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Aonso-Diego G, Macía L, Montero M, Estévez A. Cluster analysis based on gambling variables and mental health in a clinical population of gamblers. Addict Behav 2024; 157:108092. [PMID: 38905901 DOI: 10.1016/j.addbeh.2024.108092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 06/10/2024] [Accepted: 06/13/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Interest in characterizing individuals involved in addictive behaviors has been growing, which allows tailoring prevention and intervention strategies to the gambler's needs. The study aimed to 1) identify clusters of gamblers according to gambling-related characteristics and mental health; and 2) analyze differences in psychological variables between the clusters. METHODS A total of 83 participants undergoing treatment for gambling disorder (Mage = 45.52, 51.8 % female) completed a set of questionnaires. Hierarchical cluster analysis was performed to classify gambling based on gambling variables (i.e., gambling severity and gambling motives) and mental health (i.e., depression, anxiety, and hostility). Several ANOVAs were conducted to illustrate the distinguishing features of each cluster, encompassing both the variables included in the cluster analysis and other relevant psychological variables. RESULTS Findings suggest that gamblers can be classified into three clusters based on these variables: 1) "high gambling severity and good mental health," 2) "high gambling severity and poor mental health," and 3) "low gambling severity and good mental health." These clusters were differentiated as a function of psychological variables, such as emotional dependence, alexithymia, and stressful life events. CONCLUSIONS Classifying gamblers according to their profile provides a better understanding of their needs and problems, allowing for a more tailored approach in terms of prevention and intervention strategies.
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Affiliation(s)
- G Aonso-Diego
- Departament of Psychology. Faculty of Health Sciences. University of Deusto. Spain.
| | - L Macía
- Departament of Psychology. Faculty of Health Sciences. University of Deusto. Spain.
| | - M Montero
- Departament of Psychology. Faculty of Health Sciences. University of Deusto. Spain
| | - A Estévez
- Departament of Psychology. Faculty of Health Sciences. University of Deusto. Spain.
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Min J, Tam V, Fein JA, Vasan A, Griffis HM, Krass P, Doupnik SK. Psychosocial Risks and Adolescent Mental Health: The Moderating Role of Objective Neighborhood Characteristics. J Adolesc Health 2024; 75:442-450. [PMID: 39001747 DOI: 10.1016/j.jadohealth.2024.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 05/24/2024] [Accepted: 05/29/2024] [Indexed: 07/15/2024]
Abstract
PURPOSE Although previous studies have examined the association between youth psychosocial risks and their perceptions of their neighborhood, it is unclear how objective neighborhood characteristics are associated with psychosocial risks and mental health symptoms among adolescents. We investigated how neighborhood characteristics moderate the relationship between youth psychosocial characteristics and mental health symptoms. METHODS This cross-sectional study examined 13,837 emergency department visits by 14-18-year-olds who completed a standardized Behavioral Health Screening in a tertiary pediatric hospital in Philadelphia from 2013 to 2020. Psychosocial risk factors and mental health symptoms were assessed based on self-reported survey responses. We characterized neighborhoods as low-, moderate-, and high-stress based on gun violence incidence from 2013 to 2020 and the census tract-level Child Opportunity Index. Mixed effects logistic regression and Poisson models were used to examine moderation effects. RESULTS The 9,814 included patients were 64% female and 64% non-Hispanic Black. The following psychosocial risk factors were associated with two to eight times higher odds of depressive symptoms and suicide risk: exposure to trauma, bullying at school, at-risk substance use, fighting, and retaliation. Adolescents living in high-stress neighborhoods were twice as likely to report fighting and retaliation and reported more psychosocial risk factors than those in low-stress neighborhoods. Odds of mental health symptoms increased with the number of psychosocial risk factors, particularly in youth from low-stress neighborhoods. DISCUSSION Objective neighborhood characteristics had a significant interaction effect on the relationship between psychosocial risks and depression and suicide risk among adolescents seeking care in a pediatric emergency department.
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Affiliation(s)
- Jungwon Min
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Vicky Tam
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joel A Fein
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania; Center for Violence Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Aditi Vasan
- Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania; Center for Violence Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Pediatric Clinical Effectiveness and PolicyLab, Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Heather M Griffis
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Polina Krass
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Violence Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Center for Pediatric Clinical Effectiveness and PolicyLab, Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stephanie K Doupnik
- Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania; Center for Pediatric Clinical Effectiveness and PolicyLab, Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Smith BD, Spencer BH, Nur-Singletary Z, Adane N, Moser N, Powell TW. Assessing the association between safety perceptions and communication about sex and drugs among Black adolescents exposed to adversity. J Trauma Stress 2024; 37:662-671. [PMID: 38602222 DOI: 10.1002/jts.23044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/07/2024] [Accepted: 03/07/2024] [Indexed: 04/12/2024]
Abstract
The present study examined the association between safety perceptions and communication with a trusted adult about sex and drugs among Black adolescents exposed to adverse childhood experiences (ACEs) and the role of gender as a potential moderator in this association. Data were drawn from a small, randomized control pilot test of an adapted evidence-based intervention conducted from 2022 to 2023 in Baltimore, Maryland. The sample included 57 Black adolescents who had been exposed to ACEs (Mage = 15.14 years, SD = 0.81l; 47.4% female, 52.6% male). Information about safety perceptions, health communication, health behaviors, and demographic characteristics was measured using an electronic survey at baseline. Group differences by gender emerged among ACEs and substance use behaviors. Safety perceptions were significantly associated with communication with a trusted adult, B = 0.31, SE = 0.24, p = .039. As youth felt more unsafe, their communication with a trusted adult about sex and drugs increased; this association did not differ by gender. Health communication was also associated with ACEs. Black adolescents living with a parent with mental health challenges reported increased communication, B = 0.60, SE = 0.20, p = .005, whereas youth experiencing homelessness had reduced health communication, B = -0.63, SE = 0.24, p = .012. A lack of perceived safety significantly impacts health communication; however, having trusted adults outside of the home, school, and neighborhood can serve as a protective factor in reducing substance use and sexual risk-taking among this population.
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Affiliation(s)
- Bianca D Smith
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Bailey Holmes Spencer
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Nancy Adane
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Naya Moser
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Terrinieka W Powell
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Gerke DR, Atteberry-Ash B, Call J, Hostetter CR. Adolescent Substance Use at the Intersection of Sexual Orientation and Gender Identity. SUBSTANCE USE & ADDICTION JOURNAL 2024:29767342241241398. [PMID: 38567540 DOI: 10.1177/29767342241241398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Substance use in adolescence is associated with multiple negative outcomes. Lesbian, gay, or bisexual or transgender or nonbinary (TNB) youth, and those who question their sexual orientation or gender, are more likely to engage in substance use than straight or cisgender youth. However, the extant literature largely considers sexual orientation and gender identity independently. Accordingly, this study examines the associations between the intersectional identities of sexual orientation and gender and substance use to identify those with the greatest need for prevention interventions. METHODS Data were from 36 504 high school students aged 14 to 18 years (mean = 15.7, SD = 1.18) enrolled in the 2019 Healthy Kids Colorado Survey using a statewide stratified random sampling design. Logistic regression models examined the associations between intersectional sexual orientation and gender on marijuana use, prescription drug misuse, and polysubstance use, as well as depression and violence victimization (eg, forced sex, partner violence). RESULTS Adjusted odds of substance use for sexual and gender minority youth varied by intersectional identity and substance. The largest effect sizes were seen for prescription drug misuse, especially among those questioning their gender and sexual orientation and heterosexuals either questioning their gender or who identified as TNB. Effect sizes for marijuana use and polysubstance use were highest for TNB and heterosexual participants. Depression and violence victimization were significantly associated with each substance use outcome. CONCLUSIONS Interventions to reduce substance use in these populations may benefit from targeted interventions for youth with different intersectional identities, and a focus on violence prevention and depression screening and treatment.
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Affiliation(s)
- Donald R Gerke
- Department of Social Work, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Jarrod Call
- School of Social Work and Criminal Justice, University of Washington Tacoma, Tacoma, WA, USA
| | - C Riley Hostetter
- Graduate School of Social Work, University of Denver, Denver, CO, USA
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Aleebrahim F, Heidari Z, Yousefnejad S, Kheirabadi G, Tarrahi MJ. Latent class of depressive symptoms of and its determinants: A cross-sectional study among Iranian University students. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2024; 29:9. [PMID: 38524745 PMCID: PMC10956564 DOI: 10.4103/jrms.jrms_728_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 11/19/2022] [Accepted: 11/23/2022] [Indexed: 03/26/2024]
Abstract
Background According to the report of the World Health Organization, mental disorders are one of the 10 most important causes of disability in the world. This study was conducted with the aim of determining the number and frequency of latent classes of depression and its determinants in Isfahan university of medical students. Materials and Methods A total of 1408 medical students from Isfahan University of Medical Sciences, Iran, were enrolled in the study in 2017. The symptoms and severity of depression were assessed using the standard Hospital Anxiety and Depression scale questionnaire. Latent class analysis was applied to seven symptoms of depression, all of which had four levels. Latent class subgroups were compared using the Chi-square test and analysis of variance test. The regression model was used to check the relationship between identified classes and related factors. Analyzes were done using SPSS-21 and Mplus7 software. Results In this study, three latent classes were identified, that is, the group of healthy people, the group of borderline people, and the group of people suspected of depression. The prevalence of identified latent classes among medical students is 0.52, 0.32, and 0.16%, respectively. The regression results showed that compared to the healthy group, the factors affecting depression in the borderline and suspicious group were increasing age, female gender, interest in the field of study, physical activity, history of depression, and history of anxiety. Conclusion The three classes that were identified based on the students' answers to the depression symptoms questions differed only based on severity. The history of depression and anxiety were the strongest predictors of latent classes of depression.
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Affiliation(s)
- Forugh Aleebrahim
- Department of Epidemiology and Biostatistics, School of Health, Isfahan University of Medical Science, Isfahan, Iran
- Student Research Committee, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Heidari
- Department of Epidemiology and Biostatistics, School of Health, Isfahan University of Medical Science, Isfahan, Iran
| | - Shahla Yousefnejad
- Department of Epidemiology and Biostatistics, School of Health, Isfahan University of Medical Science, Isfahan, Iran
- Student Research Committee, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Gholamreza Kheirabadi
- Department of Psychiatry, Behavioral Sciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Javad Tarrahi
- Department of Epidemiology and Biostatistics, School of Health, Isfahan University of Medical Science, Isfahan, Iran
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Oh H, Winn JG, Li Verdugo J, Bañada R, Zachry CE, Chan G, Okine L, Park J, Formigoni M, Leaune E. Mental health outcomes of multiracial individuals: A systematic review between the years 2016 and 2022. J Affect Disord 2024; 347:375-386. [PMID: 38008291 DOI: 10.1016/j.jad.2023.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/02/2023] [Accepted: 11/13/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND Emerging evidence suggests that multiracial individuals are at high risk for mental health problems. Systematic and ongoing synthesis of literature is necessary to understand mental health among multiracial individuals. METHODS We conducted a systematic review of scholarly articles published during the years 2016-2022. Studies must have focused explicitly on mental health outcomes of biracial/multiracial individuals using quantitative methods. A total of 22 articles met criteria for this review. RESULTS Studies were mainly from the United States, with one study from the United Kingdom and one from the Netherlands. Sample sizes ranged from 57 to 393,681. Findings revealed a complicated picture between multiracial identity and mental health, which may be a function of how multiracial identity is defined and empirically examined. Among studies comparing multiracial individuals with monoracial groups, multiracial individuals tended to have worse mental health, with notable exceptions depending on the multiracial subgroup, the mental health outcome, and the reference group. Among studies that only examined multiracial individuals, discrimination and ethno-racial identity emerged as complex explanatory factors that can shape mental health, though each of these constructs can be explored more deeply across social milieu. LIMITATIONS The review focused on studies explicitly examining multiracial mental health, published during a limited time frame. CONCLUSION Multiracial individuals tended to have worse mental health outcomes compared to their monoracial counterparts, with variations depending on the outcomes, populations/subgroups, contexts, and reference groups. Racial discrimination and ethno-racial identity may shape mental health trajectories of multiracial people, calling for more research to inform targeted interventions.
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Affiliation(s)
- Hans Oh
- Suzanne Dworak Peck School of Social Work, University of Southern California, USA.
| | | | | | - Ronna Bañada
- Suzanne Dworak Peck School of Social Work, University of Southern California, USA.
| | - Corinne E Zachry
- Suzanne Dworak Peck School of Social Work, University of Southern California, USA.
| | - Gloria Chan
- Suzanne Dworak Peck School of Social Work, University of Southern California, USA.
| | - Lucinda Okine
- Suzanne Dworak Peck School of Social Work, University of Southern California, USA.
| | - Juyoung Park
- Suzanne Dworak Peck School of Social Work, University of Southern California, USA.
| | - Marco Formigoni
- Suzanne Dworak Peck School of Social Work, University of Southern California, USA.
| | - Edouard Leaune
- Research on Healthcare Performance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, Lyon, France.
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Jackson KF. A Critical Scoping Review of Mental Health and Wellbeing Research with Multiracial Subsamples 2012-2022. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01811-2. [PMID: 37796429 DOI: 10.1007/s40615-023-01811-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 10/06/2023]
Abstract
This critical scoping review examined a decade of mental health and wellbeing outcome research inclusive of subsamples of multiracial participants (or persons identifying with two or more different racial groups) in order to draw initial conclusions about the contemporary state of multiracial mental health. Mental health disparities research inclusive of multiracial subsamples appears to be trending upward. Studies that used subsample analyses offer initial evidence that multiracial persons are at greater risk to experience worsened mental health in comparison to white monoracial peers, and that this disparity is compounded for multiracial persons from gender and/or sexual minoritized groups. This review uncovered numerous theoretical and methodological inconsistencies that constrained existing research from advancing more meaningful understandings of how white supremacy and systemic mono/racism differently impact the mental health and wellbeing of multiracial persons in the USA. Implications for future mental health disparities research inclusive of multiracial subsamples are presented.
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Affiliation(s)
- Kelly F Jackson
- School of Social Work, Watts College of Public Service and Community Solutions, Arizona State University, Suite 800, 411 N. Central Ave., Phoenix, AZ, 85004, USA.
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Stea TH, Steigen AM, Dangmann CR, Granrud MD, Bonsaksen T. Associations between exposure to sexual abuse, substance use, adverse health outcomes, and use of youth health services among Norwegian adolescents. BMC Public Health 2023; 23:1330. [PMID: 37434128 DOI: 10.1186/s12889-023-16261-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/07/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND A strong association between sexual abuse and adverse health outcomes has been reported among adolescents. The present study aimed to provide more information about adverse health outcomes associated with sexual abuse and substance use, and to examine the use of youth health services among Norwegian adolescents. METHODS National representative cross-sectional study among 16-19-year-old Norwegian adolescents (n = 9784). Multivariable regression analyses, adjusted for socioeconomic status and age, were used to examine the association between exposure to sexual abuse, substance use and health risk factors, and the use of youth health services. RESULTS Adolescents exposed to sexual abuse had higher odds of depressive symptoms (males: OR:3.8; 95% CI:2.5-5.8, females: 2.9;2.4-3.5), daily headache (males: 5.3;2.8-10.1, females:1.9; 1.5-2.4), high medication use (males: 3.2;1.7-6.0, females: 2.0;1.6-2.6), self-harm (males: 3.8;2.4-6.0, females:3.2; 2.6-3.9), suicidal thoughts (males: 3.3; 2.2-5.0, females:3.0; 2.5-3.6) and suicide attempts (males: 9.5;5.6-16.0, females:3.6;2.7-4.9). Furthermore, exposure to sexual abuse was associated with higher odds of using school health services (males: 3.9;2.6-5.9, females: 1.6;1.3-1.9) and health services for youth (males: 4.8;3.1-7.6, females: 2.1;1.7-2.5). In general, substance use was associated with increased odds of adverse health related outcomes and use of youth health services, but the strength of the relationships varied according to sex. Finally, results indicated a significant interaction between sexual abuse and smoking that was associated with increased odds of having suicidal thoughts for males (2.6;1.1-6.5) but a decreased odds of having suicidal thoughts and have conducted suicide attempts once or more for females (0.6;0.4-1.0 and 0.5;0.3-0.9, respectively). CONCLUSIONS The present study confirmed a strong relationship between exposure to sexual abuse and health risks, especially among males. Moreover, males exposed to sexual abuse were much more likely to use youth health services compared to sexually abused females. Substance use was also associated with adverse health outcomes and use of youth health services, and interactions between sexual abuse and smoking seemed to influence risk of suicidal thoughts and attempts differently according to sex. Results from this study increase knowledge about possible health related effects of sexual abuse which should be used to identify victims and provide targeted treatment by youth health services.
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Affiliation(s)
- T H Stea
- Department of Health and Nursing Science, University of Agder, Kristiansand, Norway.
| | - A M Steigen
- Department of Health and Nursing Sciences, Inland Norway University of Applied Sciences, Elverum, Norway
| | - C R Dangmann
- Department of Social Sciences and Guidance, Faculty of Social and Health Science, Inland Norway University of Applied Sciences, Elverum, Norway
| | - M D Granrud
- Department of Social Sciences and Guidance, Faculty of Social and Health Science, Inland Norway University of Applied Sciences, Elverum, Norway
| | - T Bonsaksen
- Department of Health and Nursing Sciences, Inland Norway University of Applied Sciences, Elverum, Norway
- Department of Health, Faculty of Health Studies, VID Specialized University, Stavanger, Norway
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Baiden P, Cavazos-Rehg P, Szlyk HS, Onyeaka HK, Peoples JE, Kasson E, Muoghalu C. Association between Sexual Violence Victimization and Electronic Vaping Product Use among Adolescents: Findings from a Population-based Study. Subst Use Misuse 2023; 58:637-648. [PMID: 36803403 PMCID: PMC11177576 DOI: 10.1080/10826084.2023.2177963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Although studies have investigated the association between sexual violence (SV) victimization and substance use, few studies have examined the association between SV victimization and electronic vaping product (EVP) use among adolescents in the United States. The objective of this study was to examine the cross-sectional association between SV victimization and EVP use among adolescents. METHODS Data were pooled from the 2017 and 2019 Youth Risk Behavior Survey. An analytic sample of 28,135 adolescents (51.2% female) was analyzed using binary logistic regression. The outcome variable investigated was EVP use, and the main explanatory variable was SV victimization. RESULTS Of the 28,135 adolescents, the prevalence of past 30-day EVP use and SV victimization was 22.7% and 10.8%, respectively. Controlling for other factors, adolescents who experienced SV had 1.52 times higher odds of being EVP users when compared to their counterparts who did not experience SV (AOR = 1.52, p < .001, 95% CI = 1.27-1.82). Other factors associated with EVP use included cyberbullying victimization, symptoms of depression, and current use of cigarettes, alcohol, and marijuana. CONCLUSIONS Experiencing SV was associated with EVP use. Future studies that employ longitudinal designs may offer more insight into the mechanisms underlying the association between SV victimization and EVP use. In addition, school-based interventions that focus on sexual violence prevention and reducing substance use among adolescents are warranted.
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Affiliation(s)
- Philip Baiden
- School of Social Work, The University of Texas at Arlington, Arlington, Texas, USA
| | - Patricia Cavazos-Rehg
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Hannah S. Szlyk
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Henry K. Onyeaka
- Harvard Medical School, Department of Psychiatry, Boston, Massachusetts, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Psychiatry, McLean Hospital, Boston, Massachusetts, USA
| | | | - Erin Kasson
- Department of Psychiatry, Washington University School of Medicine, St. Louis, Missouri, USA
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Patterns of sexual behaviour associated with repeated chlamydia testing and infection in men and women: a latent class analysis. BMC Public Health 2022; 22:652. [PMID: 35382799 PMCID: PMC8981706 DOI: 10.1186/s12889-021-12394-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 12/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Adolescents and young adults are at higher risk of acquiring Chlamydia trachomatis infection (chlamydia), so testing is promoted in these populations. Studies have shown that re-testing for chlamydia is common amongst them. We investigated how sexual risk behaviour profiles are associated with repeated testing for chlamydia. METHODS We used baseline data from a cohort of 2814 individuals recruited at an urban STI -clinic. We applied latent class (LC) analysis using 9 manifest variables on sexual behaviour and substance use self-reported by the study participants. We fitted ordered logistic regression to investigate the association of LC membership with the outcomes repeated testing during the past 12 months and lifetime repeated testing for chlamydia. Models were fit separately for men and women. RESULTS We identified four LCs for men and three LCs for women with increasing gradient of risky sexual behaviour. The two classes with the highest risk among men were associated with lifetime repeated testing for chlamydia: adjOR = 2.26 (95%CI: 1.50-3.40) and adjOR = 3.03 (95%CI: 1.93-4.74) as compared with the class with lowest risk. In women, the class with the highest risk was associated with increased odds of repeated lifetime testing (adjOR =1.85 (95%CI: 1.24-2.76)) and repeated testing during past 12 months (adjOR = 1.72 (95%CI: 1.16-2.54)). An association with chlamydia positive test at the time of the study and during the participant's lifetime was only found in the male highest risk classes. CONCLUSION Prevention messages with regard to testing for chlamydia after unprotected sexual contact with new/casual partners seem to reach individuals in highest risk behaviour classes who are more likely to test repeatedly. Further prevention efforts should involve potentially more tailored sex-specific interventions taking into consideration risk behaviour patterns.
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Aksoy D, Favre CA, Janousch C, Ertanir B. Internalizing and Externalizing Symptoms in Adolescents With and Without Experiences of Physical Parental Violence, a Latent Profile Analysis on Violence Resilience. Front Psychol 2022; 13:824543. [PMID: 35432093 PMCID: PMC9008205 DOI: 10.3389/fpsyg.2022.824543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/04/2022] [Indexed: 11/19/2022] Open
Abstract
Questionnaire data from a cross-sectional study on social resilience in adolescence, with a sample of N = 1,974 Swiss seventh grade high school students ages 12-14 (M = 11.76; SD = 0.65) was used to identify and compare violence resilience profiles. Person-centered latent profile analysis (LPA) was applied and allowed for the grouping of adolescents into profiles of internalizing (depression/anxiety, dissociation) and externalizing symptoms (peer aggression, peer victimization, classroom disruption) and differentiation of adolescents with (n = 403) and without (n = 1,571) physical parental violence experiences. Subsequently, a multinomial logistic regression analysis was conducted to further investigate the sociodemographic predictors of violence resilience profiles. With LPA, we identified four distinct profiles for both adolescent groups (with and without parental physical violence experiences). The results showed three particularly burdened profiles of adolescents, one with higher externalizing and one with higher internalizing symptoms, which did not occur simultaneously to the same extent. Furthermore, the third profile contained adolescents with both elevated internalizing and externalizing symptoms, the comorbid profile. The fourth profile consisted of the majority of adolescents, who exhibited little or no internalizing and externalizing symptoms, the so-called no/low symptomatic profile. A differentiated view of the symptoms can create added value regarding the understanding of violence resilience. Moreover, in the multinomial logistic regression, significant associations were found between the profiles and adolescents' gender in the group of adolescents with parental physical violence experiences, but none were found in relation to sociocultural status and migration background.
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Affiliation(s)
- Dilan Aksoy
- Department of Research and Development, School of Education, University of Applied Sciences and Arts Northwestern Switzerland, Windisch, Switzerland
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Lardier DT, Zuhl MN, Holladay KR, Amorim FT, Heggenberger R, Coakley KE. A Latent Class Analysis of Mental Health Severity and Alcohol Consumption: Associations with COVID-19-Related Quarantining, Isolation, Suicidal Ideations, and Physical Activity. Int J Ment Health Addict 2022; 21:1-24. [PMID: 35039751 PMCID: PMC8754537 DOI: 10.1007/s11469-021-00722-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2021] [Indexed: 11/24/2022] Open
Abstract
The present study examined latent class cluster group patterns based on measures of depression and anxiety symptom severity and alcohol consumption during the COVID-19 pandemic. Hypothesized correlates with latent class cluster groups including quarantining, self-isolation, suicidal ideations, sitting hours per day, and physical activity (vigorous intensity exercise in minutes per week) were examined. The delimited participant sample consisted of 606 university young adults 18 to 25 years of age (M = 21.24 ± 1.62). Latent cluster analysis (LCA) modeled patterns of depression and anxiety symptom severity and alcohol consumption during the COVID-19 pandemic. Between group analysis and multinomial logistic regression analysis were used to examine relationships between latent class clusters and correlates including quarantining, self-isolation, suicidal ideations, sitting hours per day, and physical activity (vigorous intensity exercise in minutes per week). LCA results showed that six latent cluster groups provided optimal model-to-date fit based on mental health symptom severity and alcohol consumption (L 2 = 56.31, BIC = 5012.79, AIC = 4849.74, and the bootstrap L 2 p-value = .88; Entropy R 2 = .89). Identified latent class clusters were as follows: cluster one = moderate anxiety and depression severity and moderate alcohol consumption (n = 156; 25.7%); cluster two = high mental health severity and alcohol consumption (n = 133; 21.9%); cluster three = low mental health symptoms and moderate alcohol consumption (n = 105; 17.3%); cluster four = lowest mental health severity and alcohol consumption (n = 95; 15.7%); cluster five = moderate depression severity, low anxiety severity, and low alcohol consumptions (n = 74; 12.2%); and cluster six = moderate anxiety severity, low depression severity, and low alcohol consumption (n = 43; 7.1%). Multinomial logistic regression analysis results found that quarantining, self-isolation, suicidal ideations, sedentary behavior, and physical activity were differentially associated with cluster group membership. Findings from this study demonstrate associations between COVID-19 public health restrictions, suicidal ideations, and declines in mental health and increases in alcohol consumption among young adult university students.
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Affiliation(s)
- David T. Lardier
- Department of Psychiatry and Behavioral Sciences, University of New Mexico School of Medicine, Albuquerque, NM USA
| | - Micah N. Zuhl
- School of Health Sciences, Central Michigan University, Mt. Pleasant, MI 48859 USA
| | - Kelley R. Holladay
- College of Health Sciences, Jacksonville University, Jacksonville, FL USA
| | - Fabiano T. Amorim
- College of Education & Human Sciences, University of New Mexico, Albuquerque, NM USA
| | - Raina Heggenberger
- College of Education & Human Sciences, University of New Mexico, Albuquerque, NM USA
| | - Kathryn E. Coakley
- College of Education & Human Sciences, University of New Mexico, Albuquerque, NM USA
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Liu Z, Liu R, Zhang Y, Zhang R, Liang L, Wang Y, Wei Y, Zhu R, Wang F. Latent class analysis of depression and anxiety among medical students during COVID-19 epidemic. BMC Psychiatry 2021; 21:498. [PMID: 34641795 PMCID: PMC8506472 DOI: 10.1186/s12888-021-03459-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 09/01/2021] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE The novel coronavirus disease 2019 (COVID-19) is a global public health emergency that has caused worldwide concern. The mental health of medical students under the COVID-19 epidemic has attracted much attention. This study aims to identify subgroups of medical students based on depression and anxiety and explore the influencing factors during the COVID-19 epidemic in China. METHODS A total of 29,663 medical students were recruited during the epidemic of COVID-19 in China. Depression and anxiety symptoms were assessed using Patient Health Questionnaire 9 (PHQ9) and Generalized Anxiety Disorder 7 (GAD7) respectively. Latent class analysis was performed based on depression and anxiety symptoms in medical students. The latent class subtypes were compared using the chi-square test. Multinomial logistic regression was used to examine associations between identified classes and related factors. RESULTS In this study, three distinct subgroups were identified, namely, the poor mental health group, the mild mental health group and the low symptoms group. The number of medical students in each class is 4325, 9321 and 16,017 respectively. The multinomial logistic regression results showed that compared with the low symptoms group, the factors influencing depression and anxiety in the poor mental health group and mild mental health group were sex, educational level, drinking, individual psychiatric disorders, family psychiatric disorders, knowledge of COVID-19, fear of being infected, and participate in mental health education on COVID-19. CONCLUSIONS Our findings suggested that latent class analysis can be used to categorize different medical students according to their depression and anxiety symptoms during the outbreak of COVID-19. The main factors influencing the poor mental health group and the mild mental health group are basic demographic characteristics, disease history, COVID-19 related factors and behavioural lifestyle. School administrative departments can carry out targeted psychological counseling according to different subgroups to promote the physical and mental health of medical students.
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Affiliation(s)
- Zhuang Liu
- grid.412449.e0000 0000 9678 1884School of Public health, China Medical University, Shenyang, Liaoning China
| | - Rongxun Liu
- grid.89957.3a0000 0000 9255 8984Early Intervention Unit, Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, 264 Guangzhou Road, Nanjing, Jiangsu 210029 People’s Republic of China ,grid.412990.70000 0004 1808 322XSchool of Medical Engineering, Xinxiang Medical University, Xinxiang, Henan China
| | - Yue Zhang
- grid.412449.e0000 0000 9678 1884School of Public health, China Medical University, Shenyang, Liaoning China
| | - Ran Zhang
- grid.89957.3a0000 0000 9255 8984Early Intervention Unit, Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, 264 Guangzhou Road, Nanjing, Jiangsu 210029 People’s Republic of China
| | - Lijuan Liang
- grid.412636.4Department of Psychiatry, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning China ,grid.443397.e0000 0004 0368 7493Department of Psychology, The First Affiliated Hospital of Hainan Medical University, Haikou, Hainan China
| | - Yang Wang
- grid.411907.a0000 0001 0441 5842Psychology Institute, Inner Mongolia Normal University, Huhehaote, Inner Mongolia China
| | - Yange Wei
- grid.89957.3a0000 0000 9255 8984Early Intervention Unit, Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, 264 Guangzhou Road, Nanjing, Jiangsu 210029 People’s Republic of China
| | - Rongxin Zhu
- Early Intervention Unit, Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, 264 Guangzhou Road, Nanjing, Jiangsu, 210029, People's Republic of China.
| | - Fei Wang
- Early Intervention Unit, Department of Psychiatry, The Affiliated Brain Hospital of Nanjing Medical University, 264 Guangzhou Road, Nanjing, Jiangsu, 210029, People's Republic of China. .,Department of Psychiatry and Radiology, The First Affiliated Hospital of China Medical University, 155 Nanjing North Street, Shenyang, 110001, Liaoning, People's Republic of China. .,Nanjing Functional Brain Imaging Institute of Nanjing Medical University, 264 Guangzhou Road, Nanjing, Jiangsu, 210029, People's Republic of China.
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A Latent Class Analysis of Health Lifestyles in Relation to Suicidality among Adolescents in Mauritius. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18136934. [PMID: 34203501 PMCID: PMC8296868 DOI: 10.3390/ijerph18136934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/21/2021] [Accepted: 06/25/2021] [Indexed: 12/31/2022]
Abstract
Suicidality, which includes suicidal thoughts, planning, and suicide attempts, results mainly from a combination of psychological, sociological, and environmental factors. Despite a high prevalence of suicidality among adolescents in Africa, only a few studies have considered these factors simultaneously. The objective of the study was to identify the prevalence of suicidality, to draw up profiles of concomitant risks, and to examine the associations between these profiles and suicidality in Mauritius. This study used data from the 2017 Mauritian Global School-based Student Health Survey including 3012 adolescents with a mean age of 14.9 ± 1.4 years. Factors related to lifestyle such as consumptions of alcohol and tobacco, physical activity, violence, parental support, anxiety, and loneliness were considered. A latent class analysis was performed to identify the profiles. Finally, a modified Poisson regression analysis with generalized estimating equations, adjusted with sociodemographic characteristics, was used to assess the association between these profiles and suicidality. Overall, more than one in ten adolescents had at least one of the suicidality behaviors. Three profiles were identified: 1 = "low risk group" (63.9%); 2 = "problems with violence" (15.2%); 3 = "problems with violence, alcohol, tobacco and psychological distress" (20.9%). Profiles 2 and 3 were mainly made up of males. Adolescents under 15 represented the majority of individuals in profile 2. Finally, the risk of suicidality was higher in adolescents belonging to profiles 2 and 3 compared to profile 1 for the three suicidality behaviors (profile 3: Prevalence ratio (PR) for suicidal thoughts = 1.26, 95% CI = 1.19-1.34; PR for planning = 1.23, 95% CI = 1.17-1.30; PR for attempt = 1.23, 95% CI = 1.17-1.29). This study highlights the high prevalence of suicidality and a list of concomitant risks, emphasizing this suicidality in Mauritian adolescents. Therefore, these results recommend focusing preventive efforts toward a simultaneous consideration of these factors.
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Jeffery DD, Beymer MR, Mattiko MJ, Shell D. Health Behavior Differences Between Male and Female U.S. Military Personnel by Sexual Orientation: The Importance of Disaggregating Lesbian, Gay, and Bisexual Groups. Mil Med 2021; 186:556-564. [PMID: 33306807 DOI: 10.1093/milmed/usaa539] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/22/2020] [Accepted: 11/25/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The aims of the study are to identify health-related behaviors associated with sexual orientation among active duty military personnel and to compare those behaviors when lesbian, gay, and bisexual (LGB) groups are aggregated and disaggregated. MATERIALS AND METHODS We used public data from the 2015 Health-Related Behavior Survey of Active Duty Military Personnel. Binomial logistic regression analyses were used to examine differences between and within heterosexual, same-sex, and bisexual groups as predicted by the following correlates: demographic characteristics, physical activity, substance use, probable mood disorders, unwanted sexual contact, physical abuse, suicidal behaviors, and sexually transmitted infection (STI). RESULTS In univariate analyses, rates of lifetime unwanted sexual contact and lifetime suicidal ideation were significantly higher for bisexual females compared to other groups. The results of regression analyses differed depending on whether LGB groups were aggregated or disaggregated. Aggregated LGB versus heterosexual model found significant differences with respect to unwanted sexual contact, lifetime suicide attempt, STI, smoking, and marijuana use. Disaggregated models found different patterns of significant correlates, e.g., correlates comparing gays to heterosexual males were STI, sexual contact, lifetime suicide attempt, and age; correlates comparing lesbians to heterosexual females were heavy drinking, probable post-traumatic stress disorder, ever used marijuana, lifetime suicide attempt, lifetime physical abuse, and smoking. CONCLUSION The findings are consistent with those of previous research showing highest risk for suicidal behaviors and substance abuse among bisexual individuals. We recommend that future studies and clinical care consider LGB sexual identities as heterogeneous groups; otherwise, risks for adverse health behaviors may be overlooked.
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Affiliation(s)
- Diana D Jeffery
- Department of Defense, Defense Health Agency, Falls Church, VA 22042, USA
| | - Matthew R Beymer
- Behavioral and Social Health Outcomes Program, Defense Health Agency, US Army Satellite, Aberdeen Proving Ground, MD 21005, USA
| | - Mark J Mattiko
- Health, Safety, and Work-Life Directorate, United States Coast Guard, Washington, DC 20032, USA
| | - Donald Shell
- Department of Defense, Office of the Assistant Secretary of Defense (Health Affairs), Falls Church, VA 22042, USA
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Understanding pathways to e-cigarette use across sexual identity: A multi-group structural equation model. Addict Behav 2021; 114:106748. [PMID: 33296821 DOI: 10.1016/j.addbeh.2020.106748] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 12/28/2022]
Abstract
This study explored the relationships between sexual violence, smoking behaviors, suicidality and past 30-day e-cigarette use under the theoretical framework of Minority Stress Theory. The 2017 National Youth Risk Behavioral Survey was utilized to study a nationally representative sample of sexual minority (lesbian, gay, bisexual, and unsure) and heterosexual high school students (N = 7882). Multi-group structural equation modeling (SEM) was employed to examine whether sexual violence and suicidality had a direct effect on e-cigarette use, after controlling for prior smoking behaviors (cigarette, cigar, and marijuana use). Suicidality and smoking behaviors were examined as mediators of the relationship between sexual violence and e-cigarette use, and suicidality was examined as a mediator of the relationship between sexual violence and smoking behaviors. This model was tested for invariance across sexual minority and heterosexual students. For both groups, smoking behaviors had significant direct effects on e-cigarette use, yet suicidality revealed no significant direct effects. Both suicidality and sexual violence had significant indirect effects on e-cigarette use through their effects on smoking behaviors. Sexual violence had a significant direct effect on e-cigarette use for sexual minority students, but not for heterosexual students. Despite this notable difference, the model was found to be invariant across the two groups. These findings suggest that students who report sexual violence may experience suicidality and victimization may lead to smoking behaviors and e-cigarette use. Students' mental health and substance use behaviors should continue to be targeted in schools, particularly among sexual minority youths.
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Chadi N, Li G, Hadland SE. Adverse School Outcomes and Risky Sexual Health Behaviors among High School Students with E-Cigarette and Marijuana Use. Subst Use Misuse 2021; 56:517-521. [PMID: 33588676 PMCID: PMC7946745 DOI: 10.1080/10826084.2021.1883659] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND While several health risks of e-cigarette and marijuana use have been described, little is known about their associations with school-related outcomes and risky sexual behaviors in adolescents. Objectives: To determine the odds of adverse school outcomes and risky sexual behaviors among youth with single or dual use of e-cigarettes and marijuana. Methods: We used data from the 2015 and 2017 waves of the Youth Risk Behavior Survey, a nationally representative survey of high school students in the US. Participants (N = 30,389) were divided into four exposure groups for single or dual use of e-cigarettes and marijuana. We compared rates of e-cigarette and/or marijuana use for different demographic characteristics using chi-square tests and performed multivariate logistic regressions exploring associations among e-cigarette and marijuana use and adverse school outcomes and risky sexual behaviors adjusting for confounding factors. Results: Participants reported e-cigarette-only (7.7%), marijuana-only (8.5%), and dual e-cigarette/marijuana (9.2%) use. Youth in all three use categories had higher odds of reporting grades that were mostly C's or lower than youth with no use, but no difference was found between youth with e-cigarette-only vs marijuana-only use. Increased odds of having sex without a condom were seen in youth with marijuana-only use (vs. e-cigarette-only use or no use) but not in youth with e-cigarette-only use or dual use. Conclusions: We found increased odds of adverse school-related outcomes and contrasting sexual risk profiles among youth with single or dual e-cigarette and marijuana use. UNLABELLED Supplemental data for this article is available online at https://doi.org/10.1080/10826084.2021.1883659.
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Affiliation(s)
- Nicholas Chadi
- Division of Adolescent Medicine, Department of Pediatrics, Sainte-Justine University Hospital Centre, University of Montreal, Montreal, Canada
| | - Guilin Li
- Harvard Graduate School of Arts and Sciences, Cambridge, Massachusetts, USA
| | - Scott E Hadland
- Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, Boston, Massachusetts, USA.,Division of General Pediatrics, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts, USA
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18
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Basile KC, Clayton HB, Rostad WL, Leemis RW. Sexual Violence Victimization of Youth and Health Risk Behaviors. Am J Prev Med 2020; 58:570-579. [PMID: 32033854 PMCID: PMC7266035 DOI: 10.1016/j.amepre.2019.11.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/24/2019] [Accepted: 11/25/2019] [Indexed: 12/28/2022]
Abstract
INTRODUCTION This study assesses associations between past-12-month sexual violence victimization and recent health risk behaviors using a nationally representative sample of male and female high school students. It is hypothesized that sexual violence victimization will be associated with most of the negative health behaviors for both sexes. METHODS Data from the 2017 National Youth Risk Behavior Survey, a school-based cross-sectional survey of students in Grades 9-12, were used to assess associations between sexual violence victimization and 29 health risk behaviors in sex-stratified logistic regression models. Effect modification was also examined through sex X sexual violence victimization interactions within unstratified models. All models controlled for race/ethnicity, grade, and sexual identity. Data were analyzed in 2018. RESULTS Students who experienced sexual violence victimization were significantly more likely to report many health risk behaviors and experiences, such as substance use, injury, negative sexual health behaviors, feelings of sadness or hopelessness, suicidality, poor academic performance, and cognitive difficulties, and these associations were often stronger among male students (significant adjusted prevalence ratios ranged from 1.63 to 14.40 for male and 1.24 to 6.67 for female students). CONCLUSIONS Past-year sexual violence victimization was significantly related to various health risk behaviors, suggesting that efforts to prevent sexual violence may also be associated with decreases in poor health. Integrating violence, substance use, sexual, and other health risk prevention efforts is warranted.
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Affiliation(s)
- Kathleen C Basile
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Heather B Clayton
- National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Whitney L Rostad
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ruth W Leemis
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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