to engage parents, explaining program details to families, and helping with program consent form return and (ii) promoting vision health, including identifying vision problems in the classroom, encouraging eyeglasses wear, and supporting eyeglasses maintenance. Participants also discussed limitations in capacity to partake in these activities. ConclusionTeachers interact with parents and students throughout the SBVP process, undertaking important roles in outreach and health promotion to ensure uptake of SBVP services. SBVPs and other school-based health programs should explore strategies to support teachers in the roles they fill to optimize program impact.

School-level Factors and Consent Form Return Rate in a School-based Vision Program

Objective: School-based vision programs provide care directly in schools. Parental consent is typically required for student participation. In this paper, we examine school-level factors associated with consent form return. Methods: We included 123 schools served by a vision program in Baltimore, Maryland between the 2016-17 and 2018-19 school years. Multiple linear regression modeling was used to examine the associations between consent return rate and school type (elementary, elementary/middle or middle school), school size, student attendance, student mobility, percent of students in special education, poverty (percent eligible for free and reduced-price lunch), teacher qualifications, parent response rate to annual school climate survey, vision screening failure rate, and year of vision program participation (cohort). Results: The final model explained 26.2% of variability in consent return rate. Overall consent return rate was 57.8% (range 9.4%-100%). School size (β = -2.419, p < .01) and cohort (βCohort2 = 11.988, p < .01) were significantly associated with consent rate. Whereas poverty (β = 0.225, p < .10) and mobility (β = -0.647, p < .10) were relevant, they did not reach statistical significance. Conclusions: School-level factors are significantly associated with consent form return rates. School-based vision programs should consider additional measures to increase consent form return, especially in larger schools and schools with high rates of student mobility.

Does electronic consent improve the logistics and uptake of HPV vaccination in adolescent girls? A mixed-methods theory informed evaluation of a pilot intervention

ObjectivesTo evaluate the usability and acceptability of an electronic consent pilot intervention for school-based immunisations and assess its impact on consent form returns and human papilloma virus (HPV) vaccine uptake.DesignMixed-methods...

Impact of an influenza information pamphlet on vaccination uptake among Polish pupils in Edinburgh, Scotland and the role of social media in parental decision making

BackgroundIn Edinburgh, Scotland, lower influenza vaccine uptake has been observed in primary school children in the Polish community.MethodsTo address this disparity, the Polish-language version of the NHS Health Scotland influenza information pamphlet was updated and distributed in 2018 to all identified Polish pupils attending three pilot schools. The impact of the revised pamphlet was evaluated by examining changes in vaccine uptake in these schools as compared to a control group of schools, and a questionnaire was issued to all Polish parents in the pilot schools to explore their opinions of the pamphlet and preferred sources of immunisation information.ResultsOn average uptake was 7.4% (95% CI 1.0–13.8%, p < 0.05) higher in the three pilot schools in which the Polish-language pamphlet was distributed (28.7%) than control schools (21.3%). The questionnaire feedback was that 37.3% of respondents felt better-informed about the influenza vaccine following the pamphlet. The respondents reported that the most important information source in deciding whether to vaccinate is previous experience. Healthcare professionals were ranked lower in importance when making a decision. Parents, who refused consent (n = 65) were more likely to source information from social media, friends and family, and Polish websites compared with those who consented (n = 45).ConclusionsThese findings suggest that issuing new Polish health literature was associated with a large increase in consent form return rate and a modest increase in uptake of the influenza vaccine by Polish pupils in the pilot schools. Social media and Polish websites were found to have a greater influence over Polish parents’ decision to immunise than UK healthcare staff and health authority information. Intensive effort is required to encourage parents towards information sources where more accurate pro-vaccination messages can be promulgated by national health services and independent expert groups. The role of social media for migrant communities requires careful consideration, especially for vaccine programmes not delivered in their country of birth.

A qualitative exploration of using financial incentives to improve vaccination uptake via consent form return in female adolescents in London.

Incentivising vaccine consent form return may improve vaccine uptake and be seen as less coercive than incentivising vaccination itself. We assessed the acceptability of financial incentives in this context among adolescent females and explored potential mechanisms by which incentives might change behaviour. Focus groups and analysis of free-text questionnaire responses. Study 1: 36 female secondary students in London (age 13-14) participated in six focus groups exploring the use of incentives in the context of vaccination. Data were analysed thematically. Study 2: was conducted to triangulate the findings of Study 1, by analysing free-text questionnaire responses from 181 female secondary students in London (age 12-13) reporting their opinion of incentivising consent form return. Data from Study 1 was also used to explore perceived potential mechanisms of action by which incentives might encourage consent form return. Focus group participants had positive attitudes towards incentives, with 61% of free-text responses also expressing this. Most focus group participants thought that incentives would encourage consent form return (18% of free-text respondents spontaneously also mentioned this). While incentivising consent form return was seen as ethical, focus group participants who incorrectly thought that vaccine receipt was being incentivised raised concerns about bribery, although only 4% of free text respondents reported these concerns. Frequently raised mechanisms of action included incentives increasing engagement with, and the perceived value of consent form return. Adolescents had positive views of financially incentivising consent form return to promote vaccine uptake, although care must be taken to reduce misconceptions regarding what is being incentivised. Incentivising vaccination was seen as coercive, but incentivising actions that increase the likelihood of vaccination (i.e. consent form return) were not. Incentives may encourage adolescents to return consent forms by helping them engage with this behaviour or increasing its' perceived value.

Potential process improvements to increase coverage of human papillomavirus vaccine in schools – A focus on schools with low vaccine uptake

IntroductionHuman papillomavirus (HPV) vaccination is offered in Australia through school-based programs. While HPV vaccination coverage is high, coverage of the full course of vaccination is suboptimal in Australia and there is a drop in coverage between the first and third doses. This study aimed to describe the drivers of low HPV vaccination coverage in Western Australian (WA) schools and barriers and enablers to improving vaccine coverage. This paper focusses on process and system-level factors. Materials and methodsThis was a mixed methods study. We analysed WA vaccination coverage data by school, undertook an online survey targeting the individuals responsible for the HPV vaccination program in their schools and school nurses, and compared survey findings and HPV vaccine dose three coverage in schools with 50 or more students in the eligible cohort. We also conducted focus groups with students and interviews with parents in schools with low HPV vaccine coverage. ResultsSchools with low HPV vaccine coverage had low coverage for the first dose of HPV vaccine as well as a higher drop off between first and third doses compared to schools with higher HPV vaccine coverage. Respondents from low and middle HPV vaccine coverage schools reported more issues with return of consent forms, low parental literacy, language barriers, absenteeism and difficulty contacting parents compared to schools with high coverage. Parents and students raised a number of challenges in relation to HPV vaccination including student absenteeism, language barriers, and issues with the return of consent forms. ConclusionsA multifaceted approach to improving HPV vaccination coverage should be targeted at schools with low coverage. Based on our findings, these actions should include a range of approaches to obtaining parental consent and intensive follow up with students who are absent on vaccination days.

Parent and Teacher Perspectives on Factors Decreasing Participation in School-Based Vision Programs

ABSTRACTPurpose: To examine factors decreasing participation in school-based vision programs from parent and teacher perspectives.Methods: We conducted 41 semi-structured focus groups (20 parent groups, 21 teacher/staff groups), at 10 Baltimore and 11 Chicago public elementary and middle schools offering school-based vision programs. School-based vision programs provided vision screening, eye exams, and eyeglasses if needed. Focus groups ranged in size from 2–9 participants (median = 5). Sessions were recorded, transcribed, and coded through an iterative process to develop themes using inductive analysis.Results: Ninety parents and 117 teachers/staff participated. Participants identified five major factors decreasing participation in school-based vision programs: (1) challenges with the consent form, including distribution, collection, and literacy and language barriers; (2) having existing eye care; (3) misunderstandings about the program, especially related to cost and insurance; (4) difficulty raising parental awareness of the program; and (5) certain attitudes towards vision, eye care, and school-based programs, including low prioritization of eye care, mistrust of the program, fear of sharing private information, not believing their child needs glasses, and reluctance accepting ‘subsidized’ services.Conclusion: Parents and teachers identified important structural barriers to participation (i.e., consent form challenges and low parental awareness) and specific reasons for non-participation (i.e., attitudes, misunderstanding of the program, existing eye care) in school-based vision programs. Effective strategies are needed to facilitate return of consent forms and promote awareness of school-based vision programs among parents. Programs should also target services towards those currently without access to eye care and increase awareness about paediatric vision needs.

Information sources and attitudes of Polish migrants accepting or declining vaccination in Scotland

Abstract Background Poland has the lowest EU vaccine confidence scores. The Polish are the largest migrant group in Scotland (91,000) with a high decline rate of nasal influenza vaccination. A new Polish language information leaflet in the 2018 school influenza programme saw consent form return increase but uptake remained low. We compare vaccination attitudes of accepting and declining parents. Methods A questionnaire to 365 Polish parents after vaccination asked about the leaflet, vaccination, time in UK and included WHO Vaccine Hesitancy statements. Accepting and declining parents were compared. Results 128 (37%) responded - 42% of vaccinating and 39% declining parents. 90% were long term UK resident, 72% speak Polish at home. Previous experience had most influence in vaccination decision-making, with social media and personal contacts in Poland and Scotland also key. Decliners were more likely to cite social media than accepters. Concerns about new vaccines, side effects and ’currently uncommon conditions’ are high in the Polish community and decliners hold more negative and scientifically ’incorrect’ opinions. Parents know that Polish and UK immunisation schedules differ for influenza, a condition thought less serious in Poland than UK. Conclusions Polish norms strongly influence this migrant group. Differences in how Polish migrants who accept or decline the vaccination respond to vaccine hesitancy statements plus knowing that Polish media and the Polish community shape their views can be used by health authorities to target health messages. It is important to be aware of immunisation status and vaccination beliefs of mobile migrant groups, such as the Polish, to prevent spread of vaccine preventable diseases in Europe. Linking vaccine hesitancy statement responses and behaviour can highlight national characteristics and particular concerns of vaccine hesitant parents. This information could be used to improve vaccine uptake rates among different ethnic minorities. Key messages Polish migrant children have low nasal influenza vaccine uptake. Vaccine hesitancy statements show decliners are particularly likely to distrust new vaccines and worry about vaccine side effects. Migrants access Polish social media and information and retain vaccination beliefs and norms post migration. Knowing this allows targeting of information campaigns to increase uptake.

Factors Affecting Delivery of the HPV Vaccination: A Focus Group Study With NHS School-Aged Vaccination Teams in London.

This study sought to identify barriers and facilitators to delivery of human papillomavirus (HPV) vaccination in schools. Four focus groups were conducted with 28 staff members, from four National Health Service school-aged vaccination (SAV) teams in London. Data were analyzed using thematic analysis. School engagement and support, and understanding and education about the vaccination (or conversely, a lack of) were identified as both barriers and facilitators. Limited school and team resources, fear of the vaccination, and poor consent form return were identified as barriers. Explanations for why some girls do not complete the vaccination series were provided. Individualizing approaches used to promote and encourage the vaccination was identified as a facilitating factor. Optimal delivery of the HPV vaccination program is dependent on school engagement and the allocation of time for SAV teams to promote vaccination uptake. Immunization program providers should work with schools to improve understanding and support of the HPV vaccination program.

The Unanticipated Challenges Associated With Implementing an Observational Study Protocol in a Large-Scale Physical Activity and Global Positioning System Data Collection.

BackgroundLarge-scale primary data collections are complex, costly, and time-consuming. Study protocols for trial-based research are now commonplace, with a growing number of similar pieces of work being published on observational research. However, useful additions to the literature base are publications that describe the issues and challenges faced while conducting observational studies. These can provide researchers with insightful knowledge that can inform funding proposals or project development work.ObjectivesIn this study, we identify and reflectively discuss the unforeseen or often unpublished issues associated with organizing and implementing a large-scale objectively measured physical activity and global positioning system (GPS) data collection.MethodsThe SPACES (Studying Physical Activity in Children’s Environments across Scotland) study was designed to collect objectively measured physical activity and GPS data from 10- to 11-year-old children across Scotland, using a postal delivery method. The 3 main phases of the project (recruitment, delivery of project materials, and data collection and processing) are described within a 2-stage framework: (1) intended design and (2) implementation of the intended design.ResultsUnanticipated challenges arose, which influenced the data collection process; these encompass four main impact categories: (1) cost, budget, and funding; (2) project timeline; (3) participation and engagement; and (4) data challenges. The main unforeseen issues that impacted our timeline included the informed consent process for children under the age of 18 years; the use of, and coordination with, the postal service to deliver study information and equipment; and the variability associated with when participants began data collection and the time taken to send devices and consent forms back (1-12 months). Unanticipated budgetary issues included the identification of some study materials (AC power adapter) not fitting through letterboxes, as well as the employment of fieldworkers to increase recruitment and the return of consent forms. Finally, we encountered data issues when processing physical activity and GPS data that had been initiated across daylight saving time.ConclusionsWe present learning points and recommendations that may benefit future studies of similar methodology in their early stages of development.

Assessing the acceptability of incentivising HPV vaccination consent form return as a means of increasing uptake

BackgroundUptake of human papillomavirus (HPV) vaccination is high overall but there are disparities in uptake, particularly by ethnicity. Incentivising vaccination consent form return is a promising approach to increase vaccination uptake. As part of a randomised feasibility trial we qualitatively assessed the acceptability of increasing uptake of HPV vaccination by incentivising consent form return.MethodsIn the context of a two-arm, cluster randomised feasibility trial, qualitative free-text questionnaire responses were collected from adolescent girls (n = 181) and their parents (n = 61), assessing the acceptability of an incentive intervention to increase HPV vaccination consent form return. In the incentive intervention arm, girls who returned a signed consent form (regardless of whether consent was given or refused), had a 1-in-10 chance of winning a £50 shopping voucher. Telephone interviews were also conducted with members of staff from participating schools (n = 6), assessing the acceptability of the incentive. Data were analysed thematically.ResultsGirls and parents provided a mix of positive, negative and ambivalent responses about the use of the incentive to encourage HPV vaccination consent form return. Both girls and parents held misconceptions about the nature of the incentive, wrongly believing that the incentive was dependent on vaccination receipt rather than consent form return. School staff members also expressed a mix of opinions on the acceptability of the incentive, including perceptions of effectiveness and ethics.ConclusionsThe use of an incentive intervention to encourage the return of HPV vaccination consent forms was found to be moderately acceptable to those receiving and delivering the intervention, although a number of changes are required to improve this. In particular, improving communication about the nature of the incentive to reduce misconceptions is vital. These findings suggest that incentivising consent form return may be an acceptable means of improving HPV vaccination rates, should improvements be made.Trial registrationISRCTN Registry; ISRCTN72136061, 26 September 2016, retrospectively registered.

A protocol for a cluster randomised feasibility study of an adolescent incentive intervention to increase uptake of HPV vaccination among girls

BackgroundUptake of the human papillomavirus (HPV) vaccine in the UK is good, but there are pockets of the community who remain unprotected. Immunisation teams usually require written parental consent for a girl to receive the vaccine. Evidence suggests that uptake of the vaccine might be improved by promoting consent form return (if returned, forms are likely to grant consent). Incentivising girls to return consent forms is a promising approach to promoting consent form return. Before testing the efficacy of an incentive intervention in a randomised controlled trial (RCT), we must first establish whether the RCT is feasible. In this randomised feasibility study, we aim to establish the feasibility of conducting a cluster RCT of an adolescent incentive intervention to increase uptake of HPV vaccination.MethodsAt least six schools will be randomised to either an incentive intervention arm or a standard invitation arm. Girls in standard invitation arm schools will receive the usual HPV vaccine programme invitation materials. Girls attending schools in the incentive intervention arm will receive the standard invitation and will also be told that they will receive an incentive if they return their consent form (regardless of whether consent is granted or denied). The incentive is being entered into a prize draw to win a retail voucher. Feasibility objectives include estimating the schools’ and parents’ willingness to participate in the study and be randomised; response rates to questionnaires; the extent of missing data; the girls’ and parents’ attitudes towards the incentive offered; school staff experiences of participating, fidelity to the trial procedures, data on any unintended consequences and the possible mechanisms of action, and proof-of-concept evidence of the effect of the intervention on consent form return rates and uptake of the vaccine. Analysis of feasibility outcomes will primarily be descriptive. Consent form return rates and uptake of the vaccine will be presented by trial arm without comparison.DiscussionIncentivising HPV vaccine consent form return may promote HPV vaccine uptake. This study will provide the evidence needed to establish whether testing this incentive intervention using a RCT design in the future is feasible.Trial registrationISRCTN72136061

Five tips to maximise the return of parent consent forms

Psychologists who are carrying out research on children are faced with the challenge of obtaining parental consent for children to participate in their study (opt-in). This is a challenge I faced with my own research on children’s cognitive abilities and social behaviour and in this article I outline five tips to maximise the return of parent consent forms.

A School-Located Vaccination Adolescent Pilot Initiative in Chicago: Lessons Learned

Many adolescents underutilize preventive services and are underimmunized. To promote medical homes and increase immunization rates, we conceptualized and implemented a 3-year, 8-school pilot school-located vaccination collaborative program. We sought community, parent, and school nurse input the year prior to implementation. We selected schools with predominantly Medicaid-enrolled or Medicaid-eligible students to receive Vaccines For Children stock vaccines. Nurses employed by a mass immunizer delivered these vaccines at participating schools 3 times a year. Over 3 years, we delivered approximately 1800 vaccines at schools. School administrators, health centers, and neighboring private physicians generally welcomed the program. Parents did not express overt concerns about school-located vaccination. School nurses were not able to participate because of multiple school assignments. Obtaining parental consent via backpack mail was an inefficient process, and classroom incentives did not increase consent form return rate. The influenza vaccine had the most prolific uptake. The optimal time for administering vaccines was during regular school hours. Although school-located vaccination for adolescents is feasible, this is a paradigm shift for community members and thus accompanies challenges in implementation. High principal or school personnel turnover led to a consequent lack of institutional memory. It was difficult to communicate directly with parents. Because we were uncertain about the proportion of parents who received consent forms, we are exploring Internet-based and back-to-school registration options for making the consent form distribution and return process more rigorous. Securing an immunization champion at each school helped the immunization processes. Identifying a financially sustainable school-located vaccination model is critical for national expansion of school-located vaccination.

Factors determining vaccine uptake in Western Australian adolescents

Adolescence is the final opportunity for a large-scale immunisation programme before adulthood. The Western Australian (WA) school-based vaccination programme provides Year 7 students with free vaccination against hepatitis B virus (HBV); diphtheria, tetanus and pertussis (dTpa); varicella zoster virus (VZV); and human papilloma virus (HPV). We aimed to identify factors determining consent form return and vaccination uptake. Data were collected via a statewide, web-based database in 2009 and 2010. Proportions of students who returned a vaccine consent form, and completed HBV and HPV multi-dose courses and dTpa and VZV vaccination were determined. Factors associated with these outcomes were identified with multivariate analysis using logistic regression, accounting for clustering by school. In 2010, 92.8% of WA Year 7 students returned a vaccination consent form and 85.3%, 74.3%, 66.7.0% and 26.4% completed their adolescent vaccination(s) against dTpa, HPV (females only), HBV and VZV, respectively. Consent form return and dTpa vaccination uptake improved between 2009 and 2010. Independent and consistently negative associations were observed between outcome variables (consent form return and vaccine uptake) and male gender, geographically remote schools, government schools and schools in the most socio-economically disadvantaged areas. Both HBV and HPV course completion were higher in Catholic than government schools, and the same in government and independent schools. To effectively maximise vaccination coverage, the WA school-based adolescent vaccination programme must specifically target male students and schools in the most disadvantaged and remote areas.

Promoting Uptake of the HPV Vaccine: The Knowledge and Views of School Staff

School-based human papillomavirus (HPV)/cervical cancer vaccination programs have been implemented widely, but few studies have investigated the knowledge and views of school staff about this new vaccine. Prior to the introduction of the HPV vaccine in 2009, we surveyed staff at 14 socioeconomically diverse schools to assess views toward this new program, including staff's information needs, ideas on promoting return of consent forms, and uptake of the vaccine among minority groups. Of 583 invited staff, 456 participated (78%). About 58% of the participants knew about the link between HPV and cervical cancer, and that HPV is passed on during sexual contact. When asked if vaccination would increase sexual activity at a younger age, 71% disagreed, 6% agreed, and 23% were unsure. The majority of staff agreed that vaccine uptake could be improved through provision of information and consent forms in indigenous and Pacific languages; ensuring parents are well informed and girls educated about the vaccine; involving community groups and by extending availability of the vaccine into community settings as well as school and primary care. Three fourths of the staff surveyed wanted more information about the program before and during its implementation. This important group of stakeholders requires appropriate information so that they can support girls and their parents in deciding whether to have the vaccine. School staff members are potential health advocates with whom consultation should occur before and during the implementation of such programs.

Active Parental Consent for a School‐Based Community Violence Screening: Comparing Distribution Methods

Students are unable to benefit from many school programs designed to address their mental health needs if their parents do not consent to their participation. As part of an ongoing effort in a large urban school district to meet the mental health needs of students traumatized by violence exposure, this paper examines the impact of alternative approaches on parental response and consent rates for an initial screening to participate in a school mental health program. Two alternative approaches were used to obtain consent for students to participate in a school-based intervention for students exposed to violence. For one cohort, consent forms were distributed along with school information and other school forms during a parent orientation meeting. In the other cohort, school mental health clinicians visited student homerooms to distribute consent forms and explain the program and evaluation to students. There were significantly higher rates of return of consent forms (89.8% vs 53.2%) and parents consenting to participate (69.6% vs 27.9%) among parents receiving consent forms at a school meeting than among parents whose forms were distributed to children in a classroom, with comparable rates of active refusals to participate (20.1% vs 25.3%). Overall return rates and rates of consent for screening participation were substantially higher when the consent form and accompanying materials were provided directly to parents rather than distributed in the classroom and sent home with students. These findings have implications for efforts to obtain active consent from parents for students to participate in school mental health programs.

Creating a Successful School‐Based Mobile Dental Program

Dental disease is one of the leading causes of school absenteeism for children. This article describes the creation and evolution of the St. David's Dental Program, a mobile school-based dental program for children. The dental program is a collaboration of community partners in Central Texas that provides free dental care to low-income children in schools without relying on reimbursements or government funding. Since 1998, the program has provided 132,791 screenings for oral health treatment needs and 38,634 encounters for sealants or treatment. In 2005, the program provided $2.1 million worth of services at a cost of $1.2 million (not including donated services). Factors important to the program's success included sustained funding for general operating costs; well-compensated clinicians to deliver care and experienced human service workers to manage program operations; the devotion of resources to maximize consent form return rates; and the development of strong relationships with school district and individual school staff. By removing cost, time, transportation, and bureaucratic barriers, the program was able to reach more children than fixed-site clinics. The program was a merging of private and public health dentistries. This model can be useful to other communities in light of the unmet need for dental care and tighter federal, state, and local government budgets.

Consent Form Return Rates for Third-Grade Urban Elementary Students

Consent Form Return Rates for Third-Grade Urban Elementary Students