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RESEARCH ARTICLE
Adverse Childhood Experiences and Household Food
Insecurity: Findings From the 2016 National Survey
of Children’s Health
Dylan B. Jackson, PhD,
1
Mariana Chilton, PhD, MPH,
2
Kecia R. Johnson, PhD,
3
Michael G. Vaughn, PhD
4,5
Introduction: Research has linked adverse childhood experiences to a host of negative health out-
comes. The present study examines the link between individual and cumulative adverse childhood
experience exposure and household food insecurity in a recent, nationally representative sample of
children, and whether parent self-rated well-being attenuates these associations.
Methods: Data from the 2016 National Survey of children’s Health were analyzed in 2018
(n=50,212). Information concerning children’s exposure to multiple forms of adversity, household
availability of food, and parent self-rated well-being were available in the data. Multinomial logistic
regression was performed to analyze the data.
Results: Findings suggest that the accumulation of adverse childhood experiences is associated
with higher odds of food insecurity, with stronger associations between adverse childhood experi-
ence accumulation and moderate-to-severe food insecurity. Compared with no adverse childhood
experience exposure, exposure to 3 or more adverse experiences corresponded to an 8.14-fold
increase in the RR of moderate-to-severe food insecurity. Self-rated parent physical and mental
well-being partially attenuated these associations.
Conclusions: Policies aimed at minimizing adverse childhood experience exposure among chil-
dren may have important collateral benefits in the form of reduced household hunger. Existing
nutrition assistance programs may be enhanced by linking children and families to programs that
bolster parent and child well-being; addressing community and family violence; and providing support
for caregivers to prevent abuse, hardship, and exposure to the criminal justice system.
Am J Prev Med 2019;000(000):1
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8. © 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All
rights reserved.
INTRODUCTION
Adverse childhood experiences (ACEs), which
typically encompass various forms of family dys-
function, child abuse, and child neglect,
1
have
recently captured the attention of policymakers, practi-
tioners, and scholars.
2,3
Research suggests that ACEs are
quite common, with recent estimates indicating that by
adulthood approximately 62% of individuals have experi-
enced at least one form of adversity.
4
Cumulative ACE
exposure has been linked to a wide array of deleterious
outcomes, including physical and mental health prob-
lems,suchastype2diabetes,obesity,depression,internal-
izing and externalizing behaviors, and attention-deficit
hyperactivity disorder.
5−10
It has become evident that the
trauma of such childhood adversities, especially as they
From the
1
Department of Criminal Justice, College of Public Policy, Uni-
versity of Texas at San Antonio, San Antonio, Texas;
2
Dornsife School of
Public Health, Drexel University, Philadelphia, Pennsylvania;
3
Depart-
ment of Sociology, Mississippi State University, Starkville, Mississippi;
4
School of Social Work, College for Public Health and Social Justice, St.
Louis University, St. Louis, Missouri; and
5
Graduate School of Social Wel-
fare, Yonsei University, Seoul, Republic of Korea
Address correspondence to: Dylan B. Jackson, PhD, Department of
Criminal Justice, College of Public Policy, University of Texas at San Antonio,
501 W. Cesar E. Chavez Boulevard, San Antonio TX 78207.
E-mail: dylan.jackson@utsa.edu.
0749-3797/$36.00
https://doi.org/10.1016/j.amepre.2019.06.004
© 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights
reserved.
Am J Prev Med 2019;000(000):1−81
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accumulate within families, constitutes a public health cri-
sis that requires targeted community-based action, careful
screening procedures, and a focus on policymaking that is
trauma informed.
11
An emergent body of research suggests that ACEs may
also be closely related to food insecurity or diminished or
unreliable household availability of adequate, nutritious
food.
12−18
Findings at the nexus between ACEs and
household food insecurity are consistent with research
linking ACEs to both economic hardship and poor
health,
8−10
which have already been shown to be strongly
correlated.
19−23
In particular, caregivers who experience
adversities are more likely to report diminished mental
and physical well-being.
23−25
Poor parental well-being,
moreover, is a potent predictor of household food insecu-
rity,
19
and a key explanatory factor linking economic
hardship and cumulative ACE exposure among chil-
dren.
26
Thus, it is possible that any linkage between the
accumulation of ACEs and household food insecurity is
wholly or partly explained by parent mental and physical
well-being, although the directionality of these relation-
ships is often difficult to identify. Even so, caregiver physi-
cal and psychological ailments, which tend to co-occur
with accumulated childhood adversities,
23−25
may greatly
inform associations between individual and cumulative
ACEs and food insecurity. Despite this possibility, the
potential role of parent’s perceived physical and mental
well-being in these associations is often overlooked. Fur-
thermore, the empirical literature to date is largely cir-
cumscribed to studies examining isolated adversities
14,23
and studies using local or regional samples.
12−14,17
The
objective of the present study is to assess the following:
(1) associations between cumulative ACE exposure and
levels of household food insecurity among a recent,
nationally representative sample of children and their
families and (2) whether parent perceptions of physical
and mental well-being attenuate these associations.
METHODS
Study Sample
Data from the 2016 National Survey of Children’s Health (NSCH)
were analyzed in the year 2018 for the purposes of the present
study.
27
The Appendix contains more information concerning the
sample and how missing data were handled. This study was
approved by the IRB of the University of Texas at San Antonio.
Measures
The 2016 NSCH included one item that asked primary caregivers
about the extent to which household foods were not sufficient for
residents, in terms of quality or amount. Several recent studies
have employed items that distinguish between mild food insecu-
rity (i.e., where household residents sometimes rely on low-cost
foods and consume imbalanced meals) and moderate-to-severe food
insecurity (i.e., where residents report occasional to frequent experi-
ences of hunger).
28−30
Regardless of the details of measurement, sin-
gle-item indicators, similar to the item employed in the 2016 NSCH,
have been validated as useful proxy measures for food insecurity.
31,32
In the 2016 NSCH, primary caregivers were asked: which of
these statements best describes the food situation in your household
in the past 12 months? Response options included the following:
(1) we could always afford to eat good nutritious meals, (2) we
could always afford enough to eat but not always the kinds of food
we should eat, (3) sometimes we could not afford enough to eat,
and (4) often we could not afford enough to eat. In accordance
with recent studies, a distinction was made between households
that lacked access to enough food and those that, despite having a
sufficient amount of food, lacked access to nutritious food.
30,33,34
Therefore, respondents who reported that they could sometimes
or often not afford enough to eat were designated as experiencing
moderate-to-severe food insecurity (4.38% of sample; n=2,199),
capturing the type of food insecurity that indicates not having
enough to eat. Respondents who reported that they could always
afford enough to eat, but could not always afford to purchase
nutritious foods, were designated as experiencing mild food inse-
curity (21.32% of sample; n=10,705). Lastly, respondents who
reported being consistently able to afford good, nutritious meals
were designated as being food-secure (74.3% of sample; n=37,308).
Eight measures of ACEs were employed, which have been uti-
lized in recent research on the link between ACEs and maternal
and child health.
35
As was the case with prior iterations of the
NSCH, these items were selected and tested on the basis of the
original adult ACE study (the Behavioral Risk Factor Surveillance
Survey ACE Module). Still, modifications were made through an
extensive technical expert panel process and review.
36
These
measures are based solely on caregiver reports, as primary care-
givers were first asked: to the best of your knowledge, has (CHILD)
EVER experienced any of the following? Then, various forms of
childhood adversity were listed, including the following:
1. parent or guardian divorced or separated;
2. parent or guardian died;
3. parent or guardian served time in jail;
4. saw or heard parents or adults slap, hit, kick, or punch one
another in the home;
5. was a victim of violence, or witnessed violence, in the neighborhood;
6. lived with anyone who was mentally ill, suicidal, or severely
depressed;
7. lived with anyone who had a problem with alcohol or drugs; and
8. treated or judged unfairly because of his or her race or ethnic
group.
After this statement, primary caregivers were given the option
to indicate yes, that the child had experienced this form of adver-
sity, or no, that the child had not experienced this form of adver-
sity. Each ACE was examined as an independent variable in a
subset of analyses. The cumulative effect of ACEs on household
food insecurity was also explored. In these models, respondents
were categorized as experiencing none of the ACEs (68.56% of the
sample; n=34,426), experiencing 1 of the ACEs (18.07% of the sam-
ple; n=9,073), experiencing 2 of the ACEs (6.70% of the sample;
n=3,364), or experiencing 3 or more of the ACEs (6.67% of the
sample; n=3,349). Though the rates of ACE exposure in the present
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study are lower than those of justice-involved youth,
37
they are sim-
ilar to rates of ACE exposure in prior studies examining nationally
representative samples of youth.
7
The secondary hypothesis of the current study pertained to the
relationship between ACEs and household food insecurity and
posited that the well-being of parents may, at least in part, explain
this relationship. Two items pertaining to parent self-rated well-
being were available in the 2016 NSCH. The first item asked the
respondent parent: in general, how is your physical health?
Response options included the following: (1) excellent, (2) very
good, (3) good, (4) fair, and (5) poor. Similarly, respondent parents
were also asked: in general, how is your mental or emotional
health? Response options also included the following: (1) excellent,
(2) very good, (3) good, (4) fair, and (5) poor. Ultimately, because
of the ordering of the response options, with higher numerical
responses indicating lower well-being, these items were labeled as
“low parent self-rated physical well-being”and “low parent self-
rated mental well-being,”and were included in a subset of models
examining the robustness of the key hypothesized association
between ACEs and household food insecurity. The Appendix pro-
vides a full list of covariates.
Statistical Analysis
First, demographic characteristics of the sample were presented.
Second, bivariate patterns between ACEs and food insecurity were
examined by calculating the proportion of children experiencing
various degrees of food insecurity (i.e., none versus mild versus
moderate-to-severe) by the extent of their exposure to ACEs.
After establishing the nonrandomness of cumulative ACE
exposure, the association between ACEs and children’s exposure
to household food insecurity was re-examined using multivariate,
multinomial logistic regression. Although the primary focus of
the current study was on the accumulation of ACEs and their
association with both mild and moderate-to-severe household
food insecurity, a separate set of estimates for individual ACEs
was also included. Finally, a set of ancillary analyses explored
whether the association between cumulative ACEs and food inse-
curity was attenuated when parent self-rated mental and physical
well-being were taken into account. Thus, the current analysis of
these cross-sectional data was multifaceted to enable a robust test-
ing pattern of the associations between ACEs and food insecurity
among this large, nationally representative sample.
The multinomial logistic regression models employed in the
present study examined the predicted percentage change in the
level of food insecurity (i.e., none versus mild versus moderate-to-
severe) for a 1-unit change in the ACE variable being examined.
For the cumulative ACE measure, estimates are relative to the ref-
erence category of no ACE exposure; for individual ACEs, a 1-
unit change simply entails exposure to that particular ACE relative
to no exposure. All analyses were conducted in Stata, version 15.1.
To account for the complex survey design, sample weights that
adjust for nonresponse, probability of selection, and the demo-
graphic distribution of the target population were employed.
38
RESULTS
The analysis began with the presentation of select partic-
ipant characteristics by history of cumulative ACE
Table 1. Select Participant Characteristics by History of Cumulative ACE Exposure
ACE
Characteristics, % Full sample
None
(68.56%)
1ACE
(18.07%)
2 ACEs
(6.70%)
3+ ACEs
(6.67%)
Child characteristics and household demographics
Child age, years, mean (SD) 9.38 (0.02) 8.51 (0.03) 10.92 (0.05) 11.54 (0.08) 11.82 (0.08)
Child sex (male=1) 51.26 51.43 51.55 51.10 49.46
White 70.34 73.47 66.64 63.62 64.65
Black 6.12 4.34 9.00 10.34 8.66
Hispanic 11.00 9.73 12.70 13.90 13.98
Other race/ethnicity 12.54 12.46 11.66 12.14 12.71
Married, 2-parent household 69.90 90.79 33.17 22.72 11.96
Cohabiting, 2-parent household 4.73 3.32 7.20 8.84 8.63
Other family structure 25.37 5.89 59.63 68.44 79.41
Parental education, mean (SD) 3.47 (0.00) 3.57 (0.00) 3.32 (0.01) 3.18 (0.02) 3.08 (0.02)
Below poverty line 9.17 6.29 12.71 17.48 22.01
Low income 15.60 12.97 19.31 23.21 25.45
Moderate income 31.17 30.89 32.46 31.41 30.29
High income 44.06 49.85 35.53 27.89 22.26
Parental employment 76.64 77.52 78.22 74.07 66.29
Nutrition assistance 12.82 8.62 17.05 24.37 30.69
Parent self-rated well-being, mean (SD)
Low parent self-rated mental well-being 1.85 (0.00) 1.71 (0.00) 2.02 (0.01) 2.22 (0.02) 2.40 (0.02)
Low parent self-rated physical well-being 2.05 (0.00) 1.93 (0.00) 2.21 (0.01) 2.38 (0.02) 2.59 (0.02)
Note: ACE, adverse childhood experience.
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exposure (Table 1). Notably, representation of nearly all
the participant characteristics included in the study var-
ied by level of ACE exposure. After exploring differences
in sample demographics by degree of ACE exposure, the
proportion of children experiencing various degrees of
food insecurity (i.e., none versus mild versus moderate-
to-severe) by degree of ACE exposure was calculated in
an effort to establish a bivariate relationship that does
not yet account for covariates (Figure 1). The findings
illustrated that, whereas 81% of children exposed to
none of the ACEs were raised in food-secure homes,
only 45% of the children exposed to 3 or more ACEs
were raised in food-secure homes (chi-squared=2,900;
p<0.001). Conversely, both mild and moderate-to-severe
food insecurity became more common as the number of
ACEs increased. For instance, whereas 17% of children
exposed to none of the ACEs were raised in homes char-
acterized by mild food insecurity, 38% of the children
exposed to 3 or more ACEs were raised in homes char-
acterized by mild food insecurity (chi-squared=1,300;
p<0.001). The difference was even larger for moderate-
to-severe food insecurity, with its likelihood increasing
by a factor of 8.5 (i.e., from 2% to 17%) among children
experiencing 3 or more ACEs relative to children
experiencing none (chi-squared=1,800; p<0.001).
Next, to address potential confounding of the associa-
tion between ACEs and food insecurity, the association
between the accumulation of ACEs and children’s expo-
sure to household food insecurity was estimated using
multivariate, multinomial logistic regression models that
accounted for child characteristics and household demo-
graphics (Table 2). Although covariates were suppressed
to conserve space, the analyses revealed that cohabiting,
two-parent household (+), parental education (), each
of the income categories (e.g., high income [−]), and
nutrition assistance (+) were consistently and signifi-
cantly associated with both mild and moderate-to-severe
food insecurity. However, child age, gender, and race, in
addition to parental employment, were not consistently
predictive of household food insecurity. Furthermore,
the results indicated that, relative to children with no
history of ACEs, children with a history of ACEs (and a
greater number of ACEs) appeared to be at significantly
higher risk of residing in a food insecure household. Spe-
cifically, compared to children with no history of ACEs,
the risk of mild household food insecurity (relative to
food security) was 3.70 times higher among children
exposed to 3 or more ACEs (95% CI=2.96, 4.63;
p<0.001). Additionally, exposure to 3 or more ACEs (rel-
ative to none) was associated with an 8.14-fold increase in
the risk of moderate-to-severe household food insecurity
(relative to food security; 95% CI=5.75, 11.52; p<0.001).
Even so, experiencing only one ACE (relative to none)
still corresponded to significant increases in the risk of
both mild (RRR=1.65; 95% CI=1.39, 1.97; p<0.001) and
moderate-to-severe (RRR=2.16; 95% CI=1.60, 2.91;
p<0.001) household food insecurity. Results displayed in
Table 2 also indicated that the general pattern of statisti-
cally significant results held for most individual ACEs,
with the exception of parent death. Robustness checks
also revealed that employing a count measure of ACEs
did not alter the substantive findings. The Appendix pro-
vides results of additional ancillary analyses.
Finally, a subset of analyses examining the degree to
which parent self-rated well-being attenuated associa-
tions between ACE exposure and the different forms of
food insecurity was performed (Table 3). Broadly speaking,
evidence of a notable degree of attenuation emerged.
Figure 1. The percentage of food insecure households by number of ACEs.
ACE, adverse childhood experience.
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Table 2. The Association Between ACEs and Household Food Insecurity
a
Household food insecurity
Variable
Mild
RRR (95% CI)
Moderate-to-severe
RRR (95% CI)
Cumulative ACEs
1ACE 1.65 (1.39, 1.97) 2.16 (1.60, 2.91)
2 ACEs 2.18 (1.73, 2.74) 3.39 (4.33, 4.93)
3+ ACEs 3.70 (2.96, 4.63) 8.14 (5.75, 11.52)
Individual ACEs
Parents divorced/separated 1.61 (1.35, 1 .92) 2.01 (1.56, 2.59)
Parent died 0.80 (0.62, 1.04) 0.68 (0.47, 1.01)
Parent in jail 1.81 (1.48, 2.21) 2.41 (1.81, 3.20)
Witnessed physical violence in the home 2.39 (1.96, 2.93) 3.79 (2.83, 5.07)
Victim of or witnessed violence in the neighborhood 2.18 (1.66, 2.85) 3.33 (2.36, 4.69)
Lived with mentally ill/suicidal person 1.77 (1.75, 2.06) 3.61 (2.79, 4.68)
Lived with someone with drug/alcohol problem 2.17 (1.85, 2.56) 4.02 (3.08, 5.24)
Experienced unfair treatment because of race/ethnicity 2.62 (1.94, 3.55) 3.99 (2.59, 6.16)
Note: Boldface indicates statistical significance (p<0.05).
a
Models pertaining to cumulative ACE exposure and individual ACE exposure are calculated separately. Models include the following covariates: child
age, child sex, child race/ethnicity (i.e., black, Hispanic, other, with white as the reference category), parent marital status, cohabitation, parent’s
highest educational attainment, income-to-poverty ratio (i.e., low income, moderate income, high income, with poor [below the poverty line] as the
reference category), parent’s employment status (employed at least 50/52 weeks in the year), and nutrition assistance (i.e., a measure of WIC or
SNAP assistance in the past 12 months).
ACE, adverse childhood experience; SNAP, Supplemental Nutrition Assistance Program; WIC, Special Supplemental Nutrition Program for Women,
Infants, and Children.
Table 3. The Role of Parent Self-Rated Physical and Mental Well-Being in Attenuating Associations Between Cumulative ACE
Exposure and Household Food Insecurity
a
Household food insecurity
Cumulative ACEs Mild
b
(SE) Moderate-to-severe
b
(SE)
Parent self-rated mental and physical well-being excluded
1ACE 0.504 (0.089) 0.770 (0.153)
2 ACEs 0.778 (0.117) 1.221 (0.191)
3+ ACEs 1.310 (0.114) 2.100 (0.177)
Parent self-rated physical well-being included
1ACE 0.405 (0.093) 0.666 (0.156)
2 ACEs 0.647 (0.126) 1.110 (0.197)
3+ ACEs 1.121 (0.121) 1.894 (0.179)
Attenuation, %
1 ACE 19.64 13.51
2 ACEs 16.84 9.09
3+ ACEs 14.43 9.81
Parent self-rated mental well-being included
1ACE 0.354 (0.094) 0.569 (0.158)
2 ACEs 0.524 (0.126) 0.911 (0.206)
3+ ACEs 1.035 (0.121) 1.694 (0.181)
Attenuation, %
1 ACE 29.76 26.10
2 ACEs 32.65 25.39
3+ ACEs 20.99 19.33
Note: Boldface indicates statistical significance (p<0.05).
a
Models include all covariates.
b
Unstandardized coefficient.
ACE, adverse childhood experience.
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For instance, in the case of mental well-being, attenuation
analyses indicated that 19.33%−32.65% of the association
between ACE exposure and food insecurity was explained
by lower parent self-rated mental well-being. Attenuation
was slightly less pronounced for parent self-rated physical
well-being, ranging from 9.09% to 19.64%. Still, associa-
tions between ACE exposure and household food insecu-
rity remained statistically significant even after accounting
for parent self-rated well-being, indicating only partial
attenuation.
DISCUSSION
Results show that reports of ACEs (e.g., witnessing
domestic violence, having a parent in jail, experiencing
discrimination) are strongly associated with household
food insecurity. Additionally, the greater the number of
ACEs, the more likely the household is to report both
mild and moderate-to-severe food insecurity. Still, the
findings reveal that, despite being somewhat less impact-
ful than a multiplicity of ACEs, exposure to a single
ACE is also significantly associated with an elevated risk
of household food insecurity. These findings build on
previous research showing a strong association between
caregiver reports of ACEs during their own childhood and
severity of household food insecurity.
17
The present study
also employs a recent, nationally representative sample of
families with children, thereby extending and corroborat-
ing prior research. Findings also reinforce the interconnec-
tedness of ACE exposure, food insecurity, and parent
mental and physical well-being suggested in prior litera-
ture,
18−25
further buttressing the need to consider the over-
lap of these processes when developing effective
interventions for both household food insecurity and
ACEs such as abuse, neglect, poor parental mental health,
and incarceration.
39,40
Broadly speaking, the present results point to the need
for expanded nutrition assistance programs that are
trauma informed, and, therefore, move beyond simple
assessments of nutrient intake, disordered eating pat-
terns, and financial risk or need.
11,40
Nutrition assistance
remains a limited form of intervention to address the
issue of food insecurity, and may not adequately reduce
food hardships among families exposed to a high num-
ber of ACEs. The present findings suggest that food inse-
curity interventions must go beyond nutrition assistance
to address exposure to ACEs, and that existing nutrition
assistance programming may be more effective at reduc-
ing food hardship if integrated with approaches that link
families to programs that address community and family
violence and provide economic and socioemotional sup-
ports for caregivers to prevent abuse, hardship, and
exposure to the criminal justice system. Indeed,
addressing exposure to ACEs through such comprehen-
sive and two-generation approaches that simultaneously
help caregivers and children will likely improve health and
development over the life course.
41
Limitations
Strengths of this study are that the 2016 NSCH is repre-
sentative of the U.S. population and captures current
family experiences with food hardship and simultaneous
ACEs. This study is limited, however, in that it is cross-
sectional and therefore cannot determine the causal
direction of the relationship between adversity and food
insecurity. Still, as the ACE measures are lifetime
reports, and the item pertaining to food insecurity refer-
ences the 12 months before the survey, it is likely that in
many instances, the ACEs being referred to occurred
before the 12 months before the survey. Even so, this
causal order cannot be verified with these data. Some
recent research, moreover, suggests that household food
insecurity may precede and influence subsequent child-
hood adversities, particularly family violence.
15,18
Other
research, however, finds evidence of family violence pre-
ceding food insecurity,
23
and forms of adversity in
broader ecologic contexts (e.g., exposure to community
violence) may indeed trickle down to the household and
affect the food environment.
42
Therefore, it is likely that
a more nuanced, reciprocal relationship exists between
these risk factors that cannot currently be teased apart
given the format of the 2016 NSCH data. Despite this
limitation, additional research into common risk factors
that may explain part of the association between ACEs
and food insecurity is needed in an effort to reduce both
ACEs and food insecurity. A related limitation that can-
not be avoided with these data pertains to memory or
recall issues and caregiver awareness of or willingness to
report children’s exposure to adversity, which may com-
promise measurement validity of the ACE measures to
an unknown degree.
CONCLUSIONS
The results of the present study show that ACEs have
strong associations with increased food insecurity and
that food insecurity becomes more severe as ACEs accu-
mulate. This relationship, moreover, appears to be par-
tially explained by parental mental and physical well-
being. In an effort to build upon the current findings,
scholars should consider future research that focuses on
the effectiveness of targeted interventions that address
food insecurity and ACEs simultaneously, and that
assesses the effectiveness of existing two-generation pro-
grams on reducing food insecurity. Overall, findings
indicate a close connection between ACEs and food
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insecurity, suggesting that policies must extend beyond
the provision of nutrition assistance and integrate program-
ming that addresses intersecting adversities, such as family
and community violence, incarceration, and discrimination.
ACKNOWLEDGMENTS
No financial disclosures were reported by the authors of this
paper.
SUPPLEMENTAL MATERIAL
Supplemental materials associated with this article can be
found in the online version at https://doi.org/10.1016/j.
amepre.2019.06.004.
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