Adolescent dating violence is increasingly recognized as a public health problem. Our qualitative investigation sought input from urban, African-American adolescents at risk for dating violence concerning (Tjaden and Thoennes in Full report of the prevelance, incidence, and consequences of violence against women: findings from the national violence against women survey. US Department of Justice, Washington, DC, 2000) dating violence descriptions, (WHO multi-country study on women's health and domestic violence against women: Summary report of initial results on prevalence, health outcomes and women's responses. World Health Organization, Geneva, 2005) preferences for help-seeking for dating violence, and (Intimate partner violence in the United States. Bureau of Justice Statistics, US Department of Justice, Office of Justice Programs, Washington, DC, 2007) recommendations for a teen dating violence resource center. Four focus groups were conducted with urban, African American adolescents (n = 32) aged 13-24 recruited from an urban adolescent clinic's community outreach partners. Qualitative analysis was conducted. Participants assigned a wide range of meanings for the term "elationship drama", and used dating violence using language not typically heard among adults, e.g., "disrespect". Participants described preferences for turning to family or friends before seeking formal services for dating violence, but reported barriers to their ability to rely on these informal sources. When asked to consider formal services, they described their preferred resource center as confidential and safe, with empathetic, non-judgmental staff. Teens also gave insight into preferred ways to outreach and publicize dating violence resources. Findings inform recommendations for youth-specific tailoring of violence screening and intervention efforts. Current evidence that slang terms, i.e., "drama", lack specificity suggests that they should not be integrated within screening protocols. These data highlight the value of formative research in understanding terminology and help-seeking priorities so as to develop and refine dating violence prevention and intervention efforts for those most affected.
Keywords Adolescent * Intimate partner violence * Females * African American * Urban
Intimate partner violence (IPV) affects an estimated one in four women across the lifespan [1-3]. Adolescence is increasingly recognized as a vulnerable period for relationship violence [4, 5], reflecting both the period of intense transition of adolescence as well as their relative inexperience with dating relationships . Population-based research estimates that 1 in 5 female adolescents experience physical or sexual abuse from dating partners, and approximately 10% of male high school students experience physical dating violence . African American youth are disproportionately affected by dating violence [6-10].
As in adults [6-10], dating violence among African-American youth [11, 12] and broader samples of adolescents [13-20] is associated with poor health, including sexual risk behavior, pregnancy, substance abuse, unhealthy weight control, sexually transmitted infection and suicidality. Partner violence can also result in homicide [3, 21, 22], again with African-American women disproportionately affected . Despite their young age, adolescents also suffer intimate partner homicide with partners responsible for up to 44% of homicides for female youth aged 15-18 years old . Likely reflective of these health concerns, the prevalence of dating violence is often elevated in clinic-based samples, with approximately 40% of teen and young adult women reporting physical or sexual violence [25, 26]. These data highlight the need to identify abuse among adolescents as well as develop interventions to respond to their health and social needs.
To date, efforts to screen and support survivors of violence have largely been developed and tested among adult women [27-29]. Most notably, health care-based IPV screening has been widely recommended as a mechanism to identify and assist women in abusive relationships . While the health impact of violence screening is mixed , such screening is welcomed by patients, and may even serve as a turning point at which patients begin to recognize abuse they are experiencing [34-37]. With few notable exceptions , there is less known about how such efforts apply to teens . The prevalence of violence among adolescents and its demonstrated associations with poor health highlights the need for violence prevention and intervention with this age group. However, youth have been noted as a uniquely challenging group with regard to violence intervention. For example, youth may face difficulty in distinguishing violence from more normative relationship behaviors and may confuse abuse with love, flirting and playfulness [5, 40]. Adolescents appear to be reluctant to describe acts of pressure, coercion and control as abusive , and face conflict over whether violent behavior may actually reflect love [40, 41]. Relatively low levels of disclosure have been noted in response to IPV screening among young adults , leading to concern that this population may define and identify violence differently than adult women. Anecdotal reports from service providers suggest that teens describe relationship "drama", but little is known about what this term means with regard to dating violence. While adolescent-appropriate language has been recommended to tailor violence screening procedures for adolescent clinical settings , further research into adolescents' descriptions of abuse is needed to inform this language.
Youth-specific support and intervention programs have also been recommended in light of a growing awareness of the prevalence of adolescent dating violence and the unique developmental considerations for this age group [4, 40, 41, 44, 45]. Similar to that found among adults [2, 46-48], most youth do not disclose abuse [41, 42, 45], and those that do are more likely to turn to informal sources of support [41, 44, 45, 49]. Seeking formal help for violence victimization is often an iterative process by which survivors often first turn to informal support sources and subsequently formal services, with decisions and efficacy of help provided influenced by factors such as severity of the abuse, access to services, and prior experiences with services [48, 50, 51]. Youth appear to be similarly influenced by factors such as severity of abuse, others witnessing violence, and perceived motivation for abuse [44, 52]. While these data inform the decision-making process for help seeking, less is known about what youth may look for in seeking help for dating violence, at what point they feel that external help may be needed, and the other factors they may consider. Such work may be best conducted among those at risk for violence. The need to explore these issues among urban, African-American youth is highlighted by their disproportionate burden of abuse.
Presently, research is lacking in how to best broach the topic of dating violence with adolescents and, importantly, understand their preferences for seeking help for such abuse. This state of knowledge strongly indicates the need for formative research to understand adolescents' language for abuse and perspectives on help-seeking, particularly for urban African-American youth who are uniquely affected by violence. Such data are critical to guide the development of teen dating violence resources in community and healthcare settings. Therefore, the purposes of this study are to explore (1) youths' descriptions of dating violence, including how "drama" fits into the dynamics of teen dating violence (2) to whom teens would prefer to talk about violence, and (3) desired elements of a hypothetical teen dating violence resource center, among urban adolescents.
Four semi-structured focus groups were conducted to investigate adolescent's descriptions of teen dating violence, their preferences for help-seeking, and their insight into desirable elements of a hypothetical teen dating violence resource center. Research into these topics is limited among adolescents, thus the qualitative approach was selected for its ability to generate in-depth understanding of topics for which research is not well established [53, 54]. Each group was comprised of five to nine participants. Consistent with the overall clinic population, all participants were African American adolescents ages 13-24 years. Focus groups were loosely stratified by age (i.e., 13-16 years and 15-24 years) in an effort to group individuals developmentally while allowing flexibility for logistical considerations. Participants were recruited from community organizing and outreach programs affiliated with an urban adolescent health center; recruitment sites were selected on the basis of having substantial adolescent populations and demonstrating an interest in the research topic.
Immediately prior to the start of each focus group, participants received an invitation letter describing the purpose, procedures, risks, and benefits of the study. Verbal consent was obtained; parental consent was waived as the nature of data collected included definitions and opinions that are commonly asked during clinical visits. Focus groups were conducted on-site at the participating organizations' locations; one focus group was conducted during the day, while the remaining three were conducted in the evenings so as to meet the needs of participating youth. The 45-60 min focus groups were audio-taped and moderated by two female pediatricians with expertise in adolescent health. All focus group moderators were trained in qualitative data collection methods. Focus groups were designed to elicit general perceptions and opinions rather than personal information, and participants were instructed to not reveal any individually identifying information. All data collection procedures, including the remuneration level and focus group guide were developed with the assistance of a community coalition comprised of pediatricians, a psychologist, a youth advocate, and staff from an intimate partner violence program. Based on their experiences and interactions with youth, the committee recommended that focus groups begin with a discussion of "drama" and what it means in relationships. Thus, in a semi-structured format, participants were asked to describe teen dating violence; as part of this discussion, participants were asked to clarify the meaning of relationship "drama", a term commonly heard among youth service providers. Participants were also asked to discuss at what point behaviors become abusive, where youth might turn if faced with abuse, and desired services and characteristics for teen dating violence support centers (e.g., What are some things that are important to have in a teen dating violence center?). Following an iterative approach, small modifications were made to the focus group guide after completion of the first focus group in order to improve the flow of subsequent discussions. Upon completion of the focus groups, participants received $12.50 as compensation for their time. Funding allowed for the completion of four focus groups; moderators noted that they felt saturation had been reached. In addition, snacks or pizza and beverages were served during the focus groups. All procedures were approved by the University of Maryland Baltimore Institutional Review Board.
Audiotapes from each focus group were transcribed verbatim following a protocol to ensure de-identification of transcripts. Each transcript was reviewed by the three project moderators and reviewed against notes taken from the session to ensure fidelity to the discussion. Focus group data was analyzed using the long-table approach . Data was coded by at least two independent individuals using an inductive approach to identify emergent themes; one coder was experienced and the other less experienced. The coders met frequently to identify discrepancies and achieve consensus on the coding scheme. Codes were then conceptualized into larger themes using a similar process.
Overall, teens described "relationship drama" as well as various forms of abuse, including verbal, emotional, physical and sexual, and "disrespect". When distinguishing more normative "drama" from abusive relationships, they highlighted the role of repetition of the violence. Teens discussed their help-seeking preferences and obstacles, highlighting that they would prefer to talk to friends or family over formal services. Gender differences emerged where males strongly oppose using formal support services and females may face difficulties in relying on friends and family for support. Lastly, teens suggested that resources emphasize aspects such as confidentiality, safety, and understanding staff members in their outreach efforts in order to maintain a positive word of mouth reputation among youth.
How do Teens Describe Drama and Abuse?
Based on recommendations from the committee that helped develop the focus group guide as well as other youth service providers, focus groups began with a discussion of "drama" and what it means in relationships. While all participants recognized the term "drama", it was generally described as a normative disagreement that occurs between partners:
A lot of drama in the relationship is when two people that's in a relationship don't get along and they just be mad at each other; and they just deal with it, however, they deal with it.
Drama was also described as escalating into abuse:
In some relationships ... somebody might not, you know, say the same way the other person say; and then somebody might wanna do this--somebody might wanna do that--and then that's when conflict started. And when conflicts starts you might be abusive. In contrast, drama was also described by some as "physicalfighting," suggesting that this term holds a range of meaning for teens.
Disrespect: Verbal and Emotional Abuse
Conversations about relationship drama quickly led to discussions of "disrespect" and other forms of violence. A common theme across all focus groups was the description of "disrespect" as emotional and verbal abuse. Similar to the discussion of "drama", "disrespect" was used as euphemism for abuse, but the exact meaning of this term varied broadly.
"... mind fighting, like playing mind games with you, or making you feel that you're the person who's actually doing stuff when you're the victim"
"... emotional abuse, like just calling people out they name, making them feel low about they self, that's like a mental slap in the face."
"Calling someone out by their name," was a commonly described way of demonstrating "disrespect", and was generally defined as calling females "bitch, ho, things like that."
To illustrate the impact of disrespect, many participants described the consequences of chronic disrespect and explained how these repeated "mind games" cause victims to:
"... start acting like, like low self-esteem ... feeling like bad about yourself ... like I'm under you and like you're over me ... like I have no definite say about myself."
Sexual and Physical Abuse
When asked about what constitutes violence, most participants readily provided consistent descriptions of sexual and physical violence, using examples such as "hitting, punching, slapping", "physical abuse, um, punching, scratching, slapping, throwing things at you" and "raping".
"... If a girl wanna say 'no' then they say 'no' but sometimes the man will force them to have sex even though. or a boy it don't matter ..."
[Moderator: "And what do you mean by force them?"]
"Raping them. If a girl say 'no' and they do it anyway, that is raping."
Abuse was also described by some as extending to financial control and destruction of property:
"They don't take your money because they need It ... they do it to try to like hurt you, they take it to keep you there to control you."
"... cuttin' up your clothes, bleachin' your stuff"
"Crossing the line"
In order to better understand what level of dating violence teens consider to be abusive, participants were asked to consider at what point behavior crosses the line into becoming abusive. Many participants easily described "crossing the line" with regard to physical and sexual assault as the occurrence of the first violent act:
"... if he start putting his hands on her, that's crossin the line."
"It cross the line when they beat each other the first time."
"If a girl say 'no' and they do it anyway, that is raping."
Other teens described indicators of crossing the line that were more nuanced and spoke to the consequences of abuse:
"... like when you're second guessing yourself"
"When you start to feel like you have no confidence in yourself or when you have low self-esteem that's when you know you have to talk to someone about your problems."
For most participants, though, the element of repetition emerged as a clear indicator of "crossing the line" from more normative relationship "drama" into behavior they considered to be clearly abusive across all abuse types.
"I feel like it cross the line after I have to keep telling you over and over again ... Don't call me out my name ..."
"It cross the line when a girl say no and they keep saying no and a then a boy don't understand that and then they don't care ... sex or anything--anything that they don't wanna do--that's crossing the line."
Teen Dating Violence Help-Seeking: Preferences, Barriers, and Gender Differences
Most teens initially described strong preferences and intentions to turn to peers, "like one of my ordinary friends that I hang around", older siblings and family members first if faced with dating violence. However, a number of barriers were quickly raised, particularly for women's abilities to successfully get help from friends and family.
Women's Barriers to Reaching out to Family: Fear of Further Violence and Shame
On further discussion, many participants expressed concern that some youth, particularly women, may not reach out for fear of further violence or shame.
"If the girl's like afraid to tell somebody cause he might hit her or beat her they probably like hide their feelings or like hide from their parents or hide their bruises or anything cause they too scared and they know what he might do."
Other barriers to sharing violence with family were raised, including "girls don't tell their mothers and stuff that they havin' sex."
Women's Barriers to Reaching out to Friends: Female Friends in Similar Relationships
In considering getting help from friends, participants widely assumed that female friends would likely also be facing partner violence, which generated concern that ability of friends to provide help could be compromised.
"A female probably can't tell their female friends cause their friends probably in the same situation they in, so they probably don't know what to do cause they might be doin the same thing."
"What if they in the same situation she in? If she go and take her advice and go and try to swing back on this dude or something and then she fight, she might be dead or she might be messed up for life ..."
Women Describe Little Hesitation to Seek Formal Help
Following discussion of women's obstacles to relying on their friends or family for support, women also described little hesitation and at times a preference for formal services:
"I would want to see a professional. I mean like you might need professional services, 'cause your friends ... don't know what's really going on, but they don't see what's really going on on the inside, they might be like 'just leave him, just leave him alone'."
Men: No Barriers to Support from Friends and Family; Formal Services are a Threat to Masculinity
In contrast, most male participants described no barriers to getting support from friends and family, and indicated little interest in formal services:
"If I was in a situation like that, I'd tell my mother because my mother she feels differently cause I'm a boy she not gone be all like hurt about it, but if I was a girl it'd probably be different."
"I'm a male and I know I don't wanna go to no clinic to talk to nobody--I'd rather talk to an older sibling or something like that but I aint gonna go to no clinic."
They further described that this preference reflects an underlying perception that seeking professional help could be considered a threat to their masculinity:
"If you a male you don't wanna like make it seem like you soft--mess your pride up. I'm not gonna go to a center, tell 'em about my problems. They gonna think like, oh yeah he really soft."
Desired Qualities in Hypothetical Dating Violence Support Services
In considering what they would want in dating violence support services, all participants emphasized the importance of being able to talk freely without fear of disapproval, judgment, and incomprehension of his/her situation. They described preferences for "somebody that you feel comfortable with", "someone that's open-minded that understands" and who "is willing to hear":
It has to be someone who is not judgmental, who's welcoming, and just listening, listening to what the person came to say and not you know telling them what they think of you.
Talking with staff members who personally understood their situations, particularly peer or adult survivors of dating violence who can "understand the type of relationship," was also desired by some:
... "people who actually experienced the same type of situation that you people coming to the center have already experienced they could feel like you know, they could be empathetic to them."
Resource Center Qualities: Comfort, Safety, and Confidentiality
Comfort was central in all participants' discussions of desired qualities of a hypothetical resource center and included a welcoming atmosphere, personal safety, and assurance of confidentiality.
"It has to be a nice, comfortable atmosphere, where someone can come in. I'm not saying that they know you, but it has to (have a) warm welcome feeing that you get ... relaxing ..."
"You have to feel comfortable coming to that place ... it's like I feel as though it's like a safety thing, you know, I feel like well it's supposed to have security."
In emphasizing the need for safety and security at centers, most participants explained that they would have to be "Protected ALWAYS", and suggested
"If you had people there like security guards or retired police officers there so that you know you're safe."
Confidentiality also factored into all participants' comfort; they described their hesitation in using formal services as rooted in the fear that others would find out their secrets or simply the fact that they used such a center:
"It has to be completely confidential for someone to have to be comfortable to even discuss that with you. that you're not gonna take it no further than the room."
"Say like we got somebody in the center we tell 'em our deepest thoughts and they go back and tell this person and then they tell this person and next thing you know it's out there in the street that you do this, you do that."
Outreach and Word-of-Mouth Publicity
The importance of having a good reputation and the crucial role of peers in promoting services emerged as a strong theme across focus groups. They agreed that "hearing good things about it" would be necessary before they would consider using services. They suggested peer referral and word of mouth both to promote awareness of services.
"To refer a friend, sometimes (they are) not, sometimes they don't always look for the help, they want someone else to do that for them so you look up a couple places, you hear about that place tell a friend about it, maybe their interested maybe they're not, but at least it's there, the option is open."
They explained that the same informal peer referral could result from traditional publicity methods.
"I think that y'all should pass out flyers like in the high schools and middle schools even though some people might rip em up or throw em away like I don't care you should just do it so people can know. Maybe that one person might hand it to her friend or another person may just keep it for someone they see on the street."
Participants provided critical insights into both the language used to describe abuse, as well as preferences for, and obstacles to, violence-related help-seeking among urban, African-American youth at risk for violence victimization. A range of meanings was provided for common slang terms for abuse, e.g., "drama", suggesting that these terms may be limited in their specificity and should not be substituted for validated abuse screening instruments. Participants described complex and gendered preferences for violence-related help-seeking, and emphasized the importance of safety and confidentiality in considering formal services. The relevance of these current findings are highlighted by the growing attention to teen dating violence [13, 56, 57],the disproportionate burden of violence among African-American youth , and the concern that existing adult resources may not translate well to teens [40, 43]. Our results provide insight into tailoring adolescent screening and services related to dating violence as has been recommended [40, 43].
Overall, participants did not agree on a unified definition of drama," disrespect" or what constitutes abuse. When asked to clarify relationship drama and subsequently describe abuse in their own words, teens assigned a wide range of descriptions to drama;" they used additional terms such as disrespect" to describe abuse but hesitated to identify such relationships as violent. This finding of inconsistency assigned to these terms echoes prior research suggesting that teens have difficulty and inconsistency in defining abuse [5, 40, 42]. "Disrespect" has been previously discussed in the violence literature, primarily in street and gang-related investigations [58, 59]. Recent evidence suggests that young males feeling disrespected by their girlfriends can be a trigger for teen dating violence . The overwhelming preference of our participants to use disrespect" as a euphemism for abuse further echoes its relevance in understanding dating violence dynamics. The heterogeneity in descriptions holds implications for tailoring adolescent screening and intervention programs for dating violence both within this community and in other settings. Our findings suggest that within this community, the slang terms "disrespect" and "drama" lack specificity, and should not be substituted for validated violence screening tools. Previous work regarding the use of slang by adolescents to describe sexual health topics has also found heterogeneity in the understanding of these words and phrases, highlighting how clinicians should not assume common understanding of slang words . While the terms and euphemisms for abuse likely vary across settings and populations, providers in a range of settings should be aware that local slang terms may hold a range of meanings, particularly for sensitive topics such as abuse, and should not hesitate to clarify the meaning of such language when used by adolescents . Research with youth suggests that they do not prefer the use of slang terms by providers, but providers should make sure to not only understand the adolescent's language but also confirm that the adolescent understands the his/her language [38, 60]. Taken together, this work illustrates that as clinical providers seek to tailor violence screening tools for adolescents, formative research is valuable in identifying relevant terms and clarifying limitations on the use of these terms for clinic-based screening.
Despite the heterogeneity in definitions for "drama" and "disrespect", findings suggests that participants agree on the relevance of this language, as illustrated by the over-whelming preference of participants to use disrespect" as a euphemism for abuse. Thus these terms may hold value as examples within a violence screening conversation, or clinical 'red flags' within this specific community. For example, disrespect" could be incorporated within a leadin sentence preceding a violence screening. Initiating violence screening with youth-relevant terminology may help teens feel more comfortable, and providers with this language toolset may more easily overcome common barriers to violence-related screening e.g., patient-provider differences and discomfort while discussing intimate subjects [61-63].
New to this body of work, participants illustrated specific distinctions of "crossing the line" between normal dating and any abuse type as the repetition of the violence or requests to stop. For example, relationships with repeated disrespect or saying no" to unwanted teasing or sex were characterized as abusive. While participants indicated that some level of drama and disrespect appears common and normative among teens, chronic disrespect may be a red flag for abuse. Some teens also offered insight into other dating violence dynamics not previously identified for this population such as financial control. While financial abuse has been described among co-habitating adults , further research is needed to understand financial abuse among teens, as well as identify other elements of abuse that may manifest uniquely for adolescents.
Findings concerning help-seeking are largely consistent with prior evidence that informal help sources including older siblings, parents, and friends are preferred over formal resources [41, 44, 45, 49]. Notably, participants indicated that males may oppose seeking services for fear of losing pride or their reputations, while females fear shame from informal sources and express little hesitation for formal support sources. While this is consistent with some prior work , other findings indicate that males are more likely to actually seek formal help for violence . Concerns were raised whether females could depend on their friends and family to give them helpful advice; this finding is consistent with prior work indicating that friends and family members often inadvertently blunder disclosures of violence by not offering help, blaming the victim, or minimizing the severity of the abuse [46, 64-67]. Despite the concerns, those experiencing abuse overwhelmingly turn to friends and family members first for help [41, 44, 45, 49]. This evidence has resulted in recommendations for focusing on peer support programs [41, 45, 46, 68, 69]. Taken together, this work also suggests that since peers and family members are often not ideal sources of support training them to respond supportively to disclosures of violence and uniquely to hesitations expressed by the victim (e.g., fear of further abuse for females and threat to masculinity for males) may be a mechanism to support victims and facilitate access to services,.
Our results add to a large body of research concerning obstacles to seeking services among adolescents and adults, including confidentiality and trust of the provider . They echo findings from adults illustrating preferences for confidentiality, a supportive and compassionate environment, available resources when discussing IPV [41, 7072], and recommendations to maintain open, empathetic, nonjudgmental provider-patient relationships [73, 74].
Existing violence support services likely maintain such comfortable settings; our participants heavily emphasized the importance of communicating these qualities so as to develop a good reputation among teens. Referral to services by friends was a primary consideration for formal help-seeking. Developmentally, adolescents are highly attentive and responsive to peer influences [5, 75, 76]. Prior research also suggest the utility of peer referral and social-networking mechanisms as communication tools to reach teens for health information [75, 77-79]. Teen dating violence prevention and intervention programs may consider prioritizing establishing and maintaining a positive reputation among teens in order to raise awareness of their availability and minimize stigma associated with approaching such programs. These recommendations may help overcome the low utilization and awareness of formal services, as well as the preference to only seek informal sources of health for violence, previously documented among youth [41, 44, 45, 80].
Findings should be considered in light of several limitations. This descriptive, qualitative study used a convenience sample of teens from a single urban geographic setting and ethnic/racial group (African American). The extent to which findings may be generalizable to other groups is unknown, particularly as the interpretation of slang terms such as drama" may vary geographically and by other demographic characteristics. Focus groups were not stratified by gender so as to generate a range of opinions on the topics posed, and the gender differences that emerged were explicitly raised by participants. Given the need to explore these differences further and potentially identify additional differences based on gender, stratification may be useful in further research on this topic. While the gender differences in help-seeking preferences arose naturally in the discussion, our study was not designed to support formal comparisons based on participant characteristics (e.g., age, gender, prior experiences with violence). The age range of participants was broad; variation in experiences and preferences across this range may have compromised our ability to generate an in-depth understanding of a narrower age range. Despite these limitations, the semi-structured qualitative approach allowed us to explore complexities of teen dating violence that might have been overlooked using a quantitative study design.
Clinical, programmatic, and policy efforts are urgently needed to reduce the high prevalence of violence among adolescents [13, 56], particularly African-American youth , and mitigate its health impact [13-20]. Current findings offer insight in understanding both the language teens use for violence as well as their help-seeking preferences. Our results provide much-needed direction for prevention and intervention efforts so as to protect the health and well-being of youth.
Published online: 25 May 2011
Acknowledgments This work was supported by a grant to AMH from the American Academy of Pediatrics Community Access to Child Health Program. CEM was supported by the Johns Hopkins Predoctoral Clinical Research Training Program grant number 1TL1RR-025007 from the National Center for Research Resources (NCRR), a component of the National Institutes of Health (NIH). The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official view of NCRR or NIH.
Conflict of interest None declared.
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C. E. Martin
Johns Hopkins School of Medicine, 733 N. Broadway, Baltimore, MD 21205, USA
A. M. Houston
Assistant Commissioner for Maternal and Child Health, Baltimore City Health Department, 1001 E Fayette Street, Baltimore, MD 21202, USA
K. N. Mmari
Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E4620, Baltimore, MD 21205, USA
M. R. Decker ([mail]
Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, E4142, Baltimore, MD 21205, USA