The present study is a randomized control trial to evaluate the efficacy and effectiveness of a school-based group prevention program (Fuerte) in San Francisco Unified School District Public Schools. In addition, the present study will also inform effective procedures for adaptations of the Fuerte program for Latinx newcomer immigrant children and other newcomer immigrant youth from non-Latin American countries. Fuerte targets newcomer Latinx immigrant youth (five years or less post arrival in the U.S.) who are at risk of experiencing traumatic stress. In particular, the Fuerte program focuses on increasing youth's mental health literacy, improving their social functioning, and identifying and connecting at-risk youth to specialty mental health services. The program will be implemented by mental health providers from various county community-based organizations, as well as from the SFUSD Wellness Centers, who already offer mental health services in SFUSD schools.

Fuerte is a new prevention program that is being introduced into the mental health system of California in order to reduce behavioral health disparities among Latinx newcomer youth. School- based, preventative programming has been proposed to be the frontline for reducing behavioral health access disparities among Latinx newcomer youth. However, very few evidence-based, selective prevention programs exist that have been tailored to ensure cultural relevance for newcomer Latinx youth with limited English proficiency and low health literacy in under-resourced school settings. Like many urban school districts in California, San Francisco Unified School District is an especially relevant setting for the Fuerte program. The district has a high number of newcomer adolescents, with an average of over 500 newcomer adolescents coming into the school district per year, most from Central America and Mexico.

The Fuerte program promotes interagency and community collaboration with the explicit goals of increasing mental health literacy and service access, as it has been largely enacted through a unique collaboration between the San Francisco Unified School District, the San Francisco Department of Public Health, and the Departments of Psychiatry and Pediatrics at the University of California, San Francisco due to their common need for prevention programming for this high-needs population. Much of the curriculum of Fuerte was developed and adapted through feedback from newcomer immigrant youth and their families, as well as providers of the program. In addition, Fuerte's system of care facilitates the transition to services for youth to improve their overall functioning, including behavioral health care, medical care, educational, legal, and other services.

The Fuerte program is designed for youth ages 12 to 18 in the San Francisco Unified School District (SFUSD). In order to optimize the exposure of large number of immigrant youth with limited healthcare providers, Fuerte is designed as a group format, each group comprised of 4-8 participants. This has the additional benefit of fostering a sense of community and normalizing the therapeutic process in a supportive group setting. Participants are recruited through referrals from educators and staff in the Wellness Initiative, health centers that are co-located in schools throughout the district. Group leaders are bilingual behavioral health providers from both the school district and community-based organizations with experience working with newcomer Latinx youth.

Students will be randomized into either the Fuerte program or a delayed waitlist control group (DWC) once they are identified. In addition, focus groups will be held at the end of each group with the group participants, as well as with the group, and other newcomer immigrant students. These focus groups will assess positive aspects of Fuerte and areas of improvement as well as procedures for the implementation, sustainment, and adaptation of the program.

Additionally, we will be holding focus groups with Arabic-speaking, Middle Eastern/North African youth and community providers to help inform the adaptation of the current Fuerte curriculum for these populations. Youth will participate in a one-time focus group in order to assess the mental health and immigration-related social needs of Arabic-speaking youth. The focus groups will be held at the school and a number of questions will be posed to the group based on a framework for cultural adaptations of evidence-based programs. Additionally, focus groups will be held with adults who provide services to Middle Eastern/North African families residing in San Francisco County. Focus group questions will focus on barriers and facilitators to treatment access to these youth, and get feedback on the current Fuerte curriculum to get considerations on adaptation. The themes collected from both the youth and community provider groups will inform a future adaptation of the Fuerte program for this particular population.

Fuerte RCT Inclusion Criteria:

• SFUSD High School student
• 12 to 20 years old
• Recent Immigrant to the US (within five years of enrollment date)
• Country of origin is from Spanish-speaking Latin American countries
• Participant is fluent in Spanish
• Has not completed a Fuerte group in the past

Fuerte Facilitator and Support Staff Focus Group Inclusion Criteria:

-Must have been a facilitator for a Fuerte group after 2019 or work for a school or community-based organization directly involved in implementing a Fuerte group after 2019.

Fuerte Adaptation for MENA/Arabic-Speaking Focus Groups Inclusion Criteria:

• SFUSD High School student
• 12 to 20 years old
• Recent Immigrant to the US (within five years of enrollment date)
• Country of origin is Middle East or North African country.
• Participant is fluent in Arabic.

MENA/Arabic-Speaking Provider Focus Group inclusion criteria:

-Works for an organization that provides behavioral health, educational, and/or social services to Arabic-speaking families in San Francisco county.

Fuerte RCT Exclusion Criteria:

-Youth participant does not speak Spanish as a primary language, i.e., their primary language is an indigenous dialect/language.

Fuerte Facilitator and Support Staff Focus Group Exclusion Criteria:

-Provider has not facilitated Fuerte after 2019 or does not work for a school or community-based organization directly involved in implementing a Fuerte group after 2019.

Fuerte Adaptation for MENA/Arabic-Speaking Focus Groups Exclusion Criteria:

• Youth participant's primary language is Spanish.
• Adult provider does not engage in providing services to MENA newcomer immigrant youth.