Priority: Alcohol Use/Binge Drinking (B)

Transcription

1 111 Priority: (B) Key Data Findings Regarding alcohol related issues such as drinking and driving, alcohol abuse by persons age 21+, and alcohol use among those under age 21, adults in the St. Cloud Metro area have a higher degree of concern about these issues than adults in the greater Stearns County area. Stearns County adult males are more likely to binge drink than Stearns County adult females. Males were five times more likely to have binge drank 7 or more times within the past 30 day period than females. One third of all Stearns County adults drank at least one alcoholic beverage on three or more days in the past 30 days. Within the past 30 days, 6.5% of Stearns County adults have gotten in their car and driven when they thought that they perhaps had too much to drink. The age category to most likely drive when they have had too much to drink is in the category of age Males are also more likely to drink and drive than females. Between 2007 and 2010, alcohol use by sixth graders increased, yet it decreased for the 9 th and 12 th graders. More Stearns County sixth graders reported drinking in the last 30 days compared to their peers across the state. 8% of Stearns County ninth graders in 2010 reported binge drinking behaviors in the last two weeks. In 2010 in Stearns County, 12.5% of six graders; 7% of 9th graders and 6 % of 12th graders who reported drinking, identified that their first drink of alcohol took place at age 10 or younger. Stearns County youth access their alcohol from multiple places. Most frequently they get it from friends, family, or at parties, secondly they take it from home or other places, and least frequently they purchase it. 9 th graders take it from home more often than 12 th graders. All ages most frequently access their alcohol from friends or at parties. In 2010, 20% of Stearns County 12 th graders identified driving after using either alcohol or drugs. In 2010, 15% of 9th graders and over 30% (almost 1/3) of all 12th graders report having ridden with a friend who may have been impaired with alcohol or drugs. Thirty three percent (33%) of the males and 27% of the females at 12th grade report their parents would not care or would approve of their use of alcohol, as opposed to 10% of both males and females at the 9 th grade level. [need source Stearns County, MN, or nationwide students???] From 2008 through 2012, Stearns County had a steady increase of fatal car crashes with blood alcohol level above the legal limit. From 2008 through 2012, Stearns County has consistently had over 400 gross misdemeanor DWIs filed in court. In 2012, Stearns County spent over a half a million dollars for detox services at the detox center at the Central Minnesota Mental Health Center.

2 112 Stearns County CHIP, Community Health Improvement Plan Data GRAPH B1: ADULT ALCOHOL RELATED CONCERNS Percent Frequency In Stearns County, Alcohol Related Concerns identified by adults as moderate or serious problems (Source: Central Minnesota Community Health Survey, February 2013) Stearns County all Greater Stearns St. Cloud Metro 10 0 Drinking and Driving Alcohol Abuse 21+ Alcohol Abuse 21 and less This graph shows where alcohol related concerns ranked in priority. While drinking and driving ranked in the top 10 of the overall concerns for all of Stearns County, this concern ranked higher in those who live in the St. Cloud area versus those in the greater parts of Stearns County. Also, concerns related to alcohol abuse for Residents again were listed as a greater concern in the metro parts of Stearns than in the Rural communities.

3 113 GRAPH B2: ADULT FEMALE BINGE DRINKING Considering all types of alcoholic beverages, how many times during the past 30 days did Stearns County adult females have 4 or more drinks on one occasion? (Considered binge drinking) (Source: Central Minnesota Community Health Survey, February 2013) 100.0% 80.0% 60.0% 63.3% 40.0% 20.0% 0.0% 33.7% 2.0% 1.0% 0 times 1 3 times 4 6 times 7+ times Four or more drinks on one occasion fits within the definition of binge drinking for females. While not a large difference between males and females when it comes to binge drinking, we do see an approximately 10 percentage point difference. This 10 percentage points gets split evenly between the other three categories, making males much more likely to binge drink than females. Of those females who did report binge drinking not quite 40% report doing this one (1) time or more per month. Only 1% reported more than 7 times per month compared to the males of which over 5% reported this behavior.

4 114 Stearns County CHIP, Community Health Improvement Plan GRAPH B3: ADULT BINGE DRINKING 80.0% Considering all types of alcoholic beverages, how many times during the past 30 days did Stearns County adult males have 5 or more drinks on one occasion? (Source: Central Minnesota Community Health Survey, February 2013) 60.0% 53.9% 40.0% 36.0% 20.0% 4.6% 5.5% 0.0% 0 times 1 3 times 4 6 times 7+ times 5 or more drinks in the last 30 days fits within the definition of binge drinking for men. According to the survey, almost ½ (46.1%) of the respondents indicated they identified at least once during the past 30 days they had engaged in this risk factor. Over 10% of the respondents report having participated in this behavior four (4) or more times with over ½ of those (5.5%) reporting seven (7) or more times in a month. This compares to 1% of women reporting binge drinking behaviors.

5 115 GRAPH B4: ADULT ANY ALCOHOL 80.0% During the past 30 days, on how many days did Stearns County adults have at least one drink of any alcoholic beverage? (Source: Central Minnesota Community Health Survey 2013) 68.4% 60.0% 40.0% 20.0% 0.0% 23.4% 6.5% 1.7% 1 2 days 3 4 days 5 6 days 7+ days The above graph outlines the number of days in the past 30 days respondents report having at least one drink. Of those who responded to this the majority (68.4%) reported only 1 2 days per month. However, almost 1/3 of the respondents (31.6%) report 3 or more days. While it is not known how many drinks this involves, we know from previous responses that several of the days likely involves binge drinking behaviors.

6 116 Stearns County CHIP, Community Health Improvement Plan GRAPH B5: ADULT DRINKING AND DRIVING During the past 30 days, how many times have Stearns County adults driven when they ve had perhaps too much to drink? (Source: Central Minnesota Community Health Survey, February 2013) 100.0% 93.5% 80.0% 60.0% 40.0% 20.0% 0.0% 3.8% 1.1% 1.6% 0 times 1 times 2 times 3+ times While any numbers in this category are not good for public health, and are cause for concern in the county, almost 94% of people do not believe they have driven when they have had too much to drink. Yet, this means that 6.5% have gotten into their cars and have driven while possibly intoxicated. Education and community norm is clear that this is not an acceptable behavior. More education will only go so far, and may help keep more and more people from getting behind the wheel but more still needs to be happening to prevent this high risk behavior from occurring.

7 117 GRAPH B6: DRINKING AND DRIVING BY AGE 100.0% 90.0% During the past 30 days, how many times have Stearns County adults driven when they ve had perhaps too much to drink broken down by age (Source: Central Minnesota Community Health Survey, February 2013) 3.4% 3.9% 4.5% 2.8% 0.5% 5.6% 80.0% 70.0% 92.1% 93.3% 93.9% 100.0% 3+ times 2 times 1 time 60.0% 0 times 50.0% When breaking drunk driving data down by age group, we see a very similar percentage of people who haven t driven drunk in the past 30 days up through 70 years old. Respondents above 70 years old reported to never do this. The breakdown within age groups is very different between the three age groups. We see the only age group with a population claiming to have driven drunk 3 or more times being 31 50, and almost 4% reported doing it that often.

8 118 Stearns County CHIP, Community Health Improvement Plan GRAPH B7: ADULT DRINKING AND DRIVING BY GENDER 100.0% 90.0% During the past 30 days, how many times have Stearns County adults driven when they've perhaps had too much to drink broken down by gender (Source: Central Minnesota Community Health Survey, February 2013) 2.8% 1.8% 1.9% 0.5% 0.3% 5.9% 93.5% 93.3% 3+ times 2 times 1 time 0 times 80.0% Male Female When looking at males and females in this topic, we see almost no difference between those who reported not drinking and driving at all. It s the breakdown in frequency between males and females that s interesting. Almost all females who responded did drive after having too much to drink one time in the past 30 days, where the largest percentage of males who reported driving while drunk, did so at least 3 times in the past 30 days.

9 119 GRAPH B8: YOUTH ALCOHOL USE WITH PAST 12 MONTHS Source: Minnesota Student Survey, 2007 & 2010 Data taken from the Minnesota Student Survey Data shows that the number of students reporting one or more drinks in the past 12 months decreased in both the 9 th and 12 th grade respondents but increased consistently in the 6 th grade respondents. This is in comparison to the Minnesota aggregated data where in each age group, there was a decrease in reported drinks in last 12 months.

10 120 Stearns County CHIP, Community Health Improvement Plan GRAPH B9: YOUTH ALCOHOL USE WITHIN PAST 30 DAYS Source: Minnesota Student Survey, These data show a decrease in the number of Stearns County youth reporting one or more drinks in the past 30 days consistently except in the 6 th grade respondents from 2007 to 2010 reporting where it increased from 3.5 % to 5 %. This is in comparison to the data at the state level in which a consistent decrease was noted across all ages. It also should be noted that the Stearns County 6 th grade data is higher in comparison to the state; 5% compared to 3.5% respectively. More 6 th Graders in Stearns County in 2010 reported drinking in the last 30 days compared to their peers across the state. Other grade data comparatively between Stearns and the State in other ages (9 th and 12 th grades) is relatively close with 9 th graders slightly higher than the state.

11 121 GRAPH B10: YOUTH BINGE DRINKING Source: Minnesota Student Survey, These data show a consist reduction in 9 th and 12 th graders reporting 5 or more drinks (the definition of binge drinking for males) in the last two week as well as a lower than the state average percent. However, it still shows that 8% of 9 th graders in 2010 reported binge drinking behaviors in the last two weeks a risk factor for chronic drinking in the future.

12 122 Stearns County CHIP, Community Health Improvement Plan GRAPH B11: YOUTH AGE OF FIRST DRINK, 2007 & 2010 Source: Minnesota Student Survey, 2007 & 2010 These data outline the age of first drink not including instances that may be related to a religious ceremony. These data show that in % of six graders; 7% of 9 th graders and 6 % of 12 th graders who reported drinking, identified that their first drink of alcohol took place at age 10 or younger. This is higher than the state percent for each of these grades except the 9 th graders. For Stearns County youth, each age group decreased from 2007 to 2010 except the 6 th graders which increased. Similar changes were noted in Stearns County youth at the other age levels identified. These data show a trend in younger aged children engaging in using alcohol.

13 123 GRAPH B12: YOUTH ACCESS TO ALCOHOL, 2013 Sources of alcohol for Stearns County 9th Graders by gender (Source: Minnesota Student Survey, 2013) 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 1% 2% 6% 0% 5% 4% 1% 0% 31% 39% 13% 21% 10% 20% 18% 22% 31% 40% 37% 22% 14% 8% 4% 1% 9th Grade 2013 Male 9th Grade 2013 Female When students were asked where they received alcohol from if they had consumed it within the last 30 days, the students could give multiple responses, and this graph shows the percentage in each category broken down between males and females (which is the default reporting method of the Student Survey results). These numbers across the board are significantly lower than when this same question was asked over the past 9 years of surveying, specifically those students who reported getting it from friends of theirs, down 20 percentage points in both males and females from 2007 (51% and 60% respectively).

14 124 Stearns County CHIP, Community Health Improvement Plan GRAPH B13: YOUTH NINTH GRADE ACCESS TO ALCOHOL, Source: Minnesota Student Survey, Graphs B13 and B14 show the percent of students in 9 th and 12 th grade who identified how they obtained alcohol if they reported using in the past 30 days. Slight differences between male and female can be seen but even more interesting is that in most instances, the alcohol was obtained by someone else for the youth; particularly the older the student got. More 9 th Graders reported taking the alcohol from the home setting than their counter parts at grade 12. However, more 12 th grade students reported getting it from friends than did their peers at 9 th grade.

15 125 GRAPH B14: YOUTH TWELFTH GRADE ACCESS TO ALCOHOL, Source: Minnesota Student Survey, Graphs B13 and B14 show the percent of students in 9 th and 12 th grade who identified how they obtained alcohol if they reported using in the past 30 days. Slight differences between male and female can be seen but even more interesting is that in most instances, the alcohol was obtained by someone else for the youth; particularly the older the student got. More 9 th Graders reported taking the alcohol from the home setting than their counter parts at grade 12. However, more 12 th grade students reported getting it from friends than did their peers at 9 th grade.

16 126 Stearns County CHIP, Community Health Improvement Plan GRAPH B15: YOUTH DRINKING AND DRIVING Source: Minnesota Student Survey, This graph outlines how many times youth in 9 th and 12 th grade have driven a vehicle after they used alcohol or drugs. Stearns County is about at the state average for both age groups. Each year, the numbers have decreased but there are still over 20% of 12 th graders identifying driving after using either alcohol or drugs.

17 127 GRAPH B16: YOUTH RIDING WITH SOMEONE WHO WAS DRIVING AFTER DRINKING Source: Minnesota Student Survey, Graph B16 is different than Graph B15. It identifies the risk factor of riding with a friend after use. In all cases, Stearns County youth are at about the state average with decreases consistently each year. However, it is still concerning that around 15% of 9 th graders and over 30% (almost 1/3) of all 12 th graders report having ridden with a friend who may have been impaired with alcohol or drugs.

18 128 Stearns County CHIP, Community Health Improvement Plan GRAPH B17: YOUTH PARENTS PERCEPTION OF YOUTH SUBSTANCE USE How do you think your parents/guardian would feel if you used alcohol, marijuana or illegal drugs Male 6-Fe 9-Male 9-Fe 12-Male 12-Fe Approve/Not Care-Alcohol Approve/Not Care-Marijuana Approve/Not Care-Illegal drugs Source: [need source] Was this a survey of Stearns County, MN, or nationwide students This graph speaks to the youth s perception of parental concerns related to alcohol versus drug use. Consistently, youth feel parents would not approve of their use of illegal drugs with Marijuana following closely regardless of age. Yet, there is a drastic difference, particularly at 12 th grader, as it relates to alcohol use. Thirty three percent (33%) of the males and 27% of the females at 12 th grade report their parents would not care or would approve of their use of alcohol compared to 4% marijuana use for males and 6% females

19 129 GRAPH B18: ALL TRAFFIC CRASHES WITH BAC ABOVE LEGAL LIMIT Total Fatalities Total number of fatal traffic crashes in Stearns County with blood alcohol level above legal limit. (Source: MN Dept. of Public Safety MN Impaired Driving Facts, 2012) Total Fatal Traffic Crashes Driver had.08+ Alc This graph shows an increase from 2008 to 2010 in total fatal crashes with a leveling off in 2011 and A gradual increase from 1 to 4 where the driver had a.08 or more reading.

20 130 Stearns County CHIP, Community Health Improvement Plan GRAPH B19: ADULT FELONY AND GROSS MISDEMEANOR DWI Felony and Gross Misdemeanor DWI Stearns County adults (Source: MNJAD Court Filings data, ) Felony DWI Gross Misdemeanor DWI These data show the consistent number of felony and gross misdemeanor DWI s for Stearns County over the past 5 years with consistently gross misdemeanor DWI s over 400 per year. Gross misdemeanor DWI s are graduated by degree and depends on the number of previous offenses, level of alcohol in the blood and other factors. Felony DWI is based on previous incidents (3 or more in past 10 years) and previous convictions.

21 131 GRAPH B20: ADULT DETOX COSTS $600,000 $500,000 $400,000 $300,000 $200,000 $100,000 Stearns County detox services paid (Source: Stearns County Human Services Internal Report, ) $426,819 $417,574 $442,710 $500,467 $ These data show a consistent dollar amount being spent for the purposes of detox services that Stearns County is specifically responsible for. In 2012, over a half a million dollars were spent for detox services at the detox center at the Mental Health Center.

22 132 Stearns County CHIP, Community Health Improvement Plan Health Equity assessment Data around alcohol use has limited or no race, ethnicity, and sexual orientation or location data. None of these data reflect the percent of possible at risk populations such as homeless, LGBTQ, race; nor any related to rural compared to urban or education disparities. Any recommendations related to creating a Community Health Improvement Plan related to this topic would need to include gathering of aggregate data that is related to assessing and addressing at risk populations and their over representation related to this issue. Community feedback PUBLIC COMMENT Public Health Task Force comments Public comment during comment period FOCUS GROUP FEEDBACK Focus group identified contributing factors/sub issues Cultural acceptance family religion Rite of passage Early start (age) of drinking Financial stress o Cheap way to have fun o It s only fun if there is drinking Poverty Lack of education regarding the seriousness of drinking Drinking and Driving Using alcohol to self medicate (pain, mental health, get away ) Unemployment Home Foreclosures Ease of Access to Alcohol o All you can drink specials o Drinking games/beer Pong o Bars holding 18+ events College town

23 133 Lack of activities for year olds o No socially acceptable things to do other than drink Drinking to get drunk Lack of Social skills can lead toward drinking initiation, liquid confidence If addicted or desire alcohol and do not have any money, this can lead to shoplifting and perhaps even jail Focus group prioritization of contributing factors/sub issues Priority #1: Lack of education about seriousness of alcohol use. Priority #2: Cultural Acceptance, Rite of Passage (family, religious, societal, etc.) Priority #2: Poverty Priority #3: Drinking and Driving Priority #3: Using alcohol to self medicate (pain, mental health, get away ) Priority #3: Ease of Access to Alcohol Priority #4: Early age of first drink Priority #4: Drinking to get drunk Suggested action from community dialogue Education about the seriousness of alcohol use o What can colleges do? Model existing programming SCSU has significantly impacted their number over the past 10 years. lowering the cases of under age and binge drinking They use an environmental management model Their approach could be implemented on a broader scale They use a work sheet that they would be willing to share o Enforcement along with education is key Consequences are important. Education along with behavior modification assistance would be most helpful. Include consequences for the parents as well as educating them along with the youth (there is a generational gap between what parents learned and what we know today) o Develop county wide education campaign to Educate the older generation they have a harder time changing behaviors Work with employers to promote education programs at work Work with the media to get messages out Use message boards at gas stations; develop videos to be played in waiting areas Have education part of the license application/re application process o Alcohol Prevention education at high school and middle school levels Have parents participate, too Provide this education at student orientations o BAC level education Conduct blind study at downtown St. Cloud bars on Saturday night have patrons blow BACs and then have them be able to look up the info on a website the next day have the website have education Big discrepancy between what someone thinks their BAC is and what it actually is (they think it is much lower than what it really is)

24 134 Stearns County CHIP, Community Health Improvement Plan o Educate parents that they are influencing their children Parents don t think their kids are listening or that they don t have an impact on their kids, but they do Cultural acceptance/people consider alcohol use an expected Rite of Passage o Education about the impacts of age of first drink o Challenge the belief of responsibly teaching children about drinking Notion that introducing kids to alcohol at an early age will help them drink responsibly is not true they are more likely to develop drinking problems if they are introduced to alcohol at an early age o Social host laws are not enforced equally only ones being cited are younger (college age) adults, not parents (Peggy is going to check on the data of this) o Everyone has to come to their own realization about the dangers of drinking multiple types and methods of education needs to be developed to reach people differently Poverty and Alcohol Use o We can reach persons in poverty by providing education to persons who access Public Assistance programs or at Food Shelves. Education could be shown in waiting areas (i.e., WIC waiting areas, DMV Licensing TV screens, etc. o Better agency coordination so the need for homeless individuals to use alcohol to get a place to sleep at night is not necessary or becomes not a viable option. Homelessness drinking in order to be able to have a bed to sleep in detox Mental health o Education messaging for non English speaking persons The immigrant population listens to the radio create ads regarding the dangers and resources Work with the faith communities Catholic and Lutheran Teach in the schools Similarities to national, state, and other local planning processes HEALTHY PEOPLE 2020 Objectives related to Substance Use: Reduce the proportion of adolescents who report that they rode, during the previous 30 days, with a driver who had been drinking alcohol. Increase the proportion of adolescents never using substances. Increase the proportion of adolescents who disapprove of substance abuse. Increase the proportion of adolescents who perceive great risk associated with substance abuse. Reduce the proportion of persons engaging in binge drinking of alcoholic beverages. Reduce the proportion of adults who drank excessively in the previous 30 days. Decrease the rate of alcohol impaired driving (.08+ blood alcohol content) fatalities. Reduce the number of deaths attributable to alcohol.

25 135 HEALTHY MINNESOTA 2020 Objective: Reduce Binge Drinking CENTRACARE HEALTH COMMUNITY HEALTH NEEDS ASSESSMENT SUMMARY FOR HOSPITALS IN MELROSE, SAUK CENTRE, AND ST. CLOUD Community health issue identified as Mental Health Services. ST. CLOUD COMMUNITY PRIORITIES Support student success through a cradle to career approach for education and workforce development Enhance recreational amenities and natural resources Assist those facing poverty UNITED WAY OF CENTRAL MINNESOTA FOCUS AREAS Quality Out of School Time, Homelessness, Financial Stability ROBERT WOOD JOHNSON FOUNDATION COMMISSION TO BUILD A HEALTHIER AMERICA Fundamentally change how we revitalize neighborhoods; fully integrating health into community development. Stearns County Goals Using the Control and Influence Matrix, is an Area to Monitor. Past community health surveys have identified this as a priority and past community work has developed the following goals and strategies for consideration. Staff felt it was prudent to include this plan in the CHIP for future work. GOAL B1: INCREASE COMMUNITY AWARENESS AROUND HEALTH RISKS ASSOCIATED WITH ALCOHOL MISUSE.

26 136 Stearns County CHIP, Community Health Improvement Plan Objective B1.1: Assess physical, program and intellectual assets in the community. Suggested strategies a. Identify community, school and organization policies and programs currently in place related to addressing high risk alcohol use at all levels of prevention outcomes. b. Identify gaps in services. c. Identify all stakeholders to participate in a coalition to address alcohol use in Stearns County. Objective B1.2: Assess Community for Readiness. Suggested strategies a. Conduct a community readiness survey of community attitudes, levels of awareness, political will to change culture within the community. b. Analyze and interpret data. c. Disseminate information to the community on results. d. Develop work plan to address barriers. e. Increase community awareness through educational materials that highlight alcohol abuse/use data in Stearns County. f. Create/develop a community coalition that addresses issues related to risk behaviors around alcohol use in Stearns County. GOAL B2: REDUCE ALCOHOL USE BY YOUTH. Objective B2.1: Strengthen policies that will reduce youth access to alcohol. Suggested strategies a. Develop a youth leadership institute that is designed to address policy needs that reduce access to alcohol by youth and creates an environment where youth alcohol use is considered inappropriate and unacceptable. b. Implement policies aimed at creating an environment that eliminates youth access to alcohol. c. Research and implement social development skills in schools and community groups that address social and psychological factors that promote alcohol use. d. Implement policies that produce immediate consequences for youth who are sited for underage alcohol use.

27 137 e. Implement comprehensive and evidence based educational outreach to the community about the negative impacts of underage drinking. f. Engage parents and youth in developing at home policies that prevent youth access to alcohol. GOAL B3: REDUCE HIGH RISK ALCOHOL USE AND PROBLEMS ASSOCIATED WITH IT IN STEARNS COUNTY. Objective B3.1: Strengthen policy, system and environmental changes around driving while intoxicated. Suggested strategies a. Develop community coalitions and partnerships around the issue; including key players such as law enforcement, policy makers, community members and leaders. b. Disseminate information related to the issue; updating regularly. c. Support continued law enforcement training and enforcement around impaired driving. d. Institute regular check points by law enforcement. e. Develop processes that decrease the time between enforcement to adjudication. f. Increase the number of businesses using responsible beverage service including standard community training, policy and procedures. g. Implement policy changes related to zoning limiting alcohol outlets per capita or per square mile. h. Development and enforcement of policies that restrict access by youth such as compliance checks and registration. i. Institute policies that promote no alcohol parties. j. Research and implement evidence based programs that increase the knowledge of the community around risks of impaired driving. Measurements for success Measurements to consider tracking for this priority could include: Alcohol consumption patterns in youth Number of communities that adopt youth access policies Number of failed compliance checks by law enforcement Community opinion on youth and alcohol use Costs of detoxification services Number of youth ticketed for underage drinking

28 138 Stearns County CHIP, Community Health Improvement Plan Existing community assets and resources St. Cloud State University UChoose Program Community Neighborhood Collaboratives Partners in Hope Detox Services available within the county Potential partners Stearns County Human Services: Public Health Division, Community Supports Division, Community Corrections Division Minnesota Department of Health University of Minnesota Law Enforcement: Stearns County Sheriff, St. Cloud Police Department, other Stearns County community police departments Attorney s Offices: Stearns County Attorney s Office, St. Cloud Attorney s Office Stearns County Family Services Collaborative Universities and Colleges CentraCare Recovery Plus Stearns County school districts Community Neighborhood Collaboratives Boys and Girls Club of St. Cloud Central Minnesota Mental Health Center Detox MADD SADD Businesses Policy Makers Hospital Emergency Room Staff Physicians, Clinics Parents Students

29 139 Stearns County community health priority interconnections Refer also to these Stearns County community health priorities: Parenting Skills Mental Health Sexually Transmitted Infections Financial Stress