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Youth Violence Is a Public Health Issue

"Violence is a public health issue because of its tremendous impact on the health and well-being of our youth." So states the National Center for Injury Prevention and Control (NCIPC), Centers for Disease Control and Prevention (CDC), as it begins to describe the problem, the factors, and the facts about youth violence ( The designation of youth violence as a public health issue complements the more traditional status of the problem as a criminal justice concern and incorporates the social and developmental sciences. It allows for broader interpretation of violence as touching everyone’s life; it includes not just urban gang violence but acts of aggression such as fisticuffs on suburban playgrounds.

Public health brings a strong problem-solving approach that has worked in many different arenas, including safe water and air, childhood immunization, and prenatal care. The approach is dependent on a well-defined process, combining inclusivity through a broad degree of participation and collaboration, measurement, and communication. The process involves identifying the risk factors, designing interventions to address these factors, and evaluating the effectiveness of programmatic efforts.

Many individuals and organizations participate in the solution of any public health problem; the community is seen as the starting point. As evident in the Healthy People 2010 initiative (, accomplishing public health objectives involves not just health professionals but educators, administrators, community leaders, and government officials—all segments of society. Certainly, broad participation is necessary in youth violence prevention, among public and private organizations as well as groups of people who interact with youth in some way—parents, teachers, counselors, judges, police, clergy, peers, and so on.

Collaboration, as well as participation, has become especially evident in youth violence prevention. For example, Youth Violence: A Report of the Surgeon General ( was developed by three Federal agencies: CDC, the National Institutes of Health, and the Substance Abuse and Mental Health Services Administration.

The public health focus on violence has brought new players and new collaborative partnerships among criminologists, psychologists, psychiatrists, sociologists, neuroscientists, and others. Although physicians and other general medical service providers have not been sufficiently involved in the past, that picture has changed with the recent formation of the Commission for the Prevention of Youth Violence by the American Academy of Child and Adolescent Psychiatry, American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Medical Association Alliance, American Nurses Association, American Psychiatric Association, American Public Health Association, and the U.S. Department of Health and Human Services. (Note: The associations are members of the Healthy People Consortium (

Data and surveillance are essential to the public health approach and to answering key questions about program planning, implementation, and evaluation: How big is the problem? How have our efforts reduced the problem? In the case of youth violence, the data are dramatic, as just a few facts affirm:

  • Homicide is the second leading cause of death for persons 15 to 24 years of age. It is the leading cause of death for African Americans and the second leading cause of death for Hispanic youths in this age group.
  • In 1999, 6.9 percent of high school students reported carrying a firearm on school property at least once in the previous 30 days.

Information dissemination is very much a part of the public health mission—getting the word out to all the participants, raising awareness about the problem and the solutions, and broadening the knowledge base. Information on youth violence abounds (see Resources, page 3). For example, NCIPC recently published Best Practices of Youth Violence Prevention: A Sourcebook for Community Action ( Healthy People in Healthy Communities: A Community Planning Guide Using Healthy People 2010 (see In Print ) is another new publication intended to stimulate and guide action.

Estimating the Cost of Youth Violence

In the public health approach to prevention, one of the first questions to be answered concerns the burden of suffering—the economic costs to society. Youth violence is a relatively new field, so comprehensive cost estimates are not readily available. Measures of violence in the home and the costs of treatment for victims of violence are among the missing data.

The Surgeon General’s report provides the best estimate but it is based on data nearly a decade old: Violence costs the United States an estimated $425 billion in direct and indirect costs each year. Of these costs, approximately $90 billion is spent on the criminal justice system, $65 billion on security, $5 billion on the treatment of victims, and $170 billion on lost productivity and quality of life.

Youth Violence: Everyone’s Issue

The immediate impetus for Youth Violence: A Report of the Surgeon General  ( was the Columbine High School tragedy that occurred in 1999. Both the Administration and Congress requested a report summarizing what research has revealed about youth violence, its causes, and its prevention. Many other studies, initiatives, and programs were launched or enhanced during the days after the tragedy.

Unfortunately, the problem has not abated. The Columbine event has been followed by others, including Santee, California, where a 15-year-old has been charged with murdering two classmates. Every such event has been followed by widespread media coverage—from news articles to editorials, to columns and interviews with experts.

Youth violence is basically everyone’s issue. And it’s a public health issue…at the national level (see Focus) and locally (see Spotlight).

According to the Surgeon General’s report, "The designation of youth violence as a public health concern is a recent development...public health offers an approach to youth violence that focuses on prevention rather than consequences. It provides a framework for research and intervention that draws on the insights and strategies of diverse disciplines. Tapping into a rich but often fragmented knowledge base about risk factors, preventive interventions, and public education, the public health perspective calls for examining and reconciling what are frequently contradictory conclusions about youth violence."

As the Commission for the Prevention of Youth Violence stated (, "More school suspensions and more prisons are not the answer. The answer, rooted in public health, is prevention."

Future receipt of Prevention Report by Internet, E-mail, of Fax

Additional information:


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Life skills training, parenting workshops, essay contests… hundreds of youth violence prevention programs are being used across the country. Some are effective, some are not; some are even harmful. The challenge is to focus resources on those that work. Youth Violence: A Report of the Surgeon General ( identifies more than two dozen programs that meet rigorous scientific standards. It describes both effective and ineffective strategies for primary, secondary, and tertiary prevention.

For example, parent training can lead to clear improvements in children’s antisocial behavior (including aggression) and family management practices.

Gun buyback programs, on the other hand, are ineffective secondary prevention strategies. Evaluation of gun buyback programs, a particularly expensive strategy, consistently has shown such efforts to have no effect on gun violence, including firearm-related homicide and injury.

As Surgeon General David Satcher said in issuing the report, "The most urgent need now is a national resolve to confront the problem of youth violence systematically using research-based approaches and to correct damaging myths and stereotypes that interfere with the task at hand." He called for an end to the "waste of resources on ineffective or harmful interventions and strategies…"

Examples from the report are described below.

In Eugene, Oregon, Linking the Interests of Families and Teachers (LIFT) ( decreased children’s physical aggression on the playground, increased children’s social skills, and decreased aversive behavior in mothers rated most aversive at baseline. At followup, 5th-grade participants had fewer associations with delinquent peers, were less likely to initiate patterned alcohol use, and were significantly less likely than controls to have been arrested.

The Iowa Strengthening Families (to become the best) Program 
( has used family-focused prevention to reduce alcohol initiation substantially.

The Center for the Study and Prevention of Violence (CSPV) ( has information on several programs in the Surgeon General’s report. Founded in 1992, CSPV provides informed assistance to groups committed to understanding and preventing violence.

The Prevention Research Center ( at Pennsylvania State University has information on Promoting Alternative Positive Thinking Strategies (PATHS), which is being used in many schools in the United States and around the world. PATHS has reduced maladaptive outcomes in both normal and special needs children, including young deaf children.

The cost of programs varies. Cost-effectiveness studies do show definite benefits but comparisons are difficult because of differences in analytical approaches.

The Surgeon General’s report concludes, "The most effective youth violence prevention programs are targeted appropriately, address several age-appropriate risk and protective factors in different contexts, and include several program components that have been shown to be effective."


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Billions of Bytes of Information on Youth Violence Prevention

Federal, State, and local governments, as well as private-sector organizations, offer a substantial array of youth violence prevention-related resources on the World Wide Web. Some, mostly Federal sites, are highlighted here; they all offer links to even more resources. A search of the many online indexes and databases will yield results on even more resources, including such specific topics as support groups, youth-led activities, and gay youth.

The recently released Youth Violence: A Report of the Surgeon General ( presents important research findings from the scientific literature about what works. Research studies also are among the resources at the National Institute on Mental Health, National Institutes of Health Web site (

The National Youth Violence Prevention Resource Center  
( serves as a point of access to Federal resources, programs, and information for parents and guardians, professionals, and teens.

Youth violence is one of four priority areas for violence prevention for the Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC) ( The Division’s site links to publications and information on evaluation studies, data surveillance activities, community-based projects, and other programs. Also part of CDC’s efforts is the Web site, "Preventing Violence & Suicide: Enhancing Futures" (, which includes information on "What can I do?"

The Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration (www.mental has launched an initiative to enhance resilience in the face of problematic behaviors and to prevent youth violence in schools. CMHS is collaborating with the U.S. Department of Education, which also offers numerous resources, including "Early Warning, Timely Response: A Guide to Safe Schools" ( html). This guide describes research-based practices designed to assist school communities in identifying these warning signs early and developing prevention, intervention, and crisis response plans.

The Office of Juvenile Justice and Delinquency Programs, Office of Justice Programs, U.S. Department of Justice ( presents data, program activities, publications, calendar of events, and much more. The site links to the National Campaign Against Youth Violence (, a nonprofit organization whose mission is to engage all Americans in effective youth violence prevention.

The Partnerships Against Violence Network (PAVNET) ( is a "virtual library" of information about violence and youth at risk, representing data from seven different Federal agencies. PAVNET also offers a mailgroup for sharing information with over 650 other violence prevention professionals, a searchable database of funding resources, and information on such non-Federal resources as the Center for the Prevention of School Violence and the International Association of Chiefs of Police. Of particular value to program planners are links to dozens and dozens of community prevention efforts.

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Healthy People 2010 and Youth Violence Prevention

Reading the daily newspaper, watching the evening news, or surfing the World Wide Web provides ample evidence that youth violence is a national epidemic. Violence is a public health issue, a Healthy People issue.

A keyword search of the 467 Healthy People 2010 objectives ( identifies 5 objectives specifically addressing youth violence. If suicide prevention is included, the number goes to 12.

Many other objectives touch on youth violence in some way. For example, the first objective in Focus Area 7. Educational and Community-Based Programs calls for an increase in high school completion. Dropping out of school and poor school performance are associated with a host of social and health problems, including violence. Objective 7-11 covers the need for cultural appropriateness and linguistic competence—both important factors in reaching populations with greater problems in such areas as homicides and unintentional injuries.

Our Nation’s health depends on preventing youth violence. For communities wishing to address some aspect of youth violence prevention, the opportunities to tie in Healthy People 2010 are nearly limitless and include (link to objective details for objectives 15, 18, and 26):

15-3 Reduce firearm-related deaths.

15-6 Extend State-level child fatality review of deaths due to external causes for children 
aged 14 years and under. (Developmental objective)

15-7 Reduce nonfatal poisonings.

15-8 Reduce deaths caused by poisonings.

15-9 Reduce deaths caused by suffocation.

15-32  Reduce homicides.

15-33  Reduce maltreatment and maltreatment fatalities of children.

15-35  Reduce the annual rate of rape or attempted rape.

15-37  Reduce physical assaults.

18-1   Reduce the suicide rate.

18-2   Reduce the rate of suicide attempts by adolescents.

26-22 Increase the proportion of persons who are referred for followup care for alcohol problems, drug problems, or suicide attempts after diagnosis or treatment for one of these conditions in a hospital emergency department. (Developmental objective)

 A review of these and other objectives, plus the new Healthy People in Healthy Communities: A Community Planning Guide Using Healthy People 2010 ( and the Healthy People 2010 Toolkit: A Field Guide to Health Planning ( provide some starting points for action. Lots of other planning materials also are on the World Wide Web (see Resources).


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In Print

Educational and Community-Based Programs

The Office of Disease Prevention and Health Promotion recently released Healthy People in Healthy Communities: A Community Planning Guide Using Healthy People 2010. This publication provides information about the steps involved in forming and running a healthy community coalition. Print copies are available from the Government Printing Office (GPO) at (202)512-1800 and on the Internet at

Injury and Violence Prevention

Under the direction of the Surgeon General, the Centers for Disease Control and Prevention, the National Institutes of Health, and the Substance Abuse and Mental Health Services Administration (SAMHSA) collaborated to prepare Youth Violence: A Report of the Surgeon General. This report focuses on action steps that all Americans can take to help address the problem of youth violence and to continue to build a legacy of health and safety for our young people and the Nation as a whole. Print copies are available from GPO at (202)512-1800 and on the Internet at

Mental Health and Mental Disorders

A report by SAMHSA’s Center for Mental Health Services and Center for Substance Abuse Prevention, Preventive Interventions Under Managed Care: Mental Health and Substance Abuse Services, states that preventive programs in specific areas are available that can prevent substance abuse and promote mental health. To receive a copy of the report in print, call (800)789-2647. The report is also available at under Clearinghouses.


The National Institutes of Health, Office of Dietary Supplements (ODS) recently released the first Annual Bibliography of Significant Advances in Dietary Supplement Research. The publication is a joint effort by ODS and the Consumer Healthcare Products Association and documents the scientifically sound research being done in this field. This publication is available in print by calling ODS at (301) 435-2920 or online at


Injury and Violence Prevention

The National Children’s Center for Rural and Agricultural Health and Safety, in response to growing concerns about interpersonal violence-related injuries to children in rural communities, has compiled a list of relevant publications. The materials were selected for relevancy, comprehensiveness, availability, currency, and cost; the list is not limited to rural safety issues. Copies are available by calling (888) 924-SAFE (7233) or visiting



The National Library of Medicine (NLM) is now participating in the electronic cataloging in publication (E-CIP) program with the Library of Congress to facilitate the online publication of new medical resources. By transmitting bibliographic information in SGML format via the Internet, the Library of Congress and NLM eliminate mailing and handling of paper as well as accelerate the publication of new resource information by several weeks. Visit NLM at

Educational and Community-Based Programs

The South Central Region of the National Network of Libraries of Medicine has completed a Consumer Web Manual to help organizations that wish to develop or expand consumer health information collections. The manual is available at

In Funding

Disability and Secondary Conditions

The National Institutes of Health (NIH) is offering funding for research on primary hyperoxaluria and related stone diseases. Funds are available under the R21 Award Mechanism. To find out more about this funding, visit or the NIH Web page on Research Studies on the Hereditary Calcium Oxalate Stone Diseases:

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Immune Deficiency Foundation National Conference. Baltimore, MD. (800)296-4433, or visit June 21-23, 2001.

National Association of County and City Health Officials Annual Conference: Confronting Disparities. Raleigh, NC. (202) 783-5550, or visit June 27-30, 2001.

7th International Family Violence Research Conference. Portsmouth, NH. (603)862-1888, or visit July 22-July 25, 2001.

National Association of Local Boards of Health Annual Conference: Building Healthy Communities Through Partnerships and Policies. Cleveland, OH. (419)353-7714, or visit July 25-28, 2001.

National Criminal Justice Association: National Forum 2001. Sedona, AZ. (202)624-1440, or visit July 29-Aug. 1, 2001.

109th American Psychological Association Annual Convention. San Francisco, CA. (202)336-6020, or visit  August 24-28, 2001.

Association of State and Territorial Health Officials Annual Meeting: Infrastructure: Building Public Health Capacity. Orlando, FL. (407)354-9840, or visit September 18-21, 2001.

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Injury and Violence Prevention

Academic–Community Collaboration: An Ecology for Early Childhood Violence Prevention. G.D. Evans, et al. American Journal of Preventive Medicine,20(1S, 2001):22-30.

Academic–community collaboration can present a successful and efficient approach to violence-prevention efforts but also can bring unique challenges.

The Jacksonville, FL, First and Best Teacher (F&BT) program illustrates some of these considerations. F&BT resulted from collaboration among the Jacksonville Children’s Commission, the Jacksonville Exchange Club Family Center and Children’s Haven, and the University of Florida Department of Family, Youth, and Community Sciences. The program consisted of two interventions: (1) child care center enrichment and staff education, and (2) home visits with parent/caregiver support and education.

F&BT employed a three-tiered organizational design for its collaboration: Tier 1 included the three core partners, Tier 2 comprised participating child care center sites, and Tier 3 included local community partners. This design was helpful in moving the intervention forward, but earlier involvement of the child care centers, particularly in the project design, would have increased the commitment level of Tier 2 partners.

Conflicts occurred between the perceived goals and motives of the Tier 2 partners, especially between the University of Florida and the child care centers. Open and frequent communication proved crucial in resolving these differences.

Youth Violence: Developmental Pathways and Prevention Challenges.
L.L. Dahlberg, et al. American Journal of Preventive Medicine, 20(1S, 2001):3-14.

Youth violence occurs amid a complex biologic, social, familial, and individual environment; preventive programs must consider these myriad factors, as well as the changing developmental needs of children, adolescents, and young adults, and tailor the programs to meet those needs. 

Young people, especially those aged 15 to 19 and 20 to 24 years, made up the largest percentages of homicide victims from 1985 to 1991, when rates for the 15- to 19-year-old group began to decline. These victims are mostly young males. There is some evidence that early signs of aggressive behavior are indicators of later violent behavior.

Prevention programs that are longer term, rather than short-term may be more effective. Successful prevention programs should consider family situations, biological factors, poverty and other socioeconomic factors, peer pressures, and developmental needs in infancy, early childhood, adolescence, and young adulthood. There is some evidence that programs that include home visitations show particular long-term efficacy.

A Violence-Prevention and Evaluation Project with Ethnically Diverse Populations. R.M. Ikeda, et al. American Journal of Preventive Medicine, 20(1S, 2001):48-55.

Staff diversity and cultural competence are two important characteristics of successful violence-prevention programs in child care settings.

This project studies Safe Start, a violence prevention program for child care teachers, directors, and parents in a culturally diverse population in the San Francisco Bay area. The program, developed through a partnership between San Francisco State University and five local community colleges, seeks to increase skills in self-awareness, cultural competency and sensitivity, violence intervention for young children, and counseling on violence prevention.

Developing a culturally relevant curriculum for this program was especially challenging for this population, whose main ethnic groupings included Chinese/Chinese Americans, African/African Americans, Latino/Hispanics, and multi-ethnic people, as well as subgroups of Koreans, American Indians, Vietnamese, Laotians, and Indians.

The study would have benefited from more time for curriculum planning, instrument planning, and focus group input, recognizing that even within each ethnic category there will be divergent cultural beliefs (e.g., among newly immigrated versus second-generation Chinese Americans).

Another challenge in serving this culturally diverse population was developing study methods and instruments that were culturally sensitive. It was found that, in spite of extensive review and back translation, evaluation instruments were interpreted by some ethnic groups in unintended ways. Chinese-American parents, for example, agreed with the statement, "…too much affection…can harm or weaken a child" because they interpreted "too much affection" as "doing things for a child."

The final challenge came in hiring a capable, culturally competent, and ethnically diverse staff. Rather than matching study population ethnicities with staff ethnicities, the goal was to draw staff members from the community and have them reflect the ethnic diversity of the study population. Staff members were also required to demonstrate cultural sensitivity and competency.

Prevention of Youth Violence: The Rationale for and Characteristics of Four Evaluation Projects. R.M. Ikeda, et al. American Journal of Preventive Medicine, 20(1S, 2001):15-21.

In 1996, the Centers for Disease Control and Prevention funded four early intervention projects aimed at preventing youth violence. This article describes the characteristics and challenges of the four projects, which were located in San Francisco, CA, Jacksonville, FL, Kansas City, MO, and Columbia, SC.

All four projects included interventions aimed at the children themselves, their parents or caretakers, child care workers, and teachers. One project dealt with parents who were incarcerated. Two of the projects focused on 3- to 5-year-old children, one included 6- to 8-year-olds, and the fourth included 3- to 10-year-olds.

The projects all included some type of training to help teachers encourage, model, and reward pro-social behavior and conflict resolution in the children. Family sessions were held to improve family communication, parenting skills, parental involvement, conflict resolution skills, and knowledge of child development and to form support networks among parents. One program provided after-school mentoring by high school student tutors.

The projects had a fairly even distribution of boys and girls; three projects included mostly non-Hispanic black children, with the fourth recruiting mostly children of Asian ethnicity and "other" (not Asian, Hispanic, black, or white) ethnicities. The parents or caretakers were mostly employed, but many had incomes below the poverty line. The populations were fairly transient, with 21 to 45 percent having changed residence in the previous year.

These projects faced special challenges in recruiting and retaining study participants, monitoring and maintaining adherence to the intervention goals, and working with diverse populations.

Substance Abuse; Tobacco Use; STDs

Adolescent Peer Crowd Affiliation: Linkages With Health-Risk Behaviors and Close Friendships. A.M. La Greca, et al. Journal of Pediatric Psychology 26(April 2001):131-143.

Health promotion and disease prevention programs aimed at adolescents need to take into account the strong influence of peer networks and friendships.

Health problems in adults often have their origins in risky behaviors that begin in childhood or adolescence. This study examined the linkages between the health-risk behaviors of adolescents and those of their peer groups and friends. The 250 participants in the study attended high schools in the Miami-Dade County, FL, school district. The students were interviewed about their own peer group affiliation and health-risk behaviors; they were then asked to identify the peer crowd affiliation and health-risk behaviors of their closest friends.

Health-risk behaviors included cigarette smoking, substance use, risky sexual behavior, and general risk taking. Peer groups were designated by "crowd" names such as "brains," "burnouts," "jocks," and "alternatives." The burnouts and alternatives reported the highest rates of risky behavior; they were most likely to smoke cigarettes, use alcohol and marijuana, and engage in general risk taking. Jocks were lower on substance use but high on general risk-taking behavior. Brains were least likely to engage in any health-risk behaviors. Populars were low on substance use but above average on alcohol use.

The study found that the health-risk behaviors and crowd affiliations of participants were fairly consistent with those of their close friends. The study findings have significant implications for health promotion programs. For example, because groups such as burnouts reported higher overall health-risk behaviors, health promotion should be targeting a wide rage of these behaviors instead of only one (e.g., drug use).


Keep Food Safe to Eat: Healthful Food Must Be Safe as Well as Nutritious. C.E. Wotecki, et al. Journal of Nutrition 131(2001):502S-509S.

The 2000 edition of Dietary Guidelines for Americans includes information on food safety as well as nutrition and notes that food safety education, along with research and regulatory activities, can reduce the incidence of foodborne illness.

Surveillance activities used to monitor progress in reducing the incidence of foodborne illness include assessing knowledge and attitudes about food safety and collecting data on food safety behaviors, levels of pathogens in food products, and epidemiology of foodborne illnesses.

Strategies for improving food safety surveillance and behaviors include the use of a risk analysis framework to organize information, identify data gaps, and promote improvement strategies. Improvement of food safety education at all levels of the "farm-to-table" food continuum is essential in reducing foodborne illness. Food safety education must be targeted to producers, growers, transporters, workers in the food processing industry and retail food service, consumers, regulators, and health professionals.

Several partnerships to improve food safety knowledge and behavior have been formed, including the Food Safety Training and Education Alliance, National Food Safety System Steering Committee, and Partnership for Food Safety Education.


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The Centers for Disease Control and Prevention is promoting a new program to combat the spread of HIV. The campaign, called Sero-status Approach to Fighting the HIV Epidemic (SAFE), was unveiled at the 8th Annual Retroviral Conference in Chicago in February. SAFE has two main goals: "to increase the proportion of HIV-infected people in the United States who know they’re infected" and "to increase the proportion of HIV-infected people who are linked to appropriate care, prevention, and treatment services."

The South Carolina Office of Rural Health, with funding from the Federal Bureau of Maternal and Child Health, is sponsoring "Resource Mothers" to reach out as mentors, teachers, and friends to pregnant women in rural areas in order to reduce inadequate prenatal care and infant mortalities. The Resource Mothers visit their clients regularly before and after delivery to teach them such topics as pregnancy, breast feeding, infant health, and immunizations. The experienced women help their clients find out about and link up with needed community and health services.

New guidelines are now in place to improve the quality and oversight of substance abuse treatment programs that use methadone and other medications to treat heroin and similar addictions. Under the new regulations, these treatment programs will be accredited according to standards set by the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment, replacing oversight by the Food and Drug Administration.




The mission of the Office of Disease Prevention and Health Promotion (ODPHP) is to provide leadership for disease prevention and health promotion among Americans by stimulating and coordinating prevention activities. Prevention Report is a service of ODPHP. This information is in the public domain. Duplication is encouraged.

U.S. Department of Health and Human Services, Volume 15: Issue 3, 2001

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