Fentanyl Overdose Harm Reduction Intervention: A Pretest-Posttest Study Among High School Students in Southern California

Abstract

Fentanyl is a highly potent and dangerous synthetic opioid pervasively contributing to the opioid overdose epidemic in the U.S. Illicitly sold opioids with fentanyl are dangerous as they are uncontrolled and can lead to rapid deterioration of health, especially among growing adolescents. Within Los Angeles County, fentanyl-related deaths tied to opioid overdoses have led to a sharp increase in mortality rates. The purpose of this pre-post design study was to evaluate the effectiveness of two harm reduction videos developed by the Los Angeles County Department of Public Health. This pilot study measured the changes in the level of knowledge and attitudes that contribute to substance use behaviors among high school students (N=76). The participants included high school students recruited from two local schools. Wilcoxon Signed Rank tests were used to measure changes in attitude and level of knowledge pre-and post-test using the statistical software SPSS 29.0. Overall, the results indicate a statistically significant improvement in the level of knowledge and change in attitudes post-test and at the 3-month follow-up. The retention of overdose knowledge information did not change significantly between post-test and the 3-month follow-up, potentially due to the low sample size. The study has several implications for public health education and substance use prevention practitioners, including the importance of effective community collaborations, improved access to harm reduction resources, and large-scale adoption of feasible educational interventions to reverse the trajectory of opioid overdoses among adolescents.

Keywords

opioid overdose harm reduction adolescents evaluation naloxone prevention

Introduction

Fentanyl-related deaths among adolescents are increasing at an alarming rate both nationally and within Los Angeles County (LAC), contributing to a worsening opioid overdose epidemic in the U.S. (American Medical Association [AMA], 2023). According to the Centers for Disease Control and Prevention (CDC), U.S. drug overdose deaths increased by 30% from 2019 to 2020 and by 15% in 2021, resulting in an estimated 108,000 deaths in 2021 (Tanz et al., 2022). Among these deaths, opioid overdoses experienced a sharp increase; ten times more people died in 2022 from an opioid overdose than in 1999 (CDC, 2024) . Fentanyl has contributed significantly to the opioid overdose mortality rate across the nation; for example, accidental fentanyl overdose deaths increased by 1,280% from 109 in 2016 to 1,504 in 2021 in Los Angeles County (County of Los Angeles, Department of Public Health, 2023). Furthermore, this pervasive epidemic has negatively impacted the lives of the adolescents who are a highly vulnerable population; among youth under the age of 17 in LAC, there were a total of 31 fentanyl overdose deaths in 2021, from nine in 2019, a 244% increase (County of Los Angeles, Department of Public Health, 2023).

Researchers have found that there are various risk and protective factors associated with opioid use among adolescents. Risk factors include being female, LGBTQ+, coming from an ethnic minority group or low-income families. These populations are disproportionately affected by barriers such as access to treatments for substance use disorders (Bonar et al., 2020; McCabe et al., 2019; Nairn et al., 2022; Schuler et al., 2019). In addition, co-occurring mental health conditions such as depression, anxiety, trauma, and adolescents with a history of a psychiatric disorder, including suicide attempt, are at an increased risk of substance use (Cho et al., 2021; Das et al., 2016; Gondré-Lewis et al., 2022; Hermans et al., 2023; Jacko et al., 2021; Lyons et al., 2019; Ramos et al., 2018; Sharma et al., 2023; Suffoletto & Zeigler, 2020). Furthermore, prescription opioid misuse is a risk factor for victims of sexual assault and child abuse (Ford, 2019).

Preventing opioid-related overdoses among adolescents requires targeted prevention and harm reduction strategies, which can significantly contribute to reversing the current opioid epidemic. Health promotion strategies, such as education and awareness programs, have been shown to be effective in curtailing the opioid epidemic (Sharma et al., 2023). Furthermore, universal prevention strategies delivered early during adolescence lead to reduced drug use over the longer term (Volkow et al., 2019). At the same time, harm reduction strategies such as naloxone distribution, a highly effective measure of reversing overdoses, remain underutilized and limited in availability due to limited education, training, and access combined with stigma associated with the usage (Bell & Hadland, 2023; Volkow & Blanco, 2023).

To address this gap of providing timely education and strategies to adolescents to combat the opioid epidemic, LAC, Department of Public Health (DPH), Substance Abuse Prevention and Control (SAPC) developed a harm reduction intervention with two educational harm reduction videos. These videos instruct adolescents about fentanyl and the harmful effects of opioids, in addition to providing information on how to properly administer naloxone (an opioid receptor antagonist) and fentanyl testing strips.

The purpose of this pilot study was to assess the effectiveness of LAC, DPH, and SAPC’s harm reduction intervention in changing the level of knowledge and attitudes among high school students. The study answers three essential program evaluation questions:

Do the harm reduction videos increase the level of knowledge and awareness of opioids and the effects of fentanyl?

Do the videos increase the level of knowledge associated with the usage of naloxone and fentanyl testing strips?

Do the videos modify the attitudes of adolescents toward opioids?

Our study hypothesized that the level of knowledge and awareness of opioids, as well as knowledge associated with the usage of naloxone and fentanyl testing strips, would increase after the intervention and that the adolescents would be able to retain the knowledge and attitudes 3 months after the intervention.

Theoretical Framework

The intervention was based on the theory of planned behavior (TPB). Ample empirical evidence demonstrates that the TPB can be used to predict and explain behavior and support the development of effective behavior change interventions (Ajzen & Schmidt, 2020). TPB has been widely applied across a broad range of behavioral domains, including physical activity, substance use, sexual health behaviors, and consumer decision-making (Ajzen & Schmidt, 2020). The theory posits that the strongest predictor of a behavior is behavioral intention (Hagger et al., 2022). Further, a person’s intention to engage in a behavior is influenced by their attitudes, subjective norms, and perceived behavioral control toward a behavior. These factors ultimately contribute to whether the behavior occurs (Hagger et al., 2022).

In the context of this study, these constructs reflect adolescents’ beliefs about the risk and benefits of harm reduction practices (attitudes), perception of peers and social expectations regarding overdose prevention behaviors (subjective norms), and confidence in the ability to recognize an overdose and appropriately use naloxone and fentanyl testing strips (perceived behavioral control). Further, the intervention within our research addressed two of the three constructs of the TPB: attitudes and perceived behavioral control. Attitudes were addressed by providing information on the risks and consequences of opioid misuse during the educational intervention. Perceived behavioral control was addressed by equipping the participants with practical knowledge on recognizing an overdose and administering naloxone/fentanyl testing strips. The study tested whether changes to these TPB constructs were associated with stronger intentions to adopt harm reduction practices among adolescents.

Methods

The program evaluation followed a pretest-posttest study design. The program was designed by LAC, DPH, and SAPC for high school students in LAC and commenced in May 2024. The study was approved by LAC, DPH’s Institutional Review Board (IRB).

Participants and Recruitment

Participants included high school students from grade levels 9–12, ages from 13 to 18 years old, enrolled in two Los Angeles Unified School District (LAUSD) campuses. Demographic data, such as age and gender, were not collected from this vulnerable population to maintain a level of privacy and anonymity. Students were selected using a convenience sample from multiple health classes with all grade levels at two local high school campuses. Recruitment flyers were developed in both English and Spanish to help enroll students in the study. Enrollment in this study was voluntary. Each participant provided a signed assent form along with a parent permission form to comply with LAC’s IRB standards. Upon completion of the post-test, participants were given a 5-dollar gift card as an incentive to help with the retention of the participants at follow-up.

Intervention

The intervention was carried out during health classes at the two LAUSD campuses and involved participants completing a pre-test, watching the educational videos, and then completing the post-test immediately afterwards. The second post-test was administered electronically via email and text messages over a 4-week period, approximately 3 months after the initial post-test, using the same set of questions.

The intervention consisted of two videos offering education about the harmful effects of illicit opioids, ways to identify an overdose, as well as harm reduction training on how to administer naloxone and use fentanyl testing strips (Puri, 2023a, 2023b). The videos were approximately 10–12 min in length and were projected on a screen to students during the study in the health classrooms at the two high school campuses. The videos were developed by LAC, DPH, and SAPC, featuring the Assistant Medical Director, Dr. Siddarth Puri. This intervention ran for approximately 2 weeks in numerous health classes at the two schools. Furthermore, the program conducted a follow-up survey approximately 3 months after the initial session had been delivered. The students were expected to have seen the video once during the study.

Survey Instrument

The survey instrument was developed in collaboration with LAC, DPH, SAPC, and the current study is the first to utilize this instrument. The survey consisted of 13 questions. The questions were based on the key outcome variables as well as three identifier-type questions. Three main outcomes or dependent variables were measured: (a) the level of knowledge about opioids and the effects of fentanyl; (b) the level of knowledge associated with the usage of naloxone and fentanyl testing strips; and (c) the attitude regarding the use of fentanyl or opioids.

Knowledge of Fentanyl and Opioid Overdose (OD Knowledge)

OD knowledge was measured using five multiple-choice questions based on the content of the educational videos covering the following subjects: facts about fentanyl and its harmful effects, as well as signs to identify an overdose (the survey is included in the Supplemental Materials Section). The knowledge variable was scored as the sum of all correct responses.

Knowledge of Naloxone and Fentanyl Testing Strips Use (Naloxone Knowledge)

Naloxone knowledge was measured using three multiple-choice questions based on materials covered in the videos. The three questions tested the participants’ knowledge on the following subjects: the role naloxone plays in preventing an overdose, how to properly administer naloxone, which substances a fentanyl testing strip detects, and how to correctly read results from a fentanyl testing strip. The knowledge variable was scored as the sum of all correct responses. Some sample questions include: What role does naloxone play during an opioid overdose? Which of the following are three signs of an opioid overdose? What should you do if a person does not respond after the first dose of naloxone is administered?

Attitudes Toward the Use of Opioids

Attitudes were measured using five Likert-type questions designed to measure adolescents’ attitudes toward the use of opioids. The questions used a 5-point Likert-type scale with five representing “strongly disagree” and one representing “strongly agree”. The higher score indicated more negative attitudes toward the use of opioids. The question design was based on the subject matter expertise of the local health department and a review of other scales, such as the Prescription Drug Attitudes Questionnaire (PDAQ scale; Bodenlos et al., 2014). The median values for the 5 items were used to measure attitudes. Furthermore, qualitative feedback from students was collected verbally at the end of the initial session in a focus group format, which included questions on assessing the quality, delivery, and educational value of the educational videos.

Data were analyzed using statistical software SPSS (IBM SPSS, Inc., version 29.0, Armonk, NY) using a descriptive approach combined with inferential statistics to assess changes in attitudes and knowledge. Because the data were not normally distributed, non-parametric statistical testing was used. To assess for a change in level of OD knowledge, naloxone knowledge, and attitudes toward the use of opioids associated with the intervention, the Wilcoxon Signed Rank test was used. The analysis included the 3-month follow-up results to compare them to the baseline results to demonstrate retention of knowledge and a change in attitudes among participants.

Results

There was a total of 76 participants with a 100% response rate from the initial pre-and post-test. The retention rate after 3-months at the follow-up was 24% (N=18), which resulted in low power. The majority of respondents were 9th and 10th grade (See Table 1).

Table 1.

Total Participants and Responses by Grade Level at Three Time Points to Assess the Effectiveness of Harm Reduction Intervention.

Grade	Pre-test (n)	Post-test (n, % of pre-test)	Follow-up (n, % of pre-test)
9	42	42, 100	12, 29
10	6	6, 100	2, 33
11	5	5, 100	3, 60
12	3	3, 100	0, 0
No Stated Grade	20	20, 100	1, 5
Total	76	76	18

The median and ranges of scores from the survey instrument, which consists of knowledge and attitude questions, are described in Table 2. The scores for the majority of the questions progressively increased between the three measurement intervals.

Table 2.

Summary of Scores to Measure the Level of Knowledge and Attitudes Toward the Use of Opioids Among High School Students in Los Angeles (2024).

Assessment	Median score (Range: Min-max)
Assessment	Pre-test (Interval I)	Post-test (Interval II)	Follow-up (Interval III)
OD knowledge	4.00 (1–5)	5.00 (0–5)	4.00 (2–5)
Naloxone knowledge	2.00 (1–3)	3.00 (0–3)	2.00 (1–3)
Attitudes	4.20 (3.4–5)	4.30 (2.8–5)	4.60 (4–5)

Overall, the results indicate that harm reduction videos had a statistically significant impact on increasing the level of knowledge and attitudes among high school students. Specifically, a Wilcoxon Signed Rank test revealed that all dependent variable scores (OD knowledge, naloxone knowledge, and attitudes toward the use of opioids) were significantly improved immediately after the intervention. The results were statistically significant for all dependent variables (OD knowledge, naloxone knowledge, and attitudes toward the use of opioids) with p-values of <.05 between the pre-test and initial post-test and between the post-test and the 3-month follow-up, with the exception of the OD Knowledge (Table 3).

Table 3.

Wilcoxon Signed Rank Test Results for Each of the Associated Variables and Intervals to Assess the Effectiveness of the Harm Reduction Education Intervention.

Variable	Comparison	Z score	p-value	Median 1	Median 2
OD knowledge	Pre-test vs Post-test	2.098	.036	4.0	5.0
OD knowledge	Post-test vs Follow-up	−0.792	.428	5.0	4.0
Naloxone knowledge	Pre-test vs Post-test	3.726	<.001	2.0	3.0
Naloxone knowledge	Post-test vs Follow-up	−2.111	.035	3.0	2.0
Attitudes	Pre-test vs Post-test	2.343	.019	4.2	4.3
Attitudes	Post-test vs Follow-up	2.720	.007	4.3	4.6

Note. Total scores for OD knowledge range from 1–5, with 5 being the highest score; total scores for naloxone knowledge range from 1–3, with 3 being the highest score; mean scores for attitudes toward use of opioids range from 1–5, with 5 being the highest. Significant p values appear in bold.

The baseline results from the pre-test for OD Knowledge were relatively high at the pre-test time point, suggesting a high pre-existing level of knowledge and awareness about fentanyl, opioid overdose and naloxone. The attitude scores at post-test and follow-up, each compared to pre-test score, had p-values of .019 and .007, respectively. These results indicate that attitudes toward the use of opioids became more negative after administration of the harm reduction video presentation.

In addition, OD knowledge level also increased significantly in the post-test interval, with a p-value of .036 indicating a higher level of knowledge and awareness of opioids and the effects of fentanyl between pre-test and post-test. Naloxone knowledge demonstrated an increase in level of knowledge about administering naloxone and Fentanyl testing strips, with a statistically significant increase at the post-test interval with a p-value of <.001 and a decrease at follow-up with a p-value .035 respectively. However, the change in OD knowledge between post-test and follow-up was not statistically significant, with a p-value of .428. These results indicate that there was not a measurable loss of knowledge about overdose between the post-test and the 3-month follow-up.

The changes in median scores for each component of the attitude survey showed progressive improvement in negative attitudes toward opioids from pre-test to post-test and from post-test to follow-up. The knowledge scores (OD knowledge and naloxone knowledge) improved consistently across all questions from pre-test to post-test. However, the same scores decreased for some questions from post-test to follow-up among those who participated in the follow-up. The description of the individual questions from the survey instrument is shown in Table 4. Furthermore, this table demonstrates the percent change in scores between the various time intervals (i.e., pre-test to post-test and post-test to follow-up) based on correct responses to knowledge questions and ratings of the attitude questions.

Table 4.

Percent Changes in Mean Scores in Attitudes Toward Use of Opioids and Knowledge Questions Between Pre-Test and Post-Test and Post-Test and Follow-Up.

Number	Question	% Change in scores pre-test to post-test (N=76)	% Change in scores post-test to follow-up (N=18)
Attitudes
1	Taking unprescribed medication to cope with anxiety, depression, attention deficit disorder and eating disorder	3.53%	4.32%
2	Taking unprescribed medication to cope with stress from school, family, health and negative thoughts and feelings	1.98%	0%
3	Taking unprescribed medication due to peer pressure	0.85%	2.28%
4	Taking unprescribed medication should be illegal	4.49%	49.60%
5	Taking unprescribed medication to get “high”	2.14%	1.05%
Knowledge
1	Identify the role Naloxone plays during an opioid overdose	20.69%	5.88%
2	Identify three signs of an opioid overdose	19.61%	−26.67%
3	Identify action if someone does not respond to the first dose of naloxone	22.45%	13.33%
4	Identify factors that make fentanyl-laced drugs extremely dangerous	0%	−17.64%
5	Identify common physical and mental effects of fentanyl	15.51%	−5.88%
6	Identify which substances can be detected by a fentanyl testing strip	13.11%	−11.11%
7	Identify the correct order to test for fentanyl in a substance using a fentanyl testing strip	24%	6.66%
8	Identify the correct image that represents a positive test result on a fentanyl testing strip	114.28%	−40.0%

Discussion

Overall, this harm reduction intervention demonstrated a significant increase in the level of knowledge and a significant increase in negative attitudes toward the use of opioids among high school students in LAUSD. This suggests that harm reduction education delivered in the school setting can be an effective prevention public health strategy to increase knowledge and affect attitudes toward the use of opioids among high school students.

Our findings were similar to those of a program for medical students at Yale University (Oldfield et al., 2020). Oldfield’s study evaluated an educational workshop on preventing overdose and resulted in statistically significant improvements in students’ knowledge and preparedness to prevent an overdose.

With our evaluation, all knowledge scores increased between pre-and post-tests, suggesting that the intervention contributed to improved understanding about information such as the facts about fentanyl, signs of an overdose, and administering naloxone and fentanyl testing strips. Scores for all three variables at follow-up remained higher than baseline; however, we observed a slight drop (compared to post-test) in OD knowledge and naloxone knowledge scores specifically for two questions: signs of an overdose and how to identify a positive test result on the fentanyl testing strip. Literature suggests that identifying test results accurately on paper-based immunoassays is a complex task that requires education and training (Delaney et al., 2022; Jacka et al., 2020). While our findings confirm sustained improvement beyond baseline scores at both posttest and follow-up, they also highlight the need for ongoing education and instructions to be provided to students to strengthen retention of facts and information. However, the decrease in scores could also be due to data censoring, where the 3-month follow-up cohort (N=18) was a minority of the post-test cohort (N=76). The participants at follow-up frequently scored below the post-test median values on their own post-test evaluations. Repeated measurements that do not experience this level of attrition should be performed to conclusively identify trends in knowledge between these two time intervals.

In addition, the negative attitude scores increased from baseline to post-test to follow-up, suggesting that participants’ attitudes toward using opioids as a result of a coping mechanism, peer pressure, getting “high”, and legality were more negative toward the use of opioids. These results suggest that harm reduction education designed for adolescents can contribute to raising the level of knowledge and attitudes of high school students toward the dangers of opioids, including risk and misuse. These findings are consistent with existing research supporting the effectiveness of similar educational interventions (Bell & Hadland, 2023; Sharma et al., 2023).

The study also provided open-ended qualitative feedback from the participants for LAC, DPH, and SAPC to help improve the visual representation, engagement and accessibility of the intervention. For example, participants shared that adding live demonstrations of identifying signs of an overdose, as well as naloxone usage, adding QR codes for resources such as support calls and help lines, and using more youth-focused introductions and visuals would considerably improve the quality and value of the videos.

This program engaged adolescents in a meaningful way through delivering education that could potentially prevent future opioid overdoses, promoting safer practices of using fentanyl testing strips, and handling an overdose using naloxone. Furthermore, the timing of the study was instrumental as it coincided with the passing of the Senate Bill number 997 in California, which allowed high school students to carry naloxone with them at school. This extended the ability to provide increased access to naloxone and fentanyl testing strips to students on high school campuses across LAC through the Student Wellbeing Center Program. Finally, this study is consistent with the literature that shows that harm reduction education can be effective in promoting safer practices around substance use to reduce potential overdoses through proper administration of naloxone and fentanyl testing strips (Goldman et al., 2019; Jacka et al., 2020).

This study has several strengths. To our knowledge, this is among the first evaluation studies to assess the effectiveness of harm reduction videos in changing the level of knowledge and attitudes toward the use of opioids among adolescents and was conducted on high school campuses. Furthermore, this study successfully delivered a harm reduction intervention with results that suggest that effective education can contribute to an increase in awareness and adoption of harm reduction practices and have a prolonged impact on participants’ knowledge retention and changes in attitudes over a period of time. This is a cost-effective and feasible intervention that could be easily implemented. Finally, it can be easily shared through online forums or mobile health technologies such as smartphones, which are commonly used by adolescents.

The study is not without limitations. Prior awareness campaigns about fentanyl and naloxone targeted to the youth due to the pervasive epidemic by major providers such as the California Department of Public Health, Los Angeles County Department of Public Health, and others have likely contributed to generally higher levels of baseline knowledge and awareness of fentanyl and naloxone use among high school students in the local Los Angeles area who participated in our study. However, despite high baseline knowledge, the results showed statistically significant improvement in the scores during pre- and post-test, as well as pre-test and follow-up. Second, despite having an adequate sample size initially (power size of 0.78), the study experienced significant attrition at the 3-month follow-up following the summer school recess. The small sample size (N=18) of those who completed the follow-up test may have limited the ability to detect small changes in scores, reducing the study’s statistical power. This also restricts the generalizability of the results and introduces the possibility of confounding factors, such as the characteristics of those who completed the follow-up may differ from those who did not, potentially influencing the observed outcomes. This limited result is promising, but difficult to properly contextualize. Subsequent, more robust studies with reduced attrition that specifically investigate long-term (3 -months) follow-up periods should be performed. In addition, this study did not collect specific demographic variables, such as gender and age, from this vulnerable population to maintain a level of unobtrusiveness. For future studies, we recommend conducting inferential analysis to quantify the associations and control for confounding variables such as current use of opioids. We also recommend having a control group to strengthen the validity of the study and ensure that any observed changes can be attributed to the program rather than external factors. In addition, the instrument used to measure attitudes about opioid use was substantially modified from the original PDAQ scale and was used in a different population from which it had been validated. Finally, while multiple-choice questions offer an efficient and objective method for assessing knowledge levels, they may not fully grasp the depth of students’ understanding. Inclusion of short-answer questions and group discussions in future studies could provide a richer and more comprehensive assessment of student learning. The findings can be generalized to high school students in a diverse community residing in metropolitan areas.

Implications for Practice

The findings from this study suggest that brief, theory-based harm reduction education can be a feasible and effective prevention approach for high schools. In that format, it may positively influence adolescents’ knowledge and attitudes toward the harms of opioids, overdose risks, and the importance of harm reduction tools. As such, school-based programming constitutes protective factors against opioid overdoses and, hence, these institutions should be at the forefront of public health approaches working in collaboration with the local health departments to reduce opioid overdoses.

Based on the findings, a health promotion practitioner should consider adopting the existing harm reduction curriculum into their high schools. This curriculum is cost-effective and feasible, with web-enabled videos that could be shown in health classes to educate adolescents about the facts, risks, and prevention of opioid overdoses. The curriculum should be incorporated with a pre-and post-test to evaluate the effectiveness at the beginning, end, and a 3-month follow-up interval. The person delivering the education should also be trained effectively and consistently on the various elements of harm reduction programming, such as the harmful effects of opioids, how to recognize an overdose, and steps involved with administering naloxone, and how to use a fentanyl testing strip. It is essential that a practitioner collaborate with a local health entity, such as the health department, to gain access to harm reduction supplies while building cross-community collaboration for learning and disseminating information. Further, this collaboration could support ongoing best practices sharing while working toward innovative and novel ways to address the opioid epidemic in their respective communities.

A practitioner should also implement the program in high schools at the beginning of the academic school year and conclude by the end of the same school year, allowing ample time and a reduced attrition rate for the follow-up evaluation. It is also recommended that a peer-to-peer education model be utilized to scale the program. This model is based on educating and empowering certain students who would serve as subject matter experts to share the harm reduction education and resources with their peers. Finally, enabling high school students access to harm reduction tools such as naloxone and fentanyl testing strips through certain outlets, such as the nurse’s office or from an administrator, is highly recommended as a way of preventing opioid overdoses both on and off campus.

Implications for Research

Future longitudinal and experimental studies are recommended to further understand the effectiveness and impact of harm reduction programming at high schools. These studies should collect demographic data, incorporate a control group, and utilize rigorous statistical tests with a larger sample size to quantify and measure the direction of the associations while accounting for potential biases.

Finally, incorporating qualitative methodology would allow more in-depth exploration of the students’ attitudes and perceived behavioral control relating to opioids and overdose prevention.

Supplemental Material

sj-docx-1-hpp-10.1177_15248399261460441 – Supplemental material for Fentanyl Overdose Harm Reduction Intervention: A Pretest-Posttest Study Among High School Students in Southern California

Supplemental material, sj-docx-1-hpp-10.1177_15248399261460441 for Fentanyl Overdose Harm Reduction Intervention: A Pretest-Posttest Study Among High School Students in Southern California by Neeraj Wadhwa, Anna Nelson, Daniel Handysides and Diadrey-Anne Sealy in Health Promotion Practice

Footnotes

Acknowledgements

A Special thanks to Dr. Siddarth Puri, Medical Director, County of San Luis Obispo and the leadership team at Los Angeles County Department of Public Health, including Dr. Brian Hurley and Dr. Kevin Burns, for their invaluable guidance and organizational support.

ORCID iD

Neeraj Wadhwa

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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