JOURNAL OF ADOLESCENT HEALTH 2004;34:344 –351
INTERNATIONAL ARTICLE
Knowledge of Sleep in Italian High School Students:
Pilot-test of a School-based Sleep
Educational Program
FLAVIA CORTESI, M.D., FLAVIA GIANNOTTI, M.D., TERESA SEBASTIANI, M.D.,
OLIVIERO BRUNI, M.D., AND SALVATORE OTTAVIANO, M.D.
Purpose: To evaluate knowledge about sleep and the
effect of a sleep educational program on a group of
Italian adolescents.
Methods: The program consisted of a 2-hour interactive
sleep educational course. To assess students’ sleep pat-
terns and habits, the School Sleep Habits Survey was
completed by 540 students, aged 17 to 19 years, who were
attending three secondary public schools. Students were
randomly assigned to the control and intervention group.
Only the latter participated in the educational program.
A pre-test evaluated baseline knowledge about sleep, a
post-test measured the gain in knowledge after the
course, and a 3-month follow-up test evaluated long-term
retention of information. Improvement in knowledge
was measured by increase in correct answers and com-
parisons of means between baseline and follow-up mean
scores. Control group completed only baseline and
3-month follow-up tests. Data were analyzed using re-
peated measures analysis of variance, Cochran Q, and
McNemar tests.
Results: Paired data were available for 425 students.
Results showed unhealthy sleeping habits in 34% of
students associated with high level of subjective sleepi-
ness, increased vulnerability to injuries, and poor day-
time functioning. Pre-test score showed a value of 4.2,
post-test of 8.6 and 3-month follow-up of 6.7. Low base-
line knowledge about sleep, an increase in knowledge,
From the Center of Pediatric Sleep Disorders, Department of Devel-
opmental Neurology and Psychiatry, University of Rome “La Sapienza,”
Rome, Italy
Address correspondence to: Flavia Cortesi, M.D., Center of Pediatric
Sleep Disorders, Department of Developmental Neurology and Psychi-
atry, University of Rome “La Sapienza,” via dei Sabelli, 108 - 00185
Rome, Italy. E-mail: flavia.cortesi@uniroma1.it
Manuscript accepted July 3, 2003.
1054-139X/04/$–see front matter
doi:10.1016/j.jadohealth.2003.07.003
with an average of 50% gain in the percentage of correct
answers immediately after the course, with a good long-
term retention of information were found for the stu-
dents who received the intervention as compared with
control group.
Conclusion: Sleep educational programs for secondary
students are recommended to improve information about
sleep. © Society for Adolescent Medicine, 2004
KEY WORDS:
Adolescents
Educational program
Sleep
Italy
In adolescence, modifications in sleeping patterns
with chronological age have been well-documented
and have been related to greater social pressures, as
well as to normal ontogenetic trends [1– 4]. Several
studies have suggested that adolescents growing up,
despite an increasing physiological need of sleep,
tend to sleep less [1– 4].
Moreover, some studies pointed out the high
prevalence of sleep problems and irregular sleep
habits in this age group [5– 8]. The consequences of
chronic insufficient sleep are numerous: daytime
sleepiness, mood and behavioral problems, negative
effects on daytime functions such as poor school
achievement, greater risk of severe injuries, and
increased vulnerability to psychoactive substance
abuse [9 –13].
Recent studies showed associations between irreg-
ular sleep patterns and elevated levels of sleepiness
© Society for Adolescent Medicine, 2004
Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010
April 2004 SLEEP EDUCATIONAL PROGRAM 345

[14 –16]. In a study on the effects of regularizing

sleep/wake schedules on daytime sleepiness in 36
college students, Manber et al [14] pointed out that
subjects with regular sleep/wake schedules, when
getting enough sleep, reported greater and lasting
improvement in alertness than subjects with a good
sleep efficiency but an irregular sleep schedule.
Link and Ancoli-Israel [15] found that students
reporting higher grade point averages slept more
and complained less of daytime sleepiness than
students with poor school achievement. They sug-
gested that getting enough sleep and maintaining
more consistent sleep schedules determine the abili-
ties to be more alert and pay more attention during Figure 1. Research Design.
lessons at school and, therefore, to obtain better
school performance. Wolfson and Carskadon [16]
found, also, that high school students with inade-
Despite the knowledge that sleep plays an impor-
quate sleep and irregular sleeping habits demon-
tant role in adolescence, it has received little atten-
strated daytime behavior and emotional problems.
tion from health educators.
More recently, Trockel et al [17], analyzing the effect
An educational program, known as “crash in bed,
of several health related variables on academic per-
instead,” to educate adolescents about the impor-
formance among first year college students, found
tance of sleep, sleeping habits, and specific sleep
that poor sleeping habits were strongly associated
disorders that might affect them, was developed by
with low grade point average.
Pack and James [unpublished data, 1996]. The aim of
Although the importance of sleep problems and
this educational program was to increase knowledge
healthy sleeping habits in adolescence has been dem-
of sleep, sleepiness, and drowsy driving in an ado-
onstrated in other countries, this topic has not re-
lescent population. In a community-based study
ceived adequate interest in Italy. In previous re-
carried out with high school students aged 13 to 17
search [18] on sleep habits and problems on a
years, James pointed out that this program can
representative sample of 6632 Italian high school
improve the knowledge of sleep, sleepiness, and the
students aged 14 to 19 years, we found that about
dangers of drowsy driving in this age group [28].
19% of them showed an irregular sleep/wake sched-
More recently a pilot-test study on 27 students dem-
ule with a difference of more than 3 hours between
onstrated a positive effect of a middle school-based
bedtime and risetime on school and non-school days.
sleep educational program on adolescent sleep hab-
This sleep/wake schedule irregularity increased
its. Authors noted, in particular, “increased school-
with age and was associated with poor sleep, higher
night total sleep, earlier weekend bedtimes, greater
level of drowsiness, and tendencies to fall asleep
school-weekend night bedtime regularity, and de-
during lessons and to report more accidents.
creased weekend daytime sleepiness” after the edu-
In spite of the importance of sleeping habits in this
cational program [29].
age group, there is a lack of data on sleep knowledge
The purpose of our study was to evaluate the
in adolescence. In a recent survey carried out on 1378
knowledge of sleep among Italian high school stu-
students aged 13 to 17 years, Grunstein and Grun-
dents, to estimate the effectiveness of a 2-hour sleep
stein [19] pointed out that knowledge of sleep and
educational program, already tested in U.S. adoles-
driving in adolescence is poor.
cents, and to examine the attitudes of students to-
Recent studies pointed out the importance of these
wards this educational intervention.
educational programs in increasing knowledge of
healthy behavior in teenagers. In particular, studies
on knowledge and attitudes toward sex education, Methods
HIV and pregnancy prevention, tobacco and alcohol
abuse, eating habits, organ donation, diabetes melli- Research Design
tus treatment, and asthma prevention pointed to the The research design is summarized in Figure 1. A
effectiveness of school health educational programs baseline evaluation of sleeping habits and sleep
in adolescence [20 –27]. knowledge was conducted in all classes. On the day
346 CORTESI ET AL
of the program, after the baseline evaluation, the
classes were randomly assigned to a control or an
intervention group and only the latter group partic-
ipated in the 2-hour interactive sleep educational
program. Immediately after the end of the course,
another identical questionnaire evaluating sleep
knowledge (post-test) was filled out only by students
of the intervention group. Furthermore, a separate
comment form collected students’ evaluations and
suggestions about the educational program.
To estimate retention of information, 3 months
later, students in both control and intervention
groups completed an identical questionnaire on
sleep knowledge.
To control the effects of exposure to events that
may be responsible of the gain in sleep knowledge,
such as other educational sources (i.e. television,
news, magazines, or self-education on the subject
prompted by exposure to the baseline question-
naire), we also carried out a 3-month follow-up
survey in the control group.
All data were collected in the classrooms by staff
members trained in data collecting using self-admin-
istered questionnaires.
Participants
In the academic year 1999 –2000, three secondary
public schools in the urban area of Rome were
included in the study. These school districts were
chosen taking into consideration the heterogeneous
population in terms of socio-economic status and
because the head teachers agreed to participate in the
study. All the students aged 17 to 19 years who were
attending 25 classes in these schools, took part in the
study. For students aged 17 to 18 years, parental
consent forms were distributed by project staff mem-
bers, who requested that students bring the forms
back with a parental signature.
The study protocol was reviewed and approved
by the Institutional Review Boards of the Depart-
ment of Developmental Neurology and Psychiatry,
the Faculty of Medicine of the University of Rome
“La Sapienza,” and the Italian Ministry of Public
Education.
Measures
Sleep educational program. The sleep educational
program used in this study was the Italian transla-
tion of the “crash in bed, instead” by James and Pack
[unpublished data, 1996]. It consisted of a 2-hour
JOURNAL OF ADOLESCENT HEALTH Vol. 34, No. 4
course during lesson time conducted by a sleep
professional, who using a set of 30 slides, explained
sleep patterns and problems, also involving students
in the discussion. The main topics covered were:
functions of sleep, sleep architecture, sleep need,
propensity to sleep, sleep deprivation and sleep debt,
sleepiness and sleep problems, the additive effect of
alcohol and sleep deprivation, and the danger of
drowsy driving.
The aim of the program was to provide accurate
information about sleep, sleep deprivation, and the
negative effect of sleep debt on daytime functions.
Questionnaires. Before the course, to assess stu-
dents’ sleep patterns and to check if their sleeping
habits were similar to those of the national represen-
tative sample, all students enrolled in this study
filled out the Italian version of the School Sleep Habits
Survey by Carskadon et al [30]. This questionnaire is
a comprehensive instrument including items about
sleeping habits, such as habitual bedtime and rise-
time, sleep duration on weekdays and on weekends,
sleepiness, sleep problems, the occurrence of injuries,
and self-rated school achievement.
To evaluate students’ sleep baseline knowledge,
we used the Italian translation of a sleep knowledge
questionnaire [28], consisting of 10 questions (avail-
able from the authors). Nearly all questions were
multiple choice. Cronbach alpha in our sample was
.48. The relative low Cronbach alpha might be owing
to a poor baseline knowledge that might determine
random responses. Sleep professionals evaluated the
questionnaires. Regarding the sleep knowledge
questionnaire, we coded correct answers as “1” and
incorrect answers as “0”; therefore a total score was
obtained by summing up the correct answers.
Data Analysis
Separate data of weekday and weekend sleep vari-
ables for both boys and girls were presented as mean
and standard deviation (SD).
Socioeconomic status (SES) was computed as a
weighted composite score of maternal highest edu-
cational qualification, paternal highest educational
qualification, and occupation of the head of the
family.
The total mean score of sleep knowledge question-
naire was computed for both intervention and con-
trol group. Furthermore, for each question the per-
centage of students answering correctly was
calculated.
April 2004 SLEEP EDUCATIONAL PROGRAM 347

Unpaired Student’s t-test or Pearson Chi-square Table 1. Characteristics of Intervention and Control
were used to test for groups or gender differences as Groups
appropriate. Pearson product moment correlations Intervention Group Control Group
were used to test relationships among sleep knowl- 225 Students 200 students
edge scores (baseline and follow-ups scores) and Grade 11 (%) 54 55
SES, grade point average and sleep variables (sleep Grade 12 (%) 46 45
duration, habitual bedtime and wake-up time). Gender (% females) 55 55
Grade point average (%)
Effect of intervention, described by the change of
Mostly As and Bs 13 14
mean scores within students from baseline to after Mostly Bs and Cs 29 25
the intervention, was analyzed using one-way re- Mostly Cs and Ds 47 51
peated measures analysis of variance (rm-ANOVA), Mostly Ds and Fs 11 10
controlling for age and gender as potentially con- Intact families (%) 92 95
Father’s education (%)
founding variables. Before analysis, log-transforma-
University 5 6
tions were performed on variables to normalize High school 33 36
distribution. To reduce the likelihood of type 1 error, Less 62 58
Greenhouse-Geisser correction, which adjusts the Mother’s education (%)
numerator and denominator degrees of freedom in University 2.5 3
High school 35.5 33
repeated measures designs, was applied. For indi-
Less 62 64
vidual questions in the intervention group, the per- Occupation of head family (%)
centage of correct responses at baseline and the Professional 13 14
increase of correct answers at the two follow-up White collar 42 44
surveys were compared simultaneously using Coch- Blue collar 30 30
Unemployed 2 1
ran Q. For pairwise comparisons, McNemar test of
Retired 13 11
the two related variables was used.
The p level was set at ⬍ .05 for statistical signifi-
cance. All data were coded and computerized with not substantially different from the results re-
statistical analysis performed using STATISTICA 5.1 ported here.
package for Windows (StatSoft Inc., Tulsa, OK).
Sleep
Results Results of the School Sleep Habit Survey regarding
Participants The 540 teenagers involved in the weekday and weeknight sleeping habits are shown
study were assigned at random to the intervention on Table 2. Furthermore, a sleep schedule irregular-
group or the control group. Failure to complete the ity, considered as the difference between school and
questionnaire, inconsistencies of responses to vari- weekend bedtime and risetime greater than 3 hours,
ous questions including age and gender, and absence was found in 34% of students, with a significant
on the day of testing lowered the sample size. prevalence in males (29% females vs. 40% males; p ⬍
Therefore, the selected sample of 425 students .001). The presence of difficulties in falling asleep
(response rate 78.7%), equally distributed between was reported by 12% of students and multiple night-
control (110 females and 90 males; mean age 17.8 wakings by 10.6%. Moreover, students reported not
years, SD .8) and intervention group (124 females getting enough sleep, 21% of them rated themselves
and 101 males; mean age 18 years, SD .9) who as “poor sleepers” and 44% complained of subjective
received written parental consent to participate and sleepiness. The occurrence of one or more injuries in
completed the questionnaires (baseline and follow- the last 6 months was reported by 18.6% of subjects.
ups), formed the set of matched baseline and fol- Neither remarkable differences between genders nor
low-up responses reported in this article. differences between intervention and control groups
Characteristics of students in the intervention and were identified.
control groups are presented in Table 1.
Analysis of school-wide demographic data re-
vealed that the study sample was similar to the Baseline Survey
overall school population with regard to gender. Regarding sleep knowledge, Table 3 shows the per-
Results for the full sample of students, including centage of students answering correctly in the inter-
those who participated in only the baseline, were vention group at baseline and follow-ups.
348 CORTESI ET AL JOURNAL OF ADOLESCENT HEALTH Vol. 34, No. 4

Table 2. Means and SD of Sleep Variables

Sleep
Variables Intervention Group Means (Range and SD) Control Group Means (Range and SD)
Weekday All Boys Girls All Boys Girls
Bedtime* 10:40 pm 10:55 pm 10:25 pm 10:30 pm 10:40 pm 10:20 pm
(8 –1:30 pm, SD 94 min) (SD 60 min) (SD 50 min) (8:10 –1:10 pm, SD 80 min) (SD 60 min) (SD 45 min)
Risetime* 6:40 am 7:00 am 6:20 am 6:50 am 7:05 am 6:30 am
(5– 8 am, SD 50 min) (SD 54 min) (SD 37 min) (5:10 – 8 am, SD 45 min) (SD 50 min) (SD 30 min)
Sleep duration* 470 465 485 480 470 490
(330 – 600, SD 48 min) (SD 48) (SD 48) (350 – 610, SD 46) (SD 46) (SD 46)
Weekend All Boys Girls All Boys Girls
Bedtime* 01:30 am 02:00 am 01:0 am 01:40 am 02:10 am 01:10 am
(10 pm–5 am, SD 100 min) (SD 110 min) (SD 90 min) (10:20 pm–5 am, SD 90 min) (SD 100 min) (SD 90 min)
Risetime 10:15 am 10.20 am 10:10 am 10:20 am 10:30 am 10:10 am
(6:15 am–2.30 pm, SD 90 min) (SD 90 min) (SD 70 min) (6:30 am–2:15 pm, SD 80 min) (SD 80 min) (SD 70 min)
Sleep duration* 530 500 555 530 510 550
(210 –780, SD 101 min) (SD 106) (SD 90) (230 –750, SD 100) (SD 106) (SD 95)
* Boys vs. Girls: Unpaired Student’s t-test ⬍.001

No statistically significant gender difference was
found regarding the percentage of correct answers in
the surveys; as a result, males and females were
pooled together in the analyses. Before the pro-
gram, students had variable baseline knowledge,
with a percentage of correct answers ranging be-
tween 26% and 69%. At baseline, poor knowledge
regarded mainly questions about sleep duration
(items 1 and 2), sleepiness (item 6), sleep debt
(item 7), groups at risk for sleepiness (item 9). In
contrast, about one-half of the sample answered
questions 3, 4, 7, and 10 correctly; these questions
were, respectively, about sleep problems, sleep
propensity, sleep debt, and countermeasures
against sleepiness while driving. At baseline, the
percentage of correct answers of the intervention
group were not significantly different from those
of the control group.

Table 3. Intervention Group Percentage of Students Answering Correctly

Questions Baseline Post-test 3-Months Cochran Q Mc Nemar ␹2
1 sleep duration 29.78 89.33 55.56 Q ⫽ 173.69* Baseline vs. Post-test*
Baseline vs. 3 months*
2 REM sleep 32.89 84.44 61.33 Q ⫽ 144.68* Baseline vs. Post-test*
Baseline vs. 3 months*
3 sleep problems 48.89 77.78 49.78 Q ⫽ 64.04* Baseline vs. Post-test*
Baseline vs. 3 months NS
4 sleep propensity 67.56 95.56 72.89 Q ⫽ 62.12* Baseline vs. Post-test*
Baseline vs. 3 months NS
5 sleep need 42.67 92.44 75.56 Q ⫽ 141.04* Baseline vs. Post-test*
Baseline vs. 3 months*
6 sleepiness 29.33 79.11 41.33 Q ⫽ 183.01* Baseline vs. Post-test*
Baseline vs. 3 months NS
7 sleep debt 48.89 76.89 72.89 Q ⫽ 99.51* Baseline vs. Post-test*
Baseline vs. 3 months*
8 sleep debt ⫹ alcohol 31.11 93.78 91.11 Q ⫽ 255.98* Baseline vs. Post-test*
Baseline vs. 3 months NS
9 risk groups 30.22 89.78 84.89 Q ⫽ 238.89* Baseline vs. Post-test*
Baseline vs. 3 months*
10 countermeasures 47.11 78.67 76.89 Q ⫽ 119.32* Baseline vs. Post-test*
Baseline vs. 3 months*
* p ⬍ .001.
For questions 1–10 test statistics are Cochran Q for measuring changes in frequencies across time and McNemar to test the difference
between paired proportions.
NS ⫽ not significant.
April 2004
Figure 2. Intervention and Control Group: Percentage of Students Answering Correctly at Baseline and 3-Month Follow-up.
Post-test, and 3-Month Follow Up
We found significant differences among mean
scores, based on the sum of correct answers to
questions in the intervention group, of baseline value
(4.2), post-test value (8.6) and 3-month later test
value (6.7) (F(2.44) ⫽ 879.32, p ⬍ .001). Sheffé post-hoc
comparisons of means showed significant differ-
ences among all the three surveys. No significant
differences between mean scores of the baseline and
the 3-month later values in controls were found. In
particular, at the end of the course, students in the
intervention group demonstrated a gain in knowl-
edge reaching 74%–95% of correct answers. The
post-test showed a significant improvement in
knowledge for all the items considered, mainly about
sleep duration, sleep problems, sleep need, and
sleepiness.
Cochran Q test showed significant differences
among the percentage of correct answers at baseline,
post-test and 3-month later follow-up regarding all
10 items in the intervention group. Particularly,
McNemar Chi-square showed a significant retention
SLEEP EDUCATIONAL PROGRAM 349
of information after 3 months compared with base-
line regarding sleep duration, sleep need, sleep debt,
group at risk, and countermeasures against sleepi-
ness while driving (Table 3).
Figure 2 shows the percentages of correct answers
of the intervention and control groups at baseline
and 3-month follow-up. It is evident that the
3-month follow-up failed to show an increase in
sleep knowledge in controls. In addition, in both
groups, no significant correlations were found
among sleep knowledge scores and sleep variables,
such as sleep length, habitual bedtime and risetime,
SES, and grade point average.
Comments
Regarding students’ comments on the educational
program, 87% rated the effectiveness of the program
from “good” to “excellent,” 95% thought that it was
well-organized and well-presented, and over 90%
reported that the program was useful. About 70%
reported sleep need, sleep debt, and countermea-
350 CORTESI ET AL
sures against sleepiness as the most interesting topics
of the program, whereas sleep disorders, such as
sleep apnea and narcolepsy, were considered the
least interesting part of the program by 80% of
students.
Discussion
The positive effect of school-based health education
programs has already been documented for some
other health-related behaviors [20 –27], however, to
our knowledge, no other studies on the effect of sleep
educational courses in high school students were
carried out in Italy. Therefore, this pilot-test study is
the first sleep educational course conducted in Italy,
which evaluated also the affect of the program on the
students’ knowledge about sleep.
The results of the School Sleep Habits Survey, which
evaluated sleep patterns and problems in our sam-
ple, are consistent with our previous national survey
on Italian high school students [18] and several
studies carried out in other countries [14 –17]. It
confirmed the high prevalence of sleep problems and
irregular school nights to weekend sleep/wake
schedules also in this group of students.
This high incidence of irregular sleeping habits,
which in this sample was found in 34% of students
with sleepiness, greater risk of injuries, and poor
academic performance, has previously been reported
by several studies carried out in other countries
[11–14,16]. In the representative sample of Italian
high school students, about 37% of adolescents older
than age 17 years reported sleep irregularity, which
was more prevalent in boys than in girls [18]. Simi-
larly, in the present study we found a significant
prevalence of poor sleeping habits in boys.
To prevent these problems, it might be important
to give students accurate information about sleep
and the consequences of poor sleep. Consistent with
the findings of the community-based study carried
out by James and Lauer in the United States, the
results of this study pointed out that this classroom
sleep educational program significantly improved
knowledge about sleep [28].
As already reported by Grunstein and Grunstein
[19], Australian adolescents also showed poor
knowledge about sleep. At baseline, less than 40% of
students answered correctly questions about sleep,
sleep duration, sleepiness, sleep debt, and groups at
risk for sleepiness.
At the end of the course, their knowledge im-
proved with a percentage of correct answers of about
JOURNAL OF ADOLESCENT HEALTH Vol. 34, No. 4
90%. Therefore, students showed an average 50%
gain in the percentage of correct answers after the
course and good retention of information as shown
by the 3-month follow-up survey. It must be noted
that the long-term retention of information about
sleep relates to mainly sleep need and sleep debt,
which can be considered as the most useful informa-
tion for improving healthy sleeping habits.
Limitations
These data have several limitations. Only three pub-
lic schools took part in the study and, although
similar to the overall school population, may not
reflect the general knowledge and attitude of Italian
students. However, results regarding their sleeping
patterns and habits were similar to those reported by
the national sample. We decided to involve only
older adolescents in our pilot-test study because, on
the basis of the literature and our previous study,
they represent the age span more at risk for un-
healthy sleeping habits and sleepiness problems. At
this age in Italy, students start driving, therefore, the
consequences of these poor sleeping habits might be
more dangerous.
Another limitation of this study regards the in-
strument we used to determine the level of sleep
knowledge, which in our sample showed a relative
low reliability, probably owing to random answers.
However, because it is expected that students have
no prior knowledge of this subject matter, the ran-
dom responses verified our expectations. Further-
more, it might be possible that the gain in long-term
knowledge about sleep observed in our study might
be owing not only to the effect of the educational
course but also for other reasons. However, the short
duration of this study limited the affect of other
educational resources (i.e. television, magazines) on
participants and the lack of gain in knowledge in
controls suggested the positive effect of the educa-
tional course.
It might also be possible that the tests, rather than
the course, may have played an important role in
increasing knowledge. It must be specified that the
tests were not reviewed with the students and the
correct answers were never revealed to them.
In the future, further studies on larger adolescent
populations with a wider age span are needed to
verify the long-term affect of a better sleep knowl-
edge on adolescent lifestyle. Although Rossi de-
scribed the positive effect of a sleep educational
program not only in increasing adolescents’ sleep
knowledge, but also in improving their sleep pat-
April 2004
terns, it remains possible that the increase in knowl-
edge might not necessarily improve adolescents’
sleeping habits [30]. Therefore, future studies are
needed to verify not only the long-term retention of
information about sleep, but also its effect on adoles-
cents’ sleeping habits.
Conclusion
In conclusion, our results showed the students’ pos-
itive attitudes toward school sleep educational
courses, a low baseline knowledge, and a good
ability to learn. A 2-hour course describing sleep,
sleepiness, and the risk of poor sleep on daytime
functioning can improve the knowledge level. Be-
cause school represents the ideal place to promote
prevention, results of our pilot-test study supports
educational sleep programs for secondary students.
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