Amy R Knowlton

Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States

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Publications (83)205.31 Total impact

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    ABSTRACT: In a context with limited attention to mental health and prevalent sexual prejudice, valid measurements are a key first step to understanding the psychological suffering of sexual minority populations. We adapted the Patient Health Questionnaire as a depressive symptom severity measure for Vietnamese sexual minority women, ensuring its cultural relevance and suitability for Internet-based research. Psychometric evaluation found that the scale is mostly unidimensional and has good convergent validity, good external construct validity, and excellent reliability. The sample's high endorsement of scale items emphasizes the need to study minority stress and mental health in this population.
    No preview · Article · Feb 2016 · Journal of Gay & Lesbian Mental Health
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    ABSTRACT: Current or former injection drug users with human immunodeficiency virus (HIV) are at high risk for pain, which adversely affects their quality of life and may increase their risk for illicit drug use or relapse. We explored associations between pain symptoms and substance use among injection-drug-using study participants with HIV who had histories of heroin use. Using generalized estimating equations and controlling for prior substance use, we found that pain in each six-month period was associated with the use of heroin and prescription opioids, but not the use of nonopioid drugs or alcohol. Routine clinical assessment and improved management of pain symptoms may be needed for persons with HIV and a history of injection drug use, particularly those with chronic pain, for whom there is increased risk for heroin use.
    No preview · Article · Dec 2015 · Journal of palliative care
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    ABSTRACT: We evaluated a synergistic epidemic (syndemic) of substance use, mental illness, and familial conflict non-negotiation among HIV-positive injection drug users (IDU). Baseline BEACON study data was utilized. Latent class analyses identified syndemic classes. These classes were regressed on sex, viral suppression, and acute care non-utilization. Females were hypothesized to have higher syndemic burden, and worse health outcomes than males. Nine percent of participants had high substance use/mental illness prevalence (Class 4); 23 % had moderate levels of all factors (Class 3); 25 % had high mental illness (Class 2); 43 % had moderate substance use/mental illness (Class 1; N = 331). Compared to Classes 1-3, Class 4 was mostly female (p < .05), less likely to achieve viral suppression, and more likely to utilize acute care (p < .05). Interventions should target African-American IDU females to improve their risk of negative medical outcomes. Findings support comprehensive syndemic approaches to HIV interventions, rather than singular treatment methods.
    No preview · Article · Aug 2015 · Journal of Behavioral Medicine
  • Allysha C Robinson · Amy R Knowlton
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    ABSTRACT: Research suggests gender differences exist in achieving undetectable viral load (UVL) among persons living with HIV (PLHIV), and that psychosocial health factors may play a role. The present study examined these factors among African-American PLHIV enrolled in the BEACON study. Participants completed self-report surveys and gave biomarker data. Poisson regression with robust standard errors was implemented. Men with moderate religious activity had 1.3 times the likelihood of UVL as men with low religious activity (p < 0.10; N = 199). Men with 1-2 mental illness diagnoses had 1.3 times the likelihood of UVL as men with none (p < 0.05). Women using 1-2 substances had 28 % lower likelihood of UVL than non-using women (N = 122; p < 0.10). Finally, women with frequent doctor-patient communication had 35 % higher likelihood of UVL as women with less doctor-patient communication (p < 0.05). Results suggest that social support, substance use, and mental illness function differently among men and women. Healthcare professionals should employ gender-specific interventions to address and improve HIV health outcomes.
    No preview · Article · Jul 2015 · AIDS and Behavior
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    Carl A Latkin · Amy R Knowlton
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    ABSTRACT: Social networks provide a powerful approach for health behavior change. This article documents how social network interventions have been successfully used for a range of health behaviors, including HIV risk practices, smoking, exercise, dieting, family planning, bullying, and mental health. We review the literature that suggests the relationship between health behaviors and social network attributes demonstrates a high degree of specificity. The article then examines hypothesized social influence mechanisms including social norms, modeling, and social rewards and the factors of social identity and social rewards that can be employed to sustain social network interventions. Areas of future research avenues are highlighted, including the need to examine and to adjust analytically for contamination and social diffusion, social influence versus differential affiliation, and network change. Use and integration of mhealth and face-to-face networks for promoting health behavior change are also critical research areas.
    Full-text · Article · Jul 2015 · Behavioral Medicine
  • Mary M Mitchell · Robinson · Nguyen · Amy R Knowlton
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    ABSTRACT: Background: Few studies have examined the association between having an informal (unpaid) caregiver and viral suppression among persons living with HIV/AIDS (PLHIV) who are on antiretroviral therapy. The current study examined relationships between caregivers’ individual and social network characteristics and care recipient viral suppression. Methods: Baseline data were from the BEACON study caregivers and their HIV seropositive former or current drug using care recipients, of whom 89% were African American (N=258 dyads). Results: Using adjusted logistic regression, care recipient’s undetectable viral load was positively associated with caregiver’s limited physical functioning and negatively associated with caregivers having few family members to turn to for problem solving, a greater number of current drug users in their network, and poorer perceptions of the care recipient’s mental health. Conclusion: Results further understandings of interpersonal relationship factors important to PLHIV’s health outcomes, and the need for caregiving relationship-focused intervention to promote viral suppression among PLHIV.
    No preview · Article · May 2015 · AIDS and Behavior
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    ABSTRACT: People living with HIV/AIDS (PLHIV) have growing rates of morbidity and need for informal care, especially among drug-using PLHIV. Informal caregivers, or persons providing unpaid emotional or instrumental support, have protective effects on the health and well-being of PLHIV. Research suggests that social support, including care recipients' reciprocity of emotional support, is important to sustained caregiving. This study examined HIV caregivers' perceived emotional support over time from their current or former injection drug-using care recipients. Data were from baseline, 6-month, and 12-month follow-up of the BEACON study. Latent growth curve analysis showed a decline in reciprocated emotional support reports over time, particularly among caregivers themselves HIV seropositive or currently substance using. Researchers should develop interventions to strengthen the caregiving relationship by promoting reciprocity of emotional support, with implications for sustaining caregiving to vulnerable PLHIV and improving their health outcomes. Interventions should especially target dyads in which caregivers are also HIV positive or using substances.
    No preview · Article · Apr 2015 · AIDS Care
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    ABSTRACT: Quantitative research on parental/family disapproval and rejection of sexual/gender minority persons has often measured family rejection as one binary/continuous variable, or using several variables representing specific behaviors or dimensions of behaviors. Absent from this literature is analysis using a person-oriented approach, examining heterogeneity across individuals in the types of family treatment experience. Using data from 2,664 adult sexual minority women and transmen in Vietnam, latent class analysis was conducted on 19 items representing negative family behaviors. The six-class solution best fit the data, including one non-negative class (peace, 36.7% of the sample) and five negative classes (pressure, 34.0%; aggressive to respondent and girlfriend, 10.3%; aggressive to respondent, 8.1%; severe, 6.0%; and extreme, 4.7%). Class membership was regressed on individual, family, and contextual variables. Overall, younger age, transman identity, religious affiliation, and parent awareness predicted being in worse family treatment classes. Further research is needed to separate cohort and age effects and to examine developmental trajectories of family behavior. Findings suggested that it may be general conservativeness rather than a specific religious doctrine that predicts negative family treatment and revealed that nonparent family members’ role in family response to sexual/gender nonconformity may be significant.
    Full-text · Article · Apr 2015 · Journal of GLBT Family Studies
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    ABSTRACT: Sexual/gender minority persons commonly face rejection from parents and other family members. To date, research on this topic has either measured family rejection as one binary or continuous variable, or characterized family rejection using several variables representing specific behaviors or dimensions of behaviors (a variable-oriented approach). No research has been done on family rejection/negative treatment of sexual/gender minority people from a person-oriented approach, looking at whether the treatment by the families of different individuals could be classified into a number of categories – i.e., whether there are different types of family treatment experience. This study used data from an anonymous internet sample of 2664 adult sexual minority women and transmen in Viet Nam, and conducted latent class analysis on 19 items representing negative actions by parents or other family members. Six distinct classes were extracted: peace (36.7% of the sample), pressure (34.0%), aggressive to respondent and girlfriend (10.3%), aggressive to respondent (8.1%), severe (6.0%), and extreme (4.7%). We regressed class membership on individual, family and contextual variables, using three-step latent class regression with Vermunt correction for class uncertainty. Overall, younger age, transman identity, religion affiliation, and higher parent awareness of non-heterosexuality predicted being in more negative classes. This study shows that latent class methods can be used to expand knowledge about negative family treatment of sexual/gender minority persons by identifying a naturally occurring typology of family treatment classes and assessing predictors of negative classes. Future research should examine the effects of these family treatment classes on health and well-being.
    Full-text · Conference Paper · Nov 2014
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    ABSTRACT: Background: Due to advancements in antiretroviral therapies, persons living with HIV/AIDS (PLHAs) are living longer and with increased care needs. The objectives of this study were to assess: (1) whether vulnerable PLHAs preferred informal versus professional care; and (2) factors associated with their end of life preference. Methods: Data were from the Being Active and Connected study, which examined social factors related to health outcomes among PLHAs. Structural equation modeling was used to identify individual and network characteristics associated with PLHAs’ care preferences at end of life. Results: Nearly half of respondents (47%) indicated a preference for informal care (N=383). Predictors of family care preference included: female sex (standardized coefficient [Std. Coef.] = .12, p<.05); having a main partner as their caregiver (Std. Coef. = .14, p<.05); receiving health assistance from social network members (Std. Coef. = .22, p< .001); having more social network members who felt it was important to take HIV medications (Std. Coef. = .23, p<.001); and having more female kin in their support network (Std. Coef. = .23, p<.001). Not wanting to owe favors to anyone was negatively associated with family care preference (Std. Coef. = -.26, p<.001). Conclusions: Given PLHAs' substantial need for familial care, our results suggest that support is needed for end of life informal caregivers. Interventions should bolster caregivers' coping skills and connection to support programs. Inclusion of informal caregivers in collaborative treatment decision making can reduce early caregiving cessation and improve health outcomes in a vulnerable population with less preference and/or means for professional care.
    No preview · Conference Paper · Nov 2014
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    ABSTRACT: Limited investigations have been conducted on syndemics and HIV continuum of care outcomes. Using baseline data from a multi-site, randomized controlled study of HIV-positive injection drug users (n = 1,052), we examined whether psychosocial factors co-occurred, and whether these factors were additively associated with behavioral and HIV continuum of care outcomes. Experiencing one type of psychosocial problem was significantly (p < 0.05) associated with an increased odds of experiencing another type of problem. Persons with 3 or more psychosocial problems were significantly more likely to report sexual and injection risk behaviors and were less likely to be adherent to HIV medications. Persons with 4 or more problems were less likely to be virally suppressed. Reporting any problems was associated with not currently taking HIV medications. Our findings highlight the association of syndemics not only with risk behaviors, but also with outcomes related to the continuum of care for HIV-positive persons.
    Full-text · Article · Sep 2014 · AIDS and Behavior
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    ABSTRACT: With the advent of antiretroviral therapies, persons living with HIV/AIDS (PLHIVs) are living longer but with increased impairment and care needs. The purpose of this study was to assess whether a vulnerable population of PLHIVs preferred informal versus professional care when unable to care for themselves, and individual and support network factors associated with preference for informal care. The findings have potential implications for facilitating the population's informal care at end of life. Data were from the BEACON study, which examined social factors associated with health outcomes among former or current drug-using PLHIVs in Baltimore, MD. Structural equation modeling was used to identify individual and support network characteristics associated with PLHIVs' preference for informal (family or friends) compared to professional care. The structural equation model indicated preference for informal care was associated with female sex, greater informal care receipt, reporting one's main partner (i.e., boy/girlfriend or spouse) as the primary source of informal care, and a support network comprised greater numbers of female kin and persons supportive of the participant's HIV treatment adherence. Not asking for needed help to avoid owing favors was associated with preferring professional care. Findings suggest that interventions to promote informal end of life care should bolster supportive others' resources and skills for care provision and treatment adherence support, and should address perceived norms of reciprocity. Such intervention will help ensure community caregiving in a population with high needs for long-term care.
    No preview · Article · Sep 2014 · AIDS Care
  • Lauren R. Pacek · Carl Latkin · A.R. Knowlton

    No preview · Article · Jul 2014 · Drug and Alcohol Dependence
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    ABSTRACT: Introduction Cigarette smoking is highly prevalent among people living with HIV, and is associated with many negative health outcomes, including death. There is little research on smoking behaviors such as interest in quitting and lifetime quit attempts among smokers living with HIV. Existing research has focused on individual-level characteristics, to the neglect of social environmental characteristics. We explored individual- and social-level characteristics associated with interest in quitting and lifetime nicotine replacement (NRT) or medication use for smoking cessation. Methods Data are from a study of participants recruited from clinic and community venues originally designed to examine social environmental influences on current/former drug users’ HIV medication adherence and health outcomes. This analysis comprised 267 current smokers living with HIV. Chi-square tests were used to describe the sample; logistic regression was used to explore associations between covariates and outcomes. Results In adjusted analyses, older age (age 54-65: aOR = 4.64, 95% CI = 1.59-13.47) and lifetime use of NRT/medications (aOR = 2.02, 95% CI = 1.08-3.80) were associated with an interest in quitting smoking. Additionally, older age (age 45-49: aOR = 3.38, 95% CI = 1.57-7.26; age 54-65: aOR = 2.70 95% CI = 1.20-6.11), White race (aOR = 3.56, 95% CI = 1.20-10.62), and having a Supporter who had used NRT/medications for cessation (aOR = 2.13, 95% CI = 1.05-4.29) were associated with lifetime NRT/medications use. Conclusions Findings corroborate prior research concerning individual-level characteristics, and indicate the importance of social-level characteristics in association with prior use of NRT/medications for cessation. Findings have implications for the implementation of cessation interventions for smokers living with HIV.
    No preview · Article · May 2014 · Drug and alcohol dependence
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    ABSTRACT: Because caregivers' monitoring of care recipients' mental health status likely facilitates provision of needed forms of assistance, the current study examines relationship factors associated with agreement in caregiver- and recipient self-reports of recipients' mental health status. Participants were former or current injection drug using persons with HIV/AIDS and their main caregivers (N = 258 dyads). Care recipients completed the Center for Epidemiologic Studies Depression scale and caregivers responded to a single item rating their recipients' mental health. Nearly two-thirds (64.7 %) of dyads agreed on care recipients' mental health status (κ = .26, p < .001). More secondary stressors of care, less reciprocity, and care recipients' greater physical limitations, substance use, and younger age predicted greater agreement on recipients' having poorer mental health. Greater secondary stressors and lower income were associated with less agreement on care recipients' mental health. Findings, which suggest that promoting reciprocity and alleviating secondary stressors of caregiving may help facilitate these caregivers' improved assessment of their care recipients' mental health status, have implications to dyadic approaches to promote drug users' HIV health outcomes.
    No preview · Article · Jan 2014 · AIDS and Behavior
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    ABSTRACT: Cigarette smoking is endemic among HIV-positive populations and is related to substantial morbidity and mortality. Research has largely focused on individual-level characteristics associated with smoking, with less attention to social factors. We aimed to explore individual- and social-level characteristics associated with current cigarette smoking among people living with HIV. Data came from 358 individuals on antiretroviral therapy interviewed in a study on informal HIV caregiving, conducted in Baltimore, MD, USA. Most participants (75 %) were current smokers and 45 % reported current illegal drug use. In adjusted logistic regression analyses, current drug use (aOR 2.90, 95 % CI 1.58-5.30), 12-step program participation (aOR 1.74, 95 % CI 1.02-2.97), and having a main Supporter who is a current smoker (aOR 1.93, 95 % CI 1.12-3.33) were associated with current smoking. Findings suggest the importance of social-level factors in cigarette smoking among HIV seropositive drug users and have implications for developing targeted smoking cessation interventions for smokers living with HIV.
    No preview · Article · Nov 2013 · AIDS and Behavior
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    ABSTRACT: Objectives: Concern about mass violence has led to calls for increased mental health support for violence prevention. Health information systems may help identify persons at risk of violence who may benefit from mental support services. Emergency medical services (EMS) serve an increasingly vulnerable population that, compared to other ED users, has high mental health problems. We explored the potential utility of EMS data in identifying at-risk persons. Methods: We reviewed Baltimore's 9-1-1 dispatch data and fire department EMS records over 23 months (2008-10). Health data was categorized and violent trauma related incident data was analyzed. We examined associations of subtypes of violent incidents to patient demographics, repeat EMS use, and evidence of behavioral (mental or substance use) problems. Results: We identified 7,190 violent trauma incidents linked to patient records, comprising 57.7% assaults; 13.3% shootings; 11.8% stabbings; 2.5% abuse/sexual assaults; and 14.7% attempted or threatened self-harm including suicide. Young Black males were over-represented for all incident types except abuse/sexual assault and self-harm, for which there was a wider age range, and whites, and only moderately males, were over-represented. There was evidence of repeat EMS use and behavioral health problems for one-fifth of all persons; of persons involved in self-harm, 35.2% were repeat users and 82.3% had behavioral health problems. Conclusions: Our findings suggest EMS data may aid in identifying persons at risk of violence to themselves or others. High levels of behavioral health problems and emergency care recidivism make them important targets for enhanced assessment and preventive intervention.
    No preview · Conference Paper · Nov 2013
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    ABSTRACT: Objective: Low-income African-American, inner-city residents provide disproportionately high levels of informal (unpaid) HIV care (instrumental and emotional support) to family and friends living with HIV/AIDS. We examined evidence of the role of caregivers in care recipients' mental health and associations with their perceived associative stigma related to HIV caregiving. Methods: This study used a structural equation model to examine main effects of caregiver reports of recipients' mental health status and caregivers' self-reported associative stigma on care recipients' self-reported psychological distress (CES-D). Results: Results indicated that recipients' self-reported psychological distress was positively associated with caregiver reports of recipients' poor mental health (Beta=.24, p<.001) and with caregivers' associative stigma (Beta=.18, p<.05). In addition, stigma moderated the relationship between caregiver reports of recipients' mental health and recipient reports of their mental health (Beta=.43, p<.05), such that caregivers with higher perceived stigma and worse reports of recipients' mental health predicted recipient self reported poorer mental health. Conclusions: High agreement between caregivers' reports of recipients' mental health status and recipients' self reports of psychological distress suggest that caregivers were overall perceptive in assessing the mental health of their care recipients, and that caregivers who perceived high levels of associative stigma appeared to be most accurate in rating recipient's mental health status. These results suggest that, overall, the caregivers were aware of the mental health status of their care recipients and may provide a target population on which to focus interventions to monitor the mental health of PLHAs.
    No preview · Conference Paper · Nov 2013
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    ABSTRACT: Background: Gun violence is a major threat to US public health. Information systems are needed to improve population surveillance of violence and inform preventive intervention. Emergency medical services (EMS) system data is an understudied potential source for incident-based surveillance of shootings and examination of personal correlates of violent injury. Methods: We reviewed Baltimore City 9-1-1 call dispatch data and Baltimore City Fire Department EMS patient records in a 23 months period 2008-10. We coded health data based on a prior schema, and compared numbers of firearm related incidents to police report data in a similar period, and examined associations with patient demographics, repeat use of EMS, and behavioral (substance use and mental) health problems. Results: We identified 954 gunshot wound incidents linked to EMS patient data, representing 13.3% of violent trauma incidents in the study period. Compared to the city and to the EMS patient population, young Black males were over-represented among gunshot victims. Compared to police reports of shootings in a comparable period, EMS records contained 19.5% fewer shooting incidents. Patients with gunshot wounds had below average levels of EMS utilization and evidence of substance abuse or mental health problems in their EMS records. Conclusions: Our findings suggest that while EMS records undercounted gunshot wound incidents in the city, EMS data may be an important source of real time incident level data to complement current data sources for firearm related injury surveillance. Future research should assess and promote the validity of EMS records on violence-related injury.
    No preview · Conference Paper · Nov 2013
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    ABSTRACT: To optimize health care utilization, health outcomes, and costs, research is needed to improve an understanding of frequent users of emergency health services. Frequent use of emergency services is associated with high costs of health care and may be indicative of challenges accessing, or poor outcomes of, health care. Patient demographics and health factors related to frequent use of the emergency medical services (EMS) system of a midsized city were identified. Study findings will aid in the development of targeted interventions to improve population health. The authors reviewed 9-1-1 call dispatch data and Baltimore City Fire Department (BCFD) EMS records from 2008 through 2010. Frequent use was defined as six or more EMS incidents in the 23-month period. Analyses used census data to compare demographics of EMS users to their population distribution and examined differences in demographics and health problems of frequent EMS users compared to nonfrequent users. Frequent EMS users (n = 1,969) had a range of six to 199 EMS incidents (mean = 11.2) during the observation period, and although they accounted for only 1.5% of EMS users, they were involved in 12.0% of incidents. Frequent users, compared to nonfrequent users and to the population, were more likely to be male, African American, and 45 years of age or older. Of frequent users, the modal age group was 45 to 54 years, accounting for 29.7% of frequent users, which represented twice this age group's population distribution. Furthermore, this age group had the greatest overrepresentation of males (63.0% of frequent users) and was the peak age group for incidents related to substance abuse (28.0% of frequent users' incidents in this age group). Frequent users, compared to nonfrequent users, had lower levels of incidents related to trauma (5.1% vs. 16.7%) and higher levels of medical incidents (94.8% vs. 82.9%). As proportions of EMS incidents among frequent versus nonfrequent users, respiratory, mental health, and seizure-related incidents were highest in the youngest age groups; substance abuse-related incidents were highest in those middle-aged (35 to 44 and 45 to 54 years). Of health problems, behavioral health (mental health or substance use) contributed most to frequent EMS use (23.4% of frequent users' incidents). Across all incidents, 65.8% of frequent users had indications of behavioral health problems, representing 6.6-fold higher odds than nonfrequent users (22.5%). Frequent compared to nonfrequent users also had higher levels of select chronic conditions (diabetes, 39.9% vs. 14.6%; asthma, 40.9% vs. 13.4%; and HIV, 9.1% vs. 2.4%), with unadjusted odds almost four to seven times higher. The study findings revealed the major role of chronic somatic and behavioral health problems in frequent EMS use and that rates of frequent use were highest among those middle-aged, African American, and male. These results suggest the need for coordination of EMS with community-based, integrated medical and behavioral health services to improve access and use of preventive services, with implications for health outcomes and costs. This study demonstrates the value of EMS patient data in identifying at-risk populations and informing novel, targeted approaches to public health interventions.
    No preview · Article · Nov 2013 · Academic Emergency Medicine

Publication Stats

2k Citations
205.31 Total Impact Points

Institutions

  • 1998-2015
    • Johns Hopkins Bloomberg School of Public Health
      • • Department of Health, Behavior and Society
      • • Department of Health Policy and Management
      Baltimore, Maryland, United States
  • 1994-2011
    • Johns Hopkins University
      • • Department of Health, Behavior and Society
      • • Department of Epidemiology
      Baltimore, MD, United States