Mario Hernandez, Ph.D. Professor/Interim Chair

Promoting and supporting Culturally Appropriate Children's Mental Health Services
Mario Hernandez, Ph.D. Professor/Interim Chair Department of Child and Family Studies Louis de la Parte Florida Mental Health Studies School of Mental Health Studies The World Federation for Mental Health on Transcultural Mental Health: Building a Global Response Minneapolis, Minnesota - October 30, 2007

Purpose Why is culture important to mental health?
To share the cultural competence continuum To share a framework for building organizational cultural competence What is meant by the concept of “health disparities?”

Assumption Underlying The Class
Culture and society play pivotal roles in mental health, mental illness, and mental health services Understanding the wide-ranging roles of culture and society enables the mental health field to design and deliver services that are more responsive to the needs of culturally and linguistically diverse people

Why Culture Is Important
The dramatic change in our nation’s ethnic composition is altering the way we think about ourselves The deeper significance of America’s becoming a majority nonwhite society is what it means to the national psyche, to individuals’ sense of themselves and their nation – their (our) idea of what it is to be American (Takaki, 1993)

What Is Culture? Culture has been defined in various ways by different disciplines and for numerous purposes (Kao, Hsu, & Clark, 2004) There will probably never be a single definition of culture (Kao et al., 2004)

How Has Culture Been Defined?
The USDHHS Office of Minority Health (2000) defined culture as: “integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values and institutions of racial, ethnic, religious or social groups” (p. 2).

How Has Culture Been Defined?
The United Nations Educational, Scientific and Cultural Organization (UNESCO) defined culture as: "... culture should be regarded as the set of distinctive spiritual, material, intellectual and emotional features of society or a social group, and that it encompasses, in addition to art and literature, lifestyles, ways of living together, value systems, traditions and beliefs" (2002).

Maslow’s Hierarchy Of Needs: Humanistic Theory
Culture: The way we go about meeting our needs Self Actualization Esteem and Identity Love and Belonging Safety and Security Physiologic (e.g., Food, Water) (Cross, Bazron, Dennis, & Isaacs, 1989)

Assumption Culture influences most, if not all, aspects of human social interactions

Although culture is omnipresent, it is frequently invisible, especially to those enmeshed within a particular culture

Why Is It Important? Striking disparities for culturally/linguistically diverse people in mental health services despite having similar community rates of mental disorders Less access to mental health care than do whites Less likely to receive needed care and when they receive it, it is more likely to be poor in quality

Sadly, relatively high levels of severity of a mental health problem are required in order for culturally-diverse individuals to overcome their reluctance to seek help from a professional

Examples Of Disparities In Mental Health
African Americans Less likely to seek treatment When they do seek treatment, they are more likely to use the emergency room for mental health care, and they are more likely than whites to receive inpatient care For More Information please refer to SAMHSA Surgeon General's Report: Mental Health Fact Sheet for African Americans. Available Online at:

Latinos/Hispanic Americans In a national survey of high school students, Hispanic adolescents reported more suicidal ideation and attempts than whites and blacks Studies also show that Latino youth experience more anxiety-related and delinquency problem behaviors, depression, and drug use than do white youth For More Information please refer to SAMHSA Surgeon General's Report: Mental Health Fact Sheet for Latinos/Hispanic Americans. Available Online at:

Asian American/Pacific Islanders Only 25 percent as likely as whites and 50 percent likely as African Americans and Latinos to seek outpatient care Less likely than whites to receive inpatient care When they do seek care, they are more likely to be misdiagnosed as "problem-free" For More Information please refer to SAMHSA Surgeon General's Report: Mental Health Fact Sheet for Asian American/Pacific Islanders. Available Online at:

American Indians/Alaska Natives Appear to suffer disproportionately from depression and substance abuse Overly represented in in-patient care as compared to whites, with the exception of private psychiatric hospitals The prevalence rate of suicide is 1.5 times the national rate. Males ages 15 to 24 account for 2/3 of all AI/AN suicides For More Information please refer to SAMHSA Surgeon General's Report: Mental Health Fact Sheet for American Indians/Alaska Natives. Available Online at:

The Challenges We Face As A Field…
Income, Geographic Location, Language Managed Care, Medicare/Medicaid Stigma Lack of trust Insurance and related policies System bias and institutional racism Hernandez, M. Nesman, T., Isaacs, M., Callejas, L. M., & Mowery, D. (Eds.). (2006). Examining the research base supporting culturally competent children’s mental health services. Tampa, FL: USF, Louis de la Parte Florida Mental Health Institute, Research & Training Center for Children’s Mental Health. Online at:

Cultural Competence

Definition Of Cultural Competence
“Cultural Competence” is a set of congruent behaviors, attitudes, and policies that come together in an agency that enables employees to work effectively in cross-cultural situations The word “cultural” is used because it implies integrated patterns of human behavior that include thoughts, communications, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social group Hernandez, M. Nesman, T., Isaacs, M., Callejas, L. M., & Mowery, D. (Eds.). (2006). Examining the research base supporting culturally competent children’s mental health services. Tampa, FL: USF, Louis de la Parte Florida Mental Health Institute, Research & Training Center for Children’s Mental Health. Online at:

Essential Elements Of Cultural Competence: Dynamics Of Difference
When a system of one culture interacts with a population from another, both may misjudge the other’s actions based on learned expectations It is important to remember that …creative energy, caused by tension, is a natural part of cross-cultural relations The system of care must be constantly vigilant over the dynamics of misinterpretation and misjudgment Cross, Bazron, Dennis, & Isaacs, (1989). Towards a culturally competent system of care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed: Volume I Washington, DC: Georgetown University Child Development Center.

Definition Of Cultural Competence
The word “competence” is used because it implies having the capacity to function effectively A Culturally Competent Agency acknowledges and incorporates at all levels the importance of culture, the assessment of cross-cultural relations, vigilance towards the dynamics that result from cultural differences, the expansion of cultural knowledge, and the adaptation of services to meet culturally unique needs

Summary Of Cultural Competence Continuum
Cultural Destructiveness Cultural Incapacity Cultural Blindness Cultural Pre-Competence Cultural Competence Advanced Cultural Competence

Cultural Competence Continuum
Cultural Destructiveness Represented by attitudes, policies, and practices that are destructive to cultures and the individuals within the culture. For example: agencies, institutions that promote cultural genocide: US Chinese Exclusion Laws; KKK and other racial superiority groups.

Cultural Incapacity Lacks the capacity or will to help minority clients and employees System remains extremely biased, believes in the racial superiority of the dominant group. Maintains paternal posture toward “lesser races,” for example: lower expectations of minorities and subtle messages that they are not valued. Supports segregation as desirable policy Enforces racial policies and maintains stereotypes Disproportionately applies resources Discriminates on basis of whether people of color “know their place”

Cultural Blindness Color or culture make no difference and that all people are the same Ignores cultural strengths Encourages assimilation; thus, those who don’t are isolated Blames victim for their problems Views ethnic minorities as culturally deprived

Cultural Pre-Competence “What can we do?” Desire to deliver quality services; commitment to civil rights Realizes its weaknesses and attempts to improve some aspect of their services Explores how to better serve minority communities Agency may believe that their accomplishment of one goal or activity fulfills their obligation to minority communities; may engage in token hiring practices Often only lacks information on possibilities and how to proceed

Acceptance and respect for difference Expands cultural knowledge and resources Continuous self-assessment Pays attention to dynamics of difference to better meet client needs Variety of adaptations of service models Seeks advice and consultation from the minority community Commits to policies that enhance services to diverse clientele

Essential Elements Of Cultural Competence
The culturally competent system of care is made up of culturally competent institutions, agencies, and professionals. Five essential elements contribute to a system’s, institution’s, or agency’s ability to become more culturally competent. The culturally competent system would: Value diversity; Have the capacity for cultural self-assessment; Be conscious of the dynamics inherent when cultures interact; Institutionalize cultural knowledge; and Develop adaptations to adversity

Cultural Competence – Advanced Holds cultures in high esteem Agency seeks to add to its knowledge base Agency advocates continuously for cultural competence throughout the system

Defining Organizational Cultural Competence

Background: Defining Cultural Competence
Cultural competence has remained largely an ideology with a set of guiding principles that lack clear operationalization (Vega & Lopez, 2001)

Conceptual Model for Accessibility of Mental Health Services to
Culturally/Linguistically Diverse Populations Definition: Within a framework of addressing mental health disparities within a community, the level of a human service organization’s/system’s cultural competence can be described as the degree of compatibility and adaptability between the cultural/linguistic characteristics of a community’s population AND the way the organization’s combined policies and structures/processes work together to impede and/or facilitate access, availability and utilization of needed services/supports (Cross, Bazron, Dennis, & Isaacs, 1989; Siegel, 2004; CMHS, 1997). Community Context Cultural/Linguistic characteristics of a community’s population organizational/systemic cultural competence Degree of compatibility defines level of Outcomes: Reducing mental health disparities Compatibility Organization’s/System’s Infrastructure Domain/ Functions Direct Service Domain/ Functions Hernandez, M., & Nesman, T. (2006).

Characteristics Of The Community Population
Cultural View of Mental Health History Language Characteristics Resource Characteristics Strength Characteristics Needs Characteristics Cultural/Linguistic characteristics of a community’s population Compatibility Facilitators Cultural View of Mental Health: The common perception of mental health that is related to the culture and facilitates service use History: History of the community or population and the effects of that history Language Characteristics: Primary language of the population Resource Characteristics: Resources of the population Strength Characteristics: Strengths of the population Barriers Cultural View of Mental Health: Common cultural perceptions of mental health that present barriers to service use Need Characteristics: Needs of the population Compatibility Facilitators Compatibility Within Organization: The agency and/or interviewee identify strategies for efficient integration and operation with all components (e.g. administrators listen to family care providers and adapt program accordingly.) Knowledge of Specific Population in Community: The agency and/or interviewee establish an authentic understanding of the culture and characteristics of a specific population. Compatibility Barriers Compatibility Within Organization: The agency and/or interviewee identify challenges for efficient integration and operation with other components (e.g. administrators disregard information provided by family care providers.) Knowledge of Specific Population in Community: The agency and/or interviewee shows a lack of understanding or barriers to gaining understanding of the culture and characteristics of a specific population An organization’s/system’s combined policies, structures and processes

Conceptual Model for Accessibility of Mental Health Services to
Culturally/Linguistically Diverse Populations Definition: Within a framework of addressing mental health disparities within a community, the level of a human service organization’s/system’s cultural competence can be described as the degree of compatibility and adaptability between the cultural/linguistic characteristics of a community’s population AND the way the organization’s combined policies and structures/processes work together to impede and/or facilitate access, availability and utilization of needed services/supports (Cross, Bazron, Dennis, & Isaacs, 1989; Siegel, 2004; CMHS, 1997). Community Context Cultural/Linguistic characteristics of a community’s population organizational/systemic cultural competence Degree of compatibility defines level of Outcomes: Reducing mental health disparities Compatibility Organization’s/System’s Infrastructure Domain/ Functions Direct Service Domain/ Functions Hernandez, M., & Nesman, T. (2006).

The rate of use or usability of appropriate mental health services
Organizational/System Implementation Domains for Improving Cultural Competence Infrastructure Domain/Function Direct Service Domain/Function Access The ability to enter, navigate, and exit appropriate services and supports as needed Organizational Values Policies/Procedures/ Governance Planning/Monitoring/ Evaluation Communication Human Resources Development Community & Consumer Participation Facilitation of a Broad Service Array Organizational Infrastructure/ Supports Compatibility between the infrastructure and direct service functions of an organization Utilization The rate of use or usability of appropriate mental health services Availability Having services and supports in sufficient range and capacity to meet the needs of the populations they serve

Organizational/System Implementation Domains for Improving Cultural Competence
The Infrastructure domain is made up of multiple functions that are typical of organizations, each of which must be adapted for cultural competence. Organizational values, policies, procedures and governance contribute to cultural competence when they promote compatibility with the community served and provide support for staff to carry out needed culturally competent service practices Likewise, planning and evaluation processes contribute to cultural competence when they include communities of color as fully contributing partners with shared responsibilities, and when they collect data that reflects the diversity of the community Infrastructure Domain/Function Organizational Values Policies/Procedures/ Governance Planning/Monitoring/ Evaluation Communication Human Resources Development Community & Consumer Participation Facilitation of a Broad Service Array Organizational Infrastructure/ Supports Organizational Values: An organization’s perspective and attitudes regarding the worth and importance of cultural competence, and its commitment to providing culturally competent care. Indication of how the organization intends to serve the target population appropriately. Policies/Procedures/Governance: Oversight of the organization that sets goals and policies that ensure the delivery of culturally competent care. Includes administrators, boards of directors, committees, documents, rules, and plans that support culturally competent practices. Planning/Monitoring/Evaluation: The mechanisms and processes used for systematic collection of baseline and on-going information about groups served (needs assessment) and planning, tracking, and assessment of cultural competence.

Organizational/System Implementation Domains for Improving Cultural Competence
Communication that supports cultural competence includes two-way communication and learning within the organization and between the organization and the community Human resources and service array domains include strategies to increase bilingual/bicultural capacity, recruitment, and retention, and availability of services that are appropriate and of high quality for the target population Methods of outreach to communities and opportunities for community/consumer participation are important mechanisms that can lead to greater compatibility Organizational infrastructure can promote cultural competence by bringing in financial, technological and other needed resources Infrastructure Domain/Function Organizational Values Policies/Procedures/ Governance Planning/Monitoring/ Evaluation Communication Human Resources Development Community & Consumer Participation Facilitation of a Broad Service Array Organizational Infrastructure/ Supports Communication: Information exchange between the organization and the community, target population, partner organizations, and levels within the organization. Includes types of content (e.g. conceptions of mental health, prevention, stigma reduction, health care planning, and consumer rights), direction of exchange (e.g. community to organization and organization to community), and format and method/frequency (e.g. written documents, radio, television, , website, focus groups, community fora). Human Resources Development: An organization’s efforts to ensure staff and other service providers have the requisite attitudes, knowledge and skills for delivering culturally competent services. Including targeting and requirements for recruitment and hiring (e.g. language/culture); training, coaching, mentoring; supervision; incentives, evaluations and criteria for retention and promotion that support cultural competence. Community & Consumer Participation: Engagement of community members, organizations and clients (focus population) in planning, implementation, assessment and adaptation of organizational cultural competence strategies. Service Array: Delivery or facilitation of a variety of needed services, including outreach, navigation, translation/interpretation, and bilingual/bicultural services offered equitably and appropriately to all cultural groups served. Organizational Resources: The organizational resources required to deliver or facilitate delivery of culturally competent services, including financial/budgetary, staffing, technology, physical facility/environment, and alliances/links with community and other partners. Informal Supports: The use of informal mental health supports such as family or friends or other systems such as clergy, social services, housing, Boys & Girls clubs, etc.

Organizational/System Implementation Domains for Improving Cultural Competence Access is defined as mechanisms that facilitate entering, navigating, and exiting appropriate services and supports as needed (Number of Studies: 11 African-American; 8 Latino; 4 Asian, Pacific, and Islander; 3 Native American) Availability is defined as having services and supports in sufficient range and capacity to meet the needs of the populations they serve. This may include availability of bilingual personnel and/or trained translators (Number of Studies: 9 African-American; 10 Latino; 6 Asian, Pacific, and Islander; 6 Native American) Utilization is defined as the rate of use of services or their usability for populations served. Utilization may include issues such as length of time in service, retention, or dropout rates (Number of Studies: 20 African-American; 18 Latino; 6 Asian, Pacific, and Islander; 6 Native American) Direct Service Domain/Function Access The ability to enter, navigate, and exit appropriate services and supports as needed Utilization The rate of use or usability of appropriate mental health services Availability Having services and supports in sufficient range and capacity to meet the needs of the populations they serve

Organizational/System Implementation Domains for Improving Cultural Competence Level of compatibility can facilitate or impede utilization of services Example: Increased access through a one-stop family services center mechanism may be offset by lack of availability of bilingual services and lack of trust in an organization that is not connected with the community. This lack of trust or bilingual capacity will result in no increase in utilization. Infrastructure Domain/Function Direct Service Domain/Function Organizational Values Policies/Procedures/ Governance Planning/Monitoring/ Evaluation Communication Human Resources Development Community & Consumer Participation Facilitation of a Broad Service Array Organizational Infrastructure/ Supports Access The ability to enter, navigate, and exit appropriate services and supports as needed Compatibility between the infrastructure and direct service functions of an organization Utilization The rate of use or usability of appropriate mental health services Availability Having services and supports in sufficient range and capacity to meet the needs of the populations they serve

Organizational/System Implementation Domains for Improving Cultural Competence Infrastructure Domain/Function Direct Service Domain/Function Access The ability to enter, navigate, and exit appropriate services and supports as needed Organizational Values Policies/Procedures/ Governance Planning/Monitoring/ Evaluation Communication Human Resources Development Community & Consumer Participation Facilitation of a Broad Service Array Organizational Infrastructure/ Supports Compatibility between the infrastructure and direct service functions of an organization Utilization The rate of use or usability of appropriate mental health services Availability Having services and supports in sufficient range and capacity to meet the needs of the populations they serve

Defining Disparities

Mental Health Focused Approach To Defining Disparities
Leads to focus on mental health Access Quality Problem is that social inequities exist and that there is a relationship between social inequities and mental health Everyone has a mental health disparity Eliminating Mental Health Disparities

Aligned Approach: What are the implications for solutions to reducing mental health disparities?
Problem with the single sector definition approach. For example, the presence of over- representation in other sectors Eliminating Mental Health Disparities Over-representation in: Juvenile Justice Child Welfare Education FOSTER CARE: The following groups are overrepresented in foster care: Non-Hispanic African American: 35 percent (184,480) of the children in foster care are African American, but they make up only 15 percent of the child population, a representation rate of 2.33:1 (.35/.15). Non-Hispanic Native American: 2 percent (10,260) of the children in foster care are Native American (American Indian and Alaskan Native), but they make up only 1 percent of the child population, a representation rate of 2:1 (.02/.01). Hispanic/Latino: 17 percent (91,040) of the children in foster care are Hispanic/Latino, but they make up 19 percent of the child population, a representation rate of 1.06:1 (.17/.16). The following groups are underrepresented in foster care: Non-Hispanic White: 39 percent (203,920) of the children in foster care are Caucasian, while they represent 59 percent of the child population, a representation rate of .64:1 (.39/.59). Non-Hispanic Asian: 1 percent (3,280) of the children in foster care are Asian while they represent 4% of the child population, a representation rate of .25:1 (.01/.04). JUVENILE JUSTICE: Quoted from And Justice for Some: Differential Treatment of Youth of Color in the Justice Center. January, 2007. Although African American youth are 16% of the adolescent population in the United States, they are 38% of the almost 100,000 youth confined in local detention and state correctional systems. They were overrepresented in all offense categories. Youth of color make up the majority of youth held in both public and private facilities. Youth of color, especially Latino youth, are a much larger proportion of youth in public than private facilities, which tend to be less harsh environments. When White youth and African American youth were charged with the same offenses, African American youth with no prior admissions were six times more likely to be incarcerated in public facilities than White youth with the same background. Latino youth were three times more likely than White youth to be incarcerated. African American youth were confined on average for 61 days longer than White youth, and Latino youth were confined 112 days longer than White youth. Question then becomes how do these two areas come together?

Over-representation in Juvenile Justice:
Aligned Approach: What are the implications for solutions to reducing mental health disparities? Over-representation in Juvenile Justice: Youth of color make up the majority of youth held in public and private facilities and are a much larger proportion of youth in public than private facilities (which tend to be less harsh settings) Eliminating Mental Health Disparities How do these areas come together? When charged with the same offenses, African American youth with no prior admissions were six times more likely to be incarcerated than White youth. Latino youth were three times more likely than White youth to be incarcerated African American youth were confined on average for 61 days longer than White youth, and Latino youth were confined 112 days longer than White youth From: From: Casey Family Programs 45

Over-representation in Child Welfare:
Aligned Approach: What are the implications for solutions to reducing mental health disparities? Over-representation in Child Welfare: 35% of the children in foster care are African American, but they make up only 15% of the child population 39% of the children in foster care are Caucasian, while they represent 59% of the child population Eliminating Mental Health Disparities How do these areas come together? From: Quoted from Site: Disproportionality in the Child Welfare System: The Disproportionate Representation of Children of Color in Foster Care On September 30, 2003 over fifty percent (59% or 304,910) of the 523,085 children living in foster care placements were children of color, although they represented only 41% of the child population in the United States From: Casey Family Programs 46

Over- and Under-representation in Education:
Aligned Approach: What are the implications for solutions to reducing mental health disparities? Over- and Under-representation in Education: Among all students, African- American students are more likely to be suspended or expelled than their white peers (40% vs. 15%) African-American preschoolers were about twice as likely to be expelled as White and Latino preschoolers and over five times as likely as Asian-American preschoolers Eliminating Mental Health Disparities How do these areas come together? FROM: Children’s Mental Health Facts for Policymakers. By: Rachel Masi and Janice Cooper. Publication Date: November Online at: Among all students, African-American students are more likely to be suspended or expelled than their white peers (40% vs. 15%). Blackorby, J. & Cameto, R. (2004). Changes in school engagement and academic performance of students with disabilities. In Wave 1 Wave 2 Overview (SEELS) (pp ). Menlo Park, CA: SRI International. African-American preschoolers were about twice as likely to be expelled as White and Latino preschoolers and over five times as likely as Asian-American preschoolers. Gilliam, W. S. (2005). Prekindergartens left behind: Expulsion rates in state prekindergarten programs (FCD Policy Brief Series 3). New York, NY: Foundation for Child Development. From: Children’s Mental Health Facts for Policymakers. By: Rachel Masi and Janice Cooper. Publication Date: November 2006. Online at: 47

Why Is The Conversation So Confusing?
Some speak and focus on social disparities Some speak and focus on mental health disparities Others are concerned with over-representation Yet others are concerned about under- representation (Drop-out/Gifted, Etc.)

When we talk about disparity issues, we often confuse sectors, their solutions, and their goals Holistic solutions are few since each sector focuses on it’s particular goals and solutions Solutions are elusive because the concerns and issues facing different populations are inter-connected What is the inter-relationship between sectors and the social concerns they are focused upon?

Unrelated Solutions, Sectors, and Their Goals Mental Health Disparity Quality Appropriate Access Over- Representation Social control sectors, special education Under- Representation Education- Drop-Out Social Inequities Racism Economics Housing Transportation

Aligned Approach This leads to planning and “solution making” that:
Linked Goals Eliminating Mental Health Disparities and Beyond Reducing Over-Representation in Other Sectors This leads to planning and “solution making” that: Focuses on a community as a whole Focuses on the linkages across sectors

Aligned Approach Eliminating Mental Health Disparities
Social Inequities: Economic, Job, Housing, and Racism/Discrimination Reducing Over-Representation in Juvenile Justice Eliminating Mental Health Disparities Reducing Over-Representation in Child Welfare Linked Goals Reducing Over- and Under-Representation in Education

Example Of A New Definition
Within a community-context, the goal of eliminating mental health disparities and beyond, must be linked to the elimination of the over-representation of children and youth in Juvenile Justice, Child Welfare, and Education in order to support the wellbeing of children and their families

Consequences Of Untreated Mental Illness
"While mental disorders may touch all Americans either directly or indirectly, all do not have equal access to treatment and services. The failure to address these inequities is being played out in human and economic terms across the nation – on our streets, in homeless shelters, public health institutions, prisons and jails." United States Surgeon General Press Release: Sunday, August 26,

In Summary Operationalize cultural competence Unify solutions
Focus on broad outcomes

References Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Toward a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. Washington, DC: National Technical Assistance Center for Children’s Mental Health. Hernandez, M. Nesman, T., Isaacs, M., Callejas, L. M., & Mowery, D. (Eds.). (2006). Examining the research base supporting culturally competent children’s mental health services. Tampa, FL: USF, Louis de la Parte Florida Mental Health Institute, Research & Training Center for Children’s Mental Health. Kao, H. S., Hsu, M. T., & Clark, L. (2004). Conceptualizing and critiquing culture in health research. Journal of Transcultural Nursing, 15, Masi, R., & Cooper, J. (2006, November). Children’s Mental Health Facts for Policymakers. Takaki, R. (1993). A different mirror: A history of multicultural America. Boston, MA: Little, Brown and Company. United States Surgeon General Press Release: Sunday, August 26, U.S. Department of Health and Human Services [DHHS]. (1999). Mental health: A report of the Surgeon General. Rockville, MD: Author.

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