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Wexler L, White LA, O'Keefe VM, Rasmus S, Haroz EE, Cwik MF, Barlow A, Goklish N, Elliott E, Pearson CR, Allen J. Centering Community Strengths and Resisting Structural Racism to Prevent Youth Suicide: Learning from American Indian and Alaska Native Communities. Arch Suicide Res 2024:1-16. [PMID: 38240632 DOI: 10.1080/13811118.2023.2300321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
The persistence of extreme suicide disparities in American Indian and Alaska Native (AI/AN) youth signals a severe health inequity with distinct associations to a colonial experience of historical and on-going cultural, social, economic, and political oppression. To address this complex issue, we describe three AI/AN suicide prevention efforts that illustrate how strengths-based community interventions across the prevention spectrum can buffer suicide risk factors associated with structural racism. Developed and implemented in collaboration with tribal partners using participatory methods, the strategies include universal, selective, and indicated prevention elements. Their aim is to enhance systems within communities, institutions, and families by emphasizing supportive relationships, cultural values and practices, and community priorities and preferences. These efforts deploy collaborative, local approaches, that center on the importance of tribal sovereignty and self-determination, disrupting the unequal power distribution inherent in mainstream approaches to suicide prevention. The examples emphasize the centrality of Indigenous intellectual traditions in the co-creation of healthy developmental pathways for AI/AN young people. A central component across all three programs is a deep commitment to an interdependent or collective orientation, in contrast to an individual-based mental health suicide prevention model. This commitment offers novel directions for the entire field of suicide prevention and responds to calls for multilevel, community-driven public health strategies to address the complexity of suicide. Although our focus is on the social determinants of health in AI/AN communities, strategies to address the structural violence of racism as a risk factor in suicide have broad implications for all suicide prevention programming.
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Brent DA, Horowitz LM, Grupp-Phelan J, Bridge JA, Gibbons R, Chernick LS, Rea M, Cwik MF, Shenoi RP, Fein JA, Mahabee-Gittens EM, Patel SJ, Mistry RD, Duffy S, Melzer-Lange MD, Rogers A, Cohen DM, Keller A, Hickey RW, Page K, Casper TC, King CA. Prediction of Suicide Attempts and Suicide-Related Events Among Adolescents Seen in Emergency Departments. JAMA Netw Open 2023; 6:e2255986. [PMID: 36790810 PMCID: PMC9932829 DOI: 10.1001/jamanetworkopen.2022.55986] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
IMPORTANCE Screening adolescents in emergency departments (EDs) for suicidal risk is a recommended strategy for suicide prevention. Comparing screening measures on predictive validity could guide ED clinicians in choosing a screening tool. OBJECTIVE To compare the Ask Suicide-Screening Questions (ASQ) instrument with the Computerized Adaptive Screen for Suicidal Youth (CASSY) instrument for the prediction of suicidal behavior among adolescents seen in EDs, across demographic and clinical strata. DESIGN, SETTING, AND PARTICIPANTS The Emergency Department Study for Teens at Risk for Suicide is a prospective, random-series, multicenter cohort study that recruited adolescents, oversampled for those with psychiatric symptoms, who presented to the ED from July 24, 2017, through October 29, 2018, with a 3-month follow-up to assess the occurrence of suicidal behavior. The study included 14 pediatric ED members of the Pediatric Emergency Care Applied Research Network and 1 Indian Health Service ED. Statistical analysis was performed from May 2021 through January 2023. MAIN OUTCOMES AND MEASURES This study used a prediction model to assess outcomes. The primary outcome was suicide attempt (SA), and the secondary outcome was suicide-related visits to the ED or hospital within 3 months of baseline; both were assessed by an interviewer blinded to baseline information. The ASQ is a 4-item questionnaire that surveys suicidal ideation and lifetime SAs. A positive response or nonresponse on any item indicates suicidal risk. The CASSY is a computerized adaptive screening tool that always includes 3 ASQ items and a mean of 8 additional items. The CASSY's continuous outcome is the predicted probability of an SA. RESULTS Of 6513 adolescents available, 4050 were enrolled, 3965 completed baseline assessments, and 2740 (1705 girls [62.2%]; mean [SD] age at enrollment, 15.0 [1.7] years; 469 Black participants [17.1%], 678 Hispanic participants [24.7%], and 1618 White participants [59.1%]) completed both screenings and follow-ups. The ASQ and the CASSY showed a similar sensitivity (0.951 [95% CI, 0.918-0.984] vs 0.945 [95% CI, 0.910-0.980]), specificity (0.588 [95% CI, 0.569-0.607] vs 0.643 [95% CI, 0.625-0.662]), positive predictive value (0.127 [95% CI, 0.109-0.146] vs 0.144 [95% CI, 0.123-0.165]), and negative predictive value (both 0.995 [95% CI, 0.991-0.998], respectively). Area under the receiver operating characteristic curve findings were similar among patients with physical symptoms (ASQ, 0.88 [95% CI, 0.81-0.95] vs CASSY, 0.94 [95% CI, 0.91-0.96]). Among patients with psychiatric symptoms, the CASSY performed better than the ASQ (0.72 [95% CI, 0.68-0.77] vs 0.57 [95% CI, 0.55-0.59], respectively). CONCLUSIONS AND RELEVANCE This study suggests that both the ASQ and the CASSY are appropriate for universal screening of patients in pediatric EDs. For the small subset of patients with psychiatric symptoms, the CASSY shows greater predictive validity.
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Affiliation(s)
- David A. Brent
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- UPMC Western Psychiatric Hospital, Pittsburgh, Pennsylvania
| | - Lisa M. Horowitz
- Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland
| | | | - Jeffrey A. Bridge
- The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus
| | - Robert Gibbons
- Department of Medicine, The University of Chicago, Chicago, Illinois
- Department of Public Health Sciences (Biostatistics), The University of Chicago, Chicago, Illinois
- Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois
- Department of Comparative Human Development, The University of Chicago, Chicago, Illinois
| | - Lauren S. Chernick
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York
| | - Margaret Rea
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, California
| | - Mary F. Cwik
- Department of International Health, Social and Behavioral Interventions, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Rohit P. Shenoi
- Division of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Joel A. Fein
- Center for Violence Prevention, Children’s Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia
| | - E. Melinda Mahabee-Gittens
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shilpa J. Patel
- Division of Pediatric Emergency Medicine, Children’s National Hospital, Washington, DC
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Rakesh D. Mistry
- Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Susan Duffy
- Hasbro Children’s Hospital, Department of Pediatrics, Alpert Medical School at Brown University, Providence, Rhode Island
| | | | - Alexander Rogers
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Pediatrics, University of Michigan, Ann Arbor
| | - Daniel M. Cohen
- Division of Emergency Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Allison Keller
- Department of Pediatric Emergency Medicine, University of Utah and Primary Children’s Hospital, Salt Lake City
| | - Robert W. Hickey
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kent Page
- Department of Pediatrics, University of Utah, Salt Lake City
| | | | - Cheryl A. King
- Department of Psychiatry, Michigan Medicine, Ann Arbor
- Injury Prevention Center, The University of Michigan, Ann Arbor
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Ivanich JD, Weckstein J, Nestadt PS, Cwik MF, Walls M, Haroz EE, O’Keefe VM, Goklish N, Barlow A. Suicide and the opioid overdose crisis among American Indian and Alaska Natives: a storm on two fronts demanding swift action. Am J Drug Alcohol Abuse 2021; 47:527-534. [PMID: 34374620 PMCID: PMC9091944 DOI: 10.1080/00952990.2021.1955895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 07/06/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
The opioid crisis in the United States has received national attention and critical resources in the past decade. However, what has been overlooked is the effect the opioid crisis may be having on a three-decade suicide crisis among American Indian and Alaska Native (AIAN) communities that already have too few resources to address behavioral and mental health issues. This paper describes recent epidemiological trends associated with both opioid overdose and suicide at a national level for AIANs and the rest of the United States. We used data reported by the Centers for Disease Control and Prevention to report historical trends of opioid overdose and suicide for AIAN and non-AIAN populations. We found alarming and potentially correlated trends of opioid use and suicidality among AIAN populations. We highlight both current and future research that will be essential to understanding and addressing the unique intersection between opioid and suicide risk and protective factors to inform dual prevention and intervention efforts among AIAN populations with potential relevance to public health response among other at-risk populations.
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Affiliation(s)
- Jerreed D. Ivanich
- Centers for American Indian and Alaska Native Health, University of Colorado – Anschutz Medical Campus, Aurora, CO, USA
| | - Julia Weckstein
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul S. Nestadt
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mary F. Cwik
- Center for American Indian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Melissa Walls
- Center for American Indian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Emily E. Haroz
- Center for American Indian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Victoria M. O’Keefe
- Center for American Indian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Novalene Goklish
- Center for American Indian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Allison Barlow
- Center for American Indian Health, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Abstract
There are 600 diverse American Indian/Alaska Native communities that represent strong and resilient nations throughout Indian Country. However, a history of genocidal practices, cultural assaults, and continuing oppression contribute to high rates of mental health and substance use disorders. Underresourced mental health care and numerous barriers to services maintain these disparities. Indigenous community mental health workers hold local understandings of history, culture, and traditional views of health and wellness and may reduce barriers to care while promoting tribal health and economic self-determination and sovereignty. The combination of Native community mental health workers alongside a growing workforce of Indigenous mental health professionals may create an ideal system in which tribal communities are empowered to restore balance and overall wellness, aligning with Native worldviews and healing traditions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Abstract
The number of children and adolescents dying by suicide is increasing over time. Patterns for who is at risk are also changing, leading to a need to review clinical suicide prevention progress and identify limitations with existing practices and research that can help us further address this growing problem. This paper aims to synthesise the literature on paediatric suicide screening, risk assessment and treatment to inform clinical practice and suicide prevention efforts. Our review shows that universal screening is strongly recommended, feasible and acceptable, and that there are screening tools that have been validated with youth. However, screening may not accurately identify those at risk of dying due to the relative rarity of suicide death and the associated research and clinical challenges in studying such a rare event and predicting future behaviour. Similarly, while risk assessments have been developed and tested in some populations, there is limited research on their validity and challenges with their implementation. Several promising suicide-specific treatments have been developed for youth, but overall there is an insufficient number of randomised trials. Despite great need, the research evidence to support screening, risk assessment and treatment is still limited. As suicide rates increase for children and adolescents, continued research in all three domains is needed to reverse this trend.
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Affiliation(s)
- Mary F. Cwik
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA,Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Victoria M. O’Keefe
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Emily E. Haroz
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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O'Keefe VM, Haroz EE, Goklish N, Ivanich J, Cwik MF, Barlow A. Employing a sequential multiple assignment randomized trial (SMART) to evaluate the impact of brief risk and protective factor prevention interventions for American Indian Youth Suicide. BMC Public Health 2019; 19:1675. [PMID: 31830933 PMCID: PMC6909588 DOI: 10.1186/s12889-019-7996-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 11/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study is built on a long-standing research partnership between the Johns Hopkins Center for American Indian Health and the White Mountain Apache Tribe to identify effective interventions to prevent suicide and promote resilience among American Indian (AI) youth. The work is founded on a tribally-mandated, community-based suicide surveillance system with case management by local community mental health specialists (CMHSs) who strive to connect at-risk youth to treatment and brief, adjunctive interventions piloted in past research. METHODS Our primary aim is to evaluate which brief interventions, alone or in combination, have the greater effect on suicide ideation (primary outcome) and resilience (secondary outcome) among AI youth ages 10-24 ascertained for suicide-related behaviors by the tribal surveillance system. We are using a Sequential Multiple Assignment Randomized Trial with stratified assignment based on age and suicidal-behavior type, and randomizing N = 304 youth. Brief interventions are delivered by AI CMHSs, or by Elders with CMHS support, and include: 1) New Hope, an evidence-based intervention to reduce immediate suicide risk through safety planning, emotion regulation skills, and facilitated care connections; and 2) Elders' Resilience, a culturally-grounded intervention to promote resilience through connectedness, self-esteem and cultural identity/values. The control condition is Optimized Case Management, which all study participants receive. We hypothesize that youth who receive: a) New Hope vs. Optimized Case Management will have significant reductions in suicide ideation; b) Elders' Resilience vs. Optimized Case Management will have significant gains in resilience; c) New Hope followed by Elders' Resilience will have the largest improvements on suicide ideation and resilience; and d) Optimized Case Management will have the weakest effects of all groups. Our secondary aim will examine mediators and moderators of treatment effectiveness and sequencing. DISCUSSION Due to heterogeneity of suicide risk/protective factors among AI youth, not all youth require the same types of interventions. Generating evidence for what works, when it works, and for whom is paramount to AI youth suicide prevention efforts, where rates are currently high and resources are limited. Employing Native paraprofessionals is a means of task-shifting psychoeducation, culturally competent patient support and continuity of care. TRIAL REGISTRATION Clinical Trials NCT03543865, June 1, 2018.
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Affiliation(s)
- Victoria M O'Keefe
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Center for American Indian Health, 415 N. Washington Street, 4th Floor, Baltimore, MD, 21231, USA.
| | - Emily E Haroz
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Center for American Indian Health, 415 N. Washington Street, 4th Floor, Baltimore, MD, 21231, USA
| | - Novalene Goklish
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Center for American Indian Health, 415 N. Washington Street, 4th Floor, Baltimore, MD, 21231, USA
| | - Jerreed Ivanich
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Center for American Indian Health, 415 N. Washington Street, 4th Floor, Baltimore, MD, 21231, USA
| | | | - Mary F Cwik
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Center for American Indian Health, 415 N. Washington Street, 4th Floor, Baltimore, MD, 21231, USA
| | - Allison Barlow
- Johns Hopkins Bloomberg School of Public Health, Department of International Health, Center for American Indian Health, 415 N. Washington Street, 4th Floor, Baltimore, MD, 21231, USA
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Cwik MF, Rosenstock S, Tingey L, Goklish N, Larzelere F, Suttle R, Haroz E, Hill K, Craig M, Barlow A. Characteristics of Substance Abuse and Self-Injury among American Indian Adolescents Who Have Engaged in Binge Drinking. Am Indian Alsk Native Ment Health Res 2018; 25:1-19. [PMID: 29889946 DOI: 10.5820/aian.2502.2018.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Binge drinking appears to be a risk factor, facilitator, and method of suicidal and non-suicidal self-injury for some American Indian (AI) youth. We examined characteristics, patterns, and motivations for binge use among AI adolescents (N = 69; 10-19 years-old) who recently engaged in binge drinking. The majority used alcohol alone (53.7%) or a combination of alcohol and marijuana (31.3%) for their binge event. Gender differences emerged with boys more severely affected than girls. Forty-seven percent reported lifetime suicidal thoughts. This study represents one of the first in-depth examinations of substance use and related behaviors among AI adolescents who have engaged in recent binge use.
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Cwik MF, Rosenstock S, Tingey L, Redmond C, Goklish N, Larzelere-Hinton F, Barlow A. Exploration of Pathways to Binge Drinking Among American Indian Adolescents. Prev Sci 2018; 18:545-554. [PMID: 28130751 DOI: 10.1007/s11121-017-0752-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Binge drinking is a serious public health problem among American Indian adolescents, yet few theoretical models specific to this population and type of problematic drinking have been tested. The White Mountain Apache Tribe has begun surveillance of binge drinking and a related line of research to inform tailored prevention efforts. The goal of this paper is to use structural equation modeling to understand the relationships between different individual, family, peer, and cultural factors that predict or protect against binge drinking behavior among Apache adolescents ages 10-19 years old. A cross-sectional case-control study was completed with N = 68 Apache adolescents who required medical attention due to a recent binge event (past 90 days) and N = 55 controls with no lifetime history of binge drinking. The hypothesized model was estimated with Mplus using the WLSMV robust least squares estimator. In the final model, stressful life events were related to family functioning and peer relationships. In turn, family functioning affected peer relationships and adolescent impulsivity, which were both associated with greater risk of binge drinking. The path between peer relationships and having engaged in binge drinking was statistically significant for those expressing lower cultural identity, but not for those reporting higher cultural identity. Findings suggest preventive interventions should emphasize teaching coping skills to manage life stressors and handle impulsivity, strengthening families, and changing peer dynamics with social network-based approaches as well as social skill training. The model highlights the potentially important role of culture in strengthening positive peer relationships to reduce binge drinking risk.
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Affiliation(s)
- Mary F Cwik
- Center for American Indian Health, Johns Hopkins University, 415 North Washington Street, 4th Floor, Baltimore, MD, USA.
| | - Summer Rosenstock
- Center for American Indian Health, Johns Hopkins University, 415 North Washington Street, 4th Floor, Baltimore, MD, USA
| | - Lauren Tingey
- Center for American Indian Health, Johns Hopkins University, 415 North Washington Street, 4th Floor, Baltimore, MD, USA
| | | | - Novalene Goklish
- Center for American Indian Health, Johns Hopkins University, 415 North Washington Street, 4th Floor, Baltimore, MD, USA
| | - Francene Larzelere-Hinton
- Center for American Indian Health, Johns Hopkins University, 415 North Washington Street, 4th Floor, Baltimore, MD, USA
| | - Allison Barlow
- Center for American Indian Health, Johns Hopkins University, 415 North Washington Street, 4th Floor, Baltimore, MD, USA
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Cwik MF, Tingey L, Maschino A, Goklish N, Larzelere-Hinton F, Walkup J, Barlow A. Decreases in Suicide Deaths and Attempts Linked to the White Mountain Apache Suicide Surveillance and Prevention System, 2001-2012. Am J Public Health 2016; 106:2183-2189. [PMID: 27736202 DOI: 10.2105/ajph.2016.303453] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We evaluated the impact of a comprehensive, multitiered youth suicide prevention program among the White Mountain Apache of Arizona since its implementation in 2006. METHODS Using data from the tribally mandated Celebrating Life surveillance system, we compared the rates, numbers, and characteristics of suicide deaths and attempts from 2007 to 2012 with those from 2001 to 2006. RESULTS The overall Apache suicide death rates dropped from 40.0 to 24.7 per 100 000 (38.3% decrease), and the rate among those aged 15 to 24 years dropped from 128.5 to 99.0 per 100 000 (23.0% decrease). The annual number of attempts also dropped from 75 (in 2007) to 35 individuals (in 2012). National rates remained relatively stable during this time, at 10 to 13 per 100 000. CONCLUSIONS Although national rates remained stable or increased slightly, the overall Apache suicide death rates dropped following the suicide prevention program. The community surveillance system served a critical role in providing a foundation for prevention programming and evaluation.
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Affiliation(s)
- Mary F Cwik
- Mary F. Cwik, Lauren Tingey, Alexandra Maschino, Novalene Goklish, Francene Larzelere-Hinton, and Allison Barlow are with the Department of International Health, Center for American Indian Health, Johns Hopkins School of Public Health, Baltimore, MD. John Walkup is with the Division of Child and Adolescent Psychiatry, Weill Cornell Medical College, New York, NY
| | - Lauren Tingey
- Mary F. Cwik, Lauren Tingey, Alexandra Maschino, Novalene Goklish, Francene Larzelere-Hinton, and Allison Barlow are with the Department of International Health, Center for American Indian Health, Johns Hopkins School of Public Health, Baltimore, MD. John Walkup is with the Division of Child and Adolescent Psychiatry, Weill Cornell Medical College, New York, NY
| | - Alexandra Maschino
- Mary F. Cwik, Lauren Tingey, Alexandra Maschino, Novalene Goklish, Francene Larzelere-Hinton, and Allison Barlow are with the Department of International Health, Center for American Indian Health, Johns Hopkins School of Public Health, Baltimore, MD. John Walkup is with the Division of Child and Adolescent Psychiatry, Weill Cornell Medical College, New York, NY
| | - Novalene Goklish
- Mary F. Cwik, Lauren Tingey, Alexandra Maschino, Novalene Goklish, Francene Larzelere-Hinton, and Allison Barlow are with the Department of International Health, Center for American Indian Health, Johns Hopkins School of Public Health, Baltimore, MD. John Walkup is with the Division of Child and Adolescent Psychiatry, Weill Cornell Medical College, New York, NY
| | - Francene Larzelere-Hinton
- Mary F. Cwik, Lauren Tingey, Alexandra Maschino, Novalene Goklish, Francene Larzelere-Hinton, and Allison Barlow are with the Department of International Health, Center for American Indian Health, Johns Hopkins School of Public Health, Baltimore, MD. John Walkup is with the Division of Child and Adolescent Psychiatry, Weill Cornell Medical College, New York, NY
| | - John Walkup
- Mary F. Cwik, Lauren Tingey, Alexandra Maschino, Novalene Goklish, Francene Larzelere-Hinton, and Allison Barlow are with the Department of International Health, Center for American Indian Health, Johns Hopkins School of Public Health, Baltimore, MD. John Walkup is with the Division of Child and Adolescent Psychiatry, Weill Cornell Medical College, New York, NY
| | - Allison Barlow
- Mary F. Cwik, Lauren Tingey, Alexandra Maschino, Novalene Goklish, Francene Larzelere-Hinton, and Allison Barlow are with the Department of International Health, Center for American Indian Health, Johns Hopkins School of Public Health, Baltimore, MD. John Walkup is with the Division of Child and Adolescent Psychiatry, Weill Cornell Medical College, New York, NY
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Cwik MF, Tingey L, Wilkinson R, Goklish N, Larzelere-Hinton F, Barlow A. Suicide Prevention Gatekeeper Training: Can They Advance Prevention in Indian Country? Arch Suicide Res 2016; 20:402-11. [PMID: 26910205 DOI: 10.1080/13811118.2015.1033122] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
American Indian youth have the highest suicide rates in the United States; however, many do not use services and access barriers exist. This study was a cross-sectional evaluation of 6 gatekeeper trainings conducted on 1 reservation with N = 84 individuals. Analyses examined participant characteristics, impact on training objectives, and satisfaction. The majority of participants were American Indian and female (89.3%). Significant increases in knowledge (p < 0.001) and self-efficacy (p < 0.001) were observed post-test, as well as high satisfaction (3.53/5) and intent to use skills daily (36.4%) or monthly (66.3%). Lowest rated was how the training addressed cultural differences (2.93). While results support the promise of gatekeeper training, they identify a clear need for adaptation; specific implementation and research recommendations are discussed.
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Tingey L, Cwik MF, Rosenstock S, Goklish N, Larzelere-Hinton F, Lee A, Suttle R, Alchesay M, Massey K, Barlow A. Risk and protective factors for heavy binge alcohol use among American Indian adolescents utilizing emergency health services. Am J Drug Alcohol Abuse 2016; 42:715-725. [PMID: 27315008 DOI: 10.1080/00952990.2016.1181762] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND American Indian (AI) adolescents are disproportionately burdened by alcohol abuse and heavy binge use, often leading to problematic drinking in adulthood. However, many AI communities also have large proportions of adults who abstain from alcohol. OBJECTIVE To understand these concurrent and divergent patterns, we explored the relationship between risk and protective factors for heavy binge alcohol use among a reservation-based sample of AI adolescents. METHODS Factors at individual, peer, family, and cultural/community levels were examined using a cross-sectional case-control study design. Cases were adolescents with recent heavy binge alcohol use that resulted in necessary medical care. Controls had no lifetime history of heavy binge alcohol use. 68 cases and 55 controls were recruited from emergency health services visits. Participants were 50% male; average age 15.4 years old, range 10 to 19. Independent variables were explored using logistic regression; those statistically significant were combined into a larger multivariate model. RESULTS Exploratory analyses showed adolescents who were aggressive, impulsive, had deviant peers, poor family functioning or more people living at home were at greater risk for heavy binge alcohol use. Protective factors included attending school, family closeness, residential stability, social problem-solving skills, having traditional AI values and practices, and strong ethnic identity. Confirmatory analysis concluded that school attendance and residential stability reduce the probability of heavy binge alcohol use, even among those already at low risk. CONCLUSIONS Findings deepen the understanding of AI adolescent heavy binge alcohol use and inform adolescent intervention development fostering trajectories to low-risk drinking and abstinence.
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Affiliation(s)
- Lauren Tingey
- a Department of International Health , Johns Hopkins Center for American Indian Health , Baltimore , MD , USA
| | - Mary F Cwik
- a Department of International Health , Johns Hopkins Center for American Indian Health , Baltimore , MD , USA
| | - Summer Rosenstock
- a Department of International Health , Johns Hopkins Center for American Indian Health , Baltimore , MD , USA
| | - Novalene Goklish
- a Department of International Health , Johns Hopkins Center for American Indian Health , Baltimore , MD , USA
| | - Francene Larzelere-Hinton
- a Department of International Health , Johns Hopkins Center for American Indian Health , Baltimore , MD , USA
| | - Angelita Lee
- a Department of International Health , Johns Hopkins Center for American Indian Health , Baltimore , MD , USA
| | - Rosemarie Suttle
- a Department of International Health , Johns Hopkins Center for American Indian Health , Baltimore , MD , USA
| | - Melanie Alchesay
- a Department of International Health , Johns Hopkins Center for American Indian Health , Baltimore , MD , USA
| | - Kirk Massey
- a Department of International Health , Johns Hopkins Center for American Indian Health , Baltimore , MD , USA
| | - Allison Barlow
- a Department of International Health , Johns Hopkins Center for American Indian Health , Baltimore , MD , USA
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Cwik MF, Tingey L, Lee A, Suttle R, Lake K, Walkup JT, Barlow A. Development and piloting of a brief intervention for suicidal American Indian adolescents. Am Indian Alsk Native Ment Health Res 2016; 23:105-124. [PMID: 28562844 DOI: 10.5820/aian.2301.2016.105] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
American Indian (AI) adolescents have the highest suicide death and attempt rates of any U.S. group, yet few interventions have been developed or evaluated for this population. This paper presents the first adaptation of a brief evidence-based intervention for AI adolescents from one reservation who made a suicide attempt. We describe our community-driven approach to intervention development and a small pilot study (n = 13). Preliminary findings indicate reductions in adolescents' negative thinking, depression, and suicidal ideation, and an increase in psychological service utilization. Key innovations include delivery by AI paraprofessionals and potential to strengthen the continuum of care between emergency department and outpatient settings.
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Crosby Budinger M, Cwik MF, Riddle MA. Awareness, attitudes, and use of crisis hotlines among youth at-risk for suicide. Suicide Life Threat Behav 2015; 45:192-8. [PMID: 25093445 DOI: 10.1111/sltb.12112] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 05/30/2014] [Indexed: 01/18/2023]
Abstract
Crisis hotlines have been central to suicide prevention efforts; however, utilization among youth remains low. A sample of at-risk youth was surveyed about their awareness, utilization, and attitudes toward local and national crisis hotlines. Youth reported low rates of awareness and utilization, yet expressed a strong interest in phone hotlines (41% vs. 59% for new media categories combined). Youth reported stigma, but that help-seeking could be positively influenced by peers and adults in their support system. Implications include making crisis services available across several mediums and the importance of engaging trusted others in youth suicide awareness campaigns and prevention efforts.
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Tingey L, Cwik MF, Goklish N, Larzelere-Hinton F, Lee A, Suttle R, Walkup JT, Barlow A. Risk pathways for suicide among Native American adolescents. Qual Health Res 2014; 24:1518-1526. [PMID: 25168705 DOI: 10.1177/1049732314548688] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Native American (Native) adolescents have the highest suicide rates in the United States, yet no conceptual models describing risk factors specific to this population exist. We sought to further hone a Native-specific conceptual model developed from quantitative data with qualitative data collected from a longitudinal series of interviews with (N = 22) Native adolescents who had attempted suicide. Four levels of suicide risk emerged, detailing individual, family, community, and societal factors that affect youths' pathways to suicide, along with a variety of subthemes and constructs. Some themes parallel established models of suicide risk; however, others are unique to the experience of this sample, including the impact of overtaxed households and family composition, significant grief burden, contagion, and stigma surrounding treatment seeking. We suggest adaptations of existing themes and constructs in the model. We discuss practical implications for research and intervention development, along with strengths and limitations of the study.
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Affiliation(s)
| | - Mary F Cwik
- Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | - Angelita Lee
- Johns Hopkins University, Baltimore, Maryland, USA
| | | | - John T Walkup
- Weill Cornell Medical College, New York City, New York, USA
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Cwik MF, Barlow A, Goklish N, Larzelere-Hinton F, Tingey L, Craig M, Lupe R, Walkup J. Community-based surveillance and case management for suicide prevention: an American Indian tribally initiated system. Am J Public Health 2014; 104 Suppl 3:e18-23. [PMID: 24754618 DOI: 10.2105/ajph.2014.301872] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The National Strategy for Suicide Prevention highlights the importance of improving the timeliness, usefulness, and quality of national suicide surveillance systems, and expanding local capacity to collect relevant data. This article describes the background, methods, process data, and implications from the first-of-its-kind community-based surveillance system for suicidal and self-injurious behavior developed by the White Mountain Apache Tribe with assistance from Johns Hopkins University. The system enables local, detailed, and real-time data collection beyond clinical settings, with in-person follow-up to facilitate connections to care. Total reporting and the proportion of individuals seeking treatment have increased over time, suggesting that this innovative surveillance system is feasible, useful, and serves as a model for other communities and the field of suicide prevention.
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Affiliation(s)
- Mary F Cwik
- Mary F. Cwik, Allison Barlow, Novalene Goklish, Francene Larzelere-Hinton, and Lauren Tingey are with the Department of International Health, Center for American Indian Health, Johns Hopkins School of Public Health, Baltimore, MD. Mariddie Craig is with the White Mountain Apache Tribe's Native American Research Centers in Health, Whiteriver, AZ. Ronnie Lupe is with the White Mountain Apache Tribal Council, Whiteriver. John Walkup is with the Division of Child and Adolescent Psychiatry, Weill Cornell Medical College, New York, NY
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Cwik MF, Barlow A, Tingey L, Larzelere-Hinton F, Goklish N, Walkup JT. Nonsuicidal self-injury in an American Indian reservation community: results from the White Mountain Apache surveillance system, 2007-2008. J Am Acad Child Adolesc Psychiatry 2011; 50:860-9. [PMID: 21871368 DOI: 10.1016/j.jaac.2011.06.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 04/23/2011] [Accepted: 06/06/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To describe characteristics and correlates of nonsuicidal self-injury (NSSI) among the White Mountain Apache Tribe. NSSI has not been studied before in American Indian samples despite associated risks for suicide, which disproportionately affect American Indian youth. METHOD Apache case managers collected data through a tribally mandated surveillance system. Data from 2007 and 2008 (N = 182) were examined for rates, methods, precipitants, functions, past history of self-injury and service use, by age and gender. RESULTS The rate of NSSI among all ages was 600 in 100,000, with individuals 10 to 14 years old disproportionately affected at a rate of 3,000 in 100,000. More females (65%) reported NSSI, and cutting was the preferred method (98%) for both genders combined. Most frequently reported precipitants were peer pressure/copying, conflict with boy/girlfriend and "depression." A substantial proportion (22%) was intoxicated/high at the time. More reported the function of NSSI was to "effect internal state" (45%) than "effect circumstances" (15%). More than one-third (39%) received ED treatment and referrals for aftercare (36%). Of those referred, only 30% followed up with services. Most (79%) reported past NSSI; 30% reported past suicidal ideation and 25% attempts. CONCLUSIONS NSSI is a significant, largely unaddressed mental health problem among the White Mountain Apache Tribe and likely other reservation communities, especially as NSSI could serve as a precursor to suicide in this population. Interestingly, another self-destructive behavior, severe substance use, was reported to the surveillance system by Apaches and described in terms similar to NSSI, an important preliminary finding worth further exploration.
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Affiliation(s)
- Mary F Cwik
- Johns Hopkins Bloomberg School of Public Health, Center for American Indian Health, USA.
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Abstract
Designing a randomized controlled trial (RCT) to identify the efficacy of treatments for suicidal youths is challenging and requires great care. The lack of a comprehensive treatment evidence base for suicidal youths is largely the result of the complexity of these youths and the many impediments to mounting a RCT for the commonly used treatments-medication and psychotherapy. Correctly choosing the hypothesis to be tested, the appropriate sampling frame, the intervention and control groups, and the outcome variables increases the likelihood that the study will be feasible, ethical and clinically meaningful. To meet these goals, the sampling frame needs to be broad, but not require overly complex assessment, treatment and rescue protocols; intervention and control groups must meet or beat the 'standard of care', and be acceptable to participants and clinicians. The outcome variables need to be measurable, sensitive to change and common enough to identify between group differences without large samples. This manuscript: (1) reviews existing studies of interventions for suicidal youths, (2) describes challenges in selecting the population, treatment and control conditions, and appropriate and meaningful outcome measures, and (3) discusses alternative methodological approaches that may be necessary to address the complex treatment needs of suicidal youth.
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Affiliation(s)
- Mary F Cwik
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Espy KA, McDiarmid MM, Cwik MF, Stalets MM, Hamby A, Senn TE. The contribution of executive functions to emergent mathematic skills in preschool children. Dev Neuropsychol 2004; 26:465-86. [PMID: 15276905 DOI: 10.1207/s15326942dn2601_6] [Citation(s) in RCA: 315] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Mathematical ability is related to both activation of the prefrontal cortex in neuroimaging studies of adults and to executive functions in school-age children. The purpose of this study was to determine whether executive functions were related to emergent mathematical proficiency in preschool children. Preschool children (N = 96) were administered an executive function battery that was reduced empirically to working memory (WM), inhibitory control (IC), and shifting abilities by calculating composite scores derived from principal component analysis. Both WM and IC predicted early arithmetic competency, with the observed relations robust after controlling statistically for child age, maternal education, and child vocabulary. Only IC accounted for unique variance in mathematical skills, after the contribution of other executive functions were controlled statistically as well. Specific executive functions are related to emergent mathematical proficiency in this age range. Longitudinal studies using structural equation modeling are necessary to better characterize these ontogenetic relations.
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MESH Headings
- Aptitude/physiology
- Brain Damage, Chronic/diagnosis
- Brain Damage, Chronic/physiopathology
- Brain Damage, Chronic/psychology
- Child, Preschool
- Cross-Sectional Studies
- Female
- Humans
- Infant
- Infant, Newborn
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/physiopathology
- Infant, Premature, Diseases/psychology
- Inhibition, Psychological
- Male
- Mathematics
- Memory, Short-Term/physiology
- Models, Statistical
- Neuropsychological Tests/statistics & numerical data
- Prefrontal Cortex/physiopathology
- Problem Solving/physiology
- Psychometrics/statistics & numerical data
- Reference Values
- Risk Factors
- Set, Psychology
- Vocabulary
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Affiliation(s)
- Kimberly Andrews Espy
- Department of Family and Community Medicine, MC 6503, Southern Illinois University School of Medicine, 600 Agriculture Dr., Carbondale, IL 62901-6503, USA.
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Abstract
Preschool children have a more limited verbal repertoire, less proficient manual skills, and more variable attention spans relative to those of school age, with comparatively few neuropsychological tasks available for use in this age range. A prototypic neuropsychological test, the Trail Making Test, was adapted for use with young children, the TRAILS-P, using a developmentally salient storybook format with colorful stimuli in differing conditions with varying executive demands. The TRAILS-P was administered to 103 normally developing preschoolers between 2 and 6 years of age; 30 of these children were retested within one month to determine test reliability. Correlations among latencies to complete each condition and condition errors generally were moderate to high, suggesting coherence in test content. There also was evidence for good test-retest reliability. Latency to complete the TRAILS-P conditions differed as a function of the interaction of condition type and age group. Although the youngest children generally took more time to complete all TRAILS-P conditions, 3-year-old children were disproportionately slow to complete the condition that required shifting between stamping stimuli of two classes, with distraction by the additional presence of irrelevant stimuli. In contrast, the number of errors differed only in the 5-year-olds relative to younger children. These findings suggest that executive abilities can be assessed adequately in young children when tasks are designed to take advantage of the developmentally unique features of the preschool period.
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Affiliation(s)
- Kimberly Andrews Espy
- Department of Family & Community Medicine, Southern Illinois University School of Medicine, Carbondale, IL 62901-6503, USA.
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Espy KA, Stalets MM, McDiarmid MM, Senn TE, Cwik MF, Hamby A. Executive functions in preschool children born preterm: application of cognitive neuroscience paradigms. Child Neuropsychol 2002; 8:83-92. [PMID: 12638062 DOI: 10.1076/chin.8.2.83.8723] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Although children born preterm are at risk for neuropsychological impairments at school age and adolescence, including difficulties with visual motor integration, spatial/constructional skills, attention, arithmetic, and nonverbal executive functions, specific neuropsychological outcome has not been investigated adequately in preschoolers. Application of cognitive neuroscience tasks offers the opportunity to characterize early executive functions in young children born preterm. In a preliminary sample of 29 preschool children born preterm (M birth gestational age = 32.4 weeks), executive function outcome was compared to that of fullterm controls by contrasting performance on two prototypic delayed-response-type paradigms, Delayed Alternation and Spatial Reversal. Preschoolers born preterm correctly retrieved the reward on fewer trials on Delayed Alternation than did matched controls. Furthermore, preschool children born preterm used problem-solving strategies that included more perseverative errors than controls. These preliminary findings highlight the utility of cognitive neuroscience paradigms to understand neuropsychological outcome in preschool children born preterm and suggest areas of developmental vulnerability that may include dorsolateral prefrontal circuits.
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Affiliation(s)
- Kimberly Andrews Espy
- Department of Family and Community Medicine, Southern Illinois University School of Medicine, Carbondale, IL, 62901-6503, USA.
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