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  • Celebrating Native American Heritage Month!

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    By Dorothy Castille, Ph.D.
    Scientific Program Officer, Community Health and Population Sciences Division
    National Institute on Minority Health and Health Disparities


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    The National Institute on Minority Health and Health Disparities (NIMHD) celebrates Native American Heritage Month in November and recently published two articles featuring NIMHD-supported research on American Indian health disparities. Both featured studies were led by recipients of NIMHD’s Loan Repayment Program.

    The first article of the month highlights the Food Resource Equity and Sustainability for Health (FRESH) study by Valerie Jernigan, Ph.D., a researcher at the University of Oklahoma and a member of the Choctaw Nation of Oklahoma. In this study, also recently featured in Nature, Dr. Jernigan discusses her work with the Osage Tribe in improving the food resources and health of tribal families through a community gardening program. Read the full story.

    NIMHD’s second featured story this month introduces a Native American researcher of the Lumbee Nation at University of North Carolina-Chapel Hill School of Nursing, Jada Brooks, Ph.D., M.S.P.H., RN. Dr. Brooks has focused her studies on understanding why Lumbee women have the highest death rate related to heart disease in Robeson County, North Carolina, and determining if a positive perspective could help counteract the environmental exposures that increase their risk of heart disease. Read the full story.


  • Health Literacy: Why It Matters for Minority Health and Health Disparities

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    By Sherine El-Toukhy, Ph.D., M.A.
    Earl Stadtman Tenure-Track Investigator & NIH Distinguished Scholar
    Division of Intramural Research, National Institute on Minority Health and Health Disparities

    A basic principle of effective communication is to know the audience.1 This principle is especially important for patient-provider interactions that involve risk and diagnostic information, preventive measures, and instructions on medication regimens. But a message said is not necessarily a message understood. A patient’s understanding requires an ability to deal with written and spoken word and a grasp of basic math skills and concepts.2 It requires a health literate patient.

    As a researcher in the Division of Intramural Research at the National Institute on Minority Health and Health Disparities (NIMHD), I have been intrigued by how people of all races and ethnicities consume and understand health information and how this affects their health decision making and behaviors. Recently, I published a review of factors that affect the quality of patient-provider interactions among underserved populations.3 My co-author and I found that health literacy was prominent among other patient and clinician related factors.

    Indeed, the link between health literacy and health outcomes is indisputable. 4 From self-reported health and health knowledge, to preventive behaviors, chronic disease management, and hospitalization, individuals with limited health literacy fare worse than health literate ones.4 Even more unsettling is that minority racial/ethnic groups, individuals who are socioeconomically disadvantaged, the elderly, and immigrants are disproportionally limited in their health literacy.4 Low health literacy exacerbates poor health outcomes associated with other factors such as limited English proficiency that burden these populations to begin with.5

    Until recently, patients’ health literacy was simply presumed and sometimes overestimated.6 However, results of the National Adult Literacy Survey in the early 1990s revealed that almost 90 million Americans scored below the minimum threshold of basic skills deemed necessary to survive in an industrialized society. These basic skills include the ability to use written words and numbers in daily activities and problem solving.7 Three decades later, the numbers remain unchanged.8 These results were eye-opening because of their implications for healthcare.9

    Although the thought of a patient mistaking a “stepping stool” for a laboratory “bowel stool” sample seems improbable, there is evidence to the contrary. Researchers have documented how limited health literacy patients misunderstand doctors’ instructions and drug labels.10, 11 As one patient put it, “Sometimes [doctors] come out with big words and I don’t know what to make of it … they don’t say stomach or belly, they say something else, abdominal … I don’t understand that.”12

    Beyond patient-provider interactions, possessing the skills to seek and process medical and health information, communicate needs, and weigh available choices are prerequisites to quality patient-clinician communication, patient engagement in health decision making, medical adherence, and ultimately positive health outcomes.

    Addressing low health literacy thus is a necessity.13 The question is how? Initially, low health literacy was characterized as a patient attribute. This risked the belief that, first, limited health literacy is not malleable, and second, if it were, this responsibility rested outside the healthcare system. Alternatively, a comprehensive approach to address limited health literacy encompasses, besides the patient, the clinician, the message, the channel, and the context. Example approaches include training medical students on health literacy; tailoring easy-to-understand, culturally and linguistically appropriate messages with creative content such as risk assessment charts, cartoons, and narratives; and using different user-centric channels, such as interactive digital platforms. Within a healthcare organization, identifying limited health literacy individuals in electronic health records and building feedback systems allows for appropriate allocation of resources based on patient outcomes and reduction of health disparities as performance metrics.1, 13

    As the Institute tasked with improving minority health and reducing health disparities, NIMHD is committed to improving communications with diverse populations.3 An example of such efforts is the Language Access Portal that provides health information in seven languages in nine areas with significant disparities such as cancer and cardiovascular disease. The portal is a collaborative effort among the centers and institutes at the National Institutes of Health and other federal agencies to improve access of individuals with limited health literacy and English proficiency to health information.

    With the emphasis on patient-centeredness, a health literate public, healthcare and public health organizations are ever so important.

    References

    1. S. Department of Health and Human Services, National Institutes of Health, & National Cancer Institute. (2008). Making health communication programs work: a planner’s guide, pink book. Bethesda, MD: U.S Department of Health and Human Services.
    2. Ratzan, S. C., Parker, R. M. (2000). Introduction. In K. Patrias (Ed.), National Library of Medicine current bibligoraphies in medicine: health literacy (pp. v–vii). Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services.
    3. Pérez-Stable E.J., El-Toukhy S. Communicating with diverse patients: How patient and clinician factors affect disparities. Patient Education and Counseling, 2018
    4. Kindig D.A., Panzer A.M., Nielsen-Bohlman L. Health literacy: a prescription to end confusion: National Academies Press 2004.
    5. Sentell Sentell, T., & Braun, K. L. (2012). Low health literacy, limited English proficiency, and health status in Asians, Latinos, and other racial/ethnic groups in California. Journal of Health Communication, 17(Suppl. 3), 82– doi:10.1080/10810730.2012.712621
    6. Kelly P.A., Haidet P. Physician overestimation of patient literacy: a potential source of health care disparities. Patient Education and Counseling, 2007; 66(1): 119-22.
    7. Kirsch, I. S., Jungeblut, A., Jenkins, L., & Kolstad, A. (1993). Adult literacy in America: A first look at the results of the National Adult Literacy Survey. Washington, D.C.: National Center for Education Statistics, Office of Educational Research and Improvement.
    8. The Organisation for Economic Cooperation and Development (OECD). United States – Country Note – Survey of Adult Skills – First Results 2013. Accessed September 24, 2018.
    9. Rudd, R. E., Moeykens, B. A., & Colton, T. C. (1999). Health and literacy: a review of medical and public health literature. In C. Smith (Ed.), Annual review of adult learning and literacy, Vol. 1 (pp. 158–199); Jessup, MD: Jossey-Bass, Inc., & Office of Educational Research and Improvement.
    10. Davis, T. C., Wolf, M. S., Bass, P. F., et al. (2006). Literacy and misunderstanding prescription drug labels. Annals of Internal Medicine, 145(12), 88– doi:10.7326/0003-4819-145-12-200612190-00144
    11. Wolf, M. S., Davis, T. C., Shrank, W., Rapp, D. N., Bass, P. F., Connor, U. M., Clayman, M., & Parker, R. M. (2007). To err is human: patient misinterpretations of prescription drug label instructions. Patient Education and Counseling, 67(3), 293– doi: 10.1016/j.pec.2007.03.024
    12. Jordan, J. E., Buchbinder, R., & Osborne, R. H. (2010). Conceptualising health literacy from the patient perspective. Patient education and counseling, 79(1), 36– doi:10.1016/j.pec.2009.10.001
    13. S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National action plan to improve health literacy. Washington, D.C.: Author.

  • Tackling Health Disparities Among Latinos in the United States

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    By Mariana Sanchez, Ph.D.
    Assistant Professor, Robert Stempel College of Public Health & Social Work,
    Florida International University
    Research Associate, Center for Research on U.S. Latino HIV/AIDS and Drug Abuse

    Mario De La Rosa, Ph.D.
    Professor, Robert Stempel College of Public Health & Social Work,
    Florida International University
    Director, Center for Research on U.S. Latino HIV/AIDS and Drug Abuse


    National Hispanic Heritage Month (September 15–October 15) provides an opportunity to reflect on how the histories, cultures, and contributions of Latino Americans have enriched our nation and society. As the largest ethnic minority group in the United States, numbering nearly 58 million, Latinos are the principal driver of demographic growth, accounting for half of the national population growth since 2000.1 The U.S. Latino population continues to not only grow but diversify. While Mexicans remain the largest U.S. Latino immigrant group, shifts in immigration patterns over the past decade indicate steep increases in Latino immigrants of Caribbean and Central and South American origin arriving in the U.S.1

    Health disparities (e.g., alcohol liver disease, HIV/AIDS, obesity, and mental health) impact Latinos in the U.S. These disparities are influenced by sociodemographic, behavioral, social, and societal factors including language and cultural barriers, lack of access to health care, and structural discrimination.2,3 To tackle these issues, researchers must first identify the mechanisms influencing health disparities and explore multilevel interventions to address them. There also remains a salient need to increase the number of Latinos and other ethnic/racial minority investigators pursuing careers in biomedical and behavioral research.

    The Center for Research on U.S. Latino HIV/AIDS and Drug Abuse (CRUSADA) at Florida International University (FIU) is at the forefront of these efforts with an overarching goal to prevent and eliminate health disparities affecting Latino communities in Miami-Dade County, Florida. This work centers around conducting community-based research and establishing community engagement strategies and partnerships to build a long-term, sustainable presence in vulnerable and marginalized Latino communities, including immigrants and farmworkers. CRUSADA has also funded and trained nearly 60 health disparity professionals at the faculty, postdoctoral, and predoctoral levels. Most recently, CRUSADA is home to FIU’s Health Disparities Initiative, funded through an endowment by NIMHD.

    We are currently conducting innovative research to better understand how pre-immigration experiences influence health trajectories among Latino immigrants. While Latinos face a host of previously mentioned health disparities, there is a perplexing phenomenon known as the Hispanic/Latino Paradox. The paradox explains that even with social and structural barriers, Latinos in the U.S. tend to be in better health and live longer than non-Latino Whites. Furthermore, Latino immigrants are healthier than their U.S.-born counterpart­­­­ – experiencing health declines as their time in the U.S. increases. Diminishing health among U.S. Latino immigrants has frequently been attributed to the acculturation process. Among these, is the well-documented escalation of alcohol use and misuse.5 Yet, previous studies have focused primarily on the drinking patterns of Latinos living in the U.S. for extended periods of time. Little is known about how shifts in alcohol use behaviors occur from the pre- to post-immigration context among Latino immigrants.

    Among our ongoing research initiatives is CRUSADA’s Recent Latino Immigrant Study (RLIS). Originally funded through an NIMHD P20 Center of Excellence, the RLIS was the first community-based cohort study to examine the pre to post-immigration alcohol use trajectories of young adult, recent Latino immigrants, as well as the underlying social determinants contributing to these trajectories. Subsequently funded by the National Institute on Alcohol Abuse and Alcoholism this ongoing study has successfully followed a cohort of more than 500 immigrants representing 17 Latin American countries across a 10-year span. The study’s remarkable 97% retention rate over the past decade speaks to our culturally relevant and effective recruitment and retention strategies in the Miami-Dade County Latino community).6

    Findings from the RLIS challenge our current understanding of alcohol use trajectories among U.S. Latino immigrants and have identified various sociocultural determinants as potential mechanisms of alcohol use in this population.7 Rather than indicating typical patterns of increased alcohol use among women (and little change in men) over time, our findings revealed decreases in alcohol use in men, with no significant change in women.8 Results showed associations between various social determinants (i.e., social support, neighborhoods, religious coping, social capital, and family cohesion) as potential mechanisms of acculturative stress and alcohol use.9,10, 11, 12 Collectively, these outcomes suggest that, for at least some subsets of Latino immigrants, the well-known escalation of alcohol use as their time in the U.S. increases may not hold.

    This ongoing study continues to identify how risk and protective social determinants interact with the acculturation process to influence distinct pre- to post-immigration alcohol use patterns among distinct Latino immigrant subgroups as their time in the U.S. increases. Findings from the RLIS have laid the groundwork for the development of alcohol misuse prevention interventions targeting Latino immigrants early in the immigration process.

    References:

    1. Flores, A. (2017). How the U.S. Hispanic population is changing. Washington, DC: Pew Research Center.
    2. S. Department of Health and Human Services Office of Minority Health (2018). Profile: Hispanic/Latino Americans.
    3. Alarcón, R. D., Parekh, A., Wainberg, M. L., Duarte, C. S., Araya, R., & Oquendo, M. A. (2016). Hispanic immigrants in the U.S.A.: social and mental health perspectives. The Lancet Psychiatry, 3(9), 860–870. doi: 10.1016/S2215-0366(16)30101-8
    4. Lacayo, J. (2016). NIH endowment makes FIU regional hub for the study of HIV/AIDS, substance abuse, obesity, and diabetes. FIU News.
    5. Li, P. P., & Zamboanga, B. L. (2018). A critical review and meta-analysis of the associations between acculturation and alcohol use outcomes among Hispanic Americans.Alcoholism: Clinical and Experimental Research, 42(10), 1841– doi:10.1111/acer.13845
    6. De La Rosa, M., Babino, R., Rosario, A., Martinez, N. V., & Aijaz, L. (2012). Challenges and strategies in recruiting, interviewing, and retaining recent Latino immigrants in substance abuse and HIV epidemiologic studies. The American Journal on Addictions, 21(1), 11– doi: 10.1111/j.1521-0391.2011.00193.x
    7. De La Rosa, M., Dillon, F. R., Sastre, F., Sanchez, M., & Babino, R. (2013). Alcohol use among Latinos: a comparison of pre-immigration, post-immigration, and U.S.-born Latinos. American Journal on Addictions, 22(2), 162– doi:10.1111/j.1521-0391.2013.00310.x
    8. Sanchez, M., Rosa, M. D. L., Blackson, T. C., Sastre, F., Rojas, P., Li, T., & Dillon, F. (2014). Pre-to post-immigration alcohol use trajectories among recent Latino immigrants. Psychology of addictive behaviors, 28(4), 990. doi:10.1037/a0037807
    9. Sanchez, M., Dillon, F. R., Concha, M., & De La Rosa, M. (2015). Impact of religious coping on the alcohol use and acculturative stress of recent Latino immigrants. Journal of Religion and Health, 54(6), 1986–2004. doi:10.1007/s10943-014-9883-6
    10. Cano, M. Á., Sánchez, M., Rojas, P., Ramírez-Ortiz, D., Polo, K. L., Romano, E., & De La Rosa, M. (2018). Alcohol use severity among adult Hispanic immigrants: examining the roles of family cohesion, social support, and gender. Substance use & misuse, 53(4), 668– doi:10.1080/10826084.2017.1356333
    11. Rojas, P., Dillon, F. R., Cyrus, E., Ravelo, G. J., Malow, R. M., & De La Rosa, M. (2014). Alcohol use as a determinant of HIV risk behaviors among recent latino immigrants in South Florida. Journal of the Association of Nurses in AIDS Care, 25(2), 135-144. doi: 10.1016/j.jana.2013.02.003
    12. Sanchez, M., Romano, E., Dawson, C., Huang, H., Sneij, A., Cyrus, E., … & De La Rosa, M. (2016). Drinking and driving among recent Latino immigrants: The impact of neighborhoods and social support. International journal of environmental research and public health, 13(11), 1055. doi:10.3390/ijerph13111055

  • Healthy Mind Initiative Addresses Mental Health of Asian American and Pacific Islander Youth

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    By Victoria Chau, Ph.D., M.P.H.
    Substance Abuse and Mental Health Services Administration

    By Lieutenant Commander Kelly Leong
    United States Public Health Service

    By David J. Robles, B.A.
    Graduate Intern, Substance Abuse and Mental Health Services Administration


    From left to right: Dr. Victoria Chau, SAMHSA, LCDR Kelly Leong , United States Public Health Service and Mr. David J. Robles, SAMHSA

    July is National Minority Mental Health Awareness (NMMHA) Month—a practical time to highlight the importance of mental health for everyone. In a recent NIMHD Insights blog post, Dr. Xinzhi Zhang raised serious concerns about mental health awareness among Asian American and Pacific Islander (AAPI) youth and families. Suicide deaths have catapulted to the top as the leading cause of death for AAPI adolescents 12-19 years old in 2016.1 AAPI youth are the only racial/ethnic group for whom suicide is the leading cause of death, yet this is rarely discussed. The challenge of raising mental health awareness among AAPI communities is multifaceted but includes two key barriers: language issues and lack of culturally sensitive educators.

    In response to this urgent challenge, the Healthy Mind Initiative (HMI) was established to create a collaboration across the federal, county, and community sectors with two intents. The first aim is to improve mental health literacy in AAPI communities. The second aim is to address the mental health stigma and cultural barriers to seeking mental health treatment faced by AAPI youth and communities. The HMI is led by the Asian Pacific American Officers Committee (APAOC) of the U.S Public Health Service Commissioned Corps (USPHS), in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA), the Montgomery County Health and Human Service’s Asian American Health Initiative (AAHI), the National Institute on Minority Health and Health Disparities (NIMHD), and AAPI community organizations.

    Unique to the HMI is its focus on leveraging APAOC as primarily non-mental health professionals to deliver key mental health messages to AAPI communities with the support of SAMHSA and AAHI. The mission of the USPHS is to protect, promote, and advance the health and safety of our nation. As America’s uniformed service of public health professionals, the Commissioned Corps achieves its mission through rapid and effective response to public health needs; leadership and excellence in public health practices; and advancement of public health science. The APAOC is uniquely positioned to deliver critical, culturally specific information to AAPI communities, as it consists of multilingual “trusted messengers” in their ethnic communities. These messengers also serve as advisors to the U.S. Office of the Surgeon General on AAPI issues. Each partner agency serves a specific role. SAMHSA provides the mental health expertise by developing the educational materials with input from its federal partners and the community organization leaders. These materials serve as a guide for APAOC officers to deliver mental health training modules. AAHI assists as the community outreach expert, trains the APAOC on “Mental Health First Aid” to equip members with the skills to conduct outreach activities, and provides community resources. NIMHD promotes the initiative and is a bridge to the health disparities federal and research community interested in multi-level collaboration.

    This model highlights the potentially broad reach to diverse AAPI communities through the trusted APAOC and its partners. From this initiative, four key components to successful collaboration have emerged and include:

    1. Identifying a specific critical issue with partners who share a common vision
      A common purpose among partner agencies and community organizations is most essential to any collaboration and acts as the glue.
    2. Establishing specific roles for each partner
      Defining specific roles for each partner agency/organization from the start allows all partners to understand their role and how each complements one another, and prevents duplicating work.
    3. Securing leadership buy-in of each partner
      Having supportive leadership at each partner agency/organization help moves the project forward with greater ease and reach.
    4. Leveraging the existing resources from partners
      Each partner agency/organization has their own strength and network of resources; leveraging existing expertise and resources reduces time and cost.

    The HMI seeks to reach a population that often views mental health negatively or not at all due to stigma, lack of awareness and education, and differences in cultural conceptualization of mental health. Currently being piloted in Montgomery County, Maryland, the HMI model is an example of collaboration working to reach health equity and may be expanded to other areas as needed. As we reflect during this NMMHA Month, it is important to remember that mental health is essential to overall well-being and health. To improve the trajectories of our youth, including minority youth such as AAPI youth, it is crucial for us to increase our understanding of mental health. To learn more about mental health and the HMI partners please visit:

    Mental Health Resources

    AAPI Mental Health Resources

    HMI and Partner Websites


    References

    1Centers for Disease Control and Prevention (2018). WISQARS Leading Causes of Death Reports, 1981-2016. Retrieved from https://webappa.cdc.gov/sasweb/ncipc/leadcause.html


  • The Journey to Healthy Minds for Healthy Youth

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    By Xinzhi Zhang, M.D., Ph.D.
    Program Director, Division of Scientific Programs
    National Institute on Minority Health and Health Disparities

    Too many stories point to the troubled minds and mental struggles of our youth with the tragic event in Parkland, Florida being one of the latest. Even more saddening, these children’s cries for help are often misunderstood or ignored.

    Suicide is the second leading cause of death for children between the ages of 10–24 years old, accounting for 17.6% of deaths in this age group 1 The American Academy of Pediatrics recently updated their guidelines to include universal screening for adolescent depression (youth 12 years of age and older).2 According to the 2016 National Survey on Drug Use and Health, one in eight youth ages 12–17 years old has had a major depressive episode in the past year, with 70% of them having severe impairment.3,4

    For young Asian Americans and Pacific Islanders (AAPIs), the suicide rates are also bleak. AAPI adolescent females (15-19 years old) have a higher rate of suicide deaths (21.9%) compared to non-Hispanic Whites, non-Hispanic Blacks, and Hispanics. AAPI males aged 15–19 years have comparable or higher rates of suicide deaths (27.1%) when compared to all other racial and ethnic groups.1

    The Model Minority Myth is a stereotype that portrays all Asian Americans as academically gifted and successful. This myth wrongly portrays AAPIs as a prosperous group who have secured economic and educational success, have fewer health problems than the overall population, and do not need public assistance. In reality, AAPIs are a very heterogenous group with immigration from more than 30 different countries and ethnic groups, hundreds of languages and unique dialects, and varying degrees of economic and academic success.

    In the U.S., only half of adolescents with depression are diagnosed,5 and among them, approximately 60% do not receive appropriate treatment.4 This situation is amplified in the AAPI community due to stigma and cultural barriers.

    Many AAPIs face multiple challenges, including lack of health insurance, limited English proficiency, difficulty of acculturation and lower socioeconomic status. Less than half of AAPIs would seek help for their emotional or mental health concerns than their white counterparts.6 AAPIs tend to dismiss, psychosomaticize, deny or neglect their depressive symptoms for different reasons, such as different conceptualizations of mental health and illness or avoiding family shame.

    These reasons have prevented many AAPIs from seeking mental health counseling or medication. Parental expectations in academic excellence, cultural/family obligations, identity conflicts, societal unconscious bias, and discrimination are some of the daily challenges confronting AAPI youth and young adults.

    Parental warmth, family cohesion, and strong intergenerational relationships can help AAPI adolescents in expressing experiences with bullying and minimizing internalizing issues with immigrant parents, teachers, or the education system.7 It is critical for the AAPI community to continually strengthen family/parenting skills, build resiliency, and reduce risks for adolescent anxiety and depression. Safe, supportive, and nurturing relationships are important to children. Strong and positive self-esteem is extremely vital and can be associated with reduced risk of depression.

    There is an urgent need to improve the mental well-being of future AAPI generations. Learning how to cope with various stressors that life throws at them, work productively and fruitfully, and contribute to their community and society are key for the younger AAPI generations to actualize the great potential that lies within them. It is equally important to reduce the stigma about mental health among the AAPI community and encourage seeking help and counseling when needed. We have a lot of work to do.

    Parents, teachers and friends need to know the signs of anxiety and depression, and “act early.” The Centers for Disease Control and Prevention (CDC) offers several suggestions on their Children’s Mental Health website. I highlight a few below.

    Anxiety

    • Being very afraid when away from parents (separation anxiety)
    • Having extreme fear about a specific thing or situation, such as dogs, insects, or going to the doctor (phobias)
    • Being very afraid of school and other places where there are people (social anxiety)
    • Being very worried about the future and about bad things happening (general anxiety)
    • Having repeated episodes of sudden, unexpected, intense fear that come with symptoms like heart pounding, having trouble breathing, or feeling dizzy, shaky, or sweaty (panic disorder)

    Depression

    • Feeling sad, hopeless, or irritable a lot of the time
    • Not wanting to do or enjoy doing fun things
    • Changes in eating patterns – eating a lot more or a lot less than usual
    • Changes in sleep patterns – sleeping a lot more or a lot less than normal
    • Changes in energy – being tired and sluggish or tense and restless a lot of the time
    • Having a hard time paying attention
    • Feeling worthless, useless, or guilty
    • Self-injury and self-destructive behavior

    References:

    1. Heron M. Deaths: Leading Causes for 2015. National vital statistics reports : from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System. 2017;66(5):1-76.
    2. Zuckerbrot RA, Cheung A, Jensen PS, Stein REK, Laraque D, Glad-Pc Steering G. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): Part I. Practice Preparation, Identification, Assessment, and Initial Management. Pediatrics. 2018.
    3. Federal Interagency Forum on Child and Family Statistics. America’s Children: Key National Indicators of Well-Being. 2017.
    4. National Institute of Mental Health. Major Depression. Bethesda, MD. See: https://www.nimh.nih.gov/health/statistics/major-depression.shtml: National Institutes of Health;2017.
    5. Kessler RC, Avenevoli S, Ries Merikangas K. Mood disorders in children and adolescents: an epidemiologic perspective. Biol Psychiatry. 2001;49(12):1002-1014.
    6. Spencer MS, Chen JA, Gee GC, Fabian CG, Takeuchi DT. Discrimination and Mental Health-Related Service Use in a National Study of Asian Americans. Am J Public Health. 2010;100(12):2410-2417.
    7. Wyatt LC, Ung T, Park R, Kwon SC, Trinh-Shevrin C. Risk Factors of Suicide and Depression among Asian American, Native Hawaiian, and Pacific Islander Youth: A Systematic Literature Review. J Health Care Poor U. 2015;26(2):191-237.

    Additional Resource: