Last data update: Apr 29, 2024. (Total: 46658 publications since 2009)
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Query Trace: Demissie Z[original query] |
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Overview and methods for the Youth Risk Behavior Surveillance System - United States, 2019
Underwood JM , Brener N , Thornton J , Harris WA , Bryan LN , Shanklin SL , Deputy N , Roberts AM , Queen B , Chyen D , Whittle L , Lim C , Yamakawa Y , Leon-Nguyen M , Kilmer G , Smith-Grant J , Demissie Z , Jones SE , Clayton H , Dittus P . MMWR Suppl 2020 69 (1) 1-10 Health risk behaviors practiced during adolescence often persist into adulthood and contribute to the leading causes of morbidity and mortality in the United States. Youth health behavior data at the national, state, territorial, tribal, and local levels help monitor the effectiveness of public health interventions designed to promote adolescent health. The Youth Risk Behavior Surveillance System (YRBSS) is the largest public health surveillance system in the United States, monitoring a broad range of health-related behaviors among high school students. YRBSS includes a nationally representative Youth Risk Behavior Survey (YRBS) and separate state, local school district, territorial, and tribal school-based YRBSs. This overview report describes the surveillance system and the 2019 survey methodology, including sampling, data collection procedures, response rates, data processing, weighting, and analyses presented in this MMWR Supplement. A 2019 YRBS participation map, survey response rates, and student demographic characteristics are included. In 2019, a total of 78 YRBSs were administered to high school student populations across the United States (national and 44 states, 28 local school districts, three territories, and two tribal governments), the greatest number of participating sites with representative data since the surveillance system was established in 1991. The nine reports in this MMWR Supplement are based on national YRBS data collected during August 2018-June 2019. A full description of 2019 YRBS results and downloadable data are available (https://www.cdc.gov/healthyyouth/data/yrbs/index.htm).Efforts to improve YRBSS and related data are ongoing and include updating reliability testing for the national questionnaire, transitioning to electronic survey administration (e.g., pilot testing for a tablet platform), and exploring innovative analytic methods to stratify data by school-level socioeconomic status and geographic location. Stakeholders and public health practitioners can use YRBS data (comparable across national, state, tribal, territorial, and local jurisdictions) to estimate the prevalence of health-related behaviors among different student groups, identify student risk behaviors, monitor health behavior trends, guide public health interventions, and track progress toward national health objectives. |
Suicidal ideation and behaviors among high school students - Youth Risk Behavior Survey, United States, 2019
Ivey-Stephenson AZ , Demissie Z , Crosby AE , Stone DM , Gaylor E , Wilkins N , Lowry R , Brown M . MMWR Suppl 2020 69 (1) 47-55 Suicide is the second leading cause of death among high school-aged youths 14-18 years after unintentional injuries. This report summarizes data regarding suicidal ideation (i.e., seriously considered suicide) and behaviors (i.e., made a suicide plan, attempted suicide, and made a suicide attempt requiring medical treatment) from CDC's 2019 Youth Risk Behavior Survey. Results are reported overall and by sex, grade, race/ethnicity, sexual identity, and sex of sexual contacts, overall and within sex groups. Trends in suicide attempts during 2009-2019 are also reported by sex, race/ethnicity, and grade. During 2009-2019, prevalence of suicide attempts increased overall and among female, non-Hispanic white, non-Hispanic black, and 12th-grade students. Data from 2019 reflect substantial differences by demographics regarding suicidal ideation and behaviors. For example, during 2019, a total of 18.8% of students reported having seriously considered suicide, with prevalence estimates highest among females (24.1%); white non-Hispanic students (19.1%); students who reported having sex with persons of the same sex or with both sexes (54.2%); and students who identified as lesbian, gay, or bisexual (46.8%). Among all students, 8.9% reported having attempted suicide, with prevalence estimates highest among females (11.0%); black non-Hispanic students (11.8%); students who reported having sex with persons of the same sex or with both sexes (30.3%); and students who identified as lesbian, gay, or bisexual (23.4%). Comprehensive suicide prevention can address these differences and reduce prevalence of suicidal ideation and behaviors by implementing programs, practices, and policies that prevent suicide (e.g., parenting programs), supporting persons currently at risk (e.g., psychotherapy), preventing reattempts (e.g., emergency department follow-up), and attending to persons who have lost a friend or loved one to suicide. |
Trends in diversity-related learning among secondary schools in 35 US states, 2014–2018
Young E , Demissie Z , Szucs LE , Brener ND , Waheed F , Jasani S . Health Educ J 2024 Objective: School Health Profiles (Profiles) is a national surveillance system operated by the US Centers for Disease Control and Prevention. A school-based system of surveys, Profiles monitors school health policies and practices in US states and other jurisdictions through questionnaires completed by school principals and lead health education teachers. This study used the Profiles principal survey to identify trends in US schools’ implementation of diversity-related learning opportunities (i.e. opportunities to learn about people who are different from themselves) in secondary school classrooms and extracurricular settings. Methods: Logistic regression models using data from three cycles of School Health Profiles from 35 US states examined trends in the percentages of secondary schools offering students diversity-related learning opportunities in the following settings, each measured by using dichotomous yes/no response options: (a) clubs; (b) lessons in class and (c) special events (e.g. multicultural week, family night) sponsored by the school or community organisations. Results: Between 2014–2018, no states experienced decreases in opportunities for students to learn about people who are different from themselves; most states demonstrated no significant change. Conclusion: Findings suggest efforts are needed to strengthen capacity for and prioritisation of policies, programmes and practices promoting diversity and culturally relevant education in schools, and in turn, promote positive health and educational outcomes for youth. © The Author(s) 2024. |
Prevalence estimates and factors associated with violence among older adults: National Intimate Partner and Sexual Violence (NISVS) Survey, 2016/2017
Zhang Kudon H , Herbst JH , Richardson LC , Smith SG , Demissie Z , Siordia C . J Elder Abuse Negl 2023 1-17 Abuse of older adults is a public health problem. The National Intimate Partner and Sexual Violence Survey (NISVS) is a nationally-representative, telephone survey for non-institutionalized adults in the United States. To determine the prevalence and factors of intimate partner psychological aggression and physical violence and sexual violence by any perpetrator against older adults, we analyzed NISVS 2016/2017 data (n = 10,171, aged ≥ 60 years). Past 12-month prevalence of psychological aggression, physical violence, and sexual violence was 2.1%, 0.8%, and 1.7%, respectively. Odds of psychological aggression were significantly higher among those with hearing or vision impairment, and lower among those aged ≥70 years. Odds of physical violence were significantly higher for males and for those with hearing or vision impairment. Odds of sexual violence were significantly higher for unpartnered individuals and those with cognitive impairment; and lower for those aged ≥ 70 years. Epidemiologic studies of violence against older adults can inform population-specific prevention strategies. |
Predictors of HIV testing among youth 15-24 years in urban Ethiopia, 2017-2018 Ethiopia population-based HIV impact assessment
Ajiboye AS , Eshetu F , Lulseged S , Getaneh Y , Tademe N , Kifle T , Bray R , Eshete H , Demissie Y , Dykewicz CA , Hoos D . PLoS One 2023 18 (7) e0265710 INTRODUCTION: Youth (adolescents and young adults) aged 15-24 years comprise approximately 22% of Ethiopia's total population and make up 0.73% of HIV cases in urban Ethiopia. However, only 63% of HIV-positive youth are aware of their HIV status. We describe the HIV testing behaviors of youth 15-24 years and determined the characteristics of those who were most likely to be tested for HIV within the past year. METHODS: Using data from the 2017-2018 Ethiopia Population-based HIV Impact Assessment, we provide survey-weighted estimates and prevalence risk ratios for engagement in HIV testing in the 12 months preceding the survey. We model the likelihood of HIV testing one year or more before the survey compared to never testing, using a multinomial logistic regression model. RESULTS: Among HIV-negative and unaware HIV-positive youth 15-24 years old (N = 7,508), 21.8% [95% Confidence Interval (CI): 20.4-23.3%] reported testing for HIV in the last 12 months. Female youth [Prevalence Ratio (PR) = 1.6, 95% CI: 1.4-1.8], those aged 20-24 years (PR = 2.6, 95% CI:2.3-2.9), and those ever married (PR = 2.8, 95% CI: 2.5-3.1) were more likely to have tested for HIV within the last year. Adjusting for select demographic characteristics, sex with a non-spousal or non-live-in partner [Relative Risk (RR) = 0.3, 95% CI:0.1-0.8] among males did not increase their likelihood to test for HIV in the prior 12 months. Female youth engaged in antenatal care (RR = 3.0, 95% CI: 1.7-5.3) were more likely to test for HIV in the past year. CONCLUSION: The Ethiopian HIV case finding strategy may consider approaches for reaching untested youth, with a specific focus on adolescent males,15-19 years of age. This is critical towards achieving the UNAIDS HIV testing goal of 95% of all individuals living with HIV aware of their status by 2030. |
Predictors of HIV Testing among Youth 15-24 Years in Urban Ethiopia, 2017-2018 Ethiopia Population-Based HIV Impact Assessment (preprint)
Ajiboye AS , Eshetu F , Lulseged S , Getaneh Y , Tademe N , Kifle T , Bray R , Eshete H , Demissie Y , Dykewicz CA , Hoos D . medRxiv 2022 20 Introduction: Youth (adolescents and young adults) aged 15-24 years comprise approximately 22% of Ethiopia's total population and make up 0.73% of HIV cases in urban Ethiopia. However, only 63% of HIV-positive youth are aware of their HIV status. We described the HIV testing behaviors of youth 15-24 years and determined the characteristics of those who were most likely to be tested for HIV within the past year. Method(s): Using data from the 2017-2018 Ethiopia Population-based HIV Impact Assessment, we provide survey-weighted estimates and prevalence risk ratios for engagement in HIV testing in the 12 months preceding the survey. We model the likelihood of HIV testing one year or more before the survey compared to never testing, using a multinomial logistic regression model. Result(s): Among HIV-negative and unaware HIV-positive youth 15-24 years old (N=7,508), 21.8% [95% Confidence Interval (CI): 20.4-23.3%] reported testing for HIV in the last 12 months. Female youth [Prevalence Ratio (PR)=1.6, 95% CI: 1.4-1.8], those aged 20-24 years (PR=2.6, 95% CI:2.3-2.9), and those ever married (PR=2.8, 95% CI: 2.5-3.1) were more likely to have tested for HIV within the last year. Adjusting for select demographic characteristics, sex with a non-spousal or non-live-in partner [Relative Risk (RR)=0.3, 95% CI:0.1-0.8] among males did not increase their likelihood to test for HIV in the prior 12 months. Female youth engaged in antenatal care (RR=3.0, 95% CI: 1.7-5.3) were more likely to test for HIV in the past year. Conclusion(s): The Ethiopian HIV case finding strategy may consider approaches for reaching untested youth, with a specific focus on adolescent males. This is critical towards achieving the UNAIDS HIV testing goal of 95% of all individuals living with HIV aware of their status by 2030. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available for use under a CC0 license. |
Adolescent Health Risk Behaviors, Adverse Experiences, and Self-reported Hunger: Analysis of 10 States from the 2019 Youth Risk Behavior Surveys
Krupsky KL , Sliwa S , Seligman H , Brown AD , Liese AD , Demissie Z , Barnidge E . J Hunger Environ Nutr 2022 1-17 We examined associations between adolescent self-reported hunger, health risk behaviors, and adverse experiences during the 2018–2019 school year. Youth Risk Behavior Survey data were pooled from 10 states. Prevalence ratios were calculated, and we assessed effect measure modification by sex. The prevalence of self-reported hunger was 13%. Self-reported hunger was associated with a higher prevalence of every health risk behavior/adverse experience analyzed, even after adjusting for sex, grade, and race/ethnicity. Sex did not modify associations. Findings underscore needs for longitudinal research with more robust measures of adolescent food insecurity to clarify the temporality of relationships. |
Trends in the teaching of sexual and reproductive health topics and skills in required courses in secondary schools, in 38 US states between 2008 and 2018
Szucs LE , Demissie Z , Steiner RJ , Brener ND , Lindberg L , Young E , Rasberry CN . Health Educ Res 2022 38 (1) 84-94 Information about state and local education policies regarding sexually transmitted infections, including human immunodeficiency virus, and unintended pregnancy prevention is available, yet less is known about school-level implementation of such policies. We examine trends in the percentage of US secondary schools teaching sexual and reproductive health (SRH) topics in a required course in Grades 6-8 and 9-12, including healthy relationships, sexual abstinence, condoms and condoms with other contraceptive methods. We analyze representative data from 38 states across six cycles of School Health Profiles (2008-18) assessed through self-administered questionnaires completed by lead health teachers. Logistic regression models examined linear trends in the percentages of schools teaching topics for Grades 6-8 and 9-12, separately. Trends were calculated for states having representative data for at least three cycles, including 2018. During 2008-18, it was more common to have increases in teaching how to obtain condoms, correct condom use and use condoms with other contraceptive methods in Grades 6-12 than decreases. More states showed decreases in teaching abstinence in Grades 6-12 than increases. Most states had no change in teaching SRH topics across grades. Findings suggest some improvement in school-based SRH education, yet efforts are needed to improve comprehensive, developmentally appropriate content. |
Racial-ethnic disparities in adolescent sexual behaviours: the cross-sectional Youth Risk Behavior Survey, 2009-19
Demissie Z , Ethier K , Williams K , Dunville R , Cavalier Y , Payne R , Underwood JM . Sex Health 2022 19 (5) 456-463 BACKGROUND: There are notable disparities by race/ethnicity in the sexual health of US adolescents and young adults. Our objective was to examine change over time in racial-ethnic disparities in sexual behaviours among US high school students. METHODS: Data were analysed from six biennial cycles of the national Youth Risk Behavior Survey (2009-19), conducted among cross-sectional, nationally representative samples of 9th-12th grade students. Data were collected via self-administered questionnaires. Multivariable logistic regression models tested for linear trends by race/ethnicity (White, Black, Hispanic) and differences in these trends in: ever had sex, current sexual activity, having four or more lifetime sexual partners, and condomless sex. Prevalence ratios and risk differences by race/ethnicity for each cycle were used to calculate average percent change in the estimates to determine if health disparities changed over time. RESULTS: During 2009-19, prevalence estimates for ever had sex, current sexual activity, and having four or more lifetime sexual partners decreased overall and across all racial-ethnic groups. For condomless sex, prevalence estimates increased over time overall (38.9-45.7%) and for Black (37.6-51.8%) and White (36.7-44.2%) students, but not Hispanic (45.1-43.8%) students. Significant differences in trends by race/ethnicity were observed for all variables. Data suggest that racial-ethnic health disparities for sexual behaviours decreased over time, except for condomless sex. CONCLUSIONS: Although racial-ethnic gaps in sexual behaviours may be shrinking for many behaviours, work is still needed to achieve health equity in risks associated with HIV/AIDS, sexually transmitted infections, and pregnancy. |
Spatial distribution and determinants of HIV prevalence among adults in urban Ethiopia: Findings from the Ethiopia Population-based HIV Impact Assessment Survey (2017-2018)
Gelibo T , Lulseged S , Eshetu F , Abdella S , Melaku Z , Ajiboye S , Demissie M , Solmo C , Ahmed J , Getaneh Y , Kaydos-Daniels SC , Abate E . PLoS One 2022 17 (7) e0271221 The design and evaluation of national HIV programs often rely on aggregated national data, which may obscure localized HIV epidemics. In Ethiopia, even though the national adult HIV prevalence has decreased, little information is available about local areas and subpopulations. To inform HIV prevention efforts for specific populations, we identified geographic locations and drivers of HIV transmission. We used data from adults aged 15-64 years who participated in the Ethiopian Population-based HIV Impact Assessment survey (October 2017-April 2018). Location-related information for the survey clusters was obtained from the 2007 Ethiopia population census. Spatial autocorrelation of HIV prevalence data were analyzed via a Global Moran's I test. Geographically weighted regression analysis was used to show the relationship of covariates. The finding indicated that uncircumcised men in certain hotspot towns and divorced or widowed individuals in hotspot woredas/towns might have contributed to the average increase in HIV prevalence in the hotspot areas. Hotspot analysis findings indicated that, localized, context-specific intervention efforts tailored to at-risk populations, such as divorced or widowed women or uncircumcised men, could decrease HIV transmission and prevalence in urban Ethiopia. |
Adherence to national malaria clinical management and testing guidelines in selected private clinics of Gambela Town, Gambela Region, Ethiopia: a mixed method study
Gindola Y , Getahun D , Sugerman D , Tongren E , Tokarz R , Wossen M , Demissie K , Zemelak E , Okugn A , Wendimu J , Hailu G , Tegistu M , Begna D . Malar J 2022 21 (1) 164 BACKGROUND: The World Health Organization World Malaria Report of 2019 indicated an estimated 228 million cases of malaria occurred worldwide in 2018. More than 75% of the total area of Ethiopia is malarious, making malaria a leading public health problem in Ethiopia. Adherence to clinical guidelines improves the quality of care received by patients, thus improving patient outcomes. This study investigates healthcare workers' adherence to malaria testing and treatment guidelines in selected private clinics of Gambela Town, Ethiopia. METHODS: A mixed study design involving a retrospective review of 425 patient files and 20 healthcare worker interviews in private clinics was implemented. Data were collected using pre-tested data collection forms. The collected data were then cleaned and entered into statistical software for analysis, with a level of significance set at<0.05. A qualitative analysis was also conducted using healthcare worker interviews to identify the existing barriers to guideline adherence. RESULTS: Among the 430 cases of suspected malaria, only 65% were tested for malaria. Of those tested, 75% tested positive and 25% tested negative. The most common co-morbidity in patients treated for malaria was anaemia (30%), followed by gastroenteritis (10%). Patients with co-morbidities were more likely to receive appropriate treatment (p=0.03) compared to those without co-morbidities. All healthcare workers interviewed were aware of the existence of the malaria treatment guidelines. However, many were not aware of the contents of the guidelines and only 40% had been trained to understand the guidelines. Overall, 85% of the workers claimed to adhere to guidelines, with 15% claiming non-adherence. CONCLUSION: The gap between knowledge of the malaria treatment guidelines and their application by healthcare workers remains wide. The level of knowledge of these guidelines was also low. Continuous training, follow-up, supportive supervision, and improved adherence to the malaria guidelines are therefore recommended. |
Food insecurity and suicidal behaviors among US high school students
Brown AD , Seligman H , Sliwa S , Barnidge E , Krupsky KL , Demissie Z , Liese AD . J Sch Health 2022 92 (9) 898-906 BACKGROUND: Food insecurity (FI) rates in the United States are particularly high among households with children. This research set aims to analyze if high school students experiencing FI had higher risk for mental health and suicidal behaviors. METHODS: Using combined data from 11 states that conducted the 2017 Youth Risk Behavior Survey, a total of 26,962 and 24,051 high school students were used to estimate race/ethnicity and sex-stratified prevalence ratios (PRs) from Poisson regression models. A single-question was used to measure the exposure of FI and outcomes of mental health and suicidal behaviors. RESULTS: Overall, 10.8% of students reported FI. Students experiencing FI had increased risk for all mental health and suicide behavior outcomes, regardless of their race/ethnicity or sex. PRs ranged from 1.9 (95% confidence interval [CI]:1.8, 2.0) to 3.1 (CI: 2.7, 3.6). Among males, PRs for the association between FI and all outcomes were highest among non-Hispanic black students (PRs ranged from 2.4 [CI: 1.7, 3.2] to 5.5 [CI: 2.3, 13.3]). Among females, PRs were highest among non-Hispanic white students (PRs ranged from 1.9 [CI:1.7, 2.1] to 3.6 [CI:2.9, 4.5]). CONCLUSIONS: FI is consistently associated with mental health and suicidal behaviors among different subgroups of students. |
Factors associated with quit attempt and successful quitting among adults who smoke tobacco in Ethiopia: Global Adult Tobacco Survey (GATS) 2016
Demissie HS , Smith T , de Quevedo IG , Kress AC , Twentyman E . Tob Prev Cessat 2022 8 12 INTRODUCTION: Tobacco is the leading cause of preventable death in the world. Identification of factors associated with quit attempts and successful quitting can help strengthen tobacco cessation programs. In Ethiopia, no prior study of such factors exists. Our aim was to identify factors associated with quit attempts and successful quitting among adults who smoke tobacco in Ethiopia. METHODS: We used the Ethiopian 2016 Global Adult Tobacco Survey (GATS) data (n=10150). GATS is a nationally representative household survey that collects data on sociodemographic and tobacco-related characteristics. We calculated prevalence of reported past 12 months quit attempts and successful quitting and performed logistic regression to obtain prevalence ratios with 95% confidence intervals. A p<0.05 was considered statistically significant. RESULTS: Overall 42.0% of people who smoked tobacco made a quit attempt. Men were more likely (APR=3.9; 95% CI: 1.4-10.7) to make a quit attempt compared to women but were less likely to successfully quit (APR=0.6; 95% CI: 0.3-0.9). Those aware of the health harms of tobacco were 2.5 (95% CI: 1.1-5.5) and 3.9 (95% CI: 1.8-8.5) times as likely to make a quit attempt and successfully quit, respectively, than those unaware. Receiving healthcare provider advice to quit was not associated with quit attempts. CONCLUSIONS: More than 4 in 10 people smoking tobacco in Ethiopia are making attempts to quit. Receipt of healthcare provider advice to quit is not yet associated with quit attempts in Ethiopia; however, awareness of the health harms of tobacco is a powerful predictor of quit attempt and success in quitting. Improved access to cessation support and expanded awareness of the health harms of tobacco are urgently needed to enhance both quit attempts and success across Ethiopia. |
Trends in teaching sexual and reproductive health skills in US secondary schools in 35 states, 2008 to 2018
Young E , Demissie Z , Brener ND , Benes S , Szucs LE . J Sch Health 2022 92 (7) 711-719 BACKGROUND: Little is known about trends in implementing skills-based instruction in US schools, specifically for sexual and reproductive health (SRH). We examined state-level trends in the percentage of US secondary schools teaching SRH skills in a required course in grades 6 to 8 and 9 to 12. METHODS: Representative data from 35 states participating across 6 cycles of School Health Profiles (2008-2018) was analyzed. The prevalence of teaching four SRH skills was assessed through lead health education teacher self-administered questionnaires. Logistic regression models examined linear trends in the percentages of schools teaching SRH skills in grades 6 to 8 and 9 to 12. Trends were calculated for states with weighted data (response rates ≥70%) for at least 3 cycles, including 2018. RESULTS: During 2008 to 2018, the median percentage of schools addressing each SRH skill ranged from 63.5% to 69.7% (grades 6-8) and 88.2% to 92.0% (grades 9-12). Linear decreases in SRH skills instruction were more common for grades 6 to 8 than grades 9 to 12; linear increases were comparable for both groups. Most states demonstrated no change in the percentage of schools teaching SRH skills in grades 6 to 8 and 9 to 12. CONCLUSIONS: Limited changes and decreases in SRH skills instruction in US secondary schools suggest efforts to strengthen SRH education are needed. |
Food Insecurity and Its Association With Alcohol and Other Substance Use Among High School Students in the United States
Turner VE , Demissie Z , Sliwa SA , Clayton HB . J Sch Health 2021 92 (2) 177-184 BACKGROUND: Studies show that food insecurity is associated with adverse health behaviors for children and adults. However, published data among adolescents are limited. The objective of this study was to examine the association between food insecurity and substance use behaviors among US high school students. METHODS: Data from the 2017 Youth Risk Behavior Survey in 10 states were combined to examine the association between household food insecurity and adolescent use of alcohol, marijuana, prescription opioid misuse, and illicit drugs using logistic regression. RESULTS: Among surveyed respondents, 12.3% of high school students reported experiencing food insecurity. In unadjusted analyses, the prevalence of substance use was higher among students with food insecurity compared to food secure students: current binge drinking (16.2% vs 11.5%), current marijuana use (24.0% vs 16.2%), lifetime prescription opioid misuse (21.3% vs 12.6%), and lifetime use of illicit drugs (12.3% vs 5.0%) (all p < .05). In adjusted models, food insecurity was associated with lifetime prescription opioid misuse and lifetime use of illicit drugs (aPR 1.38 and 1.70, respectively). CONCLUSION: Students with food insecurity are a potential group at a higher rise of substance misuse and may benefit from prevention programs designed to address their needs. |
COVID-19-Associated Orphanhood and Caregiver Death in the United States
Hillis SD , Blenkinsop A , Villaveces A , Annor FB , Liburd L , Massetti GM , Demissie Z , Mercy JA , Nelson CA3rd , Cluver L , Flaxman S , Sherr L , Donnelly CA , Ratmann O , Unwin HJT . Pediatrics 2021 148 (6) BACKGROUND: Most coronavirus disease 2019 (COVID-19) deaths occur among adults, not children, and attention has focused on mitigating COVID-19 burden among adults. However, a tragic consequence of adult deaths is that high numbers of children might lose their parents and caregivers to COVID-19-associated deaths. METHODS: We quantified COVID-19-associated caregiver loss and orphanhood in the United States and for each state using fertility and excess and COVID-19 mortality data.We assessed burden and rates of COVID-19-associated orphanhood and deaths of custodial and coresiding grandparents, overall and by race and ethnicity. We further examined variations in COVID-19-associated orphanhood by race and ethnicity for each state. RESULTS: We found that fromApril 1, 2020, through June 30, 2021,>140 000 children in the United States experienced the death of a parent or grandparent caregiver. The risk of such losswas 1.1 to 4.5 times higher among children of racial and ethnicminority groups compared with non-Hispanic White children. The highest burden of COVID-19-associated death of parents and caregivers occurred in Southern border states for Hispanic children, in Southeastern states for Black children, and in stateswith tribal areas for American Indian and/or Alaska Native populations. CONCLUSIONS: We found substantial disparities in distributions of COVID-19-associated death of parents and caregivers across racial and ethnic groups. Children losing caregivers to COVID-19 need care and safe, stable, and nurturing families with economic support, quality child care, and evidence-based parenting support programs. There is an urgent need tomount an evidence-based comprehensive response focused on those children at greatest risk in the statesmost affected. © 2021 American Academy of Pediatrics. All rights reserved. |
Factors associated with unawareness of HIV-positive status in urban Ethiopia: Evidence from the Ethiopia population-based HIV impact assessment 2017-2018
Lulseged S , Belete W , Ahmed J , Gelibo T , Teklie H , West CW , Melaku Z , Demissie M , Farhani M , Eshetu F , Birhanu S , Getaneh Y , Patel H , Voetsch AC . PLoS One 2021 16 (8) e0255163 BACKGROUND: The HIV epidemic in Ethiopia is concentrated in urban areas. Ethiopia conducted a Population-based HIV Impact Assessment (EPHIA) in urban areas between October 2017 and April 2018 to measure the status of the country's response to the epidemic. METHODS: We conducted field data collection and HIV testing in randomly selected households using the national, rapid testing algorithm with laboratory confirmation of seropositive samples using a supplemental assay. In addition to self-report on HIV diagnosis and treatment, all HIV-positive participants were screened for a set of HIV antiretroviral (ARV) drugs indicative of the first- and second-line regimens. We calculated weighted frequencies and 95% confidence intervals to assess regional variation in participants' level of unawareness of their HIV-positive status (adjusted for ARV status). RESULTS: We interviewed 20,170 survey participants 15-64 years of age, of which 19,136 (95%) were tested for HIV, 614 (3.2%) tested positive, and 119 (21%) of HIV-positive persons were unaware of their HIV status. Progress towards the UNAIDS first 90 target (90% of people living with HIV would be aware of their HIV status by 2020) substantially differed by administrative region of the country. In the bivariate analysis using log binomial regression, three regions (Oromia, Addis Ababa, and Harari), male gender, and young age (15-24 years) were significantly associated with awareness of HIV positive status. In multivariate analysis, the same variables were associated with awareness of HIV-positive status. CONCLUSION: One-fifth of the HIV-positive urban population were unaware of their HIV-positive status. The number of unaware HIV-positive individuals has a different distribution than the HIV prevalence. National and regional planning and monitoring activities could address this potentially substantial source of undetected HIV infection by increasing HIV testing among young people, men and individuals who do not use condoms. |
School-level poverty and rurality associated with differences in sexual risk behaviors among U.S. public high school students
Underwood JM , Pampati S , Everett Jones S , Bryan LN , Demissie Z , Cavalier Y , Rasberry CN . J Adolesc Health 2021 69 (6) 964-969 PURPOSE: This study examined associations between student sexual behaviors and both school-level socioeconomic status and metropolitan status. METHODS: National Youth Risk Behavior Survey data from 2017 (N = 14,765, response rate = 60%) and 2019 (N = 13,677, 60%) were combined. School-level socioeconomic status (low-, mid-, and high-poverty based on the percentage of students eligible for free or reduced-price meals) and metropolitan status (urban, suburban/town, or rural) were identified for students attending public high schools. Sexual behaviors included currently sexually active, four or more lifetime sexual partners, condom use during the last sexual intercourse, hormonal birth control use during the last sexual intercourse, condom and hormonal birth control use during the last sexual intercourse, and drank alcohol or used drugs before the last sexual intercourse. Adjusted prevalence ratios were calculated using logistic regression models, controlling for sex, race/ethnicity, and grade. RESULTS: Compared to students attending low-poverty schools, high-poverty school students were significantly more likely to be currently sexually active (adjusted prevalence ratio = 1.4 [95% confidence interval = 1.1-1.8]) and have four or more lifetime sexual partners (1.6 [1.0-2.5]), but were significantly less likely to have drank alcohol or used drugs before the last sexual intercourse (.7 [.5-.9]) and have used hormonal birth control during the last sexual intercourse (.7 [.6-1.0]). Compared to students attending rural schools, urban school students were significantly less likely to be currently sexually active (.8 [.7-.9]) and have four or more lifetime sexual partners (.7 [.5-.9]). CONCLUSIONS: School-level socioeconomic status and metropolitan status were associated with differential risk in sexual behaviors. |
Initiation of nonmedical use of prescription opioids among high school students
Deputy NP , Lowry R , Clayton HB , Demissie Z , Bohm MK , Conklin S . Subst Abus 2021 42 (4) 1-6 Nonmedical use of prescription opioids (NUPO) is associated with heroin use and other adverse outcomes among adolescents. To inform the timing of substance use prevention activities and which substances to target, we examined age at NUPO initiation, associations between substance use initiation and current (past 30-day) NUPO, and order of NUPO initiation relative to other substances. Methods: Data from 2,834 students aged 15 or older participating in the 2017 Virginia Youth Survey, the first Youth Risk Behavior Surveillance System survey to assess age at NUPO initiation and current NUPO, were analyzed in 2019. Students reported current NUPO and ages at initiation for cigarettes, alcohol, marijuana, and NUPO (categorized as 12 or younger, 13 or 14, 15 or older, or never). Associations between age at substance use initiation and current NUPO were examined using adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs). Results: Overall, 12% of students reported lifetime NUPO, with 2.4%, 4.0%, and 5.6% initiating at 12 or younger, 13 or 14, and 15 or older, respectively; 5.3% reported current NUPO. Initiating cigarettes, alcohol, and marijuana at each age category (compared with never) was associated with an increased prevalence of current NUPO after adjusting for demographics and initiation of other substances. Among students initiating NUPO, initiating NUPO at 12 or younger (compared with 15 or older) was associated with an increased prevalence of current NUPO after adjusting for demographics (aPR = 1.54, 95% CI: 1.10-2.16), but not after further adjustment for initiation of other substances (aPR = 1.38, 95% CI = 0.97-1.97). Among students initiating NUPO, 45.4% initiated NUPO before or during the same age as other substances. Conclusions: More than 6% of students initiated NUPO at 14 or younger. Younger substance use initiation was associated with current NUPO, suggesting that some students may benefit from prevention activities during early adolescence that address multiple substances. |
Percentage of adolescents meeting federal fruit and vegetable intake recommendations - Youth Risk Behavior Surveillance System, United States, 2017
Lange SJ , Moore LV , Harris DM , Merlo CL , Lee SH , Demissie Z , Galuska DA . MMWR Morb Mortal Wkly Rep 2021 70 (3) 69-74 According to the 2020-2025 Dietary Guidelines for Americans, persons should consume fruits and vegetables as part of a healthy eating pattern to reduce their risk for diet-related chronic diseases, such as cardiovascular disease, type 2 diabetes, some cancers, and obesity.* A healthy diet is important for healthy growth in adolescence, especially because adolescent health behaviors might continue into adulthood (1). The U.S. Department of Agriculture (USDA) recommends minimum daily intake of 1.5 cups of fruit and 2.5 cups of vegetables for females aged 14-18 years and 2 cups of fruit and 3 cups of vegetables for males aged 14-18 years.(†) Despite the benefits of fruit and vegetable consumption, few adolescents consume these recommended amounts (2-4). In 2013, only 8.5% of high school students met the recommendation for fruit consumption, and only 2.1% met the recommendation for vegetable consumption (2). To update the 2013 data, CDC analyzed data from the 2017 national and state Youth Risk Behavior Surveys (YRBSs) to describe the percentage of students who met intake recommendations, overall and by sex, school grade, and race/ethnicity. The median frequencies of fruit and vegetable consumption nationally were 0.9 and 1.1 times per day, respectively. Nationally, 7.1% of students met USDA intake recommendations for fruits (95% confidence interval [CI] = 4.0-10.3) and 2.0% for vegetables (upper 95% confidence limit = 7.9) using previously established scoring algorithms. State-specific estimates of the percentage of students meeting fruit intake recommendations ranged from 4.0% (Connecticut) to 9.3% (Louisiana), and the percentage meeting vegetable intake recommendations ranged from 0.6% (Kansas) to 3.7% (New Mexico). Additional efforts to expand the reach of existing school and community programs or to identify new effective strategies, such as social media approaches, might help address barriers and improve adolescent fruit and vegetable consumption. |
Features of Streptococcus agalactiae strains recovered from pregnant women and newborns attending different hospitals in Ethiopia.
Ali MM , Woldeamanuel Y , Asrat D , Fenta DA , Beall B , Schrag S , McGee L . BMC Infect Dis 2020 20 (1) 848 BACKGROUND: Streptococcus agalactiae (Group B Streptococcus, GBS) serotypes, sequence types, and antimicrobial resistance profile vary across different geographic locations affecting disease patterns in newborns. These differences are important considerations for vaccine development efforts and data from large countries in Africa is limited. The aim of this study was to determine serotypes and genotypes of GBS isolates from pregnant women and their newborns in Ethiopia. METHODS: A hospital based cross-sectional study was conducted at three hospitals in Ethiopia from June 2014 to September 2015. Out of 225 GBS isolates, 121 GBS were recovered, confirmed and characterized at CDC's Streptococcus Laboratory using conventional microbiology methods and whole genome sequencing. RESULTS: Of the 121 isolates, 87 were from rectovaginal samples of pregnant women, 32 from different body parts of their newborns and 2 from blood of newborns with suspected sepsis. There were 25 mother-infant pairs and 24 pairs had concordant strains. The most prevalent serotypes among mothers and/or their babies were II, Ia and V (41.5, 20.6, 19.5 and 40.6%, 25 and 15.6%, respectively). Multilocus sequence typing (MLST) on 83 isolates showed ST10 (24; 28.9%) and ST2 (12; 14.5%) as most predominant sequence types. All GBS strains were susceptible to penicillin, cefotaxime and vancomycin, which correlated to the presence of wildtype PBP2x types and the lack of known vancomycin-resistance genes. Tetracycline resistance was high (73; 88%, associated primarily with tetM, but also tetO and tetL). Five isolates (6%) were resistant to erythromycin and clindamycin and 3 isolates were fluoroquinolone-resistant, containing associated mutations in gyrA and parC genes. All isolates were positive for one of four homologous Alpha/Rib family determinants and 1-2 of the three main pilus types. CONCLUSIONS: Predominant serotypes were II, Ia, and V. A limited number of clonal types were identified with two STs accounting for about half of the isolates. All strains collected in this study were susceptible to beta-lactam antibiotics and vancomycin. Typical of most GBS, these isolates were positive for single alpha-like family protein, serine-rich repeat gene, as well as 1-2 pilus determinants. |
School-level poverty and persistent feelings of sadness or hopelessness, suicidality, and experiences with violence victimization among public high school students
Jones SE , Michael Underwood J , Pampati S , Le VD , Degue S , Demissie Z , Adkins SH , Barrios LC . J Health Care Poor Underserved 2020 31 (3) 1248-1263 Objectives. To examine the association between school-level poverty status and students’ persistent feelings of sadness or hopelessness, suicidality, and experiences with violence victimization among U.S. high school students. Methods. Public schools captured in the 2015 and 2017 national Youth Risk Behavior Surveys were categorized as high-, mid-, or low-poverty based on the percentage of students eligible for free or reduced-price meals (N=29,448). Results. Students in high-poverty schools were significantly more likely than students in low-poverty schools to experience persistent feelings of sadness or hopelessness, experience suicidal thoughts and attempts, not go to school because of safety concerns, be threatened or injured with a weapon on school property, be bullied on school property, be physically forced to have sexual intercourse, and be victims of sexual and physical dating violence. Conclusions. School and community approaches to address suicide and violence victimization may be especially important for students living in poverty. |
Factors associated with HIV testing among Atlanta's homeless youth
Myles RL , Best J , Bautista G , Wright ER , LaBoy A , Demissie Z , Dean HD . AIDS Educ Prev 2020 32 (4) 325-336 Homeless youth experience increased risk of contracting HIV, making HIV testing imperative in this population. We analyzed factors associated with HIV testing among homeless youth in Atlanta, Georgia using data from the 2015 Atlanta Youth Count and Needs Assessment. The analysis included 693 homeless youth aged 14-25 years, of whom 88.4% reported ever being tested for HIV, and 74.6% reported being tested within the previous year. Prevalence of ever testing for HIV was significantly higher among youth who reported risk factors for HIV (sexually active, transactional sex, or ever having an STI). Higher prevalence of testing within the last year was significantly associated with experiencing physical abuse or transactional sex. However, reporting ≥ 4 sexual partners or not using condoms were not associated with higher testing. Although testing prevalence among homeless youth was high, homeless youth engaging in certain high risk behaviors could benefit from further promotion of HIV testing. |
Transgender identity and experiences of violence victimization, substance use, suicide risk, and sexual risk behaviors among high school students - 19 states and large urban school districts, 2017
Johns MM , Lowry R , Andrzejewski J , Barrios LC , Demissie Z , McManus T , Rasberry CN , Robin L , Underwood JM . MMWR Morb Mortal Wkly Rep 2019 68 (3) 67-71 Transgender youths (those whose gender identity* does not align with their sex(dagger)) experience disparities in violence victimization, substance use, suicide risk, and sexual risk compared with their cisgender peers (those whose gender identity does align with their sex) (1-3). Yet few large-scale assessments of these disparities among high school students exist. The Youth Risk Behavior Survey (YRBS) is conducted biennially among local, state, and nationally representative samples of U.S. high school students in grades 9-12. In 2017, 10 states (Colorado, Delaware, Hawaii, Maine, Maryland, Massachusetts, Michigan, Rhode Island, Vermont, Wisconsin) and nine large urban school districts (Boston, Broward County, Cleveland, Detroit, District of Columbia, Los Angeles, New York City, San Diego, San Francisco) piloted a measure of transgender identity. Using pooled data from these 19 sites, the prevalence of transgender identity was assessed, and relationships between transgender identity and violence victimization, substance use, suicide risk, and sexual risk behaviors were evaluated using logistic regression. Compared with cisgender males and cisgender females, transgender students were more likely to report violence victimization, substance use, and suicide risk, and, although more likely to report some sexual risk behaviors, were also more likely to be tested for human immunodeficiency virus (HIV) infection. These findings indicate a need for intervention efforts to improve health outcomes among transgender youths. |
Meeting fruit and vegetable consumption and physical activity recommendations among adolescents intending to lose weight
Kakinami L , Houle-Johnson SA , Demissie Z , Santosa S , Fulton JE . Prev Med Rep 2019 13 11-15 Two-thirds of adolescents who are overweight or have obesity report weight loss intentions. Most report using weight loss strategies consistent with expert recommendations for obesity prevention; however whether they meet recommended fruit and vegetable (F&V) intake and physical activity (PA) recommendations is unknown. We investigated whether weight loss attempts, and weight loss strategies were associated with meeting F&V and PA recommendations. Data were from the 2010 National Youth Physical Activity and Nutrition Study, which surveyed a cross-sectional, nationally representative sample of U.S. high school students. Analyses were restricted to overweight/obese students (n=2841). Adjusted logistic regression models assessed the odds of meeting daily F&V and weekly PA recommendations after adjusting for grade, sex, race/ethnicity and perceived weight status. Compared to students who were overweight and were not currently intending to lose weight, students who were overweight and intending to lose weight were not more likely to meet F&V or PA. Among students with obesity, those who intended to lose weight were more likely than students who were not currently intending to lose weight to meet F&V recommendations (OR: 3.62, 95% CI: 1.70-7.73). Students who were overweight/obese and used F&V or PA for weight loss were significantly more likely to meet the corresponding recommendation than students intending to lose weight without specific strategies. Weight loss attempts alone do not affect the likelihood of meeting most expert recommendations. Public health efforts emphasizing recommended strategies for healthy eating and active living still need to be encouraged for overweight/obese youth. |
Sexual teen dating violence victimization: Associations with sexual risk behaviors among U.S. high school students
Demissie Z , Clayton HB , Vivolo-Kantor AM , Estefan LF . Violence Vict 2018 33 (5) 964-980 Adolescent dating violence may lead to adverse health behaviors. We examined associations between sexual teen dating violence victimization (TDVV) and sexual risk behaviors among U.S. high school students using 2013 and 2015 National Youth Risk Behavior Survey data (combined n = 29,346). Sex-stratified logistic regression models were used to estimate these associations among students who had dated or gone out with someone during the past 12 months (n = 20,093). Among these students, 10.5% experienced sexual TDVV. Sexual TDVV was positively associated with sexual intercourse before age 13, four or more lifetime sexual partners, current sexual activity, alcohol or drug use before last sexual intercourse, and no pregnancy prevention during last sexual intercourse. Given significant findings among both sexes, it is valuable for dating violence prevention efforts to target both female and male students. |
Association between receipt of school-based HIV education and contraceptive use among sexually active high school students United States, 20112013
Demissie Z , Clayton HB , Dunville RL . Sex Educ 2018 19 (2) 237-246 Sexual health education, including HIV prevention information, can help prevent unintended pregnancy and sexually transmitted infections. National Youth Risk Behavior Survey data from 2011 and 2013 were used to determine HIV education prevalence among 9,825 currently sexually active students in grades 912. Associations between HIV education and contraceptive methods used at last sexual intercourse were examined for: (1) condom use; (2) any contraceptive method; (3) dual use of a condom and either birth control pills; IUD or implant; or shot, patch, or birth control ring; and (4) primary contraceptive method. Primary contraceptive method options were (1) no method; (2) birth control pills; (3) condoms; (4) IUD or implant; (5) shot, patch, or birth control ring; (6) withdrawal or some other method; and (7) not sure. Logistic regression (prevalence ratios [PRs] and 95% confidence intervals [CIs]) and Chi-squares were used for testing. Students who received HIV education were more likely than students who did not to use a condom (PR:1.09;CI:1.01,1.18) and any contraceptive method (PR:1.08;CI:1.04,1.12); there was no significant association with dual use. Primary contraceptive method varied significantly by receipt of HIV education (p<.001). School-based HIV education may be important for promotion of adolescent condom and contraceptive use. |
Epidemiology of influenza in Ethiopia: findings from influenza sentinel surveillance and respiratory infection outbreak investigations, 2009-2015
Woyessa AB , Mengesha M , Belay D , Tayachew A , Ayele W , Beyene B , Kassa W , Zemelak E , Demissie G , Amare B , Boulanger L , Granados C , Williams T , Tareke I , Rajatonirina S , Jima D . BMC Infect Dis 2018 18 (1) 449 BACKGROUND: Influenza is an acute viral disease of the respiratory tract which is characterized by fever, headache, myalgia, prostration, coryza, sore throat and cough. Globally, an estimated 3 to 5 million cases of severe influenza illness and 291 243-645 832 seasonal influenza-associated respiratory deaths occur annually. Although recent efforts from some African countries to describe burden of influenza disease and seasonality, these data are missing for the vast majority, including Ethiopia. Ethiopia established influenza sentinel surveillance in 2008 aiming to determine influenza strains circulating in the country and know characteristics, trend and burden of influenza viruses. METHODS: We used influenza data from sentinel surveillance sites and respiratory disease outbreak investigations from 2009 to 2015 for this analysis. We obtained the data by monitoring patients with influenza-like illness (ILI) at three health-centers, severe acute respiratory infection (SARI) at five hospitals and investigating patients during different respiratory infection outbreaks. Throat-swab specimens in viral transport media were transported to the national reference laboratory within 72 h of collection using a cold-chain system. We extracted viral RNA from throat-swabs and subjected to real-time PCR amplification. We further subtyped and characterized Influenza A-positive specimens using CDC real-time reverse transcription PCR protocol. RESULTS: A total of 4962 throat-swab samples were collected and 4799 (96.7%) of them were tested. Among them 988 (20.6%) were influenza-positive and of which 349 (35.3%) were seasonal influenza A(H3N2), 321 (32.5%) influenza A(H1N1)pdm2009 and 318 (32.0%) influenza B. Positivity rate was 29.5% in persons 5-14 years followed by 26.4% in 15-44 years, 21.2% in > 44 years and 6.4% in under five children. The highest positivity rate observed in November (37.5%) followed by March (27.6%), December (26.4%), October (24.4%) and January (24.3%) while the lowest positivity rate was in August (7.7%). CONCLUSION: In Ethiopia, seasonal Influenza A(H3N2), Influenza A(H1N1)pdm2009 and Influenza B viruses were circulating during 2009-2015. Positivity rate and number of cases peaked in November and December. Influenza is one of public health problems in Ethiopia and the need to introduce influenza vaccine and antivirus is important to prevent and treat the disease in future. |
Secular changes in physical education attendance among U.S. high school students, 1991-2015
Clennin MN , Demissie Z , Michael SL , Wright C , Silverman S , Chriqui J , Pate RR . Res Q Exerc Sport 2018 89 (4) 1-8 PURPOSE: The purpose of this study was to examine changes in school-based physical education (PE) attendance over time among nationally representative samples of U.S. high school students and how changes in PE attendance have varied across demographic subgroups. METHOD: Student demographic information and PE attendance data were obtained from 13 biennial cycles (1991-2015) of the national Youth Risk Behavior Survey (YRBS). Physical education variables derived from YRBS data included PE attendance, daily PE, average PE days/week, and PE frequency. Logistic regression models examined trends in PE attendance, daily PE, and PE frequency for the overall sample and demographic subgroups. Linear regression models examined trends in average PE days/week in the overall sample only. RESULTS: Overall, there was no significant change in the percentage of students reporting PE attendance during 1991 to 2015. However, daily PE and average PE days/week declined significantly from 1991 to 1995 (41.6% to 25.4% and 4.64 days to 3.64 days, respectively) and then remained stable through 2015 (29.8% and 4.11 days, respectively). The percentage of students reporting a PE frequency of 3 days per week increased significantly from 1991 to 1995 (1.5% to 19.0%) before stabilizing through 2015 (9.1%). Trends across demographic subgroups revealed notable differences in PE attendance. CONCLUSIONS: Study findings showed that U.S. schools have not substantially reduced PE amounts in recent years. Still, the prevalence of PE attendance among U.S. high school students is well below recommendations. For PE to contribute to increased adolescent compliance with national physical activity guidelines, significant policy actions are needed to improve PE access for all students. |
Counseling, psychological, and social services staffing: Policies in U.S. school districts
Brener N , Demissie Z . Am J Prev Med 2018 54 S215-s219 INTRODUCTION: Schools are in a unique position to meet the mental and behavioral health needs of children and adolescents because approximately 95% of young people aged 7-17 years attend school. Little is known, however, about policies related to counseling, psychological, and social services staffing in school districts. This study analyzed the prevalence of such policies in public school districts in the U.S. METHODS: Data from four cycles (2000, 2006, 2012, and 2016) of the School Health Policies and Practices Study, a national survey periodically conducted to assess policies and practices for ten components of school health, were analyzed in 2017. The survey collected data related to counseling, psychological, and social services among nationally representative samples of school districts using online or mailed questionnaires. Sampled districts identified respondents responsible for or most knowledgeable about the content of each questionnaire. RESULTS: The percentage of districts with a district-level counseling, psychological, and social services coordinator increased significantly from 62.6% in 2000 to 79.5% in 2016. In 2016, 56.3% of districts required each school to have someone to coordinate counseling, psychological, and social services at the school. Fewer districts required schools at each level to have a specified ratio of counselors to students (16.2% for elementary schools, 16.8% for middle schools, and 19.8% for high schools), and the percentage of districts with these requirements has decreased significantly since 2012. CONCLUSIONS: Increases in the prevalence of district-level staffing policies could help increase the quantity and quality of counseling, psychological, and social services staff in schools nationwide, which in turn could improve mental and behavioral health outcomes for students. SUPPLEMENT INFORMATION: This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services. |
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