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Service Delivery Innovation Profile

Bicultural, Youth Development Program for At-Risk Latino Families Enhances Overall Health, Teen Birth Control Use, and Family Communication


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Snapshot

Summary

Aquí Para Ti ("Here for You") is a comprehensive, bicultural, clinic-based youth development program providing medical care, behavioral health consultations, coaching, health education, and referrals to Latino youth (and their parents) and young adults as they transition through adolescence into adulthood. A multidisciplinary team of bilingual providers delivers parallel care to youth and their parents (mostly immigrant parents), helping them access culturally appropriate resources and coaching youth to avoid risky behaviors, particularly risky sexual behavior. The program uses a confidential, nurturing, nonjudgmental, family-centered approach, protecting patient privacy while encouraging family members to work together to achieve healthy development for the youth. The program has increased use of birth control, reduced the incidence of depressive symptoms, and enhanced overall health status among youth, while providing them with a positive, holistic clinic experience. It has also helped parents improve their ability to communicate with their children and become more aware of and comfortable accessing providers and community resources that support their children’s development.

See Problem Addressed for updated data on rates of Latina pregnancy, school dropout behavior, sexually transmitted infections, and mental health challenges; Description of the Innovative Activity for updates on care coordination and development of treatment plan, family case management, support groups for youth and their parents, and school counseling; Results for updated information on Beck Depression Inventory results and youth feedback on the program; Resources Used for updated information about costs and staffing; and Funding Sources for information on two additional funders (updated September 2013).

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key data from 141 youth who used the program's health education services between December 2007 and January 2009, comparisons of Beck Depression Inventory scores from 68 youth who completed two or more assessments, survey responses from a randomly selected group of 30 youth, and anecdotal feedback from 15 parents who participated in focus groups.
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Developing Organizations

Hennepin County Medical Center
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Date First Implemented

2002
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Patient Population

The program serves Latino youth age 10 to 18 years (and their parents) and young Latino adults up to age 24. Roughly two-thirds of youth and young adults served between 2010 and 2012 are female, and most were born in either Mexico (42 percent) or the United States (41%). Almost all parents served by the program were born in Latin America (most commonly in Mexico), and nearly half speak Spanish as the primary language at home. (Updated September 2013.)Age > Adolescent (13-18 years); Adult (19-44 years); Race and Ethnicity > Hispanic/latino-latina; Vulnerable Populations > Immigrants; Non-english speaking/limited english proficiencyend pp

Problem Addressed

Latino youth face significant health disparities, including having above-average rates of teenage pregnancy (and related school dropouts), sexually transmitted infections (STIs), and mental health challenges. Latino parents, particularly immigrants, often lack the resources and support they need to help their children avoid risky behaviors.
  • Significant health disparities: Latino youth face educational inequalities, poverty, unequal access to health care, poor environmental conditions, and language and acculturation barriers, all of which may adversely affect their health. Latino youth are more likely to be obese or overweight, less likely to be in excellent or very good health (as reported by their parents), and more likely to experience anxiety, delinquency, and depression than White youth.1 Disparities in the following areas affect the youth served by Aquí Para Ti:
    • High pregnancy rates, often leading to school dropouts: Despite a recent decline, the teen birth rate for Latinas still exceeds that of all other demographic groups.2 In Minnesota, the birth rate among Latina females age 15 to 19 years was 107.8 per 1,000 births in 2007, nearly six times higher than that of White females of the same age (18 per 1,000); many of these teens have additional children before the age of 20.3 This birth rate fell to 49.4 per 1,000 in 2011, but it remains higher than the overall rate of other groups and more than double that of non-Hispanic White females.4 Many of the pregnant teens drop out of school before or after giving birth. For example, according to the National Campaign to Prevent Teen and Unplanned Pregnancy, 69 percent of Latina teen moms drop out of high school, compared with 58 percent of teen moms overall.5 (Updated September 2013.)
    • Many STIs (including HIV): Rates of chlamydia and gonorrhea are on the rise in Minnesota. Adolescents and young adults have the highest rates of these two infections, making up 68 percent of new infections in 2012. Hispanic/Latino youth face a disproportionate risk when compared with Whites, including a risk three times higher for chlamydia, two times higher for gonorrhea.6 (Updated September 2013.)
    • Mental health challenges: As revealed in two national surveys, Latino teens struggle with high rates of mental health problems and substance abuse issues.7,8 Compared with their Black and White peers, Hispanic male and female adolescents are more likely to feel depressed, and a higher percentage of female Hispanic teens feel suicidal. Hispanic teens are also more likely to try smoking, drink alcohol (and to start at a younger age), drive with someone who has been drinking, and try cocaine, inhalants, and Ecstasy.7 (Updated September 2013.)
  • Inadequate support for parents: According to a national survey, Latino teens report that their decisions about sex are most strongly influenced by their parents' input.5 However, at least 70 percent of Latino parents need more support and guidance in communicating with their teens about healthy sexual behaviors. This finding is particularly true among immigrants and those living in predominantly Spanish-speaking households, as language and cultural barriers often arise between parents and their more acculturated teenagers.5

What They Did

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Description of the Innovative Activity

Aquí Para Ti ("Here for You") is a comprehensive, bicultural, clinic-based youth development program providing medical care, behavioral health consultations, coaching, health education, and referrals to Latino youth (and their parents) and young adults as they transition through adolescence into adulthood. A multidisciplinary team of bilingual providers delivers parallel care to youth and their parents (mostly immigrant parents), helping them access culturally appropriate resources and coaching youth to avoid risky behaviors, particularly risky sexual behavior. The program uses a confidential, nurturing, nonjudgmental, family-centered approach, protecting client privacy while encouraging family members to work together to achieve healthy development for the youth. Key program elements are outlined below:
  • Clinic logistics: Aquí Para Ti operates on Monday, Tuesday, and Thursday afternoons from 1 p.m. to 5:30 p.m. The program serves any Latino youth age 10 to 18 and their families, along with young Latino adults up to age 24, with no geographic or financial restrictions. (Updated September 2013.)
  • Bilingual/bicultural, multidisciplinary team focused on care coordination: A multidisciplinary team staffs the program, comprising a board-certified physician (in adolescent and family medicine), two community health workers, a family case manager, a school connector/youth mentor, a program coordinator, and a youth program developer. All team members are bilingual and bicultural, creating a comfortable and welcoming environment for families. Aquí Para Ti is a certified health care home that focuses on providing easy access to care, consistent communication between team and client, and coordinated care based on an established care plan, all facilitated by an electronic registry. (Updated September 2013.)
  • Initial office visit: Each participant completes an introductory office visit that typically lasts 2 hours. Parents are encouraged to attend this visit with their child. Key components are outlined below: 
    • Review of confidentiality policy: A team member meets with the youth and his or her parent(s) to go over the program's confidentiality statement, which ensures that no information shared between the teen and the program will be disclosed to parents without the teen's consent, with the exception of information about abuse or other threats to the teen's safety. The program's goal is not to segregate the parent from the teen but rather to help parents raise their teen by acting as another significant adult. 
    • Questionnaire and risk assessment: The youth completes a questionnaire designed to identify existing protective and risk factors, which helps program staff determine the teen's level of risk and intervention needs. Parents complete separate questionnaires to identify concerns about their child's behavior or development, parenting styles and efficacy, and a depression index. These separate and confidential assessments are essential to forming a care plan to provide parallel care to the family.
    • One-on-one meetings with providers: The youth meets individually with the physician and then with other members of the team as determined by the needs identified in the questionnaire. A youth with many risk factors may meet individually with all team members during the initial visit, whereas someone with few risk factors may meet with just one or two. When parents accompany the youth to a visit, a member of the team, usually the family case manager, meets with the parents to explore their concerns. 
    • Development of treatment plan and next steps: Program team members and the youth discuss and prioritize treatment needs and agree on next steps, including specific goals and subsequent visits. In 2011–2012, 107 youth created 230 individual goals as part of this process. Their goals often had to do with education (representing 46 percent of the 230 goals) and increased social support (11 percent). (Updated September 2013.)
  • Ongoing, individualized care and referrals: After the initial appointment, youth follow their individualized treatment plans under the guidance of program staff. Treatment plans vary based on the needs of the individual and may include a combination of internal program services and referrals to outside agencies and other community partners. The program team meets weekly to review cases, discuss and further develop treatment plans, and ensure that each youth's needs are being met. Although the team does not share information with parents without the youth's consent, the program encourages the youth to involve their parents in the process. Services provided as part of this ongoing care process may include any or all of the following: 
    • Primary and preventive medical care: The physician on the team becomes the primary care provider for most youth, providing full-service medical care, including physicals, treatment for common illnesses, vaccines, pregnancy testing, family planning services, and testing and treatment for STIs. For those youth who have another established primary care provider, the program physician may provide consultations on certain issues. The program physician also provides prenatal care for pregnant youth and full medical care for any children the youth may already have.
    • Family parallel care: Using the results from the GAPS and Beck screening tools, the team can provide mirror interventions with youth and their parents on relevant topics, using a consistent and team-based approach. For parents, the team works on parenting efficacy (including an assessment of mental health) and parenting style. On average, the team finds that one in three parents are diagnosed with severe depression.
    • Health education: The physician and community health workers provide the youth with health information concerning various lifestyle-related issues, such as family planning, pregnancy care, puberty, STIs, diet, and healthy control of weight, all with an emphasis on prevention. Health education services supplement the message of the physician and identify and address important issues the youth may be experiencing in greater detail. As needed, the community health worker meets with parents to discuss adolescent health issues and the challenges involved in raising healthy children. 
    • Behavioral health consultations: The physician meets with the youth for consultations on a variety of emotional and mental health topics, including depression, anxiety, anger, school issues, substance use and abuse, body image issues, relationships with family or friends, and communicating with their parents. Those who require more than a few mental health consultations receive a referral to an offsite provider for ongoing therapy. 
    • Family case management for those with complex needs: In January 2012, Aquí Para Ti hired a family case manager to support behavioral health through additional clinic visits, calls, and home visits. The family case manager works with program clinicians, program staff, families, and youth to develop individualized care plans for youth and families with complex needs, such as those dealing with unmet mental health needs, parent–adolescent conflicts, or teen pregnancies. The family case manager helps form a care plan that includes specific goals along with steps to achieve them (e.g., accessing recommended community resources) and engages youth and parents in brief behavioral coaching sessions. (Updated September 2013.) 
    • Support group for pregnant teens and new mothers: In August 2012, the program began offering a support group, known as Centering Teen, that meets every other week for 2 hours. The group serves teens who are pregnant or have recently given birth, helping to ensure they develop successful parenting skills and continue their schooling. The group also ensures that pregnant teens are prepared for delivery. After delivery, Aquí Para Ti follows and supports the needs of the babies and their teen parents. (Updated September 2013.)
    • School counseling and support: In January 2012, the program hired a bilingual/bicultural staff member known as a school connector, who engages youth through direct motivational intervention techniques that encourage the youth to stay in school. Using innovative, no-cost, supervised activities that nurture and foster creativity (e.g., summer dance programs, photography workshops), the school connector helps youth navigate the requirements for finishing high school and attending college. The connector also advocates for better educational and career opportunities for the youth. (Updated September 2013.) 
    • Referrals to outside resources: Youth who require services beyond the scope of the program receive referrals to offsite community agencies that have been vetted by program staff for cultural competency. Referral services include individual and family therapy, exercise programs, nutrition programs (e.g., the Federal Women, Infants, and Children or WIC program), housing programs, food pantries, and nurses who can provide home visits to pregnant youth. 
  • Parent education and support: Team members follow a formal curriculum developed in collaboration with the University of Minnesota for educating immigrant parents of Latino youth. This curriculum, delivered through onsite discussion groups, provides guidance to parents raising children in an unfamiliar culture, including how to improve parent–child communication so the youth will be less likely to engage in risky behaviors. Group sessions cover topics such as parenting styles, adolescent development, communication, discipline, conflict resolution, and parent and youth connectedness. In addition to hosting the onsite parenting group, program staff also use the curriculum to guide one-on-one visits with parents who request additional assistance. Beginning in the summer of 2012, Aquí Para Ti began a support group for parents that is facilitated by a licensed social worker (and former member of the program staff) and conducted in Spanish. (Updated September 2013.)
  • Free (or low-cost) services, financial assistance: Many program services are offered free of charge. For some services (primarily direct medical care), families pay according to a sliding scale based on income. In addition, onsite financial counselors assist youth and their families in applying for health insurance and other types of financial assistance.

Context of the Innovation

Aquí Para Ti is currently housed at the Hennepin East Lake Clinic, a community-based outpatient clinic primarily serving residents of southeast Minneapolis. Operated by the Hennepin County Medical Center, the clinic serves many Latino patients and features bilingual staff and onsite financial counselors. The impetus for the program came from staff at West Side Community Health Services (the largest community clinic organization in Minnesota), who recognized the growing need for culturally competent care and improved parent–child connectedness to reduce health disparities in the local Latino community. The program was originally implemented at the Minneapolis clinic site of West Side Community Health Services, but the clinic closed because of funding issues. The program later reopened in partnership with Hennepin County Medical Center. (See the Planning and Development Process section below for more details.)

Did It Work?

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Results

The program increased use of birth control, reduced the incidence of depressive symptoms, and enhanced overall health status among youth, while providing them with a positive, holistic clinic experience. It has also helped parents improve their ability to communicate with their children and become more aware of and comfortable accessing providers and community resources that support their children’s development.
  • Increased use of birth control: According to a review of patient charts, the proportion of youth reporting that they do not use any method of birth control fell from 47 percent to 13 percent after one or more office visits with the health educator. Half of all youth elected to use a highly effective method of birth control (e.g., intrauterine devices, injectable contraceptive, birth control pills, or patches) after meeting with the health educator, up from 7 percent at baseline.
  • Fewer depressive symptoms: All 68 youth who completed a baseline and a followup Beck Depression Inventory exhibited markedly fewer depressive symptoms at their final assessment. Those whose initial assessment results indicated depression experienced a clinically and statistically significant decline in symptoms over time. (Updated September 2013.)
  • Improved health status: The vast majority (86 percent) of youth reported that their overall health had improved since they initiated program services. 
  • Positive clinic experience: Nearly all youth surveyed (97 percent) reported that clinic staff supported them and their needs, and 9 in 10 believed that the prescribed treatment plan addressed their needs. All respondents reported that they trusted their doctor and other members of the program team, and that staff respected them and their concerns and were helpful in addressing those concerns. (Updated September 2013.)
  • More communicative, aware, and confident parents: Focus groups with parents suggest the program has increased parents' ability to communicate with their children, improved their understanding of available community resources and how to access them, and increased their confidence in seeking guidance and support from providers on how to support their children's development.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key data from 141 youth who used the program's health education services between December 2007 and January 2009, comparisons of Beck Depression Inventory scores from 68 youth who completed two or more assessments, survey responses from a randomly selected group of 30 youth, and anecdotal feedback from 15 parents who participated in focus groups.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Conducting community survey: West Side Community Health Services contracted with the Wilder Foundation, a local nonprofit organization, to conduct a survey identifying the service needs of the local Latino community. Parents consistently reported the need to receive guidance on how to talk to their children about healthy behaviors. Program leaders used this feedback to design a clinic-based intervention that emphasized parent–child connectedness as a vital factor in healthy youth development.
  • Transitioning to new leadership: From 2002 through 2006, Aquí Para Ti operated as a program of West Side Community Health Services. After the program's Minneapolis clinic site closed in 2006 because of funding issues, program leaders sought available clinic space from other community agencies. They eventually partnered with the Hennepin County Medical Center, which agreed to reopen and operate the clinic where the program was originally housed.
  • Establishing network of partner agencies: Program leaders used existing contacts with community agencies to help in developing a network of Latino-friendly specialty and support services to which Aquí Para Ti clients could be referred (and from which referrals to the program could be encouraged). Program representatives also attended health fairs, community events, and conferences to network and connect with new service providers. Program leaders conducted site visits or met with representatives of each potential partner site to learn  about their services and eligibility requirements, develop a relationship, and ensure cultural competence.
  • Developing parenting curriculum: The program collaborated with the University of Minnesota Program in Health Disparities Research, the Extension University of Minnesota, and other community partners to develop a risk prevention curriculum for Latino immigrant parents, which was piloted in parenting groups at Aquí Para Ti and other community organizations. Plans are under way for a second phase of the project, involving a companion curriculum for adolescents.
  • Broadening partnerships to meet wider range of needs: Aquí Para Ti leaders are currently working to create a broader, more integrated network of partnerships to better meet the wide range of needs among Latino youth and families. To that end, the program has partnered with several community-based organizations, such as Centro, Inc., and Navigate (two local organizations that support and provide resources to the Latino community in and around Minneapolis). The goal of these efforts is to integrate community and clinical services to improve the physical, emotional, and social health of Latino youth.

Resources Used and Skills Needed

  • Staffing: The program employs a full-time program developer, youth program coordinator, case manager, and school connector/youth mentor, along with two full-time community health workers. The program also employs a physician/medical director who dedicates roughly 20 hours a week to the program. (Updated September 2013.)
  • Costs: The program's current annual budget is $450,000. (Updated September 2013.)
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Funding Sources

Medica Foundation; Hennepin County Medical Center; Minnesota Department of Health Eliminating Health Disparities Initiative; EPIC Foundation
Hennepin County Medical Center pays salaries and benefits for the program developer and community health workers, and also provides in-kind support to the program, including space and supplies. The Minnesota Department of Health provides funding that covers compensation for the youth program coordinator and the school connector/youth mentor, along with a portion of the physician/medical director's salary. Hennepin County Medical Center covers the remainder of the physician's compensation. In 2012, Medica Foundation provided grant funding to cover the costs of the family case manager; the grant does not cover medical services. (Updated September 2013.)end fs

Adoption Considerations

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Getting Started with This Innovation

  • Recruit staff members who know the target population: Cultural competence, sensitivity, and a responsive attitude toward the needs of immigrant youth and families are essential qualifications for program staff. Front-line staff must speak the language of their clients and be well versed in their community values and norms. Acknowledging and mirroring these values during interactions helps create a safe, welcoming space where youth and families feel recognized and respected.  
  • Ensure that staff have experience in adolescent development: To best fit the team approach to working with youth, any physician working with the program should have an interest in and understanding of adolescent medicine. If community members recruited to fill other staff positions do not have similar expertise, they should be trained in the basics of adolescent medicine, development, and parenting. 
  • Establish partnerships wisely: Program developers should search broadly for local partners that share the program's vision and priorities and have the means to support the initiative. For example, by partnering with Hennepin County Medical Center, Aquí Para Ti secured access to clinic space and supplies from an organization dedicated to making health care affordable and accessible to all.

Sustaining This Innovation

  • Provide adequate staff support: Working on reducing health disparities for members of underserved communities can be an emotionally difficult job for front-line providers and staff. To avoid burnout, programs should ensure that staff members have adequate support and dedicated time for debriefing on difficult cases. 
  • Secure sustainable funding and partnerships to meet growing demand: Programs that provide comprehensive and culturally competent care to specific minority populations often become referral centers for the entire community, which can create financial challenges and overwhelming demand as client volume grows. To meet these challenges, programs should look for funding sources other than time-limited grants, and establish partnerships to support the provision and expansion of services over time. Developing close relationships with academia can help inform research targeted to the community served, which in turn can lead to additional sources of funding.
  • Partner for program evaluation: As program demands grow, staff focus often falls increasingly on service delivery and patient care, with little time allotted to ongoing evaluation. Programs should hire or partner with an outside entity to help with this critical function.
  • Take systematic approach to providing care: A systematic approach allows providers to address all the variables that affect the health of Latino youth, including family relationships, school, and other cultural dynamics, resulting in a long-term, positive impact on the child's health.
  • Share lessons learned: Program staff periodically share lessons learned by participating in various advisory boards and in initiatives targeted to the Latino community, which helps to disseminate best practices in adolescent care and boost support for program activities.

Additional Considerations

The program has received recognition from several outside organizations, as outlined below:
  • In December 2010, the National Multicultural Institute granted Aquí Para Ti the Leading Lights Award in recognition of being a role model for enhancing diversity and encouraging respect and inclusion within the organization and within the diverse communities it serves.
  • The National Alliance To Advance Adolescent Health has also recognized the program as exemplary; visit http://www.thenationalalliance.org/programs/program.cfm?programID=3 for more details.
  • In June 2013, Aquí Para Ti was invited to be featured by Innovatexchange, an online map that allows users to search, view, and comment on health care innovations, sponsored by the International Centre for Health Innovation within the Richard Ivey School of Business. More information is available at http://www.ivey.ca/healthinnovation.

More Information

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Contact the Innovator

Maria Veronica Svetaz, MD, MPH
Aquí Para Ti Medical Director
Adolescent Medicine/ Family Medicine Board Certified
Department of Family and Community Medicine, HCMC
East Lake Clinic/Hennepin County Medical Center
2700 East Lake Street
Minneapolis, MN 55406
Phone: (612) 873-8143
Fax: (612) 276-0188
E-mail: maria.svetaz@hcmed.org

Monica Hurtado
Aquí Para Ti Youth Program Developer
East Lake Clinic/ Hennepin County Medical Center
2700 East Lake Street
Minneapolis, MN 55406
Phone: (612) 873-8144
Fax: (612) 276-0188
E-mail: monica.hurtado@hcmed.org

Innovator Disclosures

Dr. Svetaz and Ms. Hurtado have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

The Aquí Para Ti Web site is available at http://www.hcmc.org/clinics/EastLakeClinic/aqui-para-ti/HCMC_MAINCONTENT_292.

Hennepin Health Foundation Impact Newsletter, December 2010. Available at: http://www.hcmc.org/cs/groups/public/documents/webcontent/hcmc_linkcontent_168.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.).

Allen M, Svetaz MV, Hardeman R, et al. What research tells us about Latino parenting practices and their relationship to youth sexual behavior. The National Campaign to Prevent Teen and Unplanned Pregnancy. Available at: http://thenationalcampaign.org/resource
/what-research-tells-us-about-latino-parenting-practices-and-their-relationship-youth-sexual
.

Footnotes

1 Centers for Disease Control and Prevention. Health disparities and racial/ethnic minority youth. 2009.
2 Centers for Disease Control and Prevention. Sexual and reproductive health of persons aged 10–24 years—United States, 2002-2007. Morbidity and Mortality Weekly Report. 2009;58(SS06):1-58. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5806a1.htm.
3 Minnesota Organization on Adolescent Pregnancy, Prevention, and Parenting. 2009 Minnesota adolescent sexual health report. Available at: http://teenpregnancymn.org/Documents/2009AdoHealthReport.pdf 
4 Hamilton BE, Martin JA, Ventura SJ. 2012. Births: Preliminary Data for 2011. National Vital Statistics Reports, 61(5).
5 Sabatiuk L, Flores R. Toward a common future: Latino teens and adults speak out about teen pregnancy. The National Campaign to Prevent Teen and Unplanned Pregnancy. May 2009. Available at: http://thenationalcampaign.org/sites/default/files/resource-primary-download/commonfuture.pdf.
6 Minnesota Department of Health. 2012 Minnesota sexually transmitted disease statistics. Available at: http://www.health.state.mn.us/divs/idepc/dtopics/stds/stats/2012/stdreport2012.pdf.
7 Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance—United States, 2011. Morbidity and Mortality Weekly Report. 2012;61(SS04):1-162. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6104a1.htm.
8 Johnston LD, O’Malley PM, Bachman JG, et al. 2012. Monitoring the Future. National results on adolescent drug use: overview of key findings, 2011. Ann Arbor (MI): Institute for Social Research, University of Michigan. Available at: http://www.monitoringthefuture.org/pubs/monographs/mtf-overview2011.pdf.
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Original publication: April 28, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 04, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 12, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.