Pediatric Annals

CME 

Community Matters for Children’s Health

Sheri Johnson, PhD; Katherine Dickinson, PhD; Carmen Gomez Mandic, ScD, MPH; Earnestine Willis, MD, MPH

Abstract

CME Educational Objectives

1. Describe a cross-theoretical conceptualization of how community factors affect children’s health.

2. Provide examples of how community conditions affect common health concerns often faced by health professionals in the clinical setting.

3. Identify opportunities to leverage professional knowledge of community conditions and public policy to improve the health of children.

What makes us healthy? Providing guidance to families regarding prevention and diagnosing and treating illness are the foundations of clinical practice. Yet medical care directed at improving and preserving the health of the individual patient accounts for only about 15% to 20% of what makes us healthy at a population level. Community factors, such as the quality of housing, safety of neighborhoods, and availability of livable-wage jobs for adults, frequently referred to as social determinants of health, account for a much larger proportion of what makes people healthy.


Abstract

CME Educational Objectives

1. Describe a cross-theoretical conceptualization of how community factors affect children’s health.

2. Provide examples of how community conditions affect common health concerns often faced by health professionals in the clinical setting.

3. Identify opportunities to leverage professional knowledge of community conditions and public policy to improve the health of children.

What makes us healthy? Providing guidance to families regarding prevention and diagnosing and treating illness are the foundations of clinical practice. Yet medical care directed at improving and preserving the health of the individual patient accounts for only about 15% to 20% of what makes us healthy at a population level. Community factors, such as the quality of housing, safety of neighborhoods, and availability of livable-wage jobs for adults, frequently referred to as social determinants of health, account for a much larger proportion of what makes people healthy.


What makes us healthy? Providing guidance to families regarding prevention and diagnosing and treating illness are the foundations of clinical practice. Yet medical care directed at improving and preserving the health of the individual patient accounts for only about 15% to 20% of what makes us healthy at a population level. Community factors, such as the quality of housing, safety of neighborhoods, and availability of livable-wage jobs for adults, frequently referred to as social determinants of health, account for a much larger proportion of what makes people healthy.1

The spatial and social aspects of communities form a critical part of children’s developmental contexts and play key roles in shaping children’s health-related behaviors and outcomes. Insofar as these contexts are shaped by public policies, they become legitimate targets for clinician advocates to pursue on behalf of the children they serve. Just as individual behavioral factors, adherence to medication regimens, level of physical activity, and nutritional intake are amenable to intervention and change, so too are the community-level conditions that promote and sustain health. Community-level factors are capable of either creating or constraining the opportunities children, and their caregivers have to engage in healthy behaviors and avoid negative environmental exposures.

The understanding that a child’s health is maximized through a nested, dynamic system that promotes healthy families, peer groups, neighborhoods, and schools is certainly not new or unknown to pediatricians.2 This conceptualization of children’s health, however, suggests that the focus of clinician advocates should continue to expand beyond genetic predisposition and individual behavior to include the broader social, spatial, and economic contexts where children may or may not thrive. The role that public policy can play becomes a necessary consideration when health is defined in broader terms.

This article will:

  • Describe a cross-theoretical conceptualization of how community factors affect children’s health;
  • Provide examples of how community conditions affect common health concerns that pediatricians and other child health professionals address in the clinical setting; and
  • Identify opportunities for pediatricians to leverage their knowledge of community conditions and public policy to improve the health of children in their care.

Defining Community

For the purposes of this article, we define community as the combined spatial and social contexts in which children live and grow. Our focus on community stems from a basic understanding that individuals do not exist in isolation but rather interact in socially-defined and constructed spaces. These interactions with places and people shape children’s health-related behaviors, form and sustain the conditions in which children develop, and ultimately produce health outcomes for children.

The spatial component of a child’s community is made up of the natural and built environments. This includes housing structures, air quality, child care centers, and parents’ workplaces, as well as shops, parks, food outlets, and health facilities. The social component of community includes the people with whom a child interacts in those spaces: family, friends, neighbors, teachers, doctors, social workers, and police for example. Spatial and social components are not independent of one another but rather interact in important ways to influence the circumstances that create health. Physical spaces help to shape and structure social interactions.

For example, walkable, mixed-use neighborhoods that include commercial, recreational, and residential space may foster more frequent interactions among neighbors. Conversely, predominantly car-oriented neighborhoods can make these interactions more difficult by limiting unplanned contacts and locating social venues, such as stores and churches, away from the residential area.3

Social groups can also play a role in shaping the physical environment. More cohesive, educated, and/or organized social networks may demand more sidewalks or parks, better schools, or community structures, which in turn support continued interactions among group members.

Our conceptualization draws from several other attempts to define which characteristics of community are most relevant for health. McKnight defined community as “the great ‘out-there-ness’ beyond the doors of professional offices and facilities — the social space beyond the edges of our professional systems.”4 Earls and Carlson point out that communities vary in terms of their composition (ie, racial/ethnic background, socioeconomic position); structure (ie, political and economic aspects reflected in features of housing, transportation, work, school, commerce, and recreational facilities); and function (ie, quality of interactions, collective efficacy).5

Similarly, Weijer and Emmanuel define community as a group of people who are bound together by commonalities, including: self-identification as a community; shared culture and communication networks; collective priority setting and decision-making; common economy; and political authority.6 Finally, the National Institutes of Health (NIH) define community as “target populations that may be defined by: geography, race, ethnicity, gender, sexual orientation, disability, illness, or other health condition,” or, alternatively, “groups that have a common interest or cause, such as health or service agencies and organizations, health care or public health practitioners or providers, policy makers, or lay public groups with public health concerns.”7

All of these perspectives and definitions recognize that there are spatial and social aspects of community, which affect the health and well-being of children. Policy-making processes and solutions that focus on community drivers of children’s health are therefore needed to arrange conditions and opportunities in ways that promote health and well-being and that have the potential to reduce the inequities in health outcomes that exist across and within communities.

How Community Matters for Children’s Health

Community matters because the spatial and social contexts in which children develop physically, socially, and emotionally can have profound effects on children’s health. In this section we explore two theoretical perspectives — public health and health economics — which illustrate some of the pathways through which community shapes health behaviors and health outcomes.

Public Health Perspective

Public health perspectives on the importance of community for health are informed by multiple disciplines and areas of practice, including child development, epidemiology, health promotion, social work, and sociology.2,5,8,9 Conceptually, this perspective emphasizes that health outcomes are influenced by exposures to health-promoting (positive) and health-limiting (negative) factors.

As noted by Earls and Carlson, child development research has expanded its level of focus beyond proximal family, peer, and school influences and more recently has sought to understand the complex “social ecology” of child health and well-being — including neighborhoods, religious groups, public policy, and international human rights.5 In a review of neighborhood effects on child and adolescent well-being, Leventhal and Brooks-Gunn identified three pathways through which neighborhoods may influence child development, including:

  • The availability, accessibility, affordability, and quality of institutional resources, such as learning and recreational facilities, child care, schools, medical facilities, and employment opportunities;
  • Parent-child relationships, including parenting behavior and the quality of the home environment; and
  • Community-level social processes, such as social cohesion, informal social control, and collective efficacy.10

Importantly, these are inter-related pathways. For example, the level of collective efficacy, understood as trusting relationships between neighbors enabling action to achieve social control, is correlated with reduced youth violence, substance abuse, and early pregnancy. However, collective efficacy is moderated by poverty and residential instability.10 Therefore, historical and contemporary public policy related to education, employment, and housing are at the root of community characteristics that affect health.

Public health perspectives emphasize that the accumulated affects of positive exposures (ie, quality early childhood education, availability of fresh fruits and vegetables, affordable and safe housing) and the burden of chronic, layered negative exposures (ie, violence, extreme poverty, air and water quality, lead paint) produce health outcomes. Behavioral risks are embedded in community contexts and are responsive to and consequent of the conditions that surround children and families.11

The balance of positive and negative exposures also drives differences in health between social groups. Racial and ethnic health disparities, and disparities between income groups, are created in large part by accumulated negative exposures. The social class gradient in health is well established, although clear causal mechanisms between income, social status, and health are still being studied.12

In the United States, poor and minority children are significantly more likely to live in “low-opportunity” neighborhoods as compared with their non-poor and majority peers. Low-opportunity neighborhoods are characterized by conditions that include the poor quality of the educational system, dearth of livable-wage jobs for adults, inadequate transportation systems, and low social connectedness.13,14

To exemplify the concept of layered exposures, consider a young child poisoned by lead paint from poor housing conditions in the neighborhood. Lead exposure places this child at risk for significant educational and developmental impairment. This may be compounded by the lack of quality early childhood education opportunities and/or a family environment that is challenged to support an optimal developmental outcome.

The paucity of livable-wage jobs with paid sick leave and insurance benefits affect the parent’s ability to access necessary health care. Limited public transportation options may preclude job seeking outside of the local area, impeding the likelihood of climbing the economic ladder and enabling a move to a higher opportunity neighborhood. Emerging evidence indicates that these accumulated exposures affect health into adulthood and extend to the offspring of children born into circumstances characterized by multiple risks.15

Health Economic Perspective

Health economists focus on the choices people make and how these choices are affected by the constraints or circumstances people face. From this perspective, individuals invest their available time, money, and other resources to maximize their “utility,” meaning their well-being or overall satisfaction. Being in good health can directly contribute to utility, and good health is also one component of an individual’s “human capital,” which allows one to work and be productive.16

The key insight from this model is that people’s decisions to invest in their own health (or their children’s health) will be based on the perceived costs and benefits of the investment. In addition, this model highlights the fact that good health is only one of many “commodities” that people desire, and people routinely make tradeoffs between different goods and services (including health-related goods and services).

How do community factors affect health outcomes within this framework? Community determines the choices that are available to individuals and at what cost. That is, how easy it is for people to make choices consistent with a good health outcome? Community can also play a key role in shaping the perceived benefits of different alternatives. For example, how much do people value certain behaviors and health outcomes, such as increased physical activity, safe infant sleep environments, or reduction in tobacco use or substance abuse?

As an example, imagine a mother who is deciding how many vegetables to feed her young child. The mother values vegetables as an input into the health of her child. Beyond the individual level, though, the availability of grocery stores, farmer’s markets, and convenience stores near the family’s home determines what vegetables are available and how much they cost. Furthermore, community factors, such as advertising, educational campaigns, school lunch nutrition standards, and the food-related norms of the mother’s peer group influence the mother’s attitudes and behaviors related to her child’s vegetable consumption.

The mother is also faced with difficult tradeoffs. In addition to her child’s health, the mother values her child’s education, as well as her own health, productivity, and satisfaction. More money spent on vegetables at the grocery store means less money available for shelter or after-school activities. More time maintaining a garden means less time for supervising homework or advancing employment status. Although these tradeoffs happen at the individual (or household) level, community-level factors, such as food prices and employment opportunities, play a key role in shaping the relative costs and benefits of these different alternatives.

The economic model can also shed light on how community-level factors contribute to disparities in health outcomes for different groups. Because the relative costs and benefits of health-promoting or health-limiting alternatives vary across communities, children’s health outcomes will also vary.

Put a different way, some communities make health more expensive to achieve than others. For households struggling to meet very basic needs, the perceived value of investing in uncertain future health outcomes (by eating more vegetables, for example) may be low relative to more certain short-term investments, such as purchasing a greater quantity of high-calorie yet low nutrient-containing food. All of these individual choices are influenced by community-level attitudes and resources. When these resources are limited, inequalities in child health inputs and outcomes are perpetuated.

Policy Affects Community Contexts

The theoretical perspectives described above highlight several potential pathways through which community factors can affect child health outcomes. We now move on to consider the ways in which community-level factors and public policy are linked and how they produce child health outcomes.

We focus on several prominent child health problems with strong links to community characteristics: childhood emotional and behavioral disorders and obesity. Through each of these examples, we will discuss how community-level factors influence the child health outcome or process and which public policies or programs could help assure better health outcomes.

Emotional and Behavioral Disorders

Children’s mental health is a significant concern for pediatricians, accounting for 25% of primary care office visits.17–19 Although prevalence estimates of emotional and behavioral disorders among children are limited by the absence of national survey data, a recent meta-analysis of community-level survey data indicate that 17% of children and youth have been given at least one mental health diagnosis.20 Of note, significant differences in the prevalence of mental health problems are not evident between racial/ethnic groups, when one controls for confounders, such as poverty, parental incarceration, and migrant status.20

Aspects of Community

Children’s mental health is influenced in complex ways by risks and resources at individual, family and community levels. Parental factors, such as unemployment and maternal depression, predict the development of specific mental health problems in children, including depression, conduct disorder, and anxiety.20,21 Increasing attention is directed now at public health approaches to improve children’s mental health. Significant population-level improvement in children’s clinically elevated and borderline behavioral and emotional problems following implementation of a multilevel (mass media, primary care, intensive parenting education) intervention have been reported.22

There is also some evidence that improving economic well-being translates into improved emotional and behavioral functioning for children. Costello reported significant reduction in externalizing behavior problems among Native American children following income supplementation from casino proceeds.23 These results are notable in that the income supplement was not tied to family characteristics that are related to psychological or social resourcefulness.

Other studies have found similar improvements in behavioral functioning and academic success for urban boys via improved parental and family economic circumstances. Increased opportunity for parental supervision was a mediating factor for improving boys’ behavioral functioning in each of these studies.24

Employment opportunity and income, however, are not distributed evenly across the population. Black and Hispanic adults have significantly higher rates of unemployment and lower median income compared with whites, resulting in higher poverty rates for their children. Moreover, black and Hispanic children are almost 20 times more likely than white children to live in poor families and concentrated poverty neighborhoods.13 Family and neighborhood poverty contribute to the overall stress burden, reduce the availability of necessary resources, and affect behavioral and emotional functioning.

Potential Policy Solutions

Policies that lift families out of poverty are particularly likely to have beneficial effects on the mental health of children and their adult caregivers. Evidence suggests that policy solutions that improve family economic circumstances without increasing work-hour requirements for parents afford more opportunity to provide supervision for children.

Heymann and Earle found that lack of paid family or sick leave and inflexible work schedules make it difficult for parents of children with chronic conditions and disabilities to be adequately involved with a child’s educational and health care needs.5 Because higher wage and professional workers are more likely to have paid sick and family leave, children of lower socioeconomic status with chronic health conditions are likely to have worse outcomes. Public policy that provides all workers with paid sick and family leave has the potential to improve health for children, especially those with special health care needs, and to reduce health and social inequities.

Policies to expand and improve early childhood education are also warranted based on evidence. Robust findings of the effects of early childhood education on health outcomes over the life course are well known.25 Shonkoff proposes an increased focus on staff training in the early childhood setting as a strategy for mitigating the effects of “toxic stress” on children’s well being.15 Finally, increasing community resources, such as after-school programs, might also be considered to buffer against family and community hardship and to create more equitable opportunity for health.26,27

These efforts, taken together, have the potential to reduce the demand on the health care and mental health care systems by preventing the onset of childhood behavioral disorders and the development of chronic mental health problems. Investments made in early child development have the potential of increasing wellness in future adult populations, reducing illness costs, and helping break the cycle of poor health passed from generation to generation.

Childhood Obesity

Obesity among children and adolescents is a growing problem in the United States. In 2003–2004, 19% of adolescents (12 to 19 years), 17% of children between 6 and 11 years, and 14% of children between 2 and 5 years were classified as obese.28 Large disparities in obesity outcomes exist across different racial and ethnic groups. Among adolescent girls, for example, the rate of obesity among blacks is 24%, compared with 15% among non-Hispanic whites.28

Aspects of Community

Multiple aspects of the physical and social environments affect obesity outcomes. The built environment constrains food choices and provides opportunities for, or barriers to, physical activity. A review by Davison and Lawson found that access to public play areas (eg, recreational facilities and schools) and transportation infrastructure (eg, sidewalks and controlled intersections) promoted higher activity levels, although other factors, such as high road density, traffic volume, and automobile speed, significantly decreased a child’s physical activity.29

The social environment also affects child obesity outcomes. Lovasi et al. and Davison and Lawson provide evidence that areas with higher crime rates contribute to lower levels of physical activity among children.29,30 The effect of crime and neighborhood safety is particularly interesting as it may operate through multiple channels. In addition to limiting children’s activity, areas with high crime rates may also increase children’s exposure to stressors, which have been shown to affect obesity among adolescents.31 Rather than a purely individual-level phenomenon, the evidence is mounting that community factors strongly shape obesity outcomes among adults and children.

Not surprisingly, health-promoting community characteristics are not distributed equally across different populations. Disadvantaged groups tend to be exposed to more “obesogenic” physical and social environments.30 Low-income children live in neighborhoods with more fast-food restaurants and fewer supermarkets, more crime, and fewer playgrounds.32 These groups also tend to watch more hours of television, and are consequently disproportionately exposed to advertisements for “high-calorie, low-nutrient food.”32 Collectively, differences in social norms and environmental exposure help to explain the remarkable differences in child obesity outcomes across different groups in the United States.

Potential Policy Solutions

Several policies have the potential to foster environments that are more protective against childhood obesity. Changes to eligibility requirements and enhancements to covered services in public health insurance programs, in order to assure that all children have access to preventive health care, is one approach. The recent expansion of food choices available via the Women, Infants, and Children (WIC) supplemental nutrition program, as well as potential changes to choices available through the federal Food Stamp program, might also be considered as policy interventions.1,32

Modifying local conditions to provide more access to supermarkets and exercise options, promoting traffic-and/or crime-related neighborhood safety are also viable policy solutions to childhood obesity. The Pennsylvania Fresh Food Financing Initiative, which focused on increasing access to fresh fruits and vegetables in underserved communities through state financing to supermarket operators, fostered public/private partnerships through policy in order to facilitate healthy choices at the individual and community level.33

Evidence from an ongoing French program provides hope that a concerted, community-level approach to childhood obesity prevention can yield remarkable results. Katan describes the French initiative, which began in select towns in 1992 and has since expanded into the national program EPODE (Ensemble, Prévenons l’Obésité Des Enfants – Together, Let’s Prevent Childhood Obesity).34,35

“Everyone from the mayor to shop owners, schoolteachers, doctors, pharmacists, caterers, restaurant owners, sports associations, the media, scientists, and various branches of town government joined in an effort to encourage children to eat better and move around more. The towns built sporting facilities and playgrounds, mapped out walking itineraries, and hired sports instructors. Families were offered cooking workshops, and families at risk were offered individual counseling,” he said.

Results indicate that the program has been successful. In the two towns where this initiative was first launched, child obesity rates dropped to 8.8% by 2005, while rates had risen to 17.8% in nearby comparison villages.36 Although this particular model may not be replicable in all communities, focusing on the development of policies that target communities rather than individuals may be a key in the battle against childhood obesity.

Pediatrician’s Role

The extent to which pediatricians advocate for community-level change varies widely across individuals and contexts. Nonetheless, there are important applications of a framework for children’s health that incorporates community factors and policy solutions through which pediatricians can continue to influence population health outcomes.

These include adopting an expanded conceptualization of assessment for individual patients; prescribing community-based interventions; and advocating for policy to improve community conditions that influence health and mitigate health disparities. As many of these activities increase the workload for primary care offices, payers and corporate healthcare organization leadership need to be partners in the process, providing financial incentives and time for physicians to participate in community-wide health practices that strengthen the physician-community relationship.

Expanding Social History

The social history taken in medical practice commonly focuses on individual and family influences on health. Kenyon et al. suggest that social history gathering should include information on income; housing/utilities; education; legal status/immigration; literacy, and personal safety, each of which has been shown to directly affect child health.37 A relevant social history, according to the World Health Organization (WHO), incorporates the effects of factors, such as the availability of transportation, job stress, social isolation or integration, and early childhood experiences on health and well-being.38

Medical school education programs should build increased emphasis on the effect of non-biomedical determinants of health; future physicians also need additional training on how to screen patients for community exposures and experiences that have the potential to harm their health. Twenty-five percent of graduating US medical students in 2007 reported that there was inadequate time during medical school training to address health determinants, and 33% reported inadequate time learning about the role of community health and social service agencies.39 Unfortunately, even when pediatric education programs have stressed the importance of social history taking, few practice settings can accommodate the amount of time needed to implement the practice adequately.

Prescribing Community Resources

Recognizing that child health has biological and social origins leads one to the awareness that child health cannot be improved effectively by relying solely on medical intervention. Pediatricians along with healthcare organizations need to be skilled in connecting patients and families to institutions and services that address the community contexts in which they live.

For example, medical-legal partnerships established at pediatric medical centers integrate lawyers into healthcare settings to support economically disadvantaged families in navigating complex systems in order to meet their basic needs. Parents’ ability to steer successfully around barriers in order to secure the needed community resources may be constrained by time limitations, functional literacy level, discrimination, or multiple competing demands. Zuckerman et al. proposed that lawyers can assist families and pediatricians in resolving problems, such as poor housing conditions, denial of public benefits, or educational placement options. It is argued that preventive law practiced in the healthcare setting can support pediatricians in improving the physical and social environments that effect child health.40

Pediatricians can also work to promote health literacy as a strategy to improve child health. Health literacy skills include reading and writing skills, listening and speaking skills, quantitative skills, organizational skills, as well as cultural knowledge and conceptual understanding.21 The health literacy demands of a community’s health and social service system include its administrative complexity, level of fragmentation, and communication practices of providers, each of which may affect parents’ ability to “obtain, process, and understand basic health information and services needed to make appropriate health decisions.”41

These skills interact with demands made by systems and providers to influence the success with which one can engage in clinical interactions and interventions, practice preventive care, and navigate health and social systems.42 Not surprisingly, a growing number of studies have demonstrated how deficiencies in health literacy can adversely affect chronic disease management.42–47 Research on chronic disease management has also shown that the essential ingredients for successful advocacy involve knowing whom to go to for assistance, what to ask for, and when to ask for it.

These skills may be particularly challenging for parents with limited literacy skills, English language learners, and those with little access to knowledgeable and resourceful social networks.45,48,49 Therefore, pediatricians must be able to assess family health literacy level, critically evaluate and improve their own patient communication practices, and be prepared to assist with building health literacy skills through referral to appropriate community resources.

Pediatricians can raise awareness about existing policies that have ramifications for health and encourage participation in the political process in order to modify community conditions. General awareness of policies that may affect health positively is limited (ie, family leave; employment and economic support; housing and tenant rights; education; rights to breastfeed). This may be particularly true for disenfranchised communities. One community activist noted that “policy is like air, you breathe it without noticing … until it stinks.”50

Pediatricians can be important sources of information about policies and community resources that may benefit individuals, families, and populations. Moreover, they can prescribe political participation (voter registration, attendance at public meetings, engagement with elected officials) so that community members advocate for policies that create conditions for children, youth and adults to make healthy choices more readily.

Advocacy and Activism

Finally, pediatricians can become activists themselves on behalf of the children and families they serve. By engaging in the public and private policy process, health care professionals move beyond caring for individual patients to caring for neighborhoods, communities, and society as a whole. From local programs to national policies, healthcare providers can get involved in using policy as a tool to improve the spatial and social environments or contexts where children and families live and grow.

By facilitating the development of community resources and minimizing exposure to harmful community-level risks, policy advocacy offers pediatricians an opportunity for broad and sustained health effect.

The Community Pediatrics Training Initiative (CPTI), a national initiative within the American Academy of Pediatrics (AAP), is an example of how the future pediatric workforce can be trained in advocacy and activism. The goal of community pediatrics is “to provide a far more realistic and complete clinical picture by taking responsibility for all children in a community, providing preventive and curative services, and understanding the determinants and consequences of child health and illness, as well as the effectiveness of services provided.”51 The core principles of CPTI include:

  • A perspective that enlarges the pediatrician’s focus from one child to all children in the community;
  • A recognition that family, educational, social, cultural, spiritual, economic, environmental, and political forces act favorably or unfavorably, but always significantly on the health and functioning of children; and
  • A synthesis of clinical practice and public health.

Conclusions

There is growing awareness that despite enormous spending on medical care, commensurate gains in population and individual health status have been elusive. The failure to understand and leverage the connection between social policy and community health limits progress at multiple levels. Moreover, lack of appreciation of the ways that community contexts promote or constrain opportunities to be healthy contributes to an imbalance of focus on individual and disease-oriented interventions.

Reframing health as a product of social, spatial, and biological influences, and directing investments accordingly, is required. Pediatricians have a long history of advocating for patients and families. Awareness of the ways community contexts influence a child’s health and knowledge of the ways in which policy can influence the living environment can help pediatricians assist their communities to transform social and spatial elements positively and optimize the health of all children.

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Authors

Sheri Johnson, PhD, is Assistant Professor, Department of Pediatrics, Center for the Advancement of Underserved Children, Medical College of Wisconsin, Milwaukee. Katherine Dickinson, PhD, is Post-Doctoral Fellow, Advanced Studies Program and Integrated Studies Program, National Center for Atmospheric Research, Boulder, CO. Carmen Gomez Mandic, ScD, MPH, is Research Fellow, Center for Research on Gender and Sexuality, San Francisco State University. Earnestine Willis, MD, MPH, is Kellner Professor, Department of Pediatrics, Center for Advancement of Underserved Children, Medical College of Wisconsin.

Address correspondence to: Sheri Johnson, PhD, Assistant Professor, Department of Pediatrics, Center for the Advancement of Underserved Children, Medical College of Wisconsin, Milwaukee, WI 53226; or e-mail: sxjohnso@mcw.edu.

Dr. Johnson; Dr. Dickinson; Dr. Mandic; and Dr. Willis have disclosed no relevant financial relationships. 

 

10.3928/00904481-20110217-09

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