PCN 509 Grand Canyon University Cultural Considerations Discussion

provide short answers to the statements below. Refer to the “Cultural Considerations Resource” for help in completing this assignment.

Discuss the cultural issues and trends that specifically apply to each of the following regional population groups of the United States

> Hispanic Americans in the Southwest

> Your choice of a white ethnic group (e.g., German, Irish, Italian)

PCN-509 Cultural Considerations Resources
Hmong Americans in the 2013 American Community Survey (2014)
Hmong Studies Journal (census data)
“Mental Health of Hmong Americans: A Metasynthesis of Academic Journal Article Findings,” by Lee,
from the Hmong Studies Journal (2013).
Cuban Americans
Hispanics of Cuban Origin in the United States, 2011
Hispanic Americans
Pew Hispanic Center: The 10 Largest Hispanic Origin Groups: Characteristics, Rankings, Top Countries
“Mental Health at the U.S.-Mexico Border: A BRFSS Glimpse,” by Olson et al., from Hispanic Health
Care International (2007).
Other Cultural Considerations Resources
“Stereotypes of U. S. Immigrants from Four Global Regions Stereotypes of U. S. Immigrants from Four
Global Regions,” by Timberlake and Williams, from Social Science Quarterly (Wiley-Blackwell) (2012).
© 2015. Grand Canyon University. All Rights Reserved.
See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/233507059
Mental health at the U.S.-Mexico border: A BRFSS glimpse
Article in Hispanic Health Care International · September 2007
DOI: 10.1891/1540-4153.5.3.109
4 authors, including:
Robert L. Anders
Oriana Perez
University of Texas at El Paso
Baylor College of Medicine
Some of the authors of this publication are also working on these related projects:
Obsessive-Compulsive Disorder at the U.S. Mexico Border View project
Open to ideas View project
All content following this page was uploaded by Oriana Perez on 14 February 2018.
The user has requested enhancement of the downloaded file.
Hispanic Health Care International, Vol. 5, No. 3, 2007
© 2007 Springer Publishing Company
Mental Health at the U.S.-Mexico
Border: A BRFSS Glimpse
Tom Olson, PhD, APRN, BC
Julia Bader, PhD
Robert L. Anders, DrPH, APRN, CS, CNAA
Oriana Perez, BA
University of Texas at El Paso
Attention to health at the U.S.-Mexico border has steadily risen over the past two decades, yet mental
health concerns have tended to be ignored. The purpose of this study was to provide a preliminary
description of mental health in two major border counties, using a secondary analysis of data from the
Paso del Norte Behavioral Risk Factor Surveillance System (2002), a regional application of the largest
telephone health survey in the world. The findings from the 1,326 predominantly Hispanic, randomly
selected respondents highlighted ethnic differences in reported days when their mental health was not
good, as well as in levels of heavy drinking. Overall, this regional sample revealed a dramatically higher
level of childhood emotional abuse when compared with a national sample. This study provided a
unique glimpse into mental health issues at the border, suggesting crucial areas for further research
and intervention.
En las últimas dos décadas se ha incrementado la atención dedicada a la salud de la frontera
E.U.-México, sin embargo la salud mental ha tendido a ser ignorada. El propósito de éste estudio
fue proporcionar una descripción preliminar de la salud mental en dos importantes ciudades fronterizas utilizando un análisis secundario de datos de el Sistema de Vigilancia de Factores de Riesgo
del Comportamiento del Paso del Norte (BRFSS, 2002), una aplicación regional de el cuestionario
telefónico mas grande del mundo. Los resultados de los 1326 participantes seleccionados al azar, en
su mayoría hispanos, destacaron diferencias étnicas en días reportados cuando la salud mental no fue
buena así como niveles de consumo desmesurado de alcohol. En conjunto, éste muestreo regional
reveló niveles considerablemente altos de abuso emocional durante la niñez, comparado con la
muestra nacional. Este estudio aportó un vistazo a cuestiones de salud mental en la frontera, lo cual
propone áreas importantes de investigación e intervención en el futuro.
Keywords: mental health; border; Hispanic; BRFSS
ttention to health at the U.S.-Mexico border has
steadily risen over the past two decades, paralleling a rapidly growing border population,
increasing manufacturing activity, and increased international interdependence. This attention has focused on
such issues as the pressing need for interventions to effectively address the near-epidemic of diabetes (e.g., TeufelShone, Drummond, & Rawiel, 2005), related problems
of obesity and hypertension (e.g., Jiménez-Cruz, BacardíGascón, & Spindler, 2003), environmental health issues
(e.g., Ramos, May, & Ramos, 2001), and infectious diseases (e.g. Weinberg et al., 2003). Relatively little attention,
however, has been given to mental health concerns of
the largely Hispanic border population, a situation
vividly illustrated by the fact that the only psychiatric
presentation at the last two conferences of the U.SMexico Border Health Association was a single paper on
obsessive-compulsive disorders at the border given by
the lead author. Indeed, Marin, Escobar, and Vega (2006)
point out that for Hispanics in general “we have only
fragmentary information and scarce guidelines on the
frequency, recognition, and treatment of mental illness”
(p. 23), despite the fact that Hispanics are the largest
minority in the United States.
Olson et al.
to an “epidemic of ‘uninsurance’” (Texas Comptroller
of Public Accounts, 1994, para. 7). But this is not only
a border issue, because among all ethnic groups in the
United States, Hispanic Americans are the least likely to
have health insurance, public or private (Surgeon General,
2001). A direct result of the lack of payment sources is a
shortage of skilled health providers, particularly in the area
of mental health. Although 63% of border counties were
designated by the U.S. Department of Health and Human
Services as Health Professional Shortage Areas (HPSA) for
primary medical care—a serious situation in itself—95%
of the counties, including El Paso County, were designated
HPSAs for mental health care. In general, areas with a high
concentration of minority inhabitants such as the U.S.Mexico border region have “several disparities affecting
mental health care . . . (including) less access to and availability of mental health services . . . poorer quality of mental
health care . . . (and) underrepresentation in mental health
research” (Surgeon General, 2001, p. 6; see also the President’s
New Freedom Commission on Mental Health, 2003).
In regard to the second key background area—mental
health studies involving Mexicans and Mexican Americans
along the border—major databases (PubMed, CINAHL,
and PsycInfo) were searched for research focused on mental
health issues at the border for a 20-year period from 1986
to the present. This search yielded just two studies. The first
(Lantican, 1998) looked at perceptions of mental health
services received by 56 Mexican Americans in the border
region, with most participants giving a “highly favorable”
rating to the service that they received. The second (Russell,
Williams, Farr, Schwab, & Plattsmier, 1999) examined the
mental health status of 600 young Hispanic women living
in the El Paso-Ciudad Juarez area using a self-developed
questionnaire. The researchers observed that neither group
“could be described as having positive mental status”
(p. 16), although the El Paso women reported lower life
satisfaction than the women in Ciudad Juarez. A possible
relationship was hypothesized between this last finding
and the fact that El Paso women reported “a less traditionally feminine persona” than the women living in Mexico.
The suggestion was made that Hispanic women along the
border may view giving up valued traditional identities as
the price of assimilation, with resulting effects in terms of
emotional health (Russell et al., 1999). Both of these studies laid the groundwork for further research; however, no
follow-up studies were identified. Overall, the literature
review highlighted the scarcity of psychiatric research along
the border, particularly in terms of identifying the extent of
serious psychiatric concerns in this unique region.
Clearly, the initial step toward addressing mental
health issues at the border is to better understand what
the issues are. Fortunately, data from the Paso del Norte
Behavioral Risk Factor Surveillance System, or PdN BRFSS
(Paso del Norte Health Foundation, 2002), provided at
least a beginning look into mental health in two important border counties, El Paso County in Texas and neighboring Doña Ana County in New Mexico. The PdN BRFSS
survey is a regional application of the nationwide BRFSS, a
project of the Centers for Disease Control and Prevention
(CDC) and the largest telephone health survey in the
world. The purpose of this article, then, is to provide a
preliminary description of the mental health of individuals in El Paso and Doña Ana counties, the majority of
whom are Hispanic, based on data from the PdN BRFSS.
The term Hispanic is used here in accord with the BRFSS
survey terminology and, although specific subgroups were
not identified in the survey, in the two border counties
studied Hispanic refers primarily to persons of Mexican
origin (Paso del Norte Health Foundation, 2002).
Two key background areas included: 1) characteristics of
the border region; and 2) mental health studies involving
Mexicans and Mexican Americans in this region. Each of
these areas will be briefly discussed.
In regard to the first area, the 1,951-mile U.S.-Mexico
border is the most frequently traversed international border in the world, with some 350 million people crossing (legally) every year (U.S. Embassy Mexico, 2006).
More than 12 million people reside in the 42 U.S. counties
and 39 Mexican municipalities located along the border,
with 86% of those people residing in 14 pairs of sister cities. The most populous pair of sister cites includes El Paso,
Texas (approximately 700,000 people) and Ciudad Juarez,
Mexico (approximately 2,000,000 people). The border
population is predominantly of Mexican origin and, on
the U.S. side, young and poor, with 35% living under the
officially defined poverty level (U.S.-Mexico Border Health
Commission, 2001b). Compared with the remainder of
Mexico, the Mexican border population is increasing more
quickly, is more affluent, and enjoys lower levels of unemployment. The border population is expected to double by
the year 2020, with a current growth rate on the U.S. side
that is more than three times faster than the rest of the
nation (U.S.-Mexico Border Health Commission, 2001a).
The public and personal toll exacted by psychiatric illness
in the border region is likely to be exacerbated by overall
health conditions that one government official (Strayhorn,
1998) described as “among the worst in the U.S., so distressful at times that reports on health conditions suggest
a remote country in need of medical missionaries (p. 1),”
not a part of the United States. In Texas, which accounts
for 1,250 miles of the border, only 40% of persons living
in border cities have private insurance, what amounts
A secondary analysis was completed of demographic and
mental-health related data from the PdN BRFSS (2002),
with the corresponding questionnaire and codebook
consulted for all variables used in the study. This local
Mental Health at the U.S.-Mexico Border
TABLE 1. Demographics (% and N)
version of the BRFSS was produced from data collected in
El Paso County, Texas, and Doña Ana County, New Mexico, using methods that adhered to overall standards set
by the CDC for use of this surveillance system. Following
approval by the Institutional Review Board of Texas Tech
University, data were gathered from random digit dialed
telephone interviews with area residents. The sample
included responses from non-institutionalized person
aged 18 and older, with a final sample size of 1,326 for
both counties (785 for El Paso County and 541 for Doña
Ana County). Data were collected between September
2002 and August 2003.
To account for survey design with different participant
sampling weights and the post-stratification weights, the
Stata statistical software was used for all analyses. One-way
and two-way frequency tables for categorical variables and
summary statistics such as means and standard deviations
for continuous variables were generated for the specific
objectives of the study. Logistic regression was used to
examine the relationship between selected mental health
variables and demographic characteristics. Although the
BRFSS mainly highlights physical concerns, such as asthma,
diabetes, cancer, and HIV infection, the version used for
this study incorporated several important variables related
to mental health, including number of days when an individual had mental health problems, adverse childhood
experiences (sexual, physical, and emotional abuse; and
family history of mental health problems), and patterns of
alcohol use. The analysis focused on these variables.
Hispanic Non-Hispanic
Marital status
Not married
< High school High school graduate > High School
Language spoken*
As shown in Table 1, nearly two-thirds of the respondents
were of Mexican origin, reflecting the strong Hispanic
influence along the border (missing values for selected
variables accounted for the difference in sample totals).
By comparison, 30.4% of Texas residents and 38.6% of
New Mexico residents identified themselves as Hispanic.
Compared to the non-Mexican origin persons in the sample, Mexican origin persons also tended to be younger, to
have less formal education, to earn significantly less, and
to be less likely to have health insurance. Overall, 22.3%
of all respondents lacked a high-school diploma, greater
than the statewide percentages for Texas (19.5%) and New
Mexico (14.4%). There were also clear differences in terms
of language, reflecting questions that were unique to the
regional BRFSS. Nearly all non-Hispanics reported speaking only or mostly English, whereas the largest number
of Hispanics were bilingual. But sizable percentages of
Hispanics also spoke only or mostly Spanish and only or
mostly English. At least in terms of language, Hispanics
were a more heterogeneous group than non-Hispanics.
As previously noted, the indicators of mental health are
limited in the BRFSS. Fortunately, however, certain crucial
variables were available. These included a combination of
*p < .01. questions from the national BRFSS “core” as well as additional questions from the Adverse Childhood Experiences (ACE) Study, a large-scale (N = 17,421), decade-long and ongoing collaboration between Kaiser Permanente’s Department of Preventive Medicine in San Diego and the CDC (2006). A summary of responses to variables selected for their importance to the current study is included in Table 2. The first variable, “mental health days,” was derived from the following question: “Thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?” As shown, there was a significantly higher percentage of Hispanics versus non-Hispanics who reported between 1 and 5 days in the 111 Olson et al. TABLE 2. Mental Health Issues by Ethnicity (% and N) The next four items in Table 2 were taken from the ACE study described above. This ongoing study has demonstrated that an increase in adverse childhood experiences increases the risk for multiple health problems “in a strong and graded fashion” (Edwards, Holden, Anda, & Felitti, 2003). These include mental health concerns such as alcoholism, depression, illicit drug use, and suicide attempts, as well as medical problems such as chronic obstructive pulmonary disease and ischemic heart disease. Each of the four items in Table 2 was formed by combining related questions, similar to the categories developed in the original ACE research. For instance, the first item was developed from two questions that asked respondents if, during their childhood, a member of their household was depressed, mentally ill, and/or suicidal. The results did not show a significant difference between ethnic groups and were consistent with the national study (overall percentage of 18.8% regionally; 19.4% nationally). The next three ACE items covered sexual abuse, physical abuse, and emotional abuse. Four separate questions were combined for the item on sexual abuse—while a child, had the respondent ever been touched or fondled in a sexual way by an adult or person at least five years older, and/ or had that person had the respondent touch the other person’s body in a sexual way, and/or attempted or actually had oral, anal, or vaginal intercourse with the respondent. As shown, there was not a significant difference between ethnic groups. Moreover, the overall percentage (8.1%) was less than half that of the larger study (20.7%). Reported physical abuse during childhood was also lower for the regional sample (21.1%) than the Kaiser/CDC sample (28.3%). However, there was a significant difference between ethnic groups on this item, with Hispanic individuals 6.3% more likely to have reported a history of physical abuse than non-Hispanic persons. Physical abuse included the respondent’s having been pushed, grabbed, slapped or had something thrown at them and/or hit so hard that marks or an injury resulted, and/or having witnessed any of these same things happening to their mother. The relationship to the larger Kaiser/CDC sample was reversed for emotional abuse, which included two questions that asked individuals if a parent or other adult in their household “often or very often” swore at them, insulted them, and/or acted in a way that made them think that they might be physically hurt. Although the regional BRFSS did not reveal a significant difference between ethnic groups on this item, 22.6% of the respondents reported a childhood history of emotional abuse. This was more than double the percentage of 10.6% in the larger sample. The final variable in Table 2, drinks per day of alcohol, was taken from the national BRFSS core and showed a marked difference between ethnic groups (note that the question for this item was only answered if the person had previously stated that they had at least one drink Hispanic Non-Hispanic Total Mental health days* 0 1-5 >5
Household member
depressed, suicidal,
or mentally ill‡
History of
sexual abuse‡
History of
physical abuse‡**
History of
emotional abuse‡
per day***
*p < .05 [number of days in the past 30 when mental health was not good]. ‡These items were formed by combining selected questions involving each concern area. All of these items refer to the childhood/family history of the respondent. **p < .05. ***p < .01 [Note. This question was answered only if the person previously stated that he/she had ”at least one drink in the past 30 days.“]. last 30 when their mental health was not good. This effect was even more pronounced when the data were recoded into 1 to 10 days (31.3% of Hispanics and 21.6% of nonHispanics). However, there was no significant difference when respondents were asked, in a separate question, about the number of days when physical or mental health kept them from doing their usual activities. Nationally, there was no significance between Hispanics and white non-Hispanics for a comparable time period, and the overall percentages were similar to the regional BRFSS (CDC, 2002). 112 Mental Health at the U.S.-Mexico Border high percentage without health insurance, and large numbers of Spanish-speaking persons. As previously noted, for example, across the nation Hispanic Americans are the least likely of all ethnic groups to have health insurance. The income figures from this study reflect a similar situation, with the Doña Ana and El Paso region having a greater proportion of poor and a smaller proportion of wealthy households when compared to statewide and national averages (Paso del Norte Health Foundation, 2002). Insurance and income figures are important as components in establishing an individual’s socioeconomic status (SES), which, although the intervening variables are not well understood, has been demonstrated to have a close relationship to health and illness (Paso del Norte Health Foundation, 2002). In fact, some health researchers have suggested that SES, rather than ethnicity, is the salient factor in determining levels of health and wellness (e.g., Williams & Collins, 1995). The logistic regression results for mental health days, which highlighted the significance of income and insurance, seem to support this idea. However, these factors were only partially explanative, along with sex and marital status (r2 = .079), and so other variables must also be considered in accounting for the significant difference between Hispanics and non-Hispanics in regard to reported days when mental health was a problem. Considering that many of the persons along the border are relatively recent immigrants, perhaps generational or immigration status played a role in the findings regarding mental health days. Previous research has shown, for example, that second-generation Mexican American youth have a higher risk of substance abuse and suicidality than more traditional Mexican-born youth (Pumariega, Swanson, Holzer, Linskey, & Quentero-Salinas, 1992). Other research has also supported the idea that Mexicanborn immigrants tend to have better mental health profiles than subsequent generations, despite significant socioeconomic disadvantages (Escobar, Nervi, & Gara, 2000). And yet, immigrants in general have been found to generally be at high risk for mental health problems as a result of the many traumas and stressors that they tend to face (Keyes, 2000; Fox, Burns, Popovich, & Ilg, 2001; Maddern, 2004). These differing messages highlight the need to examine the influence of immigration experiences and generational status on mental health, as well as to explore other possible risk factors and protective mechanisms for mental health along the border. Aside from the mental health day results, three other findings stood out. First was the percentage of reported childhood sexual abuse, which was dramatically lower than the Kaiser/CDC sample. Exactly what might account for this difference is not clear, although perhaps major differences between the larger and regional samples, in terms of ethnicity, preferred language, and generational status might account for some of the difference. Escobar, Nervi, and Gara (2000) have suggested that the use of protective traditional family networks, among other variables, the past 30 days). Hispanics were significantly more likely to have engaged in heavy drinking, defined as more than two drinks per day (NIAAA, 2004), compared to non-Hispanics. Overall, the total percentage of Hispanic and non-Hispanic individuals who engaged in heavy drinking (calculated separately from the data in Table 2) was 22.8% of the entire sample (N = 1326), compared to a nationwide total for heavy drinking of 5.9% (CDC, 2002). Regional ethnic differences were reinforced by additional findings that showed a statistically significant difference in binge drinking (five or more drinks on one occasion; Naimi et al., 2003), with 28.9% of Hispanics reporting two or more occasions of binge drinking in the last 30 days versus 12.5% of non-Hispanics. The former figure is supported by recent findings (Wallisch & Spence, 2006) that revealed 29.3% of border Hispanics in the 18- to 25-year age group and 23.0% of border Hispanics age 26 or older reported binge drinking in the past month. Inferential statistics provided an opportunity to further examine the relationship between mental health and demographic characteristics in general and ethnicity in particular. Regression and logistic regression analyses for each of the mental health variables showed a range of factors that had significant effects on specific mental health concerns. However, when all other variables were held constant, ethnicity was not a significant predictor. For example, sex (p < .01), age (p < .01), income (p < .01), and marital status (p < .05) were predictive of “mental health days,” with risk factors including being female, having a lower income, being unmarried, and being in the youngest age group. In regard to the broader question of days when persons were unable to do their usual activities due to physical or mental health concerns, both income (p < .01) and preferred written language (p < .01) were predictive. In regard to mental health history, only sex (p < .01) was predictive of having a family member who was depressed, suicidal, or mentally ill. Age (p < .05) and sex (p < .05) were both predictive of a history of sexual abuse, while having or not having health insurance (p < .05) was the sole predictor in regard to physical abuse. Both sex (p < .01) and preferred written language (p < .05) had significant effects on whether or not a person reported a history of emotional abuse. And age (p < .05) was the sole predictor for concerns involving alcohol. DISCUSSION AND IMPLICATIONS The PdN BRFSS provides a first step toward better understanding mental health issues at the border, a region in which concerns involving mental health and illness have tended to be ignored. Some of the results were expected, including the demographics of the region—predominant Hispanic background of participants, lower income levels, 113 Olson et al. shield more recent immigrants from at least some mental health problems. This is only speculative, however, in terms of the current research. Further research would be needed to explore such a relationship. In contrast, the next remarkable finding, the percentage of emotional abuse, was over twice as high as in the Kaiser/CDC sample. And the percentage of heavy drinking, the last most notable finding, was nearly four times the national figure for adults. These surprising results seem to contradict the protective effect mentioned above and emphasize the need for further study, both to confirm the accuracy of these findings and, if accurate, to suggest possible interventions. As shown in the regression and logistic regression analyses, age was the only variable that was shown to be predictive of heavy drinking, with 18- to 30-year-olds at greatest risk, and sex was the only variable linked to emotional abuse, with females apparently at greater risk. However, these characteristics alone do not seem to account for the tremendous difference from the Kaiser/CDC and national samples. Of course, the regional and national BRFSS have definite limitations. Because interviews were conducted only with individuals who had telephones in their homes (“land lines”), those without home telephones were not represented. This would tend to exclude persons in lower socioeconomic groups (Wallisch & Spence, 2006), representing a disproportionate number of the persons in the regional sample as compared to the Kaiser/CDC and national samples. As the BRFSS surveyors also acknowledged, reaching persons for telephone surveys has become increasingly challenging due to greater use of cell phones, answering machines, and caller identification. A survey such as this is subject to self-reporting bias, the tendency to over-report healthy behaviors and under-report unhealthy behaviors. According to the Paso del Norte Health Report (Paso del Norte Health Foundation, 2002), the regional survey used “available controls for addressing these types of potential biases and the levels of non-response were within CDC guidelines” (p. 4). An additional limitation included the fact that Hispanic and non-Hispanic subgroups were not identified in the PdN BRFSS, although as previously noted, the ethnic composition of this region strongly suggests that Hispanic respondents were of Mexican origin. Finally, length of time in the United States was not assessed, which precluded analysis of how this variable might have influenced the results. Language spoken might be considered a partial proxy for length of time in the United States, if one assumes that longer time in the United States is likely to increase the probability of the respondent being either bilingual or speaking English. This limitation in particular is being addressed in a current study (see below) of factors related to mental health in a specific El Paso community. Despite such limitations, this study provides a first of its kind glimpse into mental health issues at the border. As with many beginnings, it raises as many questions as it answers, while at the same time suggesting several crucial areas for further study. For instance, additional study is needed to clarify the relationship between ethnicity, immigration, generational status, and mental health at the border, and to identify specific risk factors for mental health concerns. The study of mental health in this region also needs to be broadened to determine incidence as well as culturally congruent interventions for persons with serious neurobiological illnesses such as major depression, bipolar disorder, schizophrenia, and obsessive compulsive disorder. Findings regarding patterns of substance use as well as sexual, emotional, and physical abuse must be clarified in light of the initial results from this study. In order to clarify and expand the PdN BRFSS results, the authors are currently involved in a face-to-face household mental health survey being conducted in one of the poorest communities in El Paso County. The community is one of approximately 1,800 unincorporated border colonias, from the Spanish term for neighborhoods, that exist in Texas. These communities often lack basic services such as water and sewer systems, paved roads, safe and sanitary housing, and medical and psychiatric health care (Ramos, May, & Ramos, 2001). This single face-to-face survey, although important, should eventually be expanded to include other such communities. Like the current analysis of the PdN BRFSS, however, it is an important next step on the path toward better understanding and more effective intervention to meet the mental health needs of the border population. Such nursing-led studies are important responses to the urgent call of Healthy Border 2010 (U.S.-Mexico Border Health Commission, 2001b) to improve mental health in the border region, and thus are crucial as well to fulfilling nursing’s mission “to improve mental health care for culturally diverse individuals, families, groups and communities” (American Psychiatric Nurses Association, n.d., para. 3). REFERENCES Centers for Disease Control and Prevention. (2002). Behavioral risk factor surveillance system. Retrieved May 29, 2006, from http://www.cdc.gov/BRFSS/ Centers for Disease Control and Prevention. (2006.). Adverse childhood experiences study. Retrieved May 29, 2006, from http://www.cdc.gov/NCCDPHP/ACE/ American Psychiatric Nurses Association. (n.d.). Vision, mission and principles. Retrieved July 7, 2006, from http://www. apna.org/aboutapna/mission.html Edwards, V. J., Holden, G. W., Anda, R. F., & Felitti, V. J. (2003). 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E-mail: tolson@utep.ed 115 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. View publication stats

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